Nature Exposure for Veterans

At the 2019 SHIFT Festival, a workshop on Military Readiness examined the therapeutic effects of nature on our wounded and non-wounded active duty service members, their families and their caregivers; the ways nature contact can help reduce levels of stress, depression, and burnout; and how nature contact can support Total Force Fitness, thereby reducing the economic costs to the military healthcare system.

Moderated by William Marchand, MD, Associate Chief of Mental Health and Chief of Psychiatry, George E. Whalen Veterans Affairs Medical Center, the workshop included panelists:

  • Keith Tidball, PhD, Cornell University (2019 SHIFT Awards Official Selection)
  • Frederick Foote, MD, Project Administrator, The Green Road (2019 SHIFT Awards Official Selection)  
  • Nick Otis, Research Associate, Naval Health Research Center (2018 SHIFT Award Official Selection)

Dr. Marchand was one of the principal authors of a study on safety and psychological impact of sailing adventure therapy among Veterans with substance use disorders.

Nick Otis collaborated with Dr. Kristen Walter at the Naval Medical Center on a randomized clinical trial of surf and hike therapy as an intervention for military veterans suffering from major depressive disorder.

Under the direction of Dr. Frederick Foote, The Green Road Project at the Walter Reed Medical Center studied the impact of time outside in a three-acre park on veterans, ascertaining positive correlations on PTSD and TBI.  

Dr. Keith Tidball, Associate Professor at Cornell, has studied the impact of hunting and angling on depression among military veterans. 

Following the workshop, Dr. Marchand, Mr. Otis and SHIFT Executive Director Christian Beckwith began to look at the development of a pilot study that examines the efficacy of hike therapy as an emotional wellness intervention for veterans while also identifying the gaps in the research necessary for a larger randomized clinical trial on the same intervention strategy for active-duty service members.

Decreasing suicide rates among active duty military members is a priority for the Department of Defense. While significant programming that addresses depression, PTSD and TBI among veterans exist—see here—no such studies have been made of active duty service members. 

Evidence in civilian populations indicates that hiking, an activity widely available to most of the population, offers a low-cost, low-risk intervention that can improve mental and emotional health outcomes. However, more research is needed to create the justification for a randomized clinical trial to establish the efficacy of hike therapy interventions conclusively among active-duty service members. 

A randomized clinical trial that determines the efficacy of hiking as a mental- and emotional-health intervention would provide the military with a novel mechanism for a prioritized issue. A pilot study that identified the gaps and needs necessary for such a trial would furthermore engage the military, one of the largest medical systems in the world, in the health benefits of nature contact, which in turn would facilitate the study of other nature-rich interventions that have proven to be effective in civilian populations, such as the ability of nature contact to improve cognitive performance. 

Should a pilot study support the efficacy of hike therapy, it would have broader implications for both the military and civilian populations that experience stress, including first responders, police officers and intensive care unit health care providers.

In the Spring of 2020, the group was joined by Gary Wynn, MD, an Assistant Professor and Assistant Chair, Department of Psychiatry, Uniformed Services University and Scientist, Center for the Study of Traumatic Stress. With guidance from Dr. Wynn, the group evolved the concept as follows.

A Randomized Controlled Trial of Nature Exposure for Veterans with Posttraumatic Stress Disorder and Major Depressive Disorder

Hypotheses:

  • A manualized nature exposure via hiking intervention is feasible and safe to utilize for PTSD and comorbid major depressive disorder
  • A manualized nature exposure via hiking intervention will result in improvement in PTSD and depressive symptoms, psychological flexibility and quality of life as well as decrease the use of inpatient and emergency services for these conditions
  • Veterans with PTSD and comorbid major depressive disorder will find a nature exposure via hiking intervention to be a pleasurable experience

Specific aims:  

  • Develop a manualized nature exposure via hiking intervention (NEH)
  • Evaluate the safety and feasibility of utilizing a manualized NEH intervention for Veterans with PTSD & MDD
  • Evaluate the short-term impact of NEH on PTSD and depressive symptoms, psychological flexibility, quality of life and the use of inpatient and emergency services for these conditions

Introduction:

Overview:  This study will be a two-arm non-blinded randomized controlled trial.  Participants will be randomized to the active intervention (NEH) + treatment as usual (TAU) or TAU only.

