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| Name | Class |
|---|---|
| University of South-Eastern Norway | OTHER |
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Depression is a common mental health condition that can cause low mood, lack of energy, sleep problems, and difficulties in daily functioning. Many people with mild to moderate depression do not receive sufficient treatment because of barriers such as limited access to services, stigma, or low motivation to seek help. Physical activity and contact with nature have been shown to improve mental health, and activities performed in natural environments ("green exercise") may provide additional psychological benefits compared with indoor exercise. However, people with depression may experience barriers to engaging in outdoor activities, such as low motivation, limited access to natural environments, or unfavorable weather conditions.
Virtual reality (VR) technology can simulate immersive natural environments and may provide a way to experience nature indoors. VR-mediated experiences of nature (or "virtual nature") can provide similar psychological benefits of rea-life nature experiences. Moreover, as virtual nature experiences have been found to elicit increased sense of nature connectedness and intention to perform green exercise, which may in turn support increase participation in actual green exercise. While virtual nature interventions have shown promising results in different health contexts and are considered safe and feasible, little research has examined their effects of integrating such medium within clinical standard treatments for depression.
The purpose of this study is to investigate whether virtual nature can be an effective supplement to standard treatment for patients with mild to moderate depression. Specifically, the study will evaluate whether the combination of standard treatment and virtual nature improves mood and reduces depressive symptoms compared with treatment as usual. The study will also explore whether the intervention influences participants' motivation to engage in physical activity and outdoor green exercise over time. Finally, the study will examine possible differences between two approaches to deliver virtual nature experiences to patients in treatment for depression, namely a "high-end" and laboratory-based approach vs a "low-end" and self-managed approach.
Participants will be recruited from a psychiatric outpatient clinic that treats individuals with depression and anxiety disorders. Eligible participants will be adults diagnosed with mild to moderate depression. Patients with additional diagnosis for dementia or psychotic illness or other serious somatic illness will be excluded. Participants will be randomly assigned to one of three groups: (1) a "high-end" and laboratory-based VR intervention combined with standard treatment, (2) a "low-end" and self-managed VR intervention combined with standard treatment, or (3) a control group receiving only standard treatment. The intervention will last three weeks, and participants will be assessed at baseline, immediately after the first session, after the intervention period, and at follow-up.
The study will examine several outcomes, both to test acute and longitudinal effects. Specifically, to test for acute effects of the two VR approaches, tested outcomes include affect state, feelings of nature connectedness, intention to perform green exercise and experiences with the virtual environment (such as enjoyment, immersion, and possible side effects like cyber sickness). To test the longitudinal effects, tested outcomes include mood, symptoms of depression and anxiety, and changes in physical activity and nature connectedness.
The main hypothesis is that patients who receive virtual nature in addition to their usual treatment will experience greater improvements in mood and depressive symptoms compared with patients receiving standard treatment alone. A secondary hypothesis is that exposure to virtual nature may increase participants' motivation and engagement in real-world outdoor physical activity over time. Finally, it is expected that the high-end and lab-based VR intervention will provide more positive overall effects.
This research will provide new knowledge about whether virtual nature experiences can support mental health treatment and help people with depression become more physically active and connected to nature. If effective, the intervention could offer a low-cost and accessible supplement to existing treatment approaches for depression.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Control (TAU) | Active Comparator | Standard treatment with therapist |
|
| Studio-based | Experimental |
| |
| Self-managed | Experimental |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Studio-based VR experiences | Other | High-end VR experience delivered by the researcher in a studio, delivered weekly, consisting of a simulated nature walk delivered through a high-end VR system connected to a manually-driven treadmill. |
| Measure | Description | Time Frame |
|---|---|---|
