Converging work suggests that there are different “elements,” “behaviours,” or “actions” that can be performed daily which are associated with mental health (henceforth referred to as “actions” for simplicity). Several research groups have attempted to identify these actions, such as the 5 types of daily actions on the “Things You Do” (TYD)—for example, healthy thinking and meaningful activities [1]; the “Act Belong Commit” campaign—for example, developing a sense of belonging [2]; the “ABCs of Mental Health”—for example, doing something actively [3]; and the PERMA model of well-being—for example, positive emotions and engagement [4]. While these attempts have taken different approaches to identifying these actions (eg, clinical judgment and survey methodology), they are all based on the premise that doing certain daily actions more frequently is associated with better mental health.

This premise is supported by research in both community and clinical samples. In community samples, performing some specific daily actions (eg, social and recreational activities) more frequently may prevent the onset of mental health difficulties [5]. Furthermore, the 5 types of daily actions captured by the Things You Do Questionnaire (TYDQ; healthy thinking, meaningful activities, goals and plans, healthy habits, and social connections) are associated with lower depression, lower anxiety, and greater life satisfaction in large community surveys [1].

These specific daily actions are arguably foundational to several psychological treatment approaches. For example, cognitive therapy relies on people increasing how often they respond to negative thoughts with thought challenging [6], and behavioral activation relies on people increasing how often they plan and participate in enjoyable and meaningful activities [7]. Studies that track the relationship between how often individuals practice these daily skills with treatment outcomes demonstrate that doing them more often is associated with lower distress [8,9]. Similar results are found when the frequency of specific daily actions that have been previously associated with mental health, as measured using the TYDQ, are tracked across transdiagnostic psychological treatment for depression and anxiety. Indeed, individuals report increasing how often they do these daily actions from baseline to posttreatment (8 weeks later), and those who reported doing the actions at least 3 to 4 times per week at posttreatment reported significantly lower depression and anxiety symptoms [10-12]. These findings suggest that specific daily actions are associated with mental health across the severity spectrum and that changes in how often individuals are performing these actions may influence psychological treatment outcomes.

There are a number of outstanding questions regarding individual differences in the frequency of daily actions associated with mental health. Identifying the individual characteristics associated with the specific type of daily action, and how often it is performed, could facilitate a more nuanced understanding of the relationship between these different actions and mental health. Such information could be used to identify who may benefit from interventions designed to increase the frequency of specific actions. In addition, previous work examining the rate at which psychological symptoms change over treatment has demonstrated that individuals report more rapid improvements in the first few weeks of treatment [13,14]. Preliminary research suggests that a similar trajectory may be observed for treatment-related increases in daily actions, such that individuals report more rapid increases in the frequency of daily actions within the first few weeks of treatment [11]. However, this finding needs to be replicated. To answer these questions, we analyzed an observational cohort of 448 adult patients who accessed an 8-week digital psychological treatment for depression and anxiety at an Australian digital psychology service. Specifically, we examined how the frequency of 5 types of daily actions, as measured using the TYDQ, differed between demographic and clinical subgroups prior to treatment, and then how the frequency of these daily actions changed over time according to demographic and clinical subgroups.

This study examined the association between individual characteristics and the frequency of daily actions prior to, during, and following a digital psychological treatment for depression and anxiety. The frequency of daily actions has been linked with mental health status—performing the specific actions measured by the TYDQ-15 at least 3 to 4 times per week is associated with significantly lower depression and anxiety symptoms [1,10,11]. Our findings replicate and extend previous work by illustrating that the majority of the change in daily action frequency (81%-97%) happens within the first month of treatment and that there may be particular groups of people who are likely to be performing daily actions less frequently or to experience the largest increases in daily action frequency after treatment. Our findings provide further evidence supporting the clinical use of assessing the frequency of daily actions as an indicator of mental health status.

A number of demographic and clinical characteristics were examined in this study, including age, sex, location, employment status, educational level, marital status, whether participants were born in Australia, whether participants reported identifying as Indigenous, the duration and severity of depressive symptoms, the duration and severity of anxiety symptoms, and the use of mental health treatment services. Being unemployed, not having a tertiary qualification, more severe or chronic depression symptoms, more severe or chronic anxiety symptoms, or experiencing depression symptoms for a longer period of time were associated with a lower frequency of actions at assessment. However, it is important to acknowledge that these analyses are exploratory in nature, and further confirmation is required before drawing conclusions regarding the impact of these individual characteristics. Nevertheless, the results do suggest that those with more chronic or severe mental health symptoms are at risk of performing daily actions less frequently.

