Depression, compassion and nature
The role of self-compassion and nature within interventions for the treatment of depression.
“All it takes is a beautiful fake smile to hide an injured soul and they will never notice how broken you really are.”
Hello, welcome to the latest Compassionate Nature research digest which looks at how self-compassion and nature-based interventions may help with depression.
This article comes with a content warning around references to suicide right from the start. In the UK there are sources of help and support such as the Samaritans who are available day or night, 365 days a year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.
The opening quote comes from the well-known actor and comedian Robin Williams. It is just over ten years ago that he died by suicide at the age of 63 and following his death details around his experience of severe depression and ill health were made public.
Yesterday (10th September) was World Suicide Prevention Day an annual awareness day organised by the World Health Organisation (WHO). The WHO estimate that around 720, 000 people globally die by suicide every year and it was the third highest cause of death in 15-29 years old in 2021. The WHO note that around 73% of deaths by suicide occur in middle and low income countries, although caution is needed with some of the statistics as global reporting of suicide is limited, sometimes due to associated taboo or stigma and it remains illegal in some countries. The WHO therefore suggest the numbers underreport the actual global levels. Here in the UK the Office for National Statistics (ONS) recently published an updated report on death by suicide in England and Wales showing suicide rates in 2023 were at their highest level for men since 1999 and for women since 1994.
The WHO highlight there can be many causes of suicide, with evidence from higher-income countries of the link between suicide and depression. Suicidal ideation and self-harm feature within clinical definitions of depression as possible symptoms individuals may experience. The ONS reported that in Autumn 2022 16% or around 1 in 6 of adults in England experienced moderate to severe depressive symptoms. This was lower than Spring of 2021 when it was 21% but higher than the 10% reported prior to the Covid pandemic. The ONS data also identified those groups who appear more likely to experience depression, including those suffering from long-term illness which prevents them from working, have a disability, fulfil unpaid full-time caring roles or live in the most socially-economic deprived areas. It also found that young adults aged 16-29 years old had the highest prevalence (28%) across all age groups, while those over 70 years old had the least (8%.) Across all age groups more women reported depression than men, most notably in the 16-29 age group, where 35% of females reported it compared to 22% of males.
Depression can be treated in various ways, from medication to therapy. One aspect of the therapeutic treatment is to address the often harsh self-critical perspective depression provides by enhancing a more self-compassionate approach. Interventions involving nature have also been used, ranging from informal social prescribing programmes to more formal therapeutic programmes, such as those involving horticultural activities. Three recent research papers help to further consider the role of self-compassionate and nature-based interventions for the treatment of depression.
A compassionate review
Areum Han and Tae Hui Kim 2023 meta-analysis of self-compassionate interventions for depression provides a review of some of the current evidence, reflecting the growing interest around the role of self-compassion in helping with symptoms of depression and supporting emotional regulation. The meta-analysis selected studies which used a Random Control Trial (RCT) design with either a passive or active control group where depression levels were assessed.
Research geek aside - an RCT is seen as a robust research design, where the participants are randomly allocated to either an intervention or a control condition. The participants should not be aware of this allocation and ideally nor should the researchers - this is called blinding. A passive control is where the participants in the control condition do not do anything, often they are on a “waitlist”. An active control is where the participants in the control condition receive an existing intervention which the study is using to compare to the intervention condition, eg comparing a new therapy with an established therapy.
The selected studies had to use self-compassion as the primary part of an intervention, use validated standard measures and involve a sustained self-compassion intervention as opposed to a one-off session. The authors selected 56 studies in total, with the majority published between 2018 and 2023. Of these 28 were delivered in-person, mainly in a group format, while 23 were online, often via a web browser interface. The remaining studies used either work-books or a mixture of the delivery formats. The self-compassion interventions ranged from a duration of 1 week to 16 weeks. Typically the interventions provided psychological information on self-compassion, related mindfulness exercises and the use of mental imagery. Sample sizes ranged from 19 to 2,161 participants, covering an age range of 14 to 59 years old. The majority (77%) of participants were female, with 11 of the studies excluding male participants. The majority of the studies (31) only had a passive control condition. Studies came from various countries, with the most from the US (11), followed by Australia, Canada and China (5 each).
The authors combined relevant RCT data for pooled analysis which included assessing the effectiveness of treating depressive symptoms and delivery formats. Effectiveness was assessed using 36 of the studies providing a combined sample of 2,960 participants. This found that at the end of the intervention period, a self-compassion approach was statistically more significant (medium effect size) in reducing depressive symptoms compared to the control condition. However this was the case only when compared to a passive control, there was no significant difference when an active control was used. Long term effectiveness was assessed by a sub-set of the 36 studies, with 14 studies providing a combined sample of 1261 participants. Again self-compassion interventions were statistically more effective, although now with a small effect size, to passive controls and no difference was found to active controls.
