Promoting and Protecting Mental Health: A Delphi Consensus Study for Actionable Public Mental Health Messages

Abstract

Purpose:

Public health campaigns are still relatively rare in mental health. This paper aims to find consensus on the preventive self-management actions (i.e. “healthy behaviors”) for common mental health problems (e.g. depression and anxiety) that should be recommended in mental health campaigns directed at the general public.

Approach:

A 3-round Delphi study

Participants:

23 international experts in mental health and 1447 members of the public, most of whom had lived experience of mental health problems.

Method:

The modified Delphi study combined quantitative and qualitative data collection: 1) online qualitative survey data collection thematically analyzed, 2) recommendations rated for consensus, 3) consensus items rated by public panel on a Likert scale.

Results:

Expert consensus was reached on 15 behaviors that individuals can engage in to sustain mental health. Eight were rated as appropriate by more than half (50%) of the public panel, including: avoiding illicit drugs (80%, n = 1154), reducing debt (72%, n = 1043), improving sleep (69%, n = 1000), regulating mood (65%, n = 941), having things to look forward to (60%, n = 869).

Conclusions:

A series of healthy behaviors for the promotion and protection of mental health received expert and public consensus. To our knowledge, this is the first study to offer a set of actions for public health messaging for the prevention of poor mental health. Future research should focus on evaluating effectiveness of these actions in a universal primary prevention context.

Keywords

campaigns prevention depression anxiety public mental health behavior change

Purpose

Prevention-focused public health approaches for mental health are an approach that should be explored in order to address the rising costs of mental-ill health both nationally and globally. Depression is one of the leading causes of disability worldwide,¹ and mental health problems are estimated to cost billions in treatment, social support and lowered employment annually.² Public health campaigns have gradually been expanding their focus to include mental health and wellbeing, using psycho-education and focusing on self-care. Examples in the UK include the Mental Health Awareness Week established in 2001 by the Mental Health Foundation,³ and the 2008 “Five Ways to Wellbeing” project commissioned by the United Kingdom Government Office for Science.⁴

Assessing expert consensus on the current evidence for healthy behaviors to protect good mental health is an important early stage in developing national health promotion messages. The momentum for this is very positive in the UK, given the recent 2019 “Every Mind Matters” campaign led by Public Health England and the Prevention Green Paper published by the Department of Health and Social Care in 2019.^5,6 However, to-date there is little consensus on what should be included in such campaigns and what might be practical and acceptable from the perspectives of both academia and those with lived experience. The endorsement of psycho-educational messages by the wider public may be especially crucial for their uptake and ultimate engagement.

Given this, the current study aimed to explore the most acceptable and evidence-informed individual-level recommendations for maintaining and protecting good mental health which can be used in public mental health messaging and campaigning in the UK. To ensure these recommendations are both based on evidence and acceptable to the public for which they are intended, a Delphi methodology was used in which first expert and secondly public panels were consulted.

Methods

The current study utilized a Delphi methodology. This approach combines qualitative and quantitative techniques to assess available evidence and reach consensus on a given topic. Specifically in mental health, it has been used to assess self-help strategies for sub-threshold depression symptoms,⁷ parenting approaches for the prevention of depression and anxiety,⁸ and prevention of body dissatisfaction and disordered eating.⁹ A strength of this approach is that it can facilitate the merging of expert consensus and advice with public opinion on the feasibility and acceptability of the public health recommendations.

A 3-round modified Delphi approach, following methodology as outlined by Jones and Hunter,¹⁰ was conducted between February 2018 and June 2019.

Sample

The expert panel was selected for cross-disciplinary expertise. International experts for the panel were recruited purposively through a mixture of Google searches and snowball sampling. To be eligible for inclusion in the expert panel, individuals were required to meet the following criteria: 1) familiarity with depressive and anxiety disorders as evidenced by their academic or clinical background, 2) willingness to participate, 3) a minimum of 10 peer-reviewed journal articles published.¹¹

The public panel was recruited through advertisements posted on the Mental Health Foundation Twitter and Facebook accounts. These posts invited followers to provide their input in helping to update the Mental Health Foundation’s guide “How to look after your mental health.”¹² The survey opened on 22nd May 2019 and closed on 3rd June 2019. Participants were required to be aged 18 or over to be eligible.

