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Recent lifestyles changes have favored increased time in contact with screens and a parallel reduction in contact with natural environments. There is growing awareness that nature exposure and screen time are related to depression. So far, the roles of how these environmental lifestyles affect depressive symptoms and disorders have not been reviewed simultaneously. The aim of this review was to gather the literature regarding the role of nature exposure and screen time in depression. An emphasis was made on clinical samples of patients with well-defined depression and the different methodological approaches used in the field. A second goal was to suggest an agenda for clinical practice and research. Studies were included if they assessed depressive symptoms in patients with a clinical diagnosis of depression. An overview of the published literature was conducted using three scientific databases up to December 2021. Several interventions involving nature exposure have shown positive effects on depressive symptoms and mood-related measures. The most consistent finding suggests that walks in natural environments may decrease depressive symptoms in patients with clinical depression. Less researched interventions, such as psychotherapy delivered in a forest or access to natural environments via virtual reality, may also be effective. In contrast, fewer observational studies and no experimental research on screen time have been conducted in patients with clinical depression. Thus, recommendations for practice and research are also discussed. Scarce research, diverse interventions, and several methodological shortcomings prevent us from drawing conclusions in this area. More high-quality experimental research is needed to establish interventions with proven efficacy in clinical depression. At this stage, it is too early to formulate practice guidelines and advise the prescription of these lifestyles to individuals with depression. The present findings may serve as a basis to develop strategies based on nature exposure and screen time targeting clinical depression.
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Citation: Balanzá-Martínez, V.;
Cervera-Martínez, J. Lifestyle
Prescription for Depression with a
Focus on Nature Exposure and
Screen Time: A Narrative Review. Int.
J. Environ. Res. Public Health 2022,19,
5094. https://doi.org/10.3390/
ijerph19095094
Academic Editors: Joan Trujols,
Maria J. Portella and Alessio Gori
Received: 13 February 2022
Accepted: 19 April 2022
Published: 22 April 2022
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4.0/).
International Journal of
Environmental Research
and Public Health
Review
Lifestyle Prescription for Depression with a Focus on Nature
Exposure and Screen Time: A Narrative Review
Vicent Balanzá-Martínez 1,2 ,* and Jose Cervera-Martínez 3,4
1Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), 28029 Madrid, Spain
2Teaching Unit of Psychiatry and Psychological Medicine, Department of Medicine, University of Valencia,
46010 Valencia, Spain
3Department of Medicine, University of Valencia, 46010 Valencia, Spain; joecerve@hotmail.com
4Hospital de Denia-Marina Salud, 03700 Denia, Spain
*Correspondence: vicente.balanza@uv.es; Tel.: +34-963-983-349
Abstract:
Recent lifestyles changes have favored increased time in contact with screens and a parallel
reduction in contact with natural environments. There is growing awareness that nature exposure
and screen time are related to depression. So far, the roles of how these environmental lifestyles
affect depressive symptoms and disorders have not been reviewed simultaneously. The aim of
this review was to gather the literature regarding the role of nature exposure and screen time in
depression. An emphasis was made on clinical samples of patients with well-defined depression and
the different methodological approaches used in the field. A second goal was to suggest an agenda
for clinical practice and research. Studies were included if they assessed depressive symptoms
in patients with a clinical diagnosis of depression. An overview of the published literature was
conducted using three scientific databases up to December 2021. Several interventions involving
nature exposure have shown positive effects on depressive symptoms and mood-related measures.
The most consistent finding suggests that walks in natural environments may decrease depressive
symptoms in patients with clinical depression. Less researched interventions, such as psychotherapy
delivered in a forest or access to natural environments via virtual reality, may also be effective.
In contrast, fewer observational studies and no experimental research on screen time have been
conducted in patients with clinical depression. Thus, recommendations for practice and research
are also discussed. Scarce research, diverse interventions, and several methodological shortcomings
prevent us from drawing conclusions in this area. More high-quality experimental research is needed
to establish interventions with proven efficacy in clinical depression. At this stage, it is too early
to formulate practice guidelines and advise the prescription of these lifestyles to individuals with
depression. The present findings may serve as a basis to develop strategies based on nature exposure
and screen time targeting clinical depression.
