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Efficacy of nature-based therapy for individuals with stress-related illnesses: randomised controlled trial

  • Ulrika Karlsson Stigsdotter (a1), Sus Sola Corazon (a1), Ulrik Sidenius (a1), Patrik Karlsson Nyed (a1), Helmer Bøving Larsen (a2) and Lone Overby Fjorback (a3)...
Abstract
Background

Stress-related illnesses are a major threat to public health, and there is increasing demand for validated treatments.

Aims

To test the efficacy of nature-based therapy (NBT) for patients with stress-related illnesses.

Method

Randomised controlled trial (ClinicalTrials.gov ID NCT01849718) comparing Nacadia® NBT (NNBT) with the cognitive–behavioural therapy known as Specialised Treatment for Severe Bodily Distress Syndromes (STreSS). In total, 84 participants were randomly allocated to one of the two treatments. The primary outcome measure was the mean aggregate score on the Psychological General Well-Being Index (PGWBI).

Results

Both treatments resulted in a significant increase in the PGWBI (primary outcome) and a decrease in burnout (the Shirom–Melamed Burnout Questionnaire, secondary outcome), which were both sustained 12 months later. No significant difference in efficacy was found between NNBT and STreSS for primary outcome and secondary outcomes.

Conclusions

The study showed no statistical evidence of a difference between NNBT and STreSS for treating patients with stress-related illnesses.

Declaration of interest

None.

Copyright
Corresponding author
Correspondence: Sus Sola Corazon, Rolighedsvej 23, 1959 Frederiksberg C, Denmark. Email: suoe@ign.ku.dk
Footnotes
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See editorial, pp. 396–397, this issue.

