Monique T Jones

Background: The rising prevalence of mental disorders, including anxiety and depression, are significantly contributing to the global burden of disease. Early-stage symptoms, if unaddressed, may persist or worsen over time, and lead to chronic mental health conditions. The COVID-19 pandemic introduced extraordinary levels of stress, isolation, and uncertainty, creating an environment where many individuals experienced heightened symptoms of anxiety, depression, and other psychological issues, including new mental health conditions in individuals who had previously been well. Promoting engagement in early intervention support for mental health was crucial to lessen individual and societal impacts of the pandemic. In March 2020, due to the COVID-19 pandemic, Australia experienced its first major lockdown. This created an opportunity to develop and deliver a clinical service, an 8-week online wellbeing program using lifestyle medicine and health coaching. It supported the general population who had not sought mental health support before to manage early signs of mental health distress (anxiety, stress, depression), and isolation (social connectedness) due to uncertainty, physical distancing, and lockdowns. This was named the EMERging Anxiety, Loneliness, and Depression (EMERALD) program. This thesis discusses how lifestyle medicine, and the modifiable lifestyle factors such as physical activity, nutrition, sleep, substance use, stress management, and social connection are recognised as fundamental to both physical and mental health. A multimodal approach recognises that clusters of health behaviours, rather than single factors, are more strongly associated with improved mental health outcomes. However, key to engaging in improving lifestyle factors, is the individual’s confidence and motivation to engage behaviour change. Health coaching, grounded in behaviour change and psychological theories, offers a collaborative relationship, placing the individual as the expert and driver of change, and employs evidence-based behaviour change techniques to enhance healthy lifestyle behaviours. Aim: The first aim of this thesis was to detail the components of the EMERALD program using a standardised intervention reporting tool. Historically, behaviour change interventions have not been described in sufficient detail to allow for replication. The Template for Intervention Description and Replication (TIDieR) checklist is used to provide detailed description of the intervention, enhancing transparency and replicability of the intervention components used in the program. The second aim was to evaluate changes in self-reported mental health outcomes following participation in the EMERALD wellbeing program, to assess its effectiveness in improving psychological wellbeing. The research hypotheses were: (i) program completion would lead to reduced depression and anxiety, decreased loneliness, improved wellbeing, and enhanced functioning; (ii) greater improvements in overall wellbeing, were predicted for those with mild baseline depression and anxiety symptoms compared to those with moderate symptoms. Methods: This was an observational and retrospective study of the EMERALD program. The TIDieR checklist was utilised to comprehensively describe the program protocol. Clinical outcomes were analysed for program completers using linear mixed-effects models to examine pre- to post intervention change. Eligibility was determined using the Generalised Anxiety Disorder Scale (GAD- 7), and the Patient Health Questionnaire (PHQ-9). Primary Outcome measures included the GAD-7 and PHQ-9, alongside the World Health Organisation (Five) Wellbeing Index (WHO-5), Work and Social Adjustment Scale (WSAS), and the De Jong Gierveld Loneliness Scale (DJGLS) enabling assessment of mental health symptoms, wellbeing, functional impairment, and loneliness. Results: The program was developed to align with the latest evidence-based literature in lifestyle medicine and solution-focused coaching. The online program also offered allied health expertise, online educational modules, and was tailored to participants. Clinical outcomes from 85 participants who completed the 8-week program between August 2020, and June 2021 are reported. Findings revealed significant improvements across all measures. These results support the benefits of online mental health coaching and lifestyle medicine interventions for improving psychological wellbeing during periods of elevated need. Discussion: The program protocol employing the TIDieR tool has been published. In doing so, this extends the current evidence base and offers sufficient detail to support replication. Findings showed the EMERALD program demonstrated the potential of telehealth-delivered lifestyle medicine, and health coaching to support mental health in the general population. These findings contribute to the growing evidence base for early intervention approaches, and highlight the importance of scalable, accessible mental health services. Given the rising global mental health burden, early intervention lifestyle medicine programs may play a vital role in mitigating progression to chronic mental health conditions. Delivering the program as a clinical service, rather than under controlled trial conditions, had notable strengths and limitations. The flexibility built into the program, including participant selection of lifestyle medicine topics and goals, and the use of health coaching and behaviour change techniques, enabled a high level of personalisation and autonomy, which likely enhanced engagement and contributed to the positive outcomes observed. However, the absence of controlled conditions, together with gaps in data collection, limits causal inference and constrained the analyses that was undertaken. This thesis contributes to the evidence of the success of early intervention lifestyle medicine and coaching programs to improve emerging mental health symptoms in the general population. Further research is recommended for the progression of EMERALD to a RCT to strengthen causal inference. The use of a standardised intervention framework to detail the intervention for transparency, and replication would benefit the evidence based.