Keywords: depression; nature exposure; screen time; lifestyle
1. Introduction
Depression is a prevalent mood disorder. It is estimated that more than 300 million
people worldwide suffer from depression [
1
]. Depression is also a leading cause of disabil-
ity and a major contributor to the overall global burden of disease [2]. Currently, first-line
treatments for depression are standalone or combined psychopharmacology and psycho-
logical therapy. However, only a subset of patients achieved clinical remission. Given
the unmet needs and potential side effects of these treatments, other strategies have been
researched to improve clinical outcomes in depression [
3
]. Lifestyle-based interventions
represent one such approach.
Physical activity, diet/nutrition, and restorative sleep are the three basic pillars of
lifestyle. Currently, lifestyle is considered a multidimensional construct, which integrates
Int. J. Environ. Res. Public Health 2022,19, 5094. https://doi.org/10.3390/ijerph19095094 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022,19, 5094 2 of 17
other behaviors, such as stress management, social support, substance use, and outdoor
activities [4].
Compared to the general population, patients with depression show unhealthier
lifestyles, including poorer sleep quality and dietary patterns, lower levels of physical
activity, smoking, and substance/alcohol abuse [
5
]. Notably, all these lifestyle factors
associated with depression are modifiable [
6
]. Growing evidence supports that lifestyle
behaviors play a role in the treatment and even prevention of several psychiatric disorders,
including depression [
7
]. Lifestyle changes aimed to manage mental disorders are the
foundations of the nascent field of Lifestyle Psychiatry [8].
In recent decades, the global changes spurred by urbanization have resulted in re-
markable shifts from traditional lifestyles and contact with nature [
9
]. Together, growing
technological developments have favored an increase in time spent in contact with screen-
based devices and a parallel reduction in time spent in nature. According to a recent
scoping review [
10
], excessive screen time seems to be associated with negative psychologi-
cal outcomes, including mental health and cognitive function, whereas time in contact with
nature seems to be associated with favorable psychological outcomes [
10
]. Nevertheless,
nature exposure and screen time are among the least researched lifestyles in depression so
far. To the best of our knowledge, the relationship between these environmental lifestyles
and depressive symptoms/disorders has not been reviewed simultaneously.
A growing number of reviews and meta-analyses supports the link between nature ex-
posure and depression [
11
16
]. For instance, short-term exposure to natural environments
has shown positive but small effects on depressive mood [
16
]. However, this evidence
mostly relies on primary studies examining either healthy subjects or patients with depres-
sive symptoms but not a primary diagnosis of clinical depression. Experimental studies
focusing on clinical depression are far fewer and have not been synthesized so far. More-
over, previous reviews adopted a restricted scope regarding nature exposure. For instance,
they focused on one type of natural environment, such as forests [
14
,
15
], or a specific
intervention, such as nature walks [
13
] and gardening [
14
]. Interestingly, no previous
literature review was restricted to patients with clinical depression. Taken together, an
overall understanding of how nature exposure impact depressive symptoms in patients
with clinical depression represents a gap in the literature.
This review is intended to address that gap by undertaking two complementary
approaches. On the one hand, we only selected studies that included populations with
clinical depression. On the other hand, we adopt a wider perspective on these topics. For
instance, here we include all types of natural environments and nature-based interventions
(NBIs). Although a consensus definition is lacking, NBIs are defined here as ‘planned,
intentional activities to promote individuals’ optimal functioning, health and well-being or
to enable restoration and recovery through exposure to or interaction with either authentic
or technological nature’ [
17
]. Screen time (ST) is defined as the viewing or use of any
technology with a screen, including television, computers, and mobile devices such as
smartphones and tablets [18].
The aim of this review was to gather the literature regarding the role of nature exposure
and screen time in depression. An emphasis was made on clinical samples of patients with
well-defined depression and the different methodological approaches used in the field. A
second goal was to suggest an agenda for clinical practice and research.