Footnotes
References
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1World Health Organization. Mental Health, Facing the Challenges, Building Solutions: Report from the WHO Ministerial Conference. WHO Regional Office for Europe, 2005.
2Juel, K, Sorensen, J, Bronnum-Hansen, H. Risk Factors and Public Health in Denmark [in Danish]. National Institute of Public Health, 2006.
3European Foundation for the Improvement of Working and Living Conditions. Work Related Stress. European Foundation for the Improvement of Working and Living Conditions, 2010 (https://www.eurofound.europa.eu/sites/default/files/ef_files/docs/ewco/tn1004059s/tn1004059s.pdf).
4Eplov, FL, Lauridsen, S. Mental Health Promotion – Background, Concepts and Determinents [in Danish]. The Danish Health Authority, 2008.
5The Danish Health Authority. Long-term Stress – Current Knowledge and Suggestions for Stress Prevention. Advice for General Practice. The Danish Health Authority, 2007.
6Corazon, SS, Stigsdotter, UK, Jensen, AG, Nilsson, K. Development of the nature-based therapy concept for patients with stress-related illness at the Danish healing forest garden Nacadia. J Am Soc Hortic Sci 2010; 20: 3451.
7Marcus, C, Barnes, M. Healing Garden - Therapeutic Benefits and Design Recommendations (1st edn). Wiley, 1999.
8Detweiler, MB, Sharma, T, Detweiler, JG, Murphy, PF, Lane, S, Carman, J, et al. What is the evidence to support the use of therapeutic gardens for the elderly? Psychiatry Investigat 2012; 9: 100–10.
9Poulsen, VD, Stigsdotter, UK, Refshauge, AD. Whatever happened to the soldiers? Nature-assisted therapies for veterans diagnosed with post-traumatic stress disorder: a literature review. Urban For Urban Green 2015; 14: 438–45.
10Annerstedt, M, Währborg, P. Nature assisted therapy: systematic review of controlled and observational studies. Scand J Publ Health 2011; 39: 371–88.
11Stigsdotter, UK, Palsdottir, AM, Burls, A, Chermaz, A, Ferrini, F, Grahn, P. Nature-based therapeutic interventions. In Forests, Trees and Human Health (eds Nilsson, K and Sangster, M): 309–42. Springer, 2011.
12Butler, AC, Chapman, JE, Forman, EM, Beck, AT. The empirical status of cognitive-behavioral therapy. A review of meta-analyses. Clin Psychol Rev 2006; 26: 1731.
13Schröder, A, Rehfeld, E, Ørnbøl, E, Sharpe, M, Licht, RW, Fink, P. Cognitive−behavioural group treatment for a range of functional somatic syndromes: randomised trial. Br J Psychiatry 2012; 200: 499507.
14World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. WHO, 1992.
15Forest & Landscape. Concept Manual for the Therapy Garden Nacadia® [In Danish]. University of Copenhagen, 2008.
16Rehfeld, E, Schröder, A, Fink, P. Specialized Treatment for Severe Bodily Stress. Aarhus University Hospital, 2009.
17Kabat-Zinn, J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Pain, Stress and Illness. Dell Publishing, 1990.
18Kaplan, R, Kaplan, S. The Experience of Nature (1st edn). Cambridge University Press, 1989.
19Fjorback, LO. Mindfulness Manual. PsykiatriFonden, 2009.
20Antonovsky, A. The salutogentic model as a theory to guide health promotion. Health Promot Int 1996; 11: 11–8.
21Chassany, O, Diderot, D, Dubois, ZD. The Psychological General Well-being Index (PGWBI) User Manual. MAPI Research Institute, 2004.
22Lundgren-Nilsson, A, Jonsdottir, IH, Ahlborg, G, Tennant, A. Construct validity of the psychological general wellbeing index (PGWBI) in a sample of patients undergoing treatment for stress-related exhaustion: a rash analysis. Health Qual. Life Outcomes 2013; 11: 2.
23Lundgren-Nilsson, A, Jonsdottir, IH, Pallant, J, Ahlborg, G. Internal construct validity of the Shirom-Melamed Burnout Questionnaire (SMBQ). BMC Public Health 2012; 11: 2.
24Lindquist, EF. Statistical Analysis in Educational Research. Houghton Mifflin, 1940.
25Alshurafa, M, Briel, M, Akl, EA, Haines, T, Moyyedi, P, Gentles, SJ, et al. Inconsistent definitions for intention-to-treat in relation to missing outcome data: systematic review of the methods literature. PLoS One 2012; 7: e49163.
26Schulz, KD, Altman, DG, Moher, D. The 2010 CONSORT statement: updated guidelines for reporting parallel group randomized trials. BMJ 2010; 340: 698703.
27Hollis, S, Campbell, F. What is meant by intention to treat analysis? Survey of published randomised controlled trials. BMJ 1999; 319: 670–74.
28Cohen, J. Statistical Power Analysis for the Behavioral Sciences. Routledge Academic, 1988.
29Campbell, M, Fitzpatrick, R, Haines, A, Kinmonth, AL, Sandercock, P, Spiegelhalter, D, et al. Framework for design and evaluation of complex interventions to improve health. Br Med J 2000; 321: 694.
30Berto, R. The role of nature in coping with psycho-physiological stress. A literature review on restorativeness. Behav Sci 2014; 4: 394409.
31Sidenius, U, Stigsdotter, UK, Poulsen, DV, Bondas, T. ‘I look at my own forest and fields in a different way’: the lived experience of nature-based therapy in a therapy garden when suffering from stress-related illness. Int J Qual Stud Health Well-Being 2017; 12: 114.
32Adams, G, Gulliford, MC, Ukoumunne, OC, Eldridge, S, Chinn, S, Campbell, MJ. Patterns of intra-cluster correlation from primary care research to inform study design and analysis. J Clin Epidemiol 2004; 57: 785–94.
33Campbell, MK, Fayers, PM, Grimshaw, M. Determinants of the intracluster correlation coefficient in cluster randomized trials: the case of implementation research. Clin Trials 2005; 2: 99107.
34Baldwin, S, Murray, DM, Shadish, WR, Pals, SL, Holland, JM, Abramowitz, JS, et al. Intraclass correlation associated with therapists: estimates and applications in planning psychotherapy research. Cogn Behav Ther 2011; 40: 1531.
35Killip, S, Mahfoud, Z, Pearce, K. What is an intracluster correlation coefficient? Crucial concepts for primary care researchers. Ann Med 2004; 2: 204–8.
36Christie, J, O'Halloran, P, Stevenson, M. Planning a cluster randomized controlled trial: methodological issues. Nurs Res 2009; 58: 128–34.
37Donner, A, Birkett, N, Buck, C. Randomization by cluster: sample size requirements and analysis. Am J Epidemiol 1981; 114: 906–14.
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Efficacy of nature-based therapy for individuals with stress-related illnesses: randomised controlled trial

