Clinical guidelines for the use of lifestyle-based mental health care in major depressive disorder: World Federation of Societies for Biological Psychiatry (WFSBP) and Australasian Society of Lifestyle Medicine (ASLM) taskforce

Figures & data

Table 1. Summary of recommendations.

Strength of supporting evidence/evidence statement phrasing
Grade B/could
Grade C1/may
Grade C3/may
Domain	Recommendation statement	Level of evidence	Recommendation Grade
5.1 Physical activity and exercise interventions	Physical activity and exercise interventions could be used to reduce depressive symptoms in people with Major Depressive Disorder	Limited; Grade B	2
5.2 Smoking cessation interventions	Smoking cessation interventions that involve counselling and/or pharmacotherapy (e.g. nicotine replacement) may be used to reduce depressive symptoms in current smokers with Major Depressive Disorder	Low; Grade C3	3
5.3 Work-directed interventions	A combination of work focussed counselling and work-directed interventions could be used to reduce depressive symptoms in people with Major Depressive Disorder	Limited; Grade B	2
5.4 Mindfulness-based and stress management interventions	Mindfulness-based therapies (e.g. Mindfulness Based Cognitive Therapy [MBCT] and Mindfulness Based Stress Reduction [MBSR]) could be used to reduce depressive symptoms in people with Major Depressive Disorder	Limited; Grade B	2
	Stress management and relaxation techniques (e.g. breathing techniques, progressive muscle relaxation) could be used to reduce depressive symptoms in people with Major Depressive Disorder	Limited; Grade B	2
5.5 Dietary interventions	Dietary counselling to improve nutritional habits that is in line with healthy dietary guidelines and/or nutrient-dense dietary patterns may be used to reduce depressive symptoms in people with Major Depressive Disorder	Low; Grade C1	3
5.6 Sleep-related interventions	Cognitive behavioural therapy for insomnia (CBT-I) could be used to reduce depressive symptoms in people with Major Depressive Disorder	Limited; Grade B	2
5.7 Loneliness and Social support- related interventions	Improving social support and reducing loneliness may be used to reduce depressive symptoms in people with Major Depressive Disorder	Low; Grade C3	3
5.8 Green space interventions	Support regarding individualised interaction with green spaces or participation in a green space-focussed program may be used to reduce depressive symptoms in people with Major Depressive Disorder	Low; Grade C1	3

Figure 1. Conceptual framework for lifestyle-based mental health care. A proposed clinical flowchart for lifestyle-based mental health care using a 4 A's (Assess, Advise, Assist, Arrange) structure. For the online/colour version of this figure, each lifestyle intervention is colour coded for grade of evidence (dark green = grade B, light green = grade C, yellow = expert opinion).

Figure 2. Guideline recommendations development process.

Table 2. Evidence Grading System as recommended by the WFSBP (Hasan et al. 2019).

Evidence that the intervention is effective	Evidence statement phrasing	Level of evidence	Explanation
Strong	Should	A	At least two independent RCTs with a low risk of bias showing efficacy (superiority to placebo or, in the case of psychotherapy studies, superiority to an ‘active psychological placebo’ in a study with adequate blinding), OR Superiority to/equivalent efficacy compared with an established comparator treatment in a three-arm study with placebo control or in a well-powered non-inferiority trial (only applicable if such a standard treatment exists) with a low risk of bias, AND No negative RCTs with a low risk of bias exist. If there are contradicting results from RCTs, the majority of RCTs AND/OR a meta-analysis with low risk of bias, and that included studies that were generally at low risk of bias, showing efficacy. If there are more than one ‘A’ treatment options, the decision should be based on head-to-head comparisons or meta-analyses showing superiority of one of the treatments
Limited	Could	B	One RCT with a moderate risk of bias showing superiority to placebo (or in the case of psychotherapy studies, superiority to an ‘active psychological placebo’) OR A randomised controlled comparison with a standard treatment without placebo control with a sample size sufficient for a non-inferiority trial with a moderate risk of bias, AND No negative studies exist OR Meta-analyses with a moderate risk of bias that show efficacy or Meta-analyses with low risk of bias that included studies that were generally at a high risk of bias
Low	May	C1	One or more prospective open studies (with a minimum of 10 evaluable participants per group) using a control group, but no randomisation, or using no control group, show efficacy OR One or more well-conducted case control or cohort studies (with a minimum of 10 evaluable patients) with a moderate probability that the relationship is causal show efficacy OR RCTs AND/OR meta-analyses with a high risk of bias showing efficacy
		C2	Non-analytic studies, e.g. case reports or case series with fewer than 10 evaluable participants show efficacy in the majority of cases
		C3	Expert opinions not based on any published data reporting efficacy
No evidence		D

RCT: randomised controlled trial.