Objective
The rising prevalence of mental health symptoms brought on by the COVID19 pandemic led to the inception and development of EMERging Anxiety, Loneliness, Depression (EMERALD) well-being programme. EMERALD was designed to improve psychological well-being of the general population who had not previously sought mental health support. The programme incorporated a focus on lifestyle medicine and was underpinned by solution focused health coaching. The aim of the paper is to describe the programme according to the Template for Intervention Description and Replication (TIDieR) checklist to provide detailed reporting of the intervention's elements.
Methods
The TIDieR checklist was utilised to comprehensively describe the programme, including theoretical underpinnings, materials, procedures, providers, mode of delivery and tailoring of the programme. The Behaviour Change Technique Taxonomy v2 was used to identify the specific behaviour change techniques used within the solution focused health coaching framework.
Results
The programme was developed to align with the latest evidence-based literature in lifestyle medicine and solution focused coaching. The programme also offered allied health expertise, online educational modules and was tailored to the participants. The programme was delivered online through a telehealth platform.
Conclusion
The TIDieR checklist has enabled the provision of a detailed structure of the EMERALD program intervention. The behaviour change taxonomy has facilitated the outlining of specific techniques used in health coaching sessions. Both structures have operationalised the detail of the intervention for the purposes of replication and informing the literature.

Recovery of functioning is integral to successful treatment outcomes in depressive illness. Optimal antidepressant treatment results in both symptomatic remission and functional recovery. Oral ketamine rapidly reduces suicidality and depression; however, reports of functional and wellbeing outcomes are lacking. This study examines participants’ social and occupational functioning and wellbeing outcomes in the Oral Ketamine Trial on Suicidality (OKTOS). Thirty adults with chronic suicidality participated in the trial over 10 weeks. Functional recovery and wellbeing were assessed using the Social and Occupational Functioning Scale (SOFAS) and World Health Organization Well-Being Index (WHO-5). Suicidality and depressive symptoms were assessed using the Beck Scale for Suicidal ideation (BSS) and Montgomery-Asberg Depression Rating Scale (MADRS). Relationships between the four treatment outcomes were analysed. Forty-three percent of participants achieved healthy function (SOFAS ≥80) and 27% reported healthy wellbeing (WHO-5 >60%) at the four-week post-treatment follow-up. Wellbeing was revealed as the data-derived treatment endpoint for the sample. Effect sizes for functioning and wellbeing outcomes were smaller than for suicidality and depression outcomes. Results suggest that reduction in depressive symptoms and suicidal ideation may be necessary but not sufficient for full resto-ration of function and wellbeing in antisuicidal and antidepressant therapy, including clinical trials.