2. Methods
This paper was planned as a narrative overview of the scientific literature, including
a critical discussion of retrieved evidence [
19
]. This review was intended to provide a
reference for wider reading instead of a systematic review [
20
]. Therefore, no systematic
literature search was attempted.
To conduct this overview, electronic databases (PubMed/MEDLINE, Science Direct
and Google Scholar) were searched up to 15 December 2021. Search terms related to
depression (e.g., ‘major depression’, ‘unipolar depression’, and ‘depressive disorder’),
Int. J. Environ. Res. Public Health 2022,19, 5094 3 of 17
nature (e.g., ‘natural environment’, ‘nature exposure’, nature contact’, ‘green space’, ‘blue
space’, ‘nature-based intervention’), and screen time (e.g., ‘screen time’, ‘media use’, ‘screen
use’, ‘screen media’, ‘social media use’) were used. The electronic search was supplemented
by hand-searching of reference lists of reviews and meta-analyses to identify additional
articles. Moreover, a snowballing method was used, searching the references of relevant
articles to identify further suitable publications [
20
]. We considered only published articles
and not grey literature. We included human observational and experimental studies on
the relationship between depression and nature exposure or screen time. Studies were
included if they assessed depressive symptoms in patients with a clinical diagnosis of
depression, regardless of the sample included other conditions (termed ‘mixed samples’
in the manuscript). We prioritized studies with clinical samples composed of patients
diagnosed with standardized criteria of depression, e.g., DSM (Diagnostic and Statistical
Manual of Mental Disorders) and ICD (International Classification of Disease). Case reports,
opinion articles, and articles not published in English were excluded. Studies about other
environmental exposures, such as light at night and air pollution, were purposely excluded
from this review.
3. Results
3.1. Nature Exposure and Depression
Several observational and intervention studies assessing the relationship between
natural environments/NBIs and depression have been published to date.
3.1.1. Observational Studies
Three observational studies were identified, although none recruited a clinical sample
restricted to participants with clinical depression [
21
23
]. In a web-based, cross-sectional
survey, Ower et al. [
21
] compared levels of physical activity (PA) developed indoors,
outdoors, or in an alpine environment in healthy controls and patients with psychosomatic
disorders, mostly somatoform disorder, and major depressive disorder (MDD). In addition,
possible mediating variables such as an individual’s resilience and quality of life were
analyzed. Only PA carried out in an alpine environment was associated with greater
resilience. Furthermore, the effect of PA carried out in alpine environments on quality of
life was partially mediated by resilience in both patients and controls. In a retrospective
cohort study with a matched sample, Währborg et al. [
22
] assessed healthcare consumption
in patients with either ICD-10 depression or reactions to severe stress that used to participate
in a multimodal nature-assisted rehabilitation program. This 12-week program combined
horticultural activities with traditional rehabilitation conducted in a green setting, e.g., a
garden designed for this purpose. A reduction in the number of visits to primary care
was observed, as well as the mean hospital stay for both psychiatric and somatic causes.
An innovative approach was adopted in the third study [
23
]. Ecological Momentary
Assessment (EMA) was used to examine the association between daily encounters with
nature or daylight and affect-related indicators. Several times per day, participants were
asked to report the number of natural elements they were exposed to and their affective
state, as measured with 12 mood items derived from the Thayer Activation-Deactivation
Checklist and University of Wales Institute of Science and Technology Mood Adjective
Checklist. Nature exposure and daily light were associated with significant benefits on the
affective state, especially in patients with higher levels of depressive symptoms. However,
the standardized diagnostic criteria of depression, e.g., ICD or DSM, were not used to
recruit participants in this study.
3.1.2. Intervention Studies
Several intervention studies were identified [
24
39
]. Of them, a minority included
patients with MDD only [
24
29
], and the majority [
21
,
30
35
,
37
39
] recruited mixed samples
including patients with depressive disorders, although separate results for that group were
not reported.
