Is there an association between exposure to or interaction with the natural environment and mental health outcomes?

RAND |May 2019 |A scoping study on the link between exposure to or interaction with the natural environment and mental health outcomes

A new report from RAND  identifies, analyses and synthesises the available
scientific literature on the association between nature and mental wellbeing, while the research acknowledges that the  evidence base is in its infancy and therefore weak; there is emerging evidence suggestive of a positive association between nature and mental health.

Key findings

  • The body of scientific literature relating to this area has been rapidly growing, from around 100 articles published per year in the 1990s, to almost 1,700 articles published in 2018. Despite this, the research area is still in its infancy and the overall evidence base needs to be strengthened.
  • Owing to the diversity of types of interventions described, definitions of nature applied, the populations assessed and tools and methods used in the literature, it is not currently possible to amalgamate the findings into any one overarching conclusion.
  • The study highlights some emerging evidence of the positive association between being in a natural environment or engaging with nature-based interventions on the one hand, and improvement in mental health on the other.

Full report available from RAND


Associations between mindfulness and general change mechanisms in individual therapy: Secondary results of a randomised controlled trial

Mindful google


The aim of this study was to investigate the possible effects of the interactions between mindfulness‐based session introductions and general change mechanisms on outcome in cognitive behavioural therapy (CBT).


We investigated the effects of different session introductions on change mechanisms and their prediction of clinical outcome over the course of 25 sessions of training therapy. We compared session introductions with mindfulness (M) elements with progressive muscle relaxation (PMR) and treatment as usual (TAU) in routine CBT sessions conducted by therapists in training. Participants included 162 patients who were diagnosed primarily with either depression or anxiety disorder and 48 therapists. To address the nested data structure, we used multilevel models.


Multilevel modelling (MLM) indicated that the interaction between an increase in several general change mechanisms and treatment condition (TAU + M vs. TAU + PMR) on therapeutic outcome was significant. From the patient perspective, MLM indicated that only the interaction between an increase in one general change mechanism (clarification of meaning) and treatment condition (TAU + M vs. TAU + PMR) turned out significantly. From both perspectives, correlation analyses revealed that general change mechanism effects on outcome were stronger in TAU + M than in TAU + PMR.


Mindfulness has an impact on general change mechanisms, especially for therapists. These associations lead to a significantly higher effect on outcome compared to introductions with PMR.


Link to article here

Using Mindfulness to Reduce Anxiety During PET/CT Studies

Image: Wikimedia Commons

Mindfulness Volume 10, Issue 6,


The aims of the present work were to identify the levels of subjective and objective anxiety and heart rate in patients attending a nuclear medicine service to undergo a 18F-FDG PET-CT scan, and to evaluate the effectiveness of an intervention based on a mindfulness meditation recording in order to verify the possible immediate effect of reducing anxiety and heart rate. This is a randomized, prospective study with pre- and post-intervention measures. The sample comprises 108 cancer patients attending the nuclear medicine service to undergo a 18F-FDG PET/CT study. Mean age was 58.81 years; 54 were assigned to the experimental group and 54 to the control group. The most frequent location of the primary tumor was in the lymphatic system (22.2%), and the most common treatment was chemotherapy (21.3%). There was no presence of artifacts (97.2%). With regard to the intervention, the group that listened to the mindfulness recording exhibited lower subjective anxiety (F, 526.95; p = 0.000; η2 partial = 0.83); lower total anxiety as measured on the State-Trait Anxiety Inventory scale (F, 271.80; p = 0.000; η2 partial = 0.72), and lower heart rate (F, 27.15; p = 0.000; η2 partial = 0.84). A single-session mindfulness practice using a meditation recording reduces both subjective and objective anxiety and heart rate in patients undergoing a PET/CT study.

Link to article here

Physical functioning and mindfulness skills training in chronic pain: a systematic review

. 2019


The importance of improved physical function as a primary outcome in the treatment of chronic pain is widely accepted. There have been limited attempts to assess the effects mindfulness skills training (MST) has on objective outcomes in chronic pain care.


This systematic review evaluated published reports of original randomized controlled trials that described physical function outcomes after MST in the chronic pain population and met methodological quality according to a list of predefined criteria. PRISMA criteria were used to identify and select studies, and assess their eligibility for inclusion. The established guidelines for best practice of systematic reviews were followed to report the results.


Of the 2,818 articles identified from the original search of four electronic databases, inclusionary criteria were met by 15 studies published as of August 10, 2015, totaling 1,199 patients. All included studies used self-report measures of physical function, and only two studies also employed performance-based measures of function. There were wide variations in how physical function was conceptualized and measured. Although the quality of the studies was rated as high, there was inconclusive evidence for improvement in physical function assessed by self-report due to contradiction in individual study findings and the measures used to assess function. Strong evidence for lack of improvement in physical function assessed via performance-based measures was found.


This review draws attention to the importance of having a unified approach to how physical function is conceptualized and assessed, as well as the importance of using quality performance-based measures in addition to subjective self-reports that appropriately assess the physical function construct within MSTs for chronic pain.


Link to article here

Behavioral and Cognitive Impacts of Mindfulness-Based Interventions on Adults with Attention-Deficit Hyperactivity Disorder: A Systematic Review.

