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.