Int. J. Environ. Res. Public Health 2022,19, 5094 4 of 17
Intervention Studies with Samples of Clinical Depression Only
A few intervention studies have examined the effects of nature contact/exposure on
clinical outcomes in patients with clinical depression only [
24
29
]. The main characteristics
of these studies appear in Table 1.
Table 1.
Main characteristics of the studies that included samples of patients with clinical depres-
sion only.
Authors
(Country) n Study Design Evaluation
Timing Intervention Details Settings Control
Groups
Depression
Measure
Other
Variables
McCaffrey,
2007
(USA) [24]
60
Qualitative
Focus group
Randomized
One focus group
the last day of
participation
Weekly sessions during 6 weeks
Group 1 (n = 20): walks alone in a
garden setting
Group 2 (n = 20): guided walks in
a garden setting
Group 3 (n = 20): art therapy
Garden
Yes
(Art ther-
apy group)
Qualitative
information
from
focus group
None
Kim et al.,
2009 (South
Korea) [25]
63
Quantitative
Quasi-
experimental
non-
randomized study
Weekly
4 cognitive-behavior therapy
sessions during 4 weeks
(3 h/session) performed in
different settings:
Group 1 (n = 23): forest
Group 2 (n = 19): hospital
Group 3 (n = 21): usual
outpatient management
Forest
garden
Yes (Usual
out-patient
manage-
ment)
HRSD
MADRS
BDI-II
Heart Rate
Variability
Salivary
Cortisol con-
centration
SF-36
Berman et al.,
2012
(Canada) [26]
20
Quantitative
Randomized and
controlled exper-
imental trial
Pre and
post-intervention
After a pre-intervention
assessment, participants were
encouraged to ruminate by
instructing them to analyze their
emotions about an unresolved
negative autobiographical
experience. After that, they were
randomly assigned to a
predefined 50 to 55 min walks
alone in nature vs. urban
environments.
Park
Yes (Urban
walking
group)
PANAS
Backwards
Digit
Span test
Frühauf et al.,
2016
(Austria) [27]
14
Quantitative
Quasi-
experimental
non-
randomized study
Pre-intervention,
after the first 15,
30 and 45 min of
the intervention
and post-
intervention.
All inpatients participated in the
3 different interventions. They
were group 60 min sessions,
developed in different days.
Sedentary control conditions:
sitting with reading materials
and board games.
Outdoor condition: Nordic
walking through a green natural
environment.
Indoor conditions: cycling in the
gym inside the hospital.
Green
natural envi-
ronment
Yes
(Sedentary
control
condi-
tion groups)
FS
MSS FAS
Korpela et al.,
2016
(Finland) [28]
13
Quantitative
Quasi-
experimental
non-
randomized study
Pre-intervention,
post-
intervention,
3-month
follow-up
8-week program with 2hr
sessions once a week about
psychoeducation. Every second
meeting was held at a preselected
place in a green environment,
and every second time indoors at
the psychiatric clinic. Indoor
sessions included
psychoeducation focusing on
depression, and outdoor sessions
included psychological tasks that
use the benefits of natural
environments in addition
to walking.
Park
or
Urban
woodland
No BDI-II ROS
SWEMWBS
Szczepanska-
Gieracha et al.,
2021
(Poland) [29]
25
Quantitative
Parallel-
group RCT
Pre-intervention,
post-intervention
and 2-week
follow-up
Both groups (intervention and
control) participated in a
psychoeducational program and
general fitness training. In
addition, the intervention group
completed 8 sessions (twice a
week) of virtual reality
Virtual
Reality with
total
immersion
in nature
Yes
(Psychoedu-
cation and
general
fitness
training)
GDS-30 HADS
Abbreviations. BDI-II: Beck Depression Inventory. FAS: Felt Arousal Scale. FS: Feeling Scale. GDS-30: Geriatric
Depression Scale. HADS: Hospital Anxiety and Depression Symptoms. HRSD: Hamilton Rating Scale for
Depression. MADRS: Montgomery–Asberg Depression Rating Scale. MSS: Mood Survey Scale. PANAS: Positive
and Negative Affect Schedule. ROS: Restorative Outcome Scale. SF-36: Short Form Health Survey Questionnnaire.