Ethical approval for the third round of the study, which involved the public panel, was obtained from Queen’s University Belfast Ethics Committee on 26th April 2018.

Procedures

Round 1

Responses were collected using online survey software (MySurveyLab^TM). Academic panelists were asked to suggest a minimum of 5 individual-level actions that can maintain good mental health and were instructed to provide the population for which the recommendation is effective as well as brief evidence of the scientific rationale for their suggestions (either by outlining the underlying therapeutic principle, or by citing relevant publications). Responses were then qualitatively synthesized.

Round 2

In round 2, academic panelists who participated in round 1 received a list of the synthesized responses, which were anonymized so that panelists were unable to identify the other contributors. Panelists were instructed to rate the list of recommendations according to a RAND/UCLA Appropriateness Method, which seeks to detect existing agreement and consensus.¹³ Recommendations were rated on a scale from 1 “very inappropriate” to 9 “very appropriate” in terms of their usefulness for preventing the onset of mental health problems and maintaining good mental health. A total of 14 panelists responded to round 2. This is approximately 2 to 5 respondents more than the recommended sample size for the RAND/UCLA method. Ratings were collated and assessed quantitatively for consensus.

Round 3

In round 3, responses which had received consensus from the academic panel in round 2 were listed in an online survey completed by a public panel in the UK. After confirming their consent to participate, public panelists were asked a series of demographic questions (age, gender, region and lived experience of mental health problems). Following this, they were asked to rate each recommendation on a 5-point Likert scale of 1 “not at all” to 5 “extremely” in terms of their usefulness and applicability to their own lives, in line with similar Delphi studies.¹⁴

Analysis

Round 1

Qualitative responses from round 1 were assessed by 2 trained researchers (JY and DE) using a thematic analysis approach and an open coding structure.¹⁵ Researchers coded the data independently, then compared the themes and resolved any conflicts.

Round 2

Following similar methodology outlined in Humphrey-Murto et al.,¹⁶ median ratings of synthesized recommendations were calculated and assigned to 1 of 3 categories: “inappropriate” (median score of 1-3); “uncertain” (median score of 4-6); and “appropriate” (median score from 7-9). Statements for which the median rating was “appropriate” were deemed to have reached consensus.

Round 3

Consensus statements from round 2 were reviewed by the public panel, and statements were deemed acceptable if more than 50% of the public panel rated them as “very” or “extremely” useful and applicable.

Results

Panel Demographics

Of those who responded to the invitation to participate in the academic panel in round 1 (n = 23), 7 were female (30%) and 16 were male (70%). In round 2, of the 14 academic panelists who participated, 11 provided information on gender, of which 73% (n = 8) were male and 27% (n = 3) were female.

Academic panel members who completed both round 1 and round 2 (n = 14) were based in Great Britain, Northern Ireland, USA, Germany, Norway, Australia and the Netherlands. Most (43%, n = 6) were public health experts, and 21% (n = 3) had expertise in psychiatry. The remainder had expertise in psychology, social work, social policy, and inclusion and lived experience.

The public panel was composed of 1447 individuals who met eligibility criteria and completed the survey in full. The age and gender of the public panel is presented in Table 1.

Table 1.

Demographic Data of Public Panel, Delphi Consensus Study, UK, 2018-19.

	n	%
Age
18 to 24	243	17
25 to 34	266	18
35 to 44	289	20
45 to 54	356	25
55 to 64	212	15
65+	78	5
Not answered	3	0
Gender
Male	220	15
Female	1204	83
Non-binary/ third gender	13	1
Prefer not to say	4	0
Prefer to self-describe	4	0
Not answered	21	1

The majority of public panelists lived in England (73%, n = 1052), most commonly the South East (19%, n = 200). A similar proportion (13%) were from the North West (n = 135), the West Midlands (n = 142) and the South West (n = 133). There were also public panelists from Scotland (12%, n = 176), Wales (6%, n = 82) and Northern Ireland (2%, n = 31). A total of 7% (n = 99) responded “Other.”