Table

Statement: Physical activity and exercise interventions could be used to reduce depressive symptoms in people with Major Depressive Disorder

Recommendation Grade: 2

Strength of evidence: Limited; Grade B Acceptability: Good

Clinical recommendation was based on: 2× Meta-analysis (k = 25–35 studies, N = 1487–2498 participants) (Schuch, Vancampfort, Rosenbaum, et al. 2016; Krogh et al. 2017) Reported effect size: Medium to large effect size (standardized mean difference = 0.66–1.11) (Schuch, Vancampfort, Rosenbaum, et al. 2016; Krogh et al. 2017) Risk of bias assessment: Low ROB meta-analyses of high ROB individual trials.

Table

Statement: Smoking cessation interventions that involve counselling and/or pharmacotherapy (e.g. nicotine replacement) may be used to reduce depressive symptoms in current smokers with Major Depressive Disorder

Recommendation Grade: 3

Strength of evidence: Low; Grade C3 Acceptability: Good

Clinical recommendation was based on: Expert opinion

Table

Statement: A combination of work focussed counselling and work-directed interventions could be used to reduce depressive symptoms in people with Major Depressive Disorder

Recommendation Grade: 2

Strength of evidence: Limited; Grade B Acceptability: Good

Clinical recommendation was based on: 1× Cochrane review (N = 8 trials, 1091 participants) (Nieuwenhuijsen et al. 2020) Reported effect size: Small (Standard mean difference = 0.25) (Nieuwenhuijsen et al. 2020) Risk of Bias assessment: Low ROB meta-analysis of high ROB individual trials.

Table 3. Available formal assessment tools and suggested prompting questions related to specific lifestyle domains^a.

Domain	Formal assessment tools	Example prompting questions as part of clinical assessment
Physical Activity	SIMPAQ (Rosenbaum and Ward 2016) Digital devices (e.g. Smart devices) and step counters	‘How many minutes/hours of physical activity do you do a day?’ ‘Which days, when and why?’ ‘What form of physical activity do you do and enjoy?’ ‘Are you sedentary for prolonged periods during the day?’
Diet	Food Frequency Questionnaires 24-h recall 3–7-day food diary e.g. 2 workdays/1 weekend day Digital tools: DietID, chronometer For more complex dietary assessment considerations please see resources section	‘Can you tell me about the last meal you ate?’ ‘What do you usually eat for breakfast, lunch and dinner?’ ‘Where and when do you usually eat your main meals?’ ‘What snacks do you eat and when?’ ‘What do you usually drink throughout the day?’
Sleep	General sleep assessments Epworth Sleepiness Scale (Johns 1991) Sleep Hygiene Index(Mastin et al. 2006) Morningness-Eveningness Questionnaire (Horne and Östberg 1976) Pittsburgh Sleep Quality Index (Buysse et al. 1989) SLEEP-50 (Spoormaker et al. 2005) Sleep diary or use of wearable Polysomnography   Others depending on specific sleep disorder: STOP BANG (Chung F et al. 2016) Insomnia Severity Index (Bastien et al. 2001) International Restless Legs Scale (Group IRLSS 2003)	‘How many hours do you usually sleep per night?’ ‘Tell me about what you usually do before going to bed’ ‘How would you rate the quality of your sleep?’ ‘How refreshed do you feel from your sleep?’ ‘Do you nap during the day? If so, for what reason?’
Smoking cessation	Heaviness of smoking index (Borland et al. 2010) Fagerstrom Test for Cigarette Dependence(Heatherton et al. 1991)	‘How many cigarettes do you smoke per day?’ ‘How long from waking until your first cigarette?’ ‘Where and when do you smoke?’ ‘What age did you start smoking?’ ‘Have you tried to quit before?’ ‘What are the benefits of smoking? What do you ‘get’ from smoking?’ ‘What are the cons?’
Alcohol	The AUDIT-C (Bush et al. 1998) The Severity of Alcohol Dependence Questionnaire (Stockwell et al. 1983)	‘How many alcoholic drinks do you consume on an average day?’ ‘When?’ (This must be specified between weekdays and weekends as hazardous ‘binge’ drinking isolated to weekends may be present) ‘What have been the positive and negative consequences of drinking?’
Other drugs	ASSIST tool (Group WAW 2002) Leeds Dependence Questionnaire (Raistrick et al. 1994) Severity Dependence Scale (Gossop et al. 1995)	‘What substances do you use?’ ‘What are the benefits of them? What do you ‘get’ from them?’ ‘What are the cons?’
Gambling	Problem Gambling Severity Index (Holtgraves 2009) Canadian Problem Gambling Index (Ferris and Wynne 2001)	‘Do you or anyone in your family have an issue with gambling?’ ‘What are the benefits?’ ‘What are the cons?’ ‘What has the (biopsychosocial-cultural-spiritual) impact been?’
Work-directed interventions	Workplace Stressors Assessment Questionnaire^b (Mahmood et al. 2010) Work Environment Subscales of the Work Health Check questionnaire^b (Gadinger et al. 2012)	‘Do you currently work or volunteer?’ ‘What are the (biopsychosocial) benefits?’
Social support and loneliness^c	LSNS-6 tool (Lubben et al. 2006) UCLA Loneliness scale (Russell 1996) Multidimensional Scale of Perceived Social Support (Zimet et al. 1988)	‘How often do you see friends and/or family?’ ‘Who can you count on to listen to you when you need to talk?’ ‘What are the benefits and barriers of connecting with your friends and/or family?’ ‘Could you tell me about your use of social media?’ ‘With social media, do you feel a compulsion to engage, engage without realizing, use in bed and/or use quickly on waking?’
Green space	–	‘How much time do you spend in a green or blue space in a week?’ ‘What green and blue spaces are safe and accessible for you?’ ‘How do you feel after spending time outdoors?’
Stress	Brief Resilience Scale (Smith BW et al. 2008) Connor Davidson Resilience Scale (Connor and Davidson 2003) Perceived Stress Scale (Cohen S et al. 1983) Depression Anxiety Stress Scale (Lovibond and Lovibond 1995)	‘What are the sources of stress in your life?’ ‘What impact do you think these are having on you?’ ‘How do you reduce and manage stress?’ ‘What helps you reduce, buffer against or manage stress?’
Resilience	Resilience Scale (Wagnild 2009) Predictive 6-Factor Resilience Scale (Rossouw and Rossouw 2016)	‘How do you adapt and cope with adversities in life? ‘How do you rate your ability to bounce back and stay motivated during adversities?’ ‘What lifestyle and social supports do you have in life to help you in difficult times?’ ‘What mental and physical wellbeing practices do you use in times of adversity?’ ‘Does a sense of vision and purpose help you in times of adversity?’
Social needs	The American Academy of Family Physicians Social Needs Screening Tool (O’Gurek and Henke 2018)