SWEMWBS: Short Warwick-Edinburgh Mental Well-Being Scale.
Int. J. Environ. Res. Public Health 2022,19, 5094 5 of 17
In the study by Kim et al. [
25
], outpatients with DSM-IV-TR depression of at least
moderate severity were assigned to three interventions over four weeks: cognitive be-
havioral therapy (CBT)-based psychotherapy delivered in a forest environment, the same
psychotherapy conducted in the hospital and usual management. Compared with the other
two interventions, the forest activity significantly decreased depressive symptoms (HRSD
baseline and endpoint total scores: 15.54 to 8.04 vs. 15.79 to 11.58 in the hospital group and
16.90 to 14.85 in the control group) and significantly improved rates of clinical remission
(61% vs. 21% in the hospital group and 5% in the control group). Interestingly, only the
forest program was associated with reduced concentrations of salivary cortisol, which is a
biomarker of stress [25].
Building upon previous studies [
26
,
30
], Korpela et al. [
28
] added nature walks to a
‘Coping with Depression’ program [
40
] in 13 patients with ICD-10 depression (see more
details in Table 1). Nature walks are ‘walks on a trail in a natural setting such as forests,
woodlands, or parks that can take any time from 15 min to a few hours’ [
12
]. A significant
decrease in depressive symptoms (Wilcoxon r =
0.49) and a significant increase in mental
well-being (r = 0.46) were observed at the end of the 8-week intervention and at three-month
follow-up. Nature walks, but not indoor sessions, produced restorative experiences that
were found to mediate these changes.
A cross-design study analyzed the role of attention and rumination in 20 patients with
DSM-IV moderate to severe MDD after taking a 50 min walk in either natural or urban
environments [
26
]. Prior to the intervention, patients with MDD were asked to think about
an unresolved negative autobiographical event to prime rumination, which is a common
symptom of depression. Before and after each condition, mood and working memory were
assessed with PANAS and the digit span backwards, respectively. Compared to the urban
condition, taking a walk in a botanical garden resulted in greater improvements in positive
affect (
ηp2
= 0.29) and cognition (working memory,
ηp2
= 0.53). However, these results
were not correlated, suggesting that separate mechanisms underly the observed benefits.
Frühauf et al. [
27
] compared the effects of indoor and outdoor PA in a sample of
14 inpatients with mild to moderate depression, as assessed by a clinician. The outdoor
PA consisted of Nordic walking in a green natural environment, while the indoor PA
consisted of cycling inside a gym. A sedentary condition in which patients sat and read
materials and board games was included to control the effects of group activity. All patients
participated in three interventions comprising 60 min group sessions conducted on different
days. Affective valence and perceived activation were evaluated with the Feeling Scale
and Felt Arousal Scale, respectively. Moreover, mood states were assessed with the Mood
Survey Scale (MSS), which includes measures of anger, excitement, activation, fatigue, and
depression, among others. Outdoor PA was found to be more beneficial than indoor PA by
generating significant changes in patients’ excitement (Cohen’s d = 1.45) and activation
(d = 2.04). The benefits in perceived activation were observed after 45 min of PA in the
outdoor. Additionally, improvement in patients’ levels of anger, fatigue, and depression
(d = 1.08) were found at the trend level.
Another study focused on elder patients with mild to moderate depression. McCaf-
frey [
24
] developed a qualitative study based on focus group interviews. Depression was
either diagnosed by a healthcare provider or based on patients’ self-report. Participants
were randomly assigned to three intervention groups: walking alone or guided walks in a
garden setting and art therapy as a control group. Healing gardens, in both guided and
non-guided groups, were found to be helpful to relieve patients’ depression and improve
their mood.
