The most common psychological conditions reported globally are depression and anxiety (Albert, 2015; Laborde-Lahoz et al., 2015). According to the World Health Organization (WHO) World Mental Health Survey, South Africa ranks among the highest mid-to-low-income countries in the lifetime prevalence of Common Mental Disease (CMD; Stein et al., 2008). It has been postulated that South Africa’s hostile history, which resulted in social inequality, conflict, and trauma, has contributed to the high prevalence of psychological distress (Das-Munshi et al., 2016; Harriman et al., 2022). Studies indicate that within South Africa, affective disorders are especially common in low socioeconomic areas (Mungai and Bayat, 2019) and in communities with high levels of social dysfunction, crime rates, and gangsterism (Tomita et al., 2015).

Despite the high prevalence of affective disorders in South Africa, mental health (MH) conditions are underdiagnosed and underreported, leading to poor health outcomes for those living with untreated mental illnesses (Meyer et al., 2019). Indeed, at an international level, expenditure on MH services in many countries is estimated at 5% or less of overall healthcare budgets (Gupta et al., 2016). With the immense financial strain that South Africa’s public health sector is experiencing, clients with CMD often fail to receive the necessary care, or any care at all (Kagee, 2008). Hence, novel approaches to addressing the MH burden are required.

The treatment of affective disorders is increasingly predicated on pharmacological protocols, yet the prevalence of MH conditions continues to rise (Mojtabai and Jorm, 2015; Jorm et al., 2017), raising questions regarding the efficacy of anti-depressant medication for curbing the escalating rates of mental distress (Khan and Brown, 2015). Further, while pharmacological approaches have benefits, they may complicate the disease profile with unpleasant side effects (Huhn et al., 2014) such as “feeling emotionally numb,” detached from reality, drowsiness, sexual dysfunction, and suicidal ideation, to name a few (Read and Williams, 2018).

There is increasing interest in the use of non-pharmacological approaches for improving MH (Manger, 2019). Indeed, there is strong evidence showing the MH benefits of interventions that promote healthy lifestyle behaviors such as exercise (Josefsson et al., 2014; Keating et al., 2018), healthy eating (Jacka et al., 2017; Owen and Corfe, 2017; Firth et al., 2020); sleep (Freeman et al., 2020; Scott et al., 2021), and exposure to nature (Taniguchi et al., 2022). In addition, positive psychology practices have been shown to improve MH (Seligman and Csikszentmihalyi, 2014; Carr et al., 2021), including expressing gratitude (Wong et al., 2018; Waters et al., 2022); identifying and using one’s signature strengths (Macfarlane, 2019); and engaging in service activities (Walsh, 2011). Notably, the implementation of lifestyle and positive psychology therapies comes with minimal to no deleterious side effects, which highlights their utility (Marx et al., 2022). However, while the benefits of these lifestyle and positive psychology strategies have been demonstrated, they are often applied as single modality interventions. The emerging discipline of “Lifestyle Psychiatry” is calling for a broader, multimodal approach (Noordsy, 2019).

A multimodal intervention that has been shown to improve participants’ MH and wellbeing is “The Lift Project” (Morton et al., 2020; Przybylko et al., 2021b,c; Renfrew et al., 2021b). The Lift Project is a positively oriented 10-week education program that experientially engages participants in wellbeing-enhancing strategies from the disciplines of lifestyle medicine and positive psychology. The Lift Project was initially designed as a mental wellbeing program for generally healthy cohorts, and numerous studies, including randomized controlled trials, have reported positive outcomes among this target population (Przybylko et al., 2021a; Renfrew et al., 2021a). However, stratified analyses have indicated that while the intervention adopts a positive orientation, participants with the lowest baseline MH metrics may benefit the most (Morton et al., 2020). This may suggest that promoting the positive may negate the negative, even among individuals with poor MH.

This study aimed to examine the potential benefits of The Lift Project intervention for adults with a diagnosed affective mood disorder living in a community in South Africa that exhibits high levels of mental distress. If efficacious, non-pharmacological interventions like The Lift Project that are positively oriented and adopt a multimodal approach may provide a useful tool for supporting individuals who suffer from affective disorders, and thereby offer a helpful solution for addressing the MH burden.

As shown in Table 2, significant improvements were observed in all outcome measures (at the 0.008 level), with large effect sizes. Based on scores reported by the participants at the conclusion of the study, approximately two-thirds (i.e., 15 of the 23) would not have met the study inclusion criteria (i.e., a MH score of ≤56 or a VIT score of ≤45).