^aThis table can serve as a non-exhaustive resource for previously used tools and proposed questions. Clinical guidance is required to inform the use of any particular assessment tool.

^bIn line with previous guidelines (Mazza et al. 2019), these tools are not recommended to be used as standalone tools but may be incorporated into a clinical assessment.

^cFurther discussion regarding relevant assessment tools are provided by Ma et al. (2020)

Table

Statement: Mindfulness-based therapies (e.g. Mindfulness Based Cognitive Therapy [MBCT] and Mindfulness Based Stress Reduction [MBSR]) could be used to reduce depressive symptoms in people with Major Depressive Disorder (Grade 2).

Recommendation Grade: 2

Strength of evidence: Limited; Grade B Acceptability: Good

Clinical recommendation was based on: 1× meta-analysis (k = 9, N = 762) (Goldberg et al. 2018) Reported effect size: Moderate (Standard mean difference = 0.59) (Goldberg et al. 2018) Risk of Bias assessment: Low risk of bias meta-analysis of moderate risk of bias trials

Statement: Stress management and relaxation techniques (e.g. breathing techniques, progressive muscle relaxation) may be used to reduce depressive symptoms in people with Major Depressive Disorder

Recommendation Grade: 2

Strength of evidence: Limited; Grade B Acceptability: Good

Clinical recommendation was based on: 1× meta-analysis (k = 8, N = 365) (Jia et al. 2020) Risk of Bias assessment: Low risk of bias meta-analysis of high risk of bias trials

Table

Statement: Dietary counselling to improve nutritional habits that is in line with healthy dietary guidelines and/or nutrient-dense dietary patterns may be used to reduce depressive symptoms in people with Major Depressive Disorder

Recommendation Grade: 3

Strength of evidence: Low; Grade C1 Acceptability: Good

Clinical recommendation was based on: 4× randomised controlled trials (N = 395 participants) (Jacka et al. 2017; Parletta et al. 2018; Francis et al. 2019; Bayes et al. 2022) Effect size: Moderate to large (Standardized mean difference = 0.65 − 1.16) Risk of Bias assessment: High Risk of Bias

Table

Statement: Cognitive behavioural therapy for insomnia (CBT-I) could be used to reduce depressive symptoms in people with Major Depressive Disorder (Grade B evidence).