Most of the public panel (89%, n = 1292) reported lived experience (current or past) of a mental health problem. Of those panelists, over 3-quarters (86%, n = 1112) reported experience of more than one mental health problem, and 58% (n = 745) reported experience of more than 2 mental health problems. Depression (85%, n = 1097) and anxiety (84%, n = 1084) were the most commonly reported mental health problems among respondents. The next most commonly reported mental health problems were self-harm (30%, n = 386), panic disorder (23%, n = 293) and post-traumatic stress disorder (PTSD) (19%, n = 242).

Rounds 1 and 2

A total of 158 recommendations were received in round 1. Two recommendations (“Reduce inter-parental conflict” and “Identify parents with mental health problems”) were excluded as they did not specifically apply to individuals, and thus were beyond the scope of the current study, though they remain important for wider prevention efforts and policy consideration.

Following thematic analysis, 29 recommendations falling within 16 general themes were identified, which are listed in Table 2 and elaborated on in Supplementary material. Of these, 15 recommendations received consensus from the academic panel in round 2. Overall, the reliability of the academic panel ratings in round 2 were satisfactory (Cronbach’s alpha = 0.79, 95% CI [0.69-0.90]) suggesting consistency among panelists. Two recommendations within the physical health theme which received consensus were deemed to be very similar, and as such it was decided that only 1 of the 2 (“engage in physical activity”) would be included in round 3. The final 14 recommendations given to the public panel are outlined in Table 2.

Table 2.

Themes and Recommendations Following Round 1 and Round 2, Delphi Consensus Study, UK, 2018-19.

Theme	Recommendations
Help from others	Seek help
	Talk to others about mental health problems
	Get support for good parenting practices
Physical health	Engage in physical activity
	Take care of your physical health
Connections	Strengthen social connections
Altruism	Help others, contribute to something bigger
Thoughts and Emotions	Learn to understand, regulate, and manage mood
	Watch your thoughts and do not believe everything you think
	Solve problems systematically
Self-Help and Personal Development	Remain curious and open for (new) experiences
	Practice gratitude and cultivate hope
	Challenge yourself and avoid avoidance behavior
	Strengthen your sense of self and self-esteem
Fun and Creativity	Prioritize fun, have something to look forward to
	Explore creativity
Substance Use	Avoid illicit drugs
	Avoid alcohol and smoking
Internet and Gaming	Reduce unlimited access to internet and gaming
Diet	Avoid caffeine
	Have a healthy diet
Finances	Avoid unmanageable debt
Work	Control your work
	Engage in work activity for cognitive stimulation
	Find job satisfaction
Mindfulness	Live in the present moment
Environment	Spend time in green spaces
Rest	Improve quality and quantity of sleep
Self-harm	Limit access to suicide means

All items were identified in Round 1; italicized items indicate those that received expert consensus in round 2.

Round 3

Statements given ratings greater than 50% by the public panel falling in the “Very” and “Extremely” useful and applicable categories were selected as the final recommendation list. These are the recommendations presented in italics in Table 3.

Table 3.

Recommendations Rated by More Than 50% of the Public Panel as “Very” or “Extremely” Useful and Applicable, Delphi Consensus Study, UK, 2018-19.

Rank	Recommendation	% (Very/Extremely)	N (Very/Extremely)
1	Avoid illicit drugs	80	1154
2	Avoid unmanageable debt	72	1043
3	Improve quantity and quality of sleep	69	1000
4	Learn to understand, regulate and manage your mood	65	941
5	Prioritize fun or have something to look forward to	60	869
6	Spend time in green spaces	60	867
7	Seek help	52	746
8	Remain curious and open for (new) experiences	51	732
9	Have a healthy diet	49	709
10	Help others, contribute to something bigger	48	692
11	Engage in physical activity	48	691
12	Practice gratitude and cultivate hope	46	661
13	Strengthen social connections	45	648
14	Get support for good parenting practices	32	470

Recommendations italicized were rated by over half of the public panel as “very” or “extremely” useful and applicable.