Finally, Szczepanska-Gieracha and colleagues [
29
] evaluated the efficacy of accessing
nature using virtual reality (VR) in elder women with depression who had not responded to
previous treatment. All patients (n = 25) participated in a psychoeducational program and
general fitness training and those randomized to the intervention group (n = 13) completed
eight sessions of VR therapy. By means of a head-mounted display, patients accessed a
total immersive experience in an interactive therapeutic garden, which was modified as the
Int. J. Environ. Res. Public Health 2022,19, 5094 6 of 17
sessions progressed, and mood changed. A significant decrease in depressive symptoms
as assessed with the Geriatric Depression Scale (GDS-30) was observed post intervention
(12.27 vs. 8.27, p= 0.001) and was maintained at 2-week follow-up (8.27 vs. 7.27, p= 0.88).
Intervention Studies with Mixed Samples
Roe and Aspinall [
30
] conducted one of the first quasi-experimental studies that
compared walks in urban and rural settings. Two groups of participants were recruited—a
mixed sample of patients attending mental health services (poor mental health group;
n = 40)
and adults from existing walking groups (good mental health group; n = 83). Walks
in rural areas were significantly correlated with positive changes in mood in both groups
but were greater in those with poor mental health. Interestingly, significant benefits of
urban walks were observed only in the latter group, for whom both urban and rural walks
were associated with positive changes on hedonic tone and stress, assessed with the Mood
Adjective Checklist.
Barton et al. [
31
] developed a pre-post intervention study with a mixed clinical sample,
including patients (n = 53) with DSM-IV-TR diagnoses of mood, anxiety, and psychotic
and substance-related disorders. The green exercise program consisted of six guided walks
that took place once a week in local public green spaces, such as country parks and natural
reserves. In order to control the effects of the social interaction and PA ingredients of
the green exercise program, two control
groups—a
social club group and a swimming
group—were
also included. Self-esteem was assessed by Rosenberg Self-Esteem Scale
(RSE), and mood was assessed by the 30-item short-form version of the Profile of Mood
States (POMS) questionnaire. After participating in a single session, an improvement in
both self-esteem and mood was observed in all groups, which was greater in the green
exercise group (self-esteem: 23.6 vs. 21.0, p< 0.0001; overall mood: 154.3 vs. 143.1,
p< 0.0001). There was evidence for a dose–response relationship, with increasing benefits
after 6 weeks of treatment.
Bielinis et al. [
32
] tested the efficacy of a forest therapy program for hospitalized
patients with ICD-10 psychotic and affective disorders, including depression. Forest therapy
or forest bathing (shinrin yoku in Japanese) refers to visiting a forest or engaging in various
therapeutic activities in a forest environment to improve one’s health and wellbeing [
41
,
42
].
In a quasi-experimental design study (n = 50), without a control group, they assessed the
effects of walking, stretching, or watching landscapes in a forest environment on anxiety
and mood state. In the affective disorders group, a single intervention of less than two hours
was associated with improvements in variables such as tension–anxiety (Cohen’s
d = 1.77),
depression–rejection (d = 2.52), fatigue (d = 1.27), confusion (d = 3.46), and vigor
(d = 1.71),
as measured with the State-Trait Anxiety Inventory-State (STAI-S), and the Profile of Mood
States (POMS).
Vujcic et al. [
33
] explored the benefits of a horticulture therapy program for a mixed
sample of 30 patients with ICD-defined adjustment disorder and a reaction to severe stress,
anxiety, or depression, who attended a day hospital. Horticultural therapy is a process
through which garden-related activities, interaction with plants and closeness to nature are
used as a rehabilitative strategy [
43
]. After 12 sessions, developed in a botanical garden,
significant benefits were observed in depression, stress, and anxiety and were assessed
with the Depression Anxiety Stress Scale (DASS21).
