Green Care as Psychosocial Intervention for Depressive Symptoms: What Might Be the Active Ingredients?

Friday, 28 July 2017

Rebecca Elizabeth Salomon, MSN, BA1
Alison Duncan Salomon, BA2
Linda S. Beeber, PhD1
(1)School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
(2)Gillings School of Global Public Health and Department of City and Regional Planning, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA


Green care is an umbrella term for psychosocial interventions that integrate biotic and abiotic elements of nature to promote an individual’s health and well-being (Haubenhofer, Elings, Hassink, & Hine, 2010). Green care interventions include animal assisted therapy, therapeutic horticulture, care farming, and others (Sempik, Hine, & Wilcox, 2010). A variety of green care interventions are used in countries such as Finland, Norway, Japan, Germany, the United Kingdom, and the United States, indicating its capacity for cultural diversity and sensitivity (Annerstedt & Währborg, 2011; Haubenhofer et al., 2010). Some green care therapies, such as community gardening, can be used as low-cost health promotion and disease prevention interventions in difficult-to-target and vulnerable populations; community gardening has been used as an intervention for displaced refugees and improves physical activity, mental health, and community development (Gerber et al., 2016).

Many green care interventions can be adapted to treat depression, which directly affects approximately 350 million and is the leading cause of disability worldwide (World Health Organization, 2015). Depression is under-diagnosed, under-treated, and recurs in at least 50 percent of patients who receive treatment (Schwenk & Terrell, 2014). Many people delay seeking treatment for symptoms, causing their depression to remain undiagnosed and untreated (Thompson, Hunt, & Issakidis, 2004). When individuals do seek help, they may encounter barriers in accessing treatment (Mohr et al., 2010). Finally, treatments are sometimes ineffective and fail to decrease symptoms by at least half (McPherson et al., 2005).

Green care interventions are novel and evidence based, offering many benefits in terms of access and cost because of their alternative delivery formats. Green care interventions are rarely clinic-based, making treatment more easily integrated into community settings (Sempik et al., 2010). Many green care interventions, such as animal-assisted therapy and horticulture therapy, vary significantly from traditional psychotherapeutic approaches in terms of their settings and format. Qualitative research shows that patients seeking green care do not feel as stigmatized in this type of therapeutic environment (Iancu, 2013). Additionally, green care interventions can often be offered in a group therapy format, which can be tailored to individual needs while providing social benefits (Sempik et al., 2010).

Multiple quantitative studies have found decreased depressive symptoms following green care therapies (Gonzalez, Hartig, Patil, Martinsen, & Kirkevold, 2011; Pedersen, Martinsen, Berget, & Braastad, 2015). Key elements identified by participants in qualitative and mixed methods studies include a positive and supportive atmosphere, social engagement, increased physical activities, and increased feelings of skill and competence (Elings & Hassink, 2008; Kam & Siu, 2010; Kogstad, Agdal, & Hopfenbeck, 2014; Nordh, Grahn, & Währborg, 2009; Pedersen, Ihlebæk, & Kirkevold, 2012).


Through a systematic review of the literature, the researchers evaluated the evidence that social support, behavioral activation, and self-efficacy mediate improvement of depressive symptoms in a range of psychosocial interventions. The findings have been used to expand the consideration of green care as an evidence based therapy and provide insight into possible active ingredients.


The researchers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and sourced English-language articles from PubMed, CINAHL and PsycINFO through July 2016. Database searches identified 159 unique articles. To meet inclusion criteria, all studies had to examine depressive symptoms, one of the three mediators of interest, and a psychosocial intervention for adults. With that in mind, the first and second author reviewed the articles separately, excluding 139 articles based on title and abstract. The remaining twenty abstracts were reviewed and screened again by authors, excluding another eight articles after discussion and agreement. Upon full text review, six articles were excluded for the following reasons: five did not analyze the effect of the mediator of interest on depressive symptoms and one did not measure depressive symptoms after the intervention was completed. Two additional articles that were known to the primary author and fit the requirements for inclusion were added at this stage. After screening and exclusions, eight articles were included in the synthesis. Each article was extracted independently; the data were combined into a matrix and analyzed for thematic content.


Two studies addressed the mediator of behavioral activation (Losada, Marquez-Gonzalez, & Romero-Moreno, 2011; Ryba, Lejuez, & Hopko, 2014), two addressed social support (Dour et al., 2014; Roth, Mittelman, Clay, Madan, & Haley, 2005), and four addressed self-efficacy(Backenstrass et al., 2006; Kavanagh & Wilson, 1989; Oman & Bormann, 2015; White, Kendrick, & Yardley, 2009). The studies were completed in a variety of Western countries: four in the United States, one in Australia, one in Spain, one in Germany, and one in England. Studies ranged in sample size from 23 subjects to 1004 subjects. A range of interventions were performed across the studies. Out of the eight studies, four interventions included some amount of Cognitive Behavioral Therapy, one was an unspecified combination of individual, family, and group psychotherapy, one was Mantram Repetition Therapy, one utilized Behavioral Activation therapy, and one was purely based on individual physical activity. The duration of each intervention also varied, ranging from six weeks in one study to one year in another study. Evidence from the studies support behavioral activation, social support, and self-efficacy as mediators of improved depressive symptoms in psychosocial interventions.


Green care interventions offer a portal for individuals of different depressive symptoms and severities to be treated alongside each other while being modified to meet the needs of each individual participant. Additionally, it offers the opportunity for interventions that target all three active mediators that could be harnessed by nurses at a variety of training levels as well as community health workers.