| Beck depression inventory II (BDI-II) | The BDI-II is a 21-item self-report questionnaire designed to measure the severity of depression. The total score is calculated by summing the ratings (0-3) for all 21 items, with minimum score 0 (no or minimal depressive symptoms) and maximum score 63 (severe, high-level depressive symptoms). A Norwegian translation of the scale commonly used in clinical settings is used in the study. | Baseline; post-intervention (week 3); follow-up (week 12). |
| Beck anxiety inventory (BAI) | The BAI is a 21-item self-report questionnaire used to measure the severity of anxiety in adults and adolescents. Each item is rated from 0 ("not at all") to 3 ("a lot"). The total score is calculated by summing the ratings for all 21 items (minimum value 0 and maximum value 63), with higher scores indicating greater severity of anxiety. A Norwegian translation of the scale commonly used in clinical settings is used in the study. | Baseline; post-intervention (week 3); follow-up (week 12). |
| Measure | Description | Time Frame |
|---|---|---|
| Hopkins symptom checklist (HSCL-10) | The HSCL-10 is a 10-item self-report questionnaire designed to screen for symptoms of anxiety and depression, commonly used in both clinical and epidemiological studies to measure psychological distress. It includes 4 items related to anxiety and 6 items related to depression, focusing on symptoms experienced during the past week. Each item is rated on a four-point scale (1 = "Not at all"; 2 = "A little"; 3 = "Quite a lot"; 4 = "Extremely"). The score is calculated by taking the mean of all item scores. The minimum Value is 1.0 (no psychological distress) while the maximum Value 4.0 (extreme psychological distress). A Cut-off Point is set at a mean score of 1.85 to identify individuals experiencing significant mental health distress. A Norwegian translation of the scale commonly used in clinical settings is used in the study. |
| Measure | Description | Time Frame |
|---|---|---|
| Enjoyment during the VR experience | This is a single item, designed by the researchers, asking the participant to rate their level of agreement with the following statement: "This expereince was enjoyable". The item is rated on a 0-10 Likert scale, with the lower values (minimum = 0) indicating no enjoyment, while the higher values (maximum = 10) indicate higher levels of enjoyment. A Norwegian translation is used. |
Inclusion Criteria:
Exclusion Criteria:
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| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Sykehus Innlandet | Hamar | Norway |
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| Label | URL |
|---|---|
| Calogiuri, G., Litleskare, S., Fagerheim, K. A., Rydgren, T. L., Brambilla, E., \& Thurston, M. (2018). Experiencing nature through immersive virtual environments: Environmental perceptions, physical engagement, and affective responses during a simulated | View source |
| Godin, G., \& Shephard, R. (1985). A simple method to assess exercise behavior in the community. Canadian journal of applied sport sciences. Journal canadien des sciences appliquees au sport, 10(3), 141-146. | View source |
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| ID | Term |
|---|---|
| D003863 | Depression |
| D008224 | Lymphoma, Follicular |
| ID | Term |
|---|---|
| D001526 | Behavioral Symptoms |
| D001519 | Behavior |
| D008228 | Lymphoma, Non-Hodgkin |
| D008223 | Lymphoma |
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| Self-managed VR experiences | Other | Low-end VR experience self-managed by the participants. After an introductory meeting with the researcher, the participants receive, for the duration of the intervention, a standalone VR headset containing a pre-set library of virtual nature experiences. The participants are encouraged to use the headset daily. The time spent using the VR headset is recorded through the device. |
|
| Standard Treatment | Other | Standard treatment with therapist |
|
| Baseline; post-intervention (week 3); follow-up (week 12). |
| Leisure time exercise questionnaire (LTEQ) | The LTEQ is a self-administered tool designed to assess the frequency and intensity of a person's leisure-time physical activity in a regular week (7 days). It measures how many times per week a person engages in strenuous, moderate, and mild/light physical activity for at least 15 minutes. In this study, a modified version was also used to measure "active commuting", defined in a caption as "Walkin, running, biking to and from destinations such as work, the grocery, etc." The participant is required to report the number of times they engage in each level of intensity (strenuous, moderate, and mild/light) during a regular week. Examples are provided for each level of intensity. Higher scores indicate higher levels of activity. The total score is calculated through the following formula: (n strenuous x 9) + (n moderate x 5) + (n mild/light x 3). A Norwegian translation is used. | Baseline; post-intervention (week 3); follow-up (week 12). |
| Intention to perform green exercise (INT-GE) | The INT-GE is a questionnaire component designed to measure an individual's motivation, plans, and likelihood of engaging in physical activity within natural environments (e.g., parks, forests, coasts). It is often developed based on the Theory of Planned Behaviour (TPB) to predict future green exercise behaviour. The scale contains five items, each rated on a 1-7 Likert scale, with the total score calculated as the mean of all items. The minimum score is 1.0 (no intention to perform green exercise), while the maximum is 5.0 (strong intention to perform green exercise). A Norwegian translation of the scale is used. | Baseline; immediately after the 1st VR exposure; post-intervention (week 3); follow-up (week 12). |