Intervention: NEH will consist of three, three-hour sessions conducted once per week over three successive weeks. Each session will include transportation from the VA Salt Lake City Health Care System (VASLCHCS) to the hiking trail and back to the facility after the hike. Transportation will require approximately 30 minutes pre- and post-hike with the actual hike lasting two hours. Hikes will occur on the Pipeline trail located in Millcreek Canyon, which is approximately 20 minutes from the VASLCHCS. The number of participants in each three-session intervention will be from five to ten.  Two study staff members will accompany the participants on, and provide leadership for, each hike.

Study location: VA Salt Lake City Health Care System and surrounding foothills of the Wasatch Mountain range

Number of subjects: 60 Veterans total, 30 in NEH + TAU and 30 in TAU only

Inclusion criteria: Veterans aged 18 – 70 currently enrolled for services at the VA Salt Lake City Health Care System. Additionally, participants must have had at least one mental health service encounter within the preceding 12 months and have been diagnosed with PTSD and MDD by a clinician within the preceding 24 months.

Exclusion criteria: Veterans with diagnoses of a psychotic spectrum illness and/or cognitive impairment will be excluded. Veterans with a physical disability/mobility limitation that would prevent participation in a two hour hike on a flat trail will be excluded.

Instruments/Outcome Measures:

  • Instruments to be used:
    • Physical Activity Enjoyment Scale (PACES) – enjoyment of activity
    • Posttraumatic Stress Disorder Checklist (PCL) – PTSD symptoms
    • Beck Depression Inventory (BDI) – depressive symptoms
    • Acceptance and Action Questionnaire–II (AAQII) – psychological flexibility
    • Positive and Negative Affect Scale (PANAS-C) – short-term positive and negative emotions
    • Quality of Life Enjoyment and Satisfaction Questionnaire – Short Form (Q-LES-Q-SF) quality of, and satisfaction with, life
  • Administration of instruments for NEH + TAU cohort:
    •  Pre-intervention instruments
      • Administered on first day of intervention prior to first hike: 
          • PCL
          • BDI
          • AAQII
          • PANAS-C
          • Q-LES-Q-SF
      • During intervention instruments
        • Pre-hikes 2 and 3:
          • AAQII 
          • PANAS-C 
        • Post-hike 2:
          • AAQII 
          • PANAS-C 
          • PACES
      • Post-intervention instruments administered on last day of intervention after hike: 
          • PCL 
          • AAQII 
          • PANAS-C 
          • BDI
          • PACES 
          • Q-LES-Q-SF
      • One month post-intervention administration of instruments by telephone:
          • PCL 
          • AAQII 
          • BDI
          • Q-LES-Q-SF
  • Other outcomes for NEH + TAU cohort:
      • Chart review 1 month pre- and 1 month post-intervention to evaluate for pre- to post- changes in the use of inpatient and emergency services for these conditions
  • Administration of instruments for TAU only cohort:
    • Pre-instruments administered on day of enrollment:
          • PCL
          • BDI
          • AAQII
          • Q-LES-Q-SF
    • Post-instruments administered 4 weeks after enrollment: 
          • PCL
          • BDI
          • AAQII
          • Q-LES-Q-SF
    • Other outcomes for TAU only cohort:
      • Chart review 1 month pre-enrollment and 2 months post-to evaluate for pre- to post- changes in the use of inpatient and emergency services for these conditions

Data analyses:

  • Within-subjects comparisons for NEH + TAU cohort only
    • Pre- to immediately post-intervention and pre- to 1 month post-intervention to assess for changes in PTSD and depressive symptoms, psychological flexibility and QOL associated with the entire intervention
          • PCL
          • BDI
          • AAQII
          • Q-LES-Q-SF
  • Pre- to post-session for each of the three NEH sessions to assess for changes in psychological flexibility and affect associated with each session
          • AAQII 
          • PANAS-C 
  • Post session for each of the three NEH sessions to assess participant enjoyment of the experience
          • PACES 
  • 1 month pre- to 1 month post-intervention for changes in use of inpatient and emergency services for these conditions
          • Review of electronic medical record
  • Between-subjects comparisons of NEH + TAU to TAU only
    • Pre- to immediate and 1 month post for between-group differences in change of PTSD and depressive symptoms, psychological flexibility and QOL
          • PCL
          • BDI
          • AAQII
          • Q-LES-Q-SF
  • Pre- to 1 month post for between-group differences in changes in use of inpatient and emergency services 
    • Review of electronic medical record

Length of study: 1 year

Identification of potential participants: Electronic record review and advertising 



 
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