Professor Nick Titov’s professional goal is to make himself redundant.
As a Professor of Psychology at Macquarie University and Director of the University’s digital mental health service, MindSpot, he wants to empower more people with mild to moderate anxiety and depression to understand what they can do each day to care for their mental health.
As part of this mission, Professor Titov and his team developed The Big 5, an evidence-based program encouraging five broad types of activities that are strongly linked with good mental health when performed regularly.
Everyone’s Big 5 activities look different, but large cohort studies in Australia and Canada found people who have healthy thought patterns, plan for the future, engage in meaningful activities, have healthy routines, and connect with friends and family at least four times a week have better mental health than those who do not.
Healthy thinking is one of the biggest individual predictors of good mental health. It includes thinking realistically about ourselves, the world and the future, and treating ourselves with respect, particularly in difficult situations.
Healthy routines might include cooking and eating a healthy meal, having a regular bedtime and getting regular exercise. Meaningful activities give us a sense of accomplishment, satisfaction or joy.
The results now include data from more than 20,000 people and show a consistent pattern: do more of The Big 5 and feel better; do less and feel worse.
I believe it’s the first study in the world to do this with the aim of linking mental health status with measurable actions.
To learn more about the benefits of The Big 5, Professor Titov designed a study in which participants would be asked to systematically reduce these activities under supervision, then resume them again so he and his team could observe their impact on symptoms of depression and anxiety. The study results were published in Behavior Research Therapy journal.
Why ask people to stop?
For physical diseases, researchers often understand the triggers and the trajectory of deterioration, leading to insight into how treatments work, but that isn’t the case in the psychological sciences.
“Despite billions of dollars being spent on mental health interventions worldwide, psychological sciences have not built a robust model that predicts not only recovery, but also deterioration,” Professor Titov says.
“If we are going to prevent mental health conditions, we need to know the triggers and mechanisms behind them. One way to do this was to ask mentally well people to give up or restrict how often they do things that we know are good for their mental health; in this case, their Big 5.
“I believe it’s the first study in the world to do this with the aim of linking mental health status with measurable actions.
“It represents a new paradigm and a potential method for improving our understanding of mental health and mental illness.
“Designing it involved careful consideration of ethics and safety, as asking people to stop activities we know are good for them isn’t something we would do lightly as mental health professionals.”
Because of this, it was decided to carefully vet the volunteers, and keep the group very small so all the participants could be closely monitored.
For those people who restricted their Big 5 activities by at least 25 per cent, we saw a significant drop in mental wellbeing.
Originally, Professor Titov aimed to recruit 26 mentally well people who would be asked in a systematic way to restrict their Big 5 activities for four weeks.
To monitor wellbeing, the volunteers would have regular phone calls with him or his colleague, registered psychologist, Victoria Barrett. They would also complete weekly self‑assessments that measured symptoms of depression and anxiety, and how many times a week the volunteers were doing their usual Big 5 activities.
However, the results were so pronounced that it was decided to reduce the sample size to 12 and cut the duration to two weeks.
“For those people who restricted their Big 5 activities by at least 25 per cent, we saw a significant drop in mental wellbeing,” Professor Titov says. “Nobody used the word ‘depression’, but they all said to us: ‘I’m struggling’.
“We were expecting to see a slight reduction in wellbeing, but we weren’t expecting it to drop so rapidly, or for it to take as long as it did for some people to recover.”
To take part, participants could not have any significant symptoms of depression or anxiety or be taking medication for mental health problems. All the participants completed assessments to establish their baseline levels of depression and anxiety, which were measured for two weeks.
Eleven were in the healthy/minimal range for symptoms of depression, with one classified as mild.
Routines in ruins
After only a week of restrictions, one participant had deteriorated so much that they were moved straight to the recovery phase.
At the two-week mark, just four participants remained in the healthy/minimal range for depression, with five moving up to mild and three progressing to moderate – the range that indicates increased risk of a clinical diagnosis of depression.
For the recovery phase, participants were instructed to return to their usual Big 5 activities, with the assistance of regular SMS prompts from the trial team.
Improvements began to appear straight away, but returning to their baseline took longer for some people.
After five weeks, 11 participants were back to the healthy/minimal range for depression symptoms, and one was in the mild range. The patterns for symptoms of anxiety were similar to those for depression, but the changes were not as pronounced.
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Professor Titov says they noticed some participants were more vulnerable to the loss of their Big 5 than others, with those who restricted their activities the most showing the most significant impact.
“One person told me they felt their entire routine had been thrown out,” he says.
“They said they noticed that they were tired in the afternoon, so they were taking a nap, which meant they weren’t sleeping well at night. That meant they slept in the next morning and didn’t have time for a shower.
“Also, the more they restricted their Big 5, the longer their recovery took.
“People reported that recovery was harder than they expected. One person described feeling like they had lost their mental fitness, and they needed to give themselves a talking to, to get back to their usual routines, habits and lifestyle.
“Everyone who took part said they had learned a valuable life lesson, but I have no doubt that had we continued, some of our participants would have been at risk of a full-blown depressive episode.”
The next steps
Professor Titov has a series of additional and larger studies planned for The Big 5. And while this study focused on anxiety and depression, he believes the same model might usefully be applied to other high-prevalence conditions such as eating disorders, body dysmorphia, or even social anxiety and generalised anxiety disorder.
Close ties: Study results show strong links between mental and physical fitness, says Professor Nick Titov, pictured above.
In parallel to the planned research, and based on the strong results, the MindSpot team is developing a free SMS prompt service that people can sign up for if they feel they are struggling mentally.
A simple intervention program based on The Big 5 is now being developed for use by therapists at MindSpot, and clinics in Australia and overseas have expressed interest.
“I think one of the really important insights this study gave us is that there are analogies between mental fitness and physical fitness,” Professor Titov says.
“They both take time to build up and if you don’t maintain certain activities for whatever reason, you can lose that fitness, which then takes longer to recover than you might expect.”
Professor Nick Titov is a Professor of Psychology at Macquarie University’s School of Psychological Sciences, and Director of MindSpot.
Visit the MindSpot website to learn more about The Big 5. You can download a set of free resources, including an information and self-assessment sheet to help identify your own Big 5, and a digital journal to keep track of how often you do them.