Comparing ratings between those public panelists with lived experience of mental health problems and those without yielded broadly similar results. Both those with lived experience (n = 1292) and those without lived experience of mental health problems (n = 153) rated the recommendations in an order similar to the full public panel. The only exceptions were: the recommendations “Prioritize fun or have something to look forward to” and “Spend time in green spaces” were joint fifth (n = 764, 59%) and the recommendation “remain curious and open for new experiences” fell just short of consensus (49%, n = 637) for the lived experience panel., and the “Seek help” recommendation was rated as less acceptable and ranked twelfth (n = 79, 52%) by the non-lived experience panel. Those in the group without lived experience rated all recommendations as having higher acceptability than the full public panel or lived experience sample, with all but 1 of the 14 recommendations receiving acceptability ratings of 50% or more.

Discussion

This Delphi study presents new evidence by consensus on what psycho-educational recommendations should be used in public messaging and campaigns to protect and promote good mental health. Due to the inclusion of both an academic and a public panel, the recommendations are both based on academic expertise and judged as acceptable for daily use by the public, particularly by those with lived experience of mental health problems. This suggests that they would be appropriate to use as part of universal mental health promotion interventions and public mental health messaging campaigns which have largely lacked underpinning academic evidence.

The top recommendations in terms of academic consensus and public acceptability cover a range of potential risk and protective factors. These recommendations serve as good examples of the breadth of influences on mental health, ranging from cognitive and psychological traits traditionally associated with mental health (such as understanding and regulating mood) to more external and expansive influences which are environmental (e.g. spending time in green spaces), behavioral (avoid illicit drugs, improve quality and quantity of sleep), social (prioritize fun, remain curious for new experiences) and economic (avoid unmanageable debt).

Comparison to Existing Literature

These findings are somewhat consistent with the results of past Delphi exercises related to mental health, though not on the exact same topic. One exercise by Morgan and Jorm (2009) which looked at coping strategies for managing sub-threshold depression found some similar themes of sleep and pleasurable activities (prioritizing fun) asking for help and reducing or eliminating the use of illicit drugs. However, the findings from Morgan & Jorm (2009), which also involved academic and public panels, included a much broader range of activities than the current study and were targeting early intervention (as opposed to health promotion), with suggestions around goal-setting, problem-solving, mindfulness, social connection, diet and exercise all receiving endorsement by both panels.7

The initial list of recommendations from the academic panel also mirrors in part the 2008 “Five Ways to Wellbeing” which focuses on social connection, physical activity, taking notice, continuous learning, and altruism, though with a lack of transparent method underpinning their production.⁴ Of those 5 ways, the only recommendation which was rated as “acceptable” by more than 50 per cent of the public panel in the current study was “continuous learning” (remain curious and open to new experiences), though recommendations related to physical activity (engage in physical activity) and altruism (help others, contribute to something bigger) were ranked just below 50% acceptability at 48%. In contrast to both Morgan & Jorm (2009) and the Five Ways to Wellbeing was the inclusion and endorsement of suggestions for spending time in green spaces and avoiding unmanageable debt.

Assessing the Recommendations

Previous reviews found support for associations between the majority of the identified recommendations and mental health.^17-26 Many factors addressed in the recommendations are likely to have bidirectional relationships with mental health and may themselves be interrelated and affected by wider societal factors. A brief overview of the recommendations rated as acceptable by the public panel, and published evidence supporting their connection to mental health is presented in Table 4.

Table 4.

Theoretical Underpinning for Top Acceptability Recommendations, Delphi Consensus Study, UK, 2018-19.