Recently, low-dose ketamine has been proposed as a rapid-acting treatment option for suicidality. The majority of studies to date have utilised intravenous (IV) ketamine, however, this route of administration has limitations. On the other hand, oral ketamine can be administered in a range of settings, which is important in treating suicidality, although studies as to safety and feasibility are lacking.
n
 = 32 adults (aged 22–72 years; 53% female) with chronic suicidal thoughts participated in the Oral Ketamine Trial on Suicidality (OKTOS), an open-label trial of sub-anaesthetic doses of oral ketamine over 6 weeks. Participants commenced with 0.5 mg/kg of ketamine, which was titrated to a maximum 3.0 mg/kg. Follow-up assessments occurred at 4 weeks after the final dose. The primary outcome measure was the Beck Scale for Suicide Ideation (BSS) and secondary measures included scales for suicidality and depressive symptoms, and measures of functioning and well-being. Mean BSS scores significantly reduced from a high level of suicidal ideation at the pre-ketamine (week 0) timepoint to below the clinical threshold at the post-ketamine (week 6) timepoint. The proportion of participants that achieved clinical improvement within the first 6 weeks was 69%, whereas 50% achieved a significant improvement by the follow-up (week 10) timepoint. Six weeks of oral ketamine treatment in participants with chronic suicidality led to significant reduction in suicidal ideation. The response observed in this study is consistent with IV ketamine trials, suggesting that oral administration is a feasible and tolerable alternative treatment for chronic suicidality.

Social anxiety disorder (SAD) is a prevalent chronic condition with a large demand for treatment. This community outpatient study examined the effectiveness of a group intervention version of the established one-to-one cognitive therapy derived from the Clark and Wells model for SAD. Questionnaires were completed pre-treatment and post-treatment for SAD symptoms (Social Phobia Scale, Social Interaction Anxiety Scale), depressive symptoms (BDI-II), self-focused attention, safety behaviours (Social Phobia Weekly Summary Scale and Subtle Avoidance Frequency Examination), and impaired functioning (Work and Social Adjustment Scale). From an initial sample of 159 participants, 101 completed at least seven of the nine weekly group sessions (Mage = 34.1 years, SDage = 10.8 years, 53% female). Significant improvements were demonstrated on all measures. Large effect sizes were found for social anxiety symptoms and safety behaviour use. Self-focused attention, depressive symptoms, and impaired functioning had moderate effect sizes. Effect sizes for anxiety (d = 1.00 and 1.32) and mood measures (d = 0.71) were as high, or in some cases, higher than previous group treatment studies. Results suggest group cognitive therapy for SAD based on the Clark and Wells model is effective in a clinical setting for individuals with moderate/severe and treatment-resistant social anxiety.

Background: The glutamatergic modulator ketamine has been shown to result in rapid reductions in both suicidal ideation (SI) and depressive symptoms in clinical trials. There is a practical need for identification of pre-treatment predictors of ketamine response. Previous studies indicate links between treatment response and body mass index (BMI), depression symptoms and previous suicide attempts. Our aim was to explore the use of clinical and demographic factors to predict response to serial doses of oral ketamine for chronic suicidal ideation. Methods: Thirty-two participants completed the Oral Ketamine Trial on Suicidality (OKTOS). Data for the current study were drawn from pre-treatment and follow-up time-points of OKTOS. Only clinical and sociodemographic variables were included in this analysis. Data were used to create a proof of concept Bayesian network (BN) model of variables predicting prolonged response to oral ketamine, as defined by the Beck Scale for Suicide Ideation (BSS). Results: The network of potential predictors of response was evaluated using receiver operating characteristic (ROC) curve analyses. A combination of nine demographic and clinical variables predicted prolonged ketamine response, with strong contributions from BMI, Social and Occupational Functioning Assessment Scale (SOFAS), Montgomery-Asberg Depression Rating Scale (MADRS), number of suicide attempts, employment status and age. We evaluated and optimised the proposed network to increase the area under the ROC curve (AUC). The performance evaluation demonstrated that the BN predicted prolonged ketamine response with 97% accuracy, and AUC = 0.87. Conclusions: At present, validated tools to facilitate risk assessment are infrequently used in psychiatric practice. Pre-treatment assessment of individuals’ likelihood of response to oral ketamine for chronic suicidal ideation could be beneficial in making more informed decisions about likelihood of success for this treatment course. Clinical trials registration number ACTRN12618001412224, retrospectively registered 23/8/2018.