We also examined how changes in daily actions during an 8-week digital treatment for depression and anxiety might differ according to these baseline demographic and clinical characteristics. Unlike at assessment, in which we observed that several baseline characteristics were associated with differences in baseline daily action frequency, change in daily actions over time was only impacted by the severity and duration of depressive symptoms. Indeed, the largest increases in daily action frequency were reported by those with the most severe depressive symptoms. It is not surprising that the individuals who report the largest improvements in depressive symptoms also reported the largest increases in daily action frequency; indeed, the TYDQ-15 includes items that capture actions that are negatively impacted in depression and improve with treatment such as doing enjoyable activities and having daily routines. In contrast, the relationship between the chronicity of depression symptoms and change in daily action frequency was not clear. The statistical analysis is likely to have been impacted by the small sample size and large variance in 1 subgroup (2 weeks or less; n=11). Further research is needed to understand how the duration of depression symptoms impacts changes in daily action frequency after psychological treatment.

The daily actions explored in this study overlap with those considered to be positive or adaptive coping behaviors. Positive coping refers to an individual’s ability to respond to stressors and includes behaviors such as seeking support from social networks, planning, cognitive reframing, and being physically active [25,26]. Of particular relevance to this study, research has found that positive coping is negatively associated with psychological distress [27-29]. For instance, positive coping (measured by self-efficacy and positive reappraisal) was negatively associated with subsequent psychological distress 6 months later within a COVID-19 context [30]. Future research may consider further exploring the overlap between positive coping behaviors (eg, measured by the Brief-COPE inventory [31]) and daily actions (eg, measured by the TYDQ-15), as well as how daily actions and positive coping behaviors interact to impact mental health for different individuals.

This study is not without limitations. First, as is inherent in observational cohort studies, we did not have a control group and cannot delineate the contribution of the treatment and nontreatment factors to the observed changes in daily action frequency. It is particularly important to have control groups in future research in this area, particularly when examining whether changes in daily actions are causally related to changes in psychological symptoms during treatment. Second, a cut-off score of 10 or greater was used as an indicator of clinical depression or anxiety symptoms. Although a score of 10 was recommended by the scale developers and is the most commonly used cutoffs [20,21,32,33], more contemporary research has criticized the use of such an approach [34]. There is evidence to support using a cut-off score of as low as 7 on the GAD-7 [33] and up to 14 on the PHQ-9 in general populations [35]. Considering these differences in how self-report measures capture clinical severity, future research in research settings with greater resource capacity may replicate our findings using diagnostic interviews.

This study illustrated that individuals experience rapid changes in how often they perform daily actions during psychological treatment, with up to 97% of the total change occurring within the first 4 weeks, although it is unclear whether the observed increases would be maintained without the ongoing support that was provided during treatment. These changes were prompted by the provision of information and skills founded in cognitive behavior principles, including psychoeducation around the nature of depression and anxiety (lesson 1, week 1), as well as thinking styles and cognitive challenges (lesson 2, week 2). Of course, due to the lack of a control group, it is unknown how much of the change in daily actions were a result of nontreatment factors (eg, contact with a credible health service and the passage of time). Nevertheless, these findings suggest that interventions and public campaigns that are carefully designed to support people to increase how often they perform healthy daily actions may result in improved mental health. First, the Skills for Psychological Recovery program for trauma-related mental health difficulties is based on 6 core skills (eg, helpful thinking, healthy social connections, and positive activities) and preliminary evidence suggests that it is associated with reduced psychological distress [36]. Second, the Act Belong Commit is a lifestyle framework based on 3 types of activities—keeping active, developing a sense of belonging, and doing meaningful activities [2]. The public health campaign has been associated with increased help-seeking behavior [37], and the impact of the campaign on mental health symptoms has yet to be evaluated. Third, we recently developed a 1-lesson unguided digital intervention based on daily actions. In a randomized controlled trial, the intervention was associated with reduced depression and anxiety for up to 3 months later [12]. Action-based interventions may offer a way of providing rapid and scalable mental health support outside the context of traditional psychological treatments.

Our current understanding of the individual differences in how modifiable, daily actions impact changes in mental health is underdeveloped. This study explored how demographic and clinical characteristics are associated with the frequency of daily actions prior to, during, and following a digital psychological treatment for depression and anxiety. We found that a number of baseline characteristics were associated with how often people were performing daily actions prior to beginning psychological treatment; however, only depression severity and duration were associated with differences in how these actions changed over time. Our findings provide further evidence supporting the relationship between daily actions and mental health, as well as clear directions for future research that builds on these findings.