Nacadia Effect Study (NEST)
Condition: Stress-related Problem
Study type: Observational

Summary: 
      This research project deals with stress treatment in the form of garden therapy in the
      therapy garden Nacadia. The therapy Garden Nacadia has an evidence-based design that is
      specially designed for the treatment of stressed people.

      Nacadia-therapy can be described as a process in which the patient's health and well-being is
      assumed to enhance by the presence of the natural environment and through participating in
      meaningful gardening activities.

      NEST concerns research on the effect of Nacadia-therapy. The study consists of randomized and
      longitudinal studies of the effects of Nacadia-therapy compared to acknowledged cognitive
      behavioral therapy (CBT).

      The outcome measures for example consist of: ability to return to work, health care use,
      psychological measurements related to stress, health, quality of life and changes in
      medication use. Further, exploratory studies of the garden therapy in the form of
      observations and interviews will be performed, to get a better understanding of the garden
      and the garden activities' importance for the therapeutic purposes.

      Hypothesis:

      - garden therapy, in a designed natural environment, will lead to improved health and
      well-being for people who are off sick with stress-related disorders
    

Detailed description: 
      In order to strengthen the project's quality as evidence-based research, the intervention is
      designed as a randomized controlled trial comparing two treatments on repeated measurements
      of the same variables over a period of time.

      The treatment options in this study is Nacadia-therapy (garden therapy) and cognitive
      behavioral therapy (CBT - control group). Because the Nacadia-therapy uses a large number of
      hours, it has been decided to compare it with the longest conventional treatment that can be
      offered through the public health insurance of stress-related disorders such as anxiety and
      depression.

        1. Number of participants (N): 80

             1. 40 (n) Nacadia Therapy

             2. 40 (n) CBT

        2. Type of environment

             1. The therapy garden Nacadia (outdoors or greenhouse)

             2. Clinic (indoors)

        3. Therapists and staff

             1. 2 psychologists and a gardener

             2. 2 psychologists

        4. Length of treatment

             1. 10 weeks

             2. 10 weeks

        5. Treatment content

             1. 96 hours of Nacadia-therapy (including 79 hours of gardening therapy, 10x½ hour
                individual conversations, and 4x3 hours of transition conversation)

             2. 20 hours individual CBT (including 16 hours of treating conversational therapy and
                4x1 hour of transition conversation)

        6. Treatment set-up

             1. Group of 8

             2. Individual

      Consistent factors in the two treatment options:

        -  The psychologists involved in both therapy types are authorized, and trained in CBT.

        -  Conversational therapy: Psychotherapeutic conversations in both treatments are primarily
           based on CBT.

        -  The treatments have the same length of time of 10 weeks

      Diverging factors in the two treatment options:

        -  Environment: In the Nacadia-therapy the treatment is taking place in a designed natural
           environment, and in CBT the treatment takes place in the psychologists' treatment rooms.

        -  The number of hours: In Nacadia-therapy the individual sessions last three hours, with
           two sessions per week the first and last week and three sessions a week in week 2-9.
           This gives a total of 96 hours, including 4 x 3 hours transition conversation and 10 x ½
           hour individual interviews. In CBT, the duration of the individual sessions are one
           hour, and there are 1-2 sessions per. week, totaling 20 hours, incl. 4 hours of
           transition conversations.

        -  Treatment content: in Nacadia-therapy experiences and activities related to the garden
           environment are integrated with mindfulness exercises. The individual conversations in
           the Nacadia-therapy will be mindfulness-based CBT, whereas in the control group the
           conversations will be exclusively CBT-based.

        -  Number of hours for conversational therapy: 20 hours of individual psychotherapy in CBT,
           10 x ½ an hour for individual psychotherapy in Nacadia-therapy.

      The project is targeted at citizens who are severely burdened by stress (including ICD
      categories, F 43.0-9(minus 1 = PTSD), and F45.3), which can be expected to correspond to 6-24
      months sick leave.

      Data Collection will be carried out through questionnaire surveys (at the beginning and
      ending of the treatment, and 3, 6, and 12 months after the treatment) as well as as well as
      from National Data Registers on use of Health care, medicine, and on amount of sick leave.
      This data will be retrieved three years before treatment and one year after treatment.
    

Observational model: Case-Control
Time perspective: Other
Sampling method: Probability Sample
Study population: 
        The project has agreed with a number of surrounding municipalities that they refer
        participants of both genders who are 20-60 years of age to the project through the
        rehabilitation institutions 'Incita' and 'Væksthuset', WHO are external collaborators
        Affiliated with the local job centers. Furthermore, local citizens can through their own
        doctor / psychiatrist or if they are customers at the Insurance Company 'TopDanmark', join
        the project. They will be provided with detailed information about the project, the target
        group and the triage procedure.