. 2019; 2019

Mindfulness-based interventions (MBIs) are becoming increasingly popular as treatments for physical and psychological problems. Recently, several studies have suggested that MBIs may also be effective in reducing symptoms of attention-deficit hyperactivity disorder (ADHD). Most studies have examined the effectiveness in children, but there are now a sufficient number of individual treatment trials to consider a systematic review in adults. Majority of existing systematic reviews and meta-analyses only consider ADHD symptoms as an outcome, and most of them do not fully report potential biases of included studies, thus limiting considerably their conclusions. This is an important facet because some studies could be found ineligible to be included in future analysis due to their low quality.

In this systematic review, we followed the PRISMA/PICO criteria and we thoroughly assessed the risks of bias for each of the selected studies according to Cochrane guidelines. We searched the available literature concerning MBIs in adult participants with ADHD using PsycINFO, PubMed, Scopus, and ERIC databases. In total, 13 studies conducted with 753 adults (mean age of 35.1 years) were identified as eligible. Potential moderators such as participants’ age, ADHD subtypes, medication status, comorbidity, intervention length, mindfulness techniques, homework amount, and training of therapists were carefully described. Aside from measuring the symptoms of ADHD, outcome measures were categorized into executive/cognitive functioning, emotional disturbances, quality of life, mindfulness, and grade point average at school.

According to presented descriptive results, all the studies (100%) showed improvement of ADHD symptoms. In addition, mindfulness meditation training improves some aspects of executive function and emotion dysregulation. Although these are promising findings to support treatment efficacy of MBIs for ADHD, various biases such as absence of randomization and lack of a control group may affect the actual clinical value and implications of the studies. Moreover, the relatively low quality of selection and performance criteria in several studies, as well as relatively high attrition bias across studies, call for caution before considering conducting further analysis.

Link to article here

A literature review of interventions to reduce stress in doctors.


 2019 May 20

Stress is prevalent among doctors, and interventions are offered, often as part of their continuing professional development, to help doctors learn in the workplace about the recognition, prevention and management of the harmful effects of stress. The aim of this review was to examine existing research to ascertain the features of successful educational interventions with practising doctors and any factors that may affect outcomes.

We searched key databases for papers published between 1990 and 2017 on the themes of stress that included an education-based intervention and practising doctors. Using an inclusive approach to the review, a broad evaluation was made of the primary research using both quantitative and/or qualitative evidence where the study reported a positive outcome in terms of stress management.

Review criteria were met in 31 studies of 1,356 originally retrieved. Three broad categories of interventions emerged from the coding process: mindfulness-type (n = 12), coping and solutions focused (CSF) (n = 12) and reflective groups (n = 7). There is evidence that these interventions can be successful to help doctors deal with stress. Based on the results from this review, an original guide is advanced to help educators choose an educational intervention.

Although evidence for some interventions may be ‘hierarchically stronger’, it is misleading to assume that interventions can be imported as successfully into any context. Factors such as medical specialty and health care systems may affect which intervention can be used. The guide offers an evidence base on which further research can be built.


Link to article here

The effect of exercise therapy combined with psychological therapy on physical activity and quality of life in patients with painful diabetic neuropathy: a systematic review.

 2019 May 21.

Background and aims

Approximately 25% of patients with diabetes mellitus type 2 (DMII) develop painful diabetic neuropathy (PDN). PDN is known to affect both mental and physical wellbeing, resulting in anxiety, depression, low quality of life and physical disability. Pharmacological treatment of PDN aims at pain relief and is often ineffective and/or has many side effects. Rehabilitation treatment modalities that are designed to help the patient deal with PDN related complaints, are mostly focussed on either physical (e.g. exercise therapy) or psychological aspects (e.g. cognitive behavioural therapy, CBT). There is emerging evidence that PDN can be approached from a biopsychosocial perspective, in which physical and psychosocial aspects are integrated. From this biopsychosocial approach it is plausible that integrated treatment modalities such as acceptance commitment therapy (ACT) or exposure in vivo (EXP) could be effective in patients with PDN. The objective of this review was to provide an overview of the current evidence on the effects of rehabilitation treatments that combine exercise therapies with psychological therapies in order to improve physical activity (PA) and quality of life (QoL) in patients with PDN.


Systematic review of the current literature. EMBASE, MEDLINE, Medline In-Process citations and e-Pubs ahead-of-print, Pedro, Web of Science, PsycINFO, CENTRAL, PubMed and Google Scholar were searched. All studies on interventions combining exercise therapy with psychological interventions in patients with PDN, aged >18 years, were included. Outcome measures were PA, QoL.


The search resulted in 1603 records after removing duplicates. After screening on titles and abstracts, 100 records remained. From these, not one study reported on interventions that combined exercise therapy with psychological interventions. Through a secondary hand search, a total of three reviews were identified that described a total of five studies regarding either physical or psychological interventions in patients with PDN. These studies reported moderate effects of (1) mindfulness meditation on QoL, (2) CBT on pain severity, (3) mindfulness-based stress reduction intervention on function, health-related QoL, pain catastrophizing and depression, (4) aerobic exercise on QoL and (5) Tai Chi on glucose control, balance, neuropathic symptoms, and some dimensions of QoL in patients with PDN. All studies were of a moderate quality, and results should be interpreted with caution.


Based on increasing knowledge in the domain of chronic pain, it could be assumed that integrated rehabilitation treatments for patients with PDN are beneficial. There is no literature to support this and more research should be done on integrated biopsychosocial interventions in patients with PDN.


Link to article here