Recommendation	Link to mental health
Sleep	Studies estimate as many as 90% of patients with major depression report sleep disturbances, which precede the onset of a depressive episode in a significant number of cases.¹⁹ In non-clinical populations, sleep difficulties have been linked to increased risk of mental health problems in children and adults.^19,21
Understanding and Managing Mood	There is support in the literature for an association between maladaptive emotion regulation strategies and increased risk of internalizing disorders in both adults and adolescents.^18,23
Drug Use	There is a high degree of comorbidity of mental health problems and substance use disorders and use of substances has been linked to poorer physical and mental health outcomes for individuals with depression.¹⁷
Prioritizing Fun	Activity scheduling and prioritizing of pleasant activities is a core component of Behavioral Activation, an effective approach for treatment of depression.²²
Avoid Unmanageable Debt	There is an established link between personal debt and mental health problems, with severe personal debt associated with depression, suicidal ideation, problem drinking and drug dependence.²⁰
Seeking Help	Help-seeking interventions have been found to be generally effective in improving attitudes, intentions and behaviors to seek formal mental health support which can aid in early identification and intervention.²⁶
Spending Time in Green Spaces	There is growing evidence to suggest a beneficial association between green space exposure and mental wellbeing in children and young people, and urban green space has found to be positively associated with mood.^24,25
Curiosity	We were unable to identify a systematic review of the connection between curiosity and mental health, suggesting further research in this area is needed.

Though the recommendations are intended as individual actions, the societal and environmental impact on the feasibility for individuals of many of these recommendations cannot be discounted. For example, their living environment (poor housing conditions, road traffic noise etc.) will likely impact on an individual’s ability to obtain good quality sleep, regardless of actions taken by the individual to improve sleep hygiene practices. Similarly, socio-economic status, particularly poverty and low income, may mean for some individuals that it is not possible to avoid unmanageable debt when endeavoring to meet their day to day needs and the needs of those they live with, particularly if good quality and accessible debt advice is unavailable. In order to easily spend time in green spaces, safe, appealing and publicly accessible green spaces must be available, which may not be the case in deprived urban areas. In these cases, individual actions must be enabled and accompanied by effective use of policy levers to create the conditions needed for individuals to be able to act in these ways. As such, these recommendations for individual actions for promoting and protecting mental health can also be of importance when considering inequalities, and national, regional and local policy development in relation to public mental health and wellbeing.

Strengths and Limitations

This study followed a systematic approach focused on developing recommendations that are evidence-led and acceptable to the wider public.

The response rates for the academic panel rounds of our study exceeded the requirements for the RAND/UCLA Method, which indicates that panels should consist of 9 to 12 experts. The internal consistency of academic panelist ratings was satisfactory, suggesting consistency of panelist responses. Recommendations by members of the academic panel were further strengthened by panelists being required to submit theoretical support for their suggestions. This allowed the study team to ensure all contributions were based on relevant available evidence (see Table 4). However, the Delphi methodology also has limitations. One particular limitation of this approach is that there are no established guidelines for conducting a Delphi study, and various methodologies have been used across the literature.²⁷ This means that results from this study may not be directly comparable to previous or future studies where different methodologies (i.e. panel selection, inclusion/exclusion criteria, public consultation) are employed to collect recommendations and establish consensus.

The current sample both in the public panel and the academic panel may not be representative of the wider academic public mental health community nor the general population. Both samples experienced selection bias, with the academic panel composed predominantly of respondents that were male and from developed countries. For the public panel, respondents were predominately female, with adults over 65 underrepresented. Further, socio-economic data on the panelists were not available. The public panelists were from the U.K., again limiting potential generalizability to other environments and countries, though we hope that other research could replicate or adapt our findings.

Furthermore, the structure of the acceptability question presented to the public panel may have benefited from greater clarity. The question asked participants to rate how useful and applicable the recommendations were to daily life. Feedback from one member of the public panel highlighted that some recommendations may be beneficial but difficult to implement without help, and the degree to which individual panelists focused on each of these aspects may have affected their ratings. Future research may benefit from separating these 2 components of acceptability (usefulness and applicability) into unique questionnaire items.