  • Ulrika Karlsson Stigsdotter (a1), Sus Sola Corazon (a1), Ulrik Sidenius (a1), Patrik Karlsson Nyed (a1), Helmer Bøving Larsen (a2) and Lone Overby Fjorback (a3)...
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eLetters

Environmental preference might mediate the benefits of nature-based therapies

Jacob King, Research Associate, Centre for Urban Design and Mental Health
15 August 2018

The benefits of psychotherapies are highly variable between patients, perhaps most notably due to personality types, cultural background and one’s conception of mental ill health, among others (Petronzi & Masciale, 2015). Case in point, many patients consider group psychotherapy unacceptable and others do not consider psychotherapy credible at all. Similar variations are surely also implicated in nature-based psychotherapies (NBTs).

For example, in the first instance, evidence over recent years has increasingly pointed to a benefit to mental health outcomes, from exposure to and use of natural environments, commonly conceived in the literature as ‘urban green spaces’. The causal mechanisms are complex, but usually distilled to; improved exercise and socialisation opportunities, reduced exposure to air and noise pollution, and importantly for NBTs, psychological stress-reduction and attention restoration (Markevych et al., 2017). As well as being evidenced, it is easy to anecdotally see how these non-psychotherapeutic components of NBT – the simple exposure and interaction with one’s natural environment - are mediated culturally, and also by personality and personal environmental preferences inter alia. Between cultures, for example, there is dramatic variation in perceptions of natural environments and understandings of appropriate uses of these spaces (Buijs, Elands, & Langers, 2009). These variations are likely to modulate the causal mechanisms of the green space / mental health benefit.

Secondly, it is reasonable to suggest that these variations in the perceptions of natural environments affect the acceptability, credibility and therefore adherence and completion rates of NBTs. Until now the evidence for green space benefit to mental health outcomes has come largely from observational studies, which demonstrated varied effect sizes, and suggested differences due to quality of environments, perceived safety concerns, among other individual personality and community factors (Gascon et al., 2015).

Stigsdotter and colleagues’ most recent report therefore, which demonstrates non-inferiority of one particular brand of NBT for stress-related mental illnesses compared to a more mainstream CBT, is to be welcomed (Stigsdotter et al., 2018).

While of course randomisation of patients is an essential facet in the production of reliable and valid science, this may have masked a sub-population with complementary personalities and cultural characteristics (etc.) for nature-based psychotherapies. And as authors allude, given equal study withdrawal rates after randomisation, there may well be an equal sub-population with preference of office-based CBT, (perhaps for perceived credibility reasons). The non-inferiority demonstrated in this trial therefore gives us the option that those patients who may be open, and keen on the idea of NBTs may be at greater benefit, may be more adherent, more likely to complete the intervention, and independently receive greater benefit through the causal mechanisms described above. Nature-based therapies therefore might now be considered another option (rather than any kind of replacement) in the tool kit of primary care or mental health services towards addressing the high burden of stress morbidity, especially for those expressing a preference for it.

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Conflict of interest: None declared

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