| Connectedness with nature scale (CNS) | The state version of the CNS measures an individual's affective, experiential connection to the natural world at a given moment ("right now"). Based on the previous trait version of the scale, the state version is sensitive to acute changes. It contains 13 items, which are rated on a 1-7 Likert scale (1 = "Strongly disagree"; 7 = "Strongly agree"). The total score is calculated as the mean of all items, with lower scores (minimum value = 1.0) indicating a weaker sense of connectedness, while the higher scores (maximum value = 7.0) indicate a stronger sense of connectedness. A Norwegian translation of the scale is used. | Baseline; immediately after the 1st VR exposure; post-intervention (week 3); follow-up (week 12). |
| Affect Scale (PAAS) | The PAAS is a 12-item self-report questionnaire designed to measure feeling states. It evaluates emotional responses across four distinct subscales (Positive affect, Negative affect, Tranquillity, and Fatigue) and is especially sensitive to acute changes associated with physical activity. The PAAS consists of 12 items (three items per subscale), each describing a feeling (e.g., "Energetic", "Discouraged", "Relaxed", "Worn-out"). Participants rate their current feelings on a 5-point Likert scale, commonly ranging from 0 ("do not feel") to 4 ("feel very strongly"). Mean scores are calculated for each subscale, with a minimum possible score of 0 and a maximum of 4, with higher scores indicating higher levels for the subcategory. A Norwegian translation is used. | Baseline; immediately after the 1st VR exposure; post-intervention (week 3); follow-up (week 12). |
| Immediately after the 1st VR exposure |
| Sense of presence during the VR experience | The scale assesses the extent to which participants perceive themselves to be immersed or embedded within a virtual environment (i.e., presence). Each item relates to different aspects that can influence a person's sense of presence either positively (Being there, Realism, Sense of reality) or negatively (Awareness, Other persons, External noises, Flatness, Movement lag). The items are formulated as statements, each participant being asked to rate the extent to which they agreed with each of them on an 11-point Likert scale (0 = absolutely disagree, 10 = absolutely agree). Each item is scored and treated individually. For Being there, Realism, and Sense of reality, higher scores indicate stronger sense of presence, hence greater effectiveness of the VR experience. For the other items, higher scores indicate a poorer sense of presence. | Immediately after the 1st VR exposure |
| Simulator sickness questionnaire (SSQ) | The SSQ measures symptoms similar to motion sickness but tailored to computer-based simulations. It asks participants to rate 16 symptoms (e.g., headache, eye strain, dizziness, nausea) on a four-point scale (0 = None; 1 = Slight; 2 = Moderate; 3 = Severe). The 16 symptoms are grouped into three subscales (Nausea, Oculomotor, and Disorientation), which are weighted and summed to calculate a total score. The minimum score is 0 (no symptoms, ideal outcome), and the maximum is 300 (extremely severe symptoms). A Norwegian translation is used | Immediately after the 1st VR exposure |
| Perceived Environmental Restorativeness | The Perceived Environmental Restorativeness is a self-reported measure of an environment's potential to help individuals recover from mental fatigue, stress, and cognitive overload according to the Attention-Restoration Theory. It contains 16 items, grouped in four subcategories: Fascination (5 items), Being Away (2 items), Extent/Coherence (4 items), and Compatibility (5 items). Each item is rated on a 0-10 Likert scale. The score of each subcategory is calculated as the mean of the related items. For Fascination, Being Away, and Compatibility, lower scores (minimum = 0.0) indicate smaller restorative potential, while higher scores (maximum = 10.0) indicate larger restorative potential. Unless the scores for Extent/Coherence are reversed, lower scores (minimum = 0.0) indicate larger restorative potential, while higher scores (maximum = 10.0) indicate smaller restorative potential. A Norwegian translation of the scale is used. | Immediately after the 1st VR exposure |
| Hartig, T. (1996). Validation of a measure of perceived environmental restorativeness. Goteborg psychological reports, 26(7). | View source |
| Mayer, F. S., \& Frantz, C. M. (2004). The connectedness to nature scale: A measure of individuals' feeling in community with nature. Journal of environmental psychology, 24(4), 503-515. | View source |
| Nichols, S., Haldane, C., \& Wilson, J. R. (2000). Measurement of presence and its consequences in virtual environments. International Journal of Human-Computer Studies, 52(3), 471-491. | View source |
| D009370 |
| Neoplasms by Histologic Type |
| D009369 | Neoplasms |
| D008232 | Lymphoproliferative Disorders |
| D008206 | Lymphatic Diseases |
| D006425 | Hemic and Lymphatic Diseases |
| D007160 | Immunoproliferative Disorders |
| D007154 | Immune System Diseases |