It is important to note that of the public panel, most respondents reported lived experience of mental health problems, mainly depression and anxiety. This is valuable as the recommendations proposed here bear the added benefit of hindsight by individuals who have experienced difficulties with their mental health. Analysis of the subset of the public panel without lived experience suggested that overall acceptability was similar, and in some cases higher, for this group compared to those with lived experience, however, further research with larger sample sizes is needed to confirm these findings.

The combination of the evidence sources in this study provide confidence for the findings which are drawn from academic experts, rated by the public, and confirmed by high quality published evidence. A traditional literature review approach would likely produce some similar evidence, but also likely lead to a higher ranking for certain statements, for example around healthy diet, exercise and drinking alcohol in moderation. However, this study’s approach has generated recommendations that are much more likely to be applicable in the real world, and there is learning for how health promotion interventions should be informed by people’s lived experiences.

So What?

What is already known on this topic?

Primary prevention of mental health problems may be enabled through sharing accessible and evidence-based information that improves the mental health literacy of the public. However, there are no transparent methods that have produced such content that can be used in mental health promotion campaigns.

What does this article add?

The current study established a set of recommendations for maintaining and protecting good mental health that were supported by a panel of academic experts and deemed acceptable by a sample of the wider public.

What are the implications for health promotion practice or research?

These recommendations are useful candidates for inclusion in wider public-health messaging such as mental health awareness campaigns targeted at the general public. There is a role for wider policy action to mitigate the social and environmental risk factors that impact on mental health on a population level and affect people’s ability to promote and protect their mental health in these ways. Thus, these recommendations can be the first step in a stepped-care approach to preventing mental health problems. Future research should focus on evaluating such initiatives for their effectiveness for universal primary mental ill-health prevention, and on assessing the applicability of policy levers for effecting change in these domains.

Supplemental Material

Supplemental Material, sj-pdf-1-ahp-10.1177_0890117121998536 - Promoting and Protecting Mental Health: A Delphi Consensus Study for Actionable Public Mental Health Messages

Supplemental Material, sj-pdf-1-ahp-10.1177_0890117121998536 for Promoting and Protecting Mental Health: A Delphi Consensus Study for Actionable Public Mental Health Messages by Josefien J. F. Breedvelt, Jade Yap, Dorien D. Eising, David D. Ebert, Filip Smit, Lucy Thorpe and Antonis A. Kousoulis in American Journal of Health Promotion

Footnotes

Acknowledgments

We thank V. Zamperoni for providing input and guidance on the analysis and interpretation of data and contributing to drafting of the manuscript. Ethical approval for the third round of the study, which involved the public panel, was obtained from Queen’s University Belfast Ethics Committee on 26th April 2018.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

ORCID iD

Antonis A. Kousoulis, MD

References

Vos

Barber

Bell

, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. 2015;386(9995):743–800.

OECD, EU. Health at a Glance: Europe 2018 State of Health in the EU Cycle. OECD Publishing; 2016. doi:10.1787/9789264261433-ko

Kousoulis

. Prevention and mental health. Mental Health Foundation; 2019.

Thompson

Aked

Marks

Cordon

. Five Ways to Well-Being. Government Office for Science; 2008.

Public Health England, NHS. Every Mind Matters | One You; 2019. Accessed February 22, 2021. https://www.nhs.uk/oneyou/every-mind-matters/

Department of Health and Social Care. Prevention is better than cure: our vision to help you live well for longer—GOV.UK. 2018:41.

Morgan

Jorm

. Self-help strategies that are helpful for sub-threshold depression: a Delphi consensus study. J Affect Disord. 2009;115(1-2):196–200. doi:10.1016/j.jad.2008.08.004

Yap

MBH

Pilkington

Ryan

Jorm

. Parental factors associated with depression and anxiety in young people: a systematic review and meta-analysis. J Affect Disord. 2014;156:8–23. doi:10.1016/j.jad.2013.11.007

Hart

Damiano

Chittleborough

Paxton

Jorm

. Parenting to prevent body dissatisfaction and unhealthy eating patterns in preschool children: a Delphi consensus study. Body Image. 2014;11(4):418–425. doi:10.1016/j.bodyim.2014.06.010

10.

