Title: A nature-based intervention to improve mental health: Efficacy of an angling intervention for military veterans with post-traumatic stress disorder.
Funder: Department of Health and Social Care

Abstract: Research question. Does a nature-based, group-delivered angling intervention improve the mental health of military veterans with post-traumatic stress disorder (PTSD)? Background. PTSD is a common mental disorder in the community estimated to affect 4% of the UK population. It is characterised by: re-experiencing of the traumatic event in the form of vivid intrusive memories, nightmares or flashbacks ; hypervigilance and hyperarousal with a feeling of being under threat; avoidance of memories or situations that may exacerbate symptoms. Despite these symptoms and their impacts on the lives of those affected, many people with PTSD (particularly military veterans) do not seek treatment or drop out early if they do. Veterans in particular are often sceptical of medical intervention. Consequently, alternative evidence-based treatments are required. One promising approach is the use of nature-based interventions. Various methods have been trialed including surfing and hiking. However, evidence to date is limited to pre-post trials; controlled studies are needed to establish the efficacy of nature-based interventions to improve the mental health of people with PTSD. Preliminary findings from our group suggest that angling, in a tranquil, rural yet social setting may be an effective intervention. An angling intervention has been developed by the group together with patient representatives and veterans organisations. Aims and objectives. The goal of the research is to conduct a full-scale randomised controlled trial to test the efficacy of a brief, group-delivered, nature-based angling intervention for improving the mental health of veterans with PTSD. This trial will provide important evidence to inform the use of this intervention in social prescribing. Prior to embarking on the main phase, a development research phase is required to address the following aims: Extend the evidence from our preliminary studies to provide the necessary data to calculate the power and sample size required for the main phase study; assess the feasibility of collecting outcome data using online tools; develop an intervention manual; explore ways to increase the attractiveness of the intervention to populations not traditionally associated with angling (i.e. women and people from a minoritized racial background); identify and secure funding for the main phase of the project and engage a Clinical Trials Unit. Development Phase Methods. Design: A waitlist-controlled randomised controlled trial will measure mental health and wellbeing using established, validated measures of PTSD, depression, anxiety, social function, wellbeing, psychological growth and loneliness, pre- intervention and at 2-week and 4-week follow-up. Participants: Military veterans with PTSD not concurrently in receipt of psychotherapy will be eligible to participate. 48 veterans will be randomised to the intervention or the waitlist control group. Timelines for delivery. 7-months duration. Anticipated impact and dissemination. The results from this development phase will be disseminated via a written report to the funder, an academic paper submitted for publication, a plain English summary, and a dissemination event at the University of Essex. The results will inform the proposed main phase that has the potential to transform policy regarding the role of nature-based interventions for mental health and to lead to substantial impacts for individuals with PTSD.

Lay abstract: The purpose of this research is to test whether angling in a natural and social setting will improve mental health of military veterans with post-traumatic stress disorder (PTSD). Anyone who has experienced a traumatic event or episode in their life might develop PTSD but it is particularly noted in military veterans who have seen combat. PTSD is characterised by persistently feeling under threat and experiencing vivid memories, nightmares and flashbacks of the trauma that may occur at any time. Many people with PTSD avoid thinking or talking about their trauma, and situations that could provoke anxiety. This often results in losing partners, friends and employment. Despite this, people with PTSD, especially military veterans, often do not seek help or drop out early if they do. The purpose of this research project is to evaluate a new, engaging way to help people with PTSD recover their wellbeing. We have worked with veterans who have lived with PTSD for many years and with veterans support charities to develop a new intervention. The new intervention involves learning to fish and socialising in small groups in a tranquil, rural setting. The idea behind this approach is threefold: First, being amongst people with similar experiences makes it easier to share concerns and memories. Second, natural environments are restorative and free from attention-grabbing triggers (such as unpredictable urban sounds that trigger flashbacks). Third, developing a skill encourages post-traumatic growth. We already have findings from a small sample of military veterans who have experienced dramatic improvements in their symptoms compared to a control group. Before we can conduct a full-scale trial of this new approach, we need to undertake some development phase research. We will invite 48 military veterans to take part and randomly allocate them to experience our intervention right away, or to wait a while. The aims of this phase are to: provide evidence that the intervention causes improvements in mental health that last 4 weeks; find out how many people we need for a full-scale study; test whether we can collect most data online; create a manual that describes how to run the intervention; explore ways to increase the appeal of angling to those who do not usually go fishing; secure funding for the main phase intervention. We will present the results of our study in a plain-English summary for participants, their families and interested parties, a report for funders, an academic paper, and at an event at the University of Essex. The information will enable us to design and run a full-scale randomised controlled study to test how well the intervention works. In future it might be possible to expand the programme to non-veterans with PTSD.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: MENTAL HEALTH