The delivery format appeared to show differences. Based on 23 studies and 1390 participants, in-person delivery showed a statistically significant difference, with a medium effect size, at the end of the intervention in comparison to a control. A subset of 8 studies allowed long-term analysis of 447 participants which showed this difference and effect was maintained at a follow-up point. In comparison online delivery based on 12 studies and 1328 participants showed a statistically significant difference with a small effect size at end of the intervention which was not maintained at the follow-up based on 5 studies and 572 participants.
Overall the meta-analysis suggests that self-compassion focused interventions are at least as effective as existing treatment and in-person delivery formats appear to provide greater, long-term benefits than online formats. However there are limitations, notably that 35 of the selected 56 studies were assessed as having a high risk of bias, principally due to reasons such as incomplete reporting of output data, concern around the random allocation of participants and blinding control. Additionally there was limited reporting of participation attrition rates, which is an important consideration of any intervention assessment.
I would also add caution given the diverse mixture of the participants when pooled together. Each of the selected studies had a specific sample, including pregnant mothers, undergraduate students, cancer patients, teachers and employees of an automobile company. There will be specifics to those participants that will affect the outcomes. Additionally the review covered different types of self-compassion interventions, which may differ in how self-compassion is conceptualised and presented. It is also worth noting it is not unusual when comparing therapeutic approaches that similar results or only small differences between the therapies are found on the symptoms of depression. This underlines the message that it is getting help which provides the biggest benefit towards managing and treating depression.
Physiological evidence
The studies in the meta-analysis only used standard self-report measures which can be subjective and open to participant biases when responding. A study from the University of Queensland in Australia looked at a physiological measure that appears related to compassion and mental health.
Jeffrey Kim and colleagues 2024 paper considered the effect of a compassion based exercise upon heart rate variability (HRV), which is the very small time variation between heartbeats, measured in milliseconds. Higher HRV is seen as more healthy, with some research finding lower HRV associated with health issues, including depression. HRV is controlled by the autonomic nervous system (ANS), which automatically manages body functions such as the heart and lungs. The ANS is further divided into the sympathetic nervous system which manages arousal and the parasympathetic nervous system which manages restoration. HRV can be influenced by many factors including stress and psychological distress.
The study used the concept of the Compassionate Self taken from Compassion Focused Therapy and examined if a related mental practice would influence the HRV of individuals with depression. It is worth highlighting that the Compassionate Self is different, although perhaps not obviously, to self-compassion. The Compassionate Self is an image of oneself which embodies the wisdom, courage and commitment of someone responding to distress with compassion. (I used a cycling metaphor in this recent blog post for Balanced Minds which explains the differences in more detail).
The study had 41 participants, of whom 32 were female, with an average age of 22.5 years old and who had severe depression. At the start of a two week period (timepoint 1) each participant listened to a 15 minute long audio-guided Compassionate Self practice, with their HRV measured by electrocardiogram (ECG) before (at rest), during and after the practice. They were then given access to online resources for self-directed practices and encouraged to use them daily, before returning at the end of the two weeks (timepoint 2) to repeat having their HRV measured before, during and after the same 15 minute exercise.
Analysis showed that at both timepoints participants HRV data were statistically significantly higher after the exercise than before. For 10 participants at timepoint 1 and 7 participants at timepoint 2 this raised their HRV above the clinical threshold considered as an “at-risk” low HRV. However there was no significant difference between the timepoint 1 at rest HRV reading and the HRV reading after the Compassionate Self exercise at timepoint 2. Analysis of participants HRV during the Compassionate Self exercise showed a marked decrease in HRV during the part when the participants were asked to think of a time when they had been self-critical due to a personal mistake or failure. This is suggestive that a sense of threat during the self-critical reflection period lowered HRV while the compassion focused part of the exercise showed increased HRV, supportive of other research findings.
It was also found that nearly half of the participants did not access the self-directed resources during the two weeks. However analysis showed no differences in HRV responses between those who did engage and those who didn’t. This may suggest that individuals with depression can struggle to complete self-directed activities, perhaps from the low motivation that accompanies depression or from a fear of compassion which can be prevalent in individuals with depression.
Study limitations include the short duration of the overall intervention, lack of a control condition and there may be confounding factors which influence the results, including breathing rates and medication. The study also focused on state HRV levels and future studies could consider the influence of compassion focused interventions on an individuals trait HRV. However these points aside, the study results do show that a compassion-based intervention appears to help improve HRV for severely depressed individuals in the short term, a physiological indication of a benefit to mental health.
