Mental health and the Big 5

Like you, I am worried about the mental health of Australians. We frequently see media reporting on the mental health challenges affecting our community and we are all aware that the housing shortage and cost of living crisis is making more people more vulnerable.

Those of us working in mental health are not just managing increasing caseloads, but we are also trying to look after the mental health of our co-workers, our loved ones and if we can, ourselves.

This phenomenon is not unique to Australia — rates of psychological distress have increased around the world, more people are being prescribed antidepressants or anxiolytics, and waiting times to see a counsellor, psychologist or psychiatrist are no longer measured in weeks, but in months.

But, what if there were things that we could do for our mental health, to become more resilient? What if there were things we could do which would give us a 10% or 20% buffer in our mental health?

We all know that there are things we can do to look after our physical health (for example, eat three meals a day, brush your teeth twice a day). But are there things we can or even should do to improve our mental health?

For almost two decades my team and I have considered this question, not just from a research perspective, but because, as mental health professionals, we are deeply concerned that we aren’t doing enough to prevent mental health difficulties. We started with a simple observation, that is, when we successfully treat a person with depression or anxiety, we see profound changes in their behaviour. They become more engaged with life, often become more social and they think differently, or at least, much less negatively.

This led to other questions — are some actions more important than others for our mental health and is there a tipping point — that is, do we need to do some things a minimum number of times each week to get a benefit?

We have now conducted studies with more than 20,000 Australian adults and have some basic answers. In an early study we created a list of almost 100 actions that were believed to affect mental health.

This list included actions drawn from the broad scientific and popular literature and from recommendations from colleagues and consumers. Examples of these actions include regular social contact, exercise, healthy eating, gratitude, kindness, meditation and so on.

Over two studies we asked more than 6000 Australians how often they did each of these actions in the previous week plus we measured symptoms of depression, anxiety and satisfaction with life. And, out of all the things people could do, five groups of actions were dominant.

Five groups of actions — the Big 5

These five groups of actions, now called the Big 5, were consistently the most important for most people, regardless of age, gender, employment status or education status. Since then we have consistently found that people who perform the Big 5 actions at least half the days of the week are likely to have good mental health, while people doing the Big 5 less frequently are at risk of poor mental health.

The Big 5 include three groups of actions which have been recognised for centuries as important for good mental health, including 1) Doing things that are meaningful (and often fun); 2) Having regular social contact with people we love and respect; and, 3) Keeping our thinking grounded and keeping things in perspective. But, our work identified two other critical domains, 4) Having healthy daily routines; and, 5) Having goals and plans. In addition, our work has shown that doing the Big 5 is important, but doing these at least half the days of each week is a key to good mental health.

In one recent randomised controlled clinical trial led by Dr Madelyne Bisby, we demonstrated that simply providing information about the Big 5 and sending SMS nudges to do the Big 5 led to significant improvements in mood in people who had been troubled by symptoms of depression and anxiety. And, the improvements were mostly sustained three months after the SMS messages ended. That study demonstrated how the Big 5 can become embedded in our everyday lives by simply reminding people about things that are good to do.

We recently extended this work by testing what happens when people reduce the Big 5. In a recently published pilot study we recruited a group of 12 psychologically healthy people and after monitoring their mental health for two weeks we asked them to restrict how often they did the Big 5. The results were surprising and profound.

Participants who reduced how often they performed the Big 5 by at least 25% showed significant increases in depressive symptoms within two weeks. After this restriction phase participants were then instructed to resume doing the Big 5. Then we saw another interesting effect, it took some people twice as long to recover as it did to deteriorate. And the recovery wasn’t smooth, most people said that they had lost their ‘mental fitness’, much like they would have lost their physical fitness if they stopped exercising, although within five weeks of resuming the Big 5 all participants had regained their mental health.

Using the Big 5

For those of us worried about our patients, colleagues, family or even our own mental health, the Big 5 framework provides another option for self-help. Rather than immediately reaching out for professional help, which is appropriate if symptoms are sufficiently serious, focusing on the Big 5 may provide another option for self-care and self-management. The Big 5 builds on a person’s natural strengths — most people are already doing the Big 5, but just might not be doing them frequently enough.

Simple steps

Most people ‘get’ the Big 5 — it isn’t hard to understand or explain. Many of my team have adopted the Big 5 for themselves and their families, and we have used the Big 5 framework as a way of supporting a mentally healthy workplace. We are about to deploy the Big 5 as an initial level of care in our mental health services and see this as offering a non-stigmatising and non-pathologising way to support our patients to improve their own mental health. I personally use the Big 5 and have found the following simple steps have significantly improved my own mental health:

Step 1: Understand that the actions you take each day affect your mental and our physical health. This means you have some control over how you feel.

Step 2: Complete the Big 5 Checklist. This is a simple tool that asks how often a person has done the Big 5 in the previous 7 days. Answers are colour coded with a simple traffic light model and it has suggestions for increasing the Big 5.

Step 3: Increase how often you do the Big 5. Pick one area of ‘red’ or ‘amber’ and plan to do one extra action in the next day. Make sure it is achievable and rewarding. Once that is achieved, pick another action. Completing each action is naturally reinforcing, which encourages doing more.

Step 4: Maintain. My personal experience is that within a week of doing more of the Big 5 my mental health improves. I have a monthly calendar reminder to prompt me to check my Big 5, which I find essential for keeping me on track.

When using the Big 5 in a clinical context and with people with chronic symptoms, more prompts and support may be needed, until the extra actions become part of the person’s regular everyday life. A key to success is to make doing the Big 5 a natural part of one’s daily and weekly rhythm.

The Big 5 is a simple strengths-based framework for good mental health. It can be used as a standalone tool for those who just need a reminder about the things they can do to support their own mental health. It can also be used as a complement to a psychological or pharmacological treatment. And, if people can’t apply the Big 5 because of their symptoms of distress, depression or anxiety, they would benefit from professional assessment and treatment.

Copies of the Big 5 Checklist are available on the Health Direct website and the MindSpot website.

*Professor Nick Titov is Co-Director of the eCentreClinic, a research unit that develops and evaluates digital mental health services. He is also Executive Director of MindSpot, at MQ Health, Macquarie University.

MindSpot operates two digital mental health clinics, the MindSpot Clinic and PORTS (Practitioner Online Referral Treatment Service), which serve 25,000 Australians per year.

Titov has co-developed more than 12 online psychological interventions. These have been evaluated in more than 80 clinical trials of internet-delivered treatments involving more than 9000 people across four countries.

Image caption: iStock.com/PeopleImages