Recommendation Grade: 2

Strength of evidence: Limited; Grade B Acceptability: Good

Clinical recommendation was based on: 1× Meta-analysis (k = 8 studies, N = 491 participants) (Selvanathan et al. 2021) Reported effect size: Medium effect size (standardized mean difference = 0.5) Risk of bias assessment: Low ROB meta-analyses of high ROB individual trials.

Table

Statement: Improving social support and reducing loneliness may be used to reduce depressive symptoms in people with Major Depressive Disorder

Recommendation Grade: 3

Strength of evidence: Low; Grade C3 Acceptability: Good

Clinical recommendation was based on: Expert opinion Risk of bias assessment: Not applicable

Table

Statement: Support regarding individualised interaction with green spaces or participation in a green space-focussed program may be used to reduce depressive symptoms in people with Major Depressive Disorder

Recommendation Grade: 3

Strength of evidence: Low; Grade C1 Acceptability: Good

Clinical recommendation was based on: 2 randomised controlled trial and 2 non-randomised clinical trials (N = 116 participants) (Barton et al. 2012; Berman et al. 2012; Korpela et al. 2016; Vujcic et al. 2017) Reported effect size: Small to Large (Multiple effect size metrics used) (Barton et al. 2012; Berman et al. 2012; Korpela et al. 2016; Vujcic et al. 2017) Risk of bias assessment: High ROB

Figure 3. Core implementation considerations, factors, and lifestyle interventions for lifestyle-based mental health care. To yield the greatest benefits from lifestyle-based mental health care, it requires personalised individual and group clinical approaches enabled by health service and model of care innovation including health coaching, digital technology, interdisciplinary teams, group and peer-based supports, adapted in the context of socio-economic, cultural and environmental determinants. Each lifestyle intervention is colour coded for grade of evidence (dark green = grade B, light green = grade C, yellow = expert opinion).

Table 4. Future implementation considerations.

1. Lifestyle assessment and interventions are foundational to mental health care and may form a starting point for treatment (sequential approach) and/or accompany psychological, pharmaceutical, or procedural interventions (adjunctive approach) to improve mental and physical health outcomes and mitigate adverse outcomes.

2. Combining multiple lifestyle-based approaches (e.g. dietary and exercise interventions) may enhance treatment response. However, personalised considerations based on individual (e.g. motivation, acuity) and clinical (e.g. capacity, expertise) circumstances are required.

3. Assessment of lifestyle factors (using either formal tools or clinical interview) should be conducted for all people with MDD, both before and after intervention, as a means of assessing current lifestyle status and measuring progress in lifestyle changes and quality of care.

4. Formal assessment and consideration of social needs (e.g. housing, utilities, food, childcare) should be conducted to guide the provision of lifestyle-based approaches.

5. A person-centered, individualised approach, based on need and preference, incorporating behaviour change techniques and applying a biopsychosocial model, may aid the delivery and maintenance of lifestyle-based mental health care for people with MDD.

6. Assessment and intervention plans informed by a culturally safe, culturally aware, and responsive approach may be beneficial to outcomes and improve access to high-quality lifestyle-based mental health care.

7. Including peer support workers, family, friends, and carers may aid the uptake and maintenance of lifestyle-based mental health care for people with MDD.

8. Self-management supported by digital delivery is a potentially feasible, low-cost paradigm for translation of lifestyle-based approaches into health systems worldwide

9. If available, lifestyle interventions that involve relevant allied health professionals (e.g. exercise physiologists, dieticians) may be more beneficial for improving mental health than those that do not.

10. Substance use should be assessed and, where available, existing alcohol and other drug guidelines should be employed to appropriately support cessation or minimisation using established therapeutic approaches.

Figure 4. Stepped Care Model of lifestyle-based mental health care. Lifestyle and psychological approaches are to be discussed with all people with Major Depression Disorder. Lifestyle assessment and interventions can be considered core and foundational components of care based on their strong safety profile and evidence of effect on mental, physical and social wellbeing. These approaches can be combined with other evidence-based therapies with the goal of functional recovery.

Figure 5. A Swiss cheese model of Lifestyle-based mental health care. Lifestyle-based mental health care is not a single intervention but rather several mutually supportive and interacting approaches that involve lifestyle domains (covered in section 4) combined with models of care including interdisciplinary teams, peers and carers, health coaching behaviour change approaches, and digital technology (covered in section 6). The more each of these layers are cultivated and built within a person’s life and environments, the greater the likelihood of preventing disease progression, enhancing resilience against adverse internal or external events, and improving mental, physical and social wellbeing. This is illustrated by disease progression (thick black line) being mitigated by the additional layers of lifestyle approaches and implementation considerations. Each lifestyle intervention is colour coded for grade of evidence (dark green = grade B, light green = grade C, yellow = expert opinion).

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