Nature’s influence
As many previous Compassionate Nature articles have shown there is a strong evidence base for the mental health benefits of exposure to and contact with nature, which many people sense intuitively. A 2023 paper by Katrina Hyvönen and a Finnish research team used a RCT study to compare a nature-based intervention with standard care for the treatment of depression.
The study ran during 2019 to 2020 and participants were invited to take part if they had a primary diagnosis of depression. The majority (82%) of participants were female, with an average age of 45 (age range 19 to 64) and 67% were taking medication for the treatment of depression. They were randomly allocated to either the nature-based Flow with Nature intervention or undertook “treatment as usual” as the control condition. The overall sample size was 136, with 59 participants in the nature condition and 77 in the control. Measurements of depression, sense of restoration and ability to work/study were taken at the start, end and a follow-up after three months. Additionally the 77 participants in the control condition were invited at the follow-up point to also complete the nature intervention, which 29 did. Their data was included with the initial 59 nature participants in the analysis.
The Flow with Nature intervention consisted of 12 weekly sessions lasting 90 minutes each and held as group sessions at various natural locations, where participants were encouraged to engage with natural stimuli using all their senses and use nature to describe their experience of depression. Analysis found that both the nature and the control groups had statistically lower levels of depressive symptoms at the end of the intervention, although the change appeared slightly more pronounced in the nature-based group, albeit with a small effect size. The nature-based participants reported lower psychological distress, greater sense of restoration and more improved work/study ability than the control group at the end of the intervention, although at the three month follow-up only the work/study ability was statistically higher. Interestingly participants who were not on medication appeared to show greater benefits, which may reflect differences due to severity of symptoms.
Overall the authors highlight that 20% of the control group were reported as showing clinical level recovery compared to 36% of the nature-based participants at the end of the intervention. That said a clinical reduction in depression assessment scores was only seen in 29% of the nature-based intervention group which is lower than other similar studies. The study has several limitations to consider. Participants asked to take part, so may present a bias in their responses, and the majority were female, so the results are not generalisable. The nature based intervention was group based and the research did not explore the different nature and social elements which may have contributed to the benefits. There was a high participant attrition rate from the nature based intervention and part of the study period involved covid public health restrictions which may have affected results.
Similar to the compassion findings, the results suggest that adding nature-based activities to existing treatment approaches may provide additional psychological benefits.
“If you know someone who’s depressed, please resolve never to ask them why. Depression isn’t a straightforward response to a bad situation; depression just is, like the weather. Try to understand the blackness, lethargy, hopelessness, and loneliness they’re going through.
Be there for them when they come through the other side. It’s hard to be a friend to someone who’s depressed, but it is one of the kindest, noblest, and best things you will ever do.”
Stephen Fry’s words highlight the challenges that depression brings. It can be hard to live with and hard for those who care for the person experiencing it. The research reviewed is not saying that depression can be treated by being a little more kind to yourself or going off for a walk in the park. It is more complicated than that and it takes strength and courage to be compassionate towards oneself when depression is telling you a different story about yourself. The role of nature in providing respite and restoration can be helpful, although again this may require a level of motivation and bravery which can be challenging.
Sadly for some help is too late or they do not see as worthwhile. Behind all the statistics are individuals and their familes. Often messages on depression are about reaching out to someone to help, which some people find unable to do. Rather waiting to be asked, if you are concerned about someone, please check in with them, as challenging as that can be.
Such an act of compassion towards someone who is really struggling could make all the difference. It could save a life.
This post is dedicated to the memory of my friend Lou.
Thank you for reading the article and if you have been affected by any of the topics covered please try to talk about it to someone or seek out local help and support. Those Samaritans details again - available day or night, 365 days a year, free calls to 116 123, email at jo@samaritans.org, or visit www.samaritans.org.
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References
Han, A., & Kim, T. H. (2023). Effects of self-compassion interventions on reducing depressive symptoms, anxiety, and stress: a meta-analysis. Mindfulness, 14(7), 1553-1581.https://doi.org/10.1007/s12671-023-02148-x
Hyvönen, K., Salonen, K., Paakkolanvaara, J. V., Väkeväinen, P., & Korpela, K. (2023). Effects of nature-based intervention in the treatment of depression: A multi-center, randomized controlled trial. Journal of Environmental Psychology, 85, 101950. https://doi.org/10.1016/j.jenvp.2022.101950
Kim, J. J., Sherwell, C., Parker, S. L., & Kirby, J. N. (2024). Compassion training influences heart-rate variability within severe depression. Journal of Affective Disorders Reports, 16, 100760. https://doi.org/10.1016/j.jadr.2024.100760