The mean changes in the weekly MH and VIT scores are illustrated in Figures 1, 2, respectively. The ANOVA indicated significant changes over time for both MH (F ratio = 15.4, p ≤ 0.001, Partial Eta Squared = 0.412) and VIT (F ratio = 20.5, p ≤ 0.001, Partial Eta Squared = 0.483). Post-hoc analyses indicated that significant improvements were reported after only 1 week in both MH (p = 0.005) and VIT (p = 0.015), after which the reported MH and VIT scores were significantly higher than baseline at the <0.001 level for all subsequent weeks. As can be observed in Figures 1, 2, there was a trend for incremental improvement in the MH and VIT scores over the 10 weeks of the intervention.

Two participants made changes to their prescriptions over the duration of the study. Thyroid medication was added to one participant’s medication list in week 9 of the intervention and another participant had their anti-depressant medication reduced to half during week 4.

The findings of this pilot study suggest that positively oriented MH interventions that incorporate an array of lifestyle medicine and positive psychology strategies may support and improve the MH of individuals with diagnosed affective disorders. Previous studies have demonstrated that The Lift Project intervention used in this study is efficacious and acceptable among healthy cohorts, but the outcomes of this study suggest that the intervention might benefit people across the MH spectrum. These findings may have important implications as they suggest that interventions similar in design to that used in the current study might offer a stigma-free way of providing MH promotion and treatment at a population level, using a universal prevention approach.

The effect sizes observed in this study were substantially larger than those observed in other studies that have utilized the same intervention among relatively healthy cohorts. For example, in a randomized controlled trial involving 425 general community members from Australasia, effect sizes of 0.42 and 0.45 were observed for change in MH and VIT, respectively (Przybylko et al., 2021a). The very large effect sizes observed in the present study (i.e., >1.0) are encouraging, although it is recognized that the individuals have more scope of improvement when starting from a lower baseline. Indeed, in a study of The Lift Project intervention among College students, the greatest improvements were observed among those with the poorest baseline MH scores (Morton et al., 2020).

This is the first study of The Lift Project to document weekly changes in MH and VIT throughout the duration of the 10-week intervention. The observation that significant improvements in MH and VIT were recorded after only 1 week is notable, but the impetus for such rapid improvements warrants investigation. It is hypothesized that the act of engaging with an intervention might instill hope, which alone is mood-enhancing, independent of the “challenges” issued to the participants as part of the intervention. Indeed, hope is an important MH determinant (Van Gestel-Timmermans et al., 2010; Schrank et al., 2012). While further studies are required to ascertain the potential contributors to the observed rapid improvements in MH and VIT, these measures continued to increase incrementally throughout the duration of the intervention which suggests that the intervention did not merely instill “false hope,” but that the activities were beneficial.

While the week-by-week MH and VIT data showed a progressive upward trend over the 10 weeks of the intervention, further studies are required to confirm these observations and to determine causality. Understanding the time-course of potential improvements in MH metrics as well as “plateauing” may help inform the design of interventions with regard to optimal duration. Shorter interventions may be administered more cost-effectively, although interventions of longer durations might better support long-term behavior change. A study involving a lifestyle intervention targeting cardiovascular disease found that an 8 or 16 sessions intervention produced similar outcomes in the short-term (Morton et al., 2017), but longer interventions might better cement behavior change and result in more sustained benefits. Indeed, there is a need to further investigate the relative merits of shorter and longer interventions, especially with regard to long-term benefits. While the current pilot study only examined pre-to post-intervention changes, a randomized controlled trial using the same intervention observed sustained benefits at 3-month follow-up (Przybylko et al., 2021a). Longer-term follow-up should be included in future studies.

The findings of this pilot study indicate that a positively oriented, multimodal intervention that incorporates lifestyle medicine and positive psychology strategies may benefit individuals living with an affective disorder. Given that interventions like The Lift Project have also shown to be efficacious among non-clinical cohorts, it may support the use of such interventions at a population level as a universal MH prevention strategy.

The datasets presented in this article are not readily available because Ethical clearance to share the data set has not been granted. Requests to access the datasets should be directed to darren.morton@avondale.edu.au.

The studies involving human participants were reviewed and approved by Avondale University Human Research Ethics committee. The patients/participants provided their written informed consent to participate in this study.

AO-C was responsible for conceiving the study, conducting the intervention, data collection and collation, and writing the paper. DM led the development of the intervention and assisted with data analyses. DM, MR, and PR contributed to the study design and provided editorial input on the paper. All authors contributed to the article and approved the submitted version.

Publication costs were provided by the Lifestyle Medicine and Health Research Centre at Avondale University.

DM is the founding director of a profit-for-purpose trust that owns the intervention used in this study. He has received no financial reimbursement.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.