Jones

Hunter

. Qualitative research: consensus methods for medical and health services research. BMJ. 1995;311(7001):376–380. doi:10.1136/bmj.311.7001.376

11.

Michael

Erio

. Gazing Into the Oracle: The Delphi Method and Its Application to Social Policy and Public Health. Jessica Kingsley Publishers; 1996.

12.

Mental Health Foundation. How to look after your mental health | Mental Health Foundation; 2021. Accessed February 23, 2021. https://www.mentalhealth.org.uk/publications/how-to-mental-health

13.

Fitch

Bernstein María

Aguilar

, et al. The RAND/UCLA Appropriateness Method User’s Manual. Defense Technical Information Center; 2001.

14.

Toma

Picioreanu

. The Delphi technique : methodological considerations and the need for reporting guidelines in medical journals. Int J Public Health Res. 2016;4(6):47–59.

15.

Brady

. Utilizing and adapting the Delphi method for use in qualitative research. Int J Qualitative Meth. 2015;14(5):160940691562138. doi:10.1177/1609406915621381

16.

Humphrey-Murto

Varpio

Gonsalves

Wood

. Using consensus group methods such as Delphi and nominal group in medical education research*. Med Teach. 2017;39(1):14–19. doi:10.1080/0142159X.2017.1245856

17.

Jané-Llopis

Matytsina

Mental health and alcohol, drugs and tobacco: a review of the comorbidity between mental disorders and the use of alcohol, tobacco and illicit drugs. Drug Alcohol Rev. 2006;25(6):515–536. doi:10.1080/09595230600944461

18.

Aldao

Nolen-Hoeksema

Schweizer

Emotion-regulation strategies across psychopathology: a meta-analytic review. Clin Psychol Rev. 2010;30(2):217–237. doi:10.1016/j.cpr.2009.11.004

19.

Lopresti

Hood

Drummond

PD.

A review of lifestyle factors that contribute to important pathways associated with major depression: diet, sleep and exercise. J Affect Disord. 2013;148(1):12–27. doi:10.1016/j.jad.2013.01.014

20.

Richardson

Elliott

Roberts

The relationship between personal unsecured debt and mental and physical health: a systematic review and meta-analysis. Clin Psychol Rev. 2013;33(8):1148–1162. doi:10.1016/j.cpr.2013.08.009

21.

Shochat

Cohen-Zion

Tzischinsky

Functional consequences of inadequate sleep in adolescents: asystematic review. Sleep Med Rev. 2014;18(1):75–87. doi:10.1016/j.smrv.2013.03.005

22.

Ekers

Webster

Van Straten

Cuijpers

Richards

Gilbody

. Behavioural activation for depression; an update of meta-analysis of effectiveness and sub group analysis. PLoS One. 2014;9(6):e100100. Aleman

, ed. doi:10.1371/journal.pone.0100100

23.

Schäfer

Naumann

Holmes

Tuschen-Caffier

Samson

. Emotion regulation strategies in depressive and anxiety symptoms in youth: a meta-analytic review. J Youth Adolesc. 2017;46(2):261–276. doi:10.1007/s10964-016-0585-0

24.

Kondo

Fluehr

McKeon

Branas

. Urban green space and its impact on human health. Int J Environ Res Public Health. 2018;15(3):445. doi:10.3390/ijerph15030445

25.

Vanaken

Danckaerts

Impact of green space exposure on children’s and adolescents’ mental health: a systematic review. Int J Env Res Pub He. 2018;15(12):2668. doi:10.3390/ijerph15122668

26.

Huang

Kösters

, et al. Effectiveness of interventions to promote help-seeking for mental health problems: systematic review and meta-analysis. Psychol Med. 2018;48(16):2658–2667. doi:10.1017/S0033291718001265

27.

Trevelyan

Robinson

. Delphi methodology in health research: how to do it? Eur J Integr Med. 2015;7(4):423–428. doi:10.1016/j.eujim.2015.07.002

Supplementary Material

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