Moreover, Triguero-Mas et al. [
34
] differentiated natural outdoor environments (NOE)
into green and blue spaces, which were compared to the ‘built environment’ in an urban
district. Using a randomized, case-crossover design, they analyzed the effects of exposure
to PA in the three environments on psychological (measured as Total Mood Disturbance,
TMD) and physiological variables, including salivary cortisol levels, blood pressure, and
heart rate variability. Participants (n = 26) had previously scored below the 50th percentile
on the Mental Health Inventory scale (MHI-5). Exposure to a green space (a natural park)
was associated with significant reductions in mood disturbance (
4.78 points in TMD
score) and salivary cortisol (
0.21 log nmol/L), while exposure to a blue space (a beach)
Int. J. Environ. Res. Public Health 2022,19, 5094 7 of 17
improved mood (
4.53 points in TMD score) and heart rate indicators. Interestingly, PA
and self-perceived restoration experience were found to partially mediate the association
between NOE exposure and mood.
Maund et al. [
35
] conducted a 6-week, multimodal intervention in a natural setting,
including bird watching, free or guided walks, and canoeing. A mixed clinical sample
of 16 patients with depression and/or anxiety was recruited. Significant improvements
in anxiety (Generalized Anxiety Disorder-7), stress (Perceived Stress Scale), and emo-
tional wellbeing (Positive and Negative Affect Schedule and Warwick Edinburgh Mental
Wellbeing Scale) were observed after the program. Significant changes in the latter scale
were assumed to represent improved depressive symptoms (37 vs. 41 points; p< 0.009).
Moreover, in a qualitative analysis, patients highlighted a reduction in social isolation, an
increase in confidence to be in nature, and an improvement in the management of PA.
In a laboratory investigation, Hüfner et al. [
36
] exposed healthy controls and patients
with mental disorders, such as somatoform, depressive, and anxiety disorders, to visual
stimuli from alpine environments vs. neutral stimuli. A positive effect of alpine vs. neutral
visual stimuli, assessed by Self-Assessment Manikin, was observed on emotional analytics
for both groups.
Suicidal behavior, which is usually associated with depression, has also been targeted
by NBI. Sturm et al. [
37
] carried out a randomized crossover trial with a small sample
(n = 20)
of high-risk suicide patients with depression and other psychiatric disorders. The
intervention, consisting of a 9-week, mountain hiking program, was effective in reducing
hopelessness (assessed by Beck Hopelessness Scale; d =
1.4, p< 0.0001), depression
(assessed by Beck Depression Inventory; d =
1.38, p< 0.0001), and suicide ideation within
the hiking phase (assessed by Beck Scale of Suicide Ideation; d =
0.79, p= 0.005). Despite
their severe clinical state, patients were found to be sufficiently motivated to participate in
the program.
Regarding adolescents, Bowen et al. [
38
] developed a 10-week program based on
Wilderness Adventure Therapy (WAT) [
44
] for outpatients with mixed psychiatric diag-
noses (n = 36), mostly depression and conduct disorder. The WAT model emphasizes the
development of social-emotional competencies and coping skills through group-based
adventure experiences that are facilitated by a psychologist. In this case, activities included
bushwalking, abseiling, cross country skiing, or white-water rafting. A post-intervention
improvement of self-esteem (Hedge’s g = 0.26) and psychological resilience (g = 0.49)
was observed, as well as a reduction in depressive symptoms (g = 0.46), especially in
participants with worse baseline scores. At three-month follow-up, the improvement in
depressive outcomes was maintained.
Finally, Gonzalez et al. [
39
] developed a study with a single-group of 28 patients with
DSM-IV defined MDD, dysthymia, or depressive phase of bipolar disorder type II, which
participated in a 12-week therapeutic horticulture program. Compared to baseline, mean
scores on the Beck Depression Inventory (BDI) significantly decreased 4.5 points at the end
of the intervention (p= 0.002) and were maintained at the three-month follow-up. The
intervention was also associated with an improvement in attention, as measured with the
Attentional Function Index (AFI) scores.
3.1.3. Potential Causal Mechanisms
The positive effects of nature exposure on depressive symptoms likely result from
the interaction of multiple mechanisms. Two major theories have been invoked to explain
these benefits: attention restoration theory [
45
] and stress reduction theory [
46
]. Attention
restoration theory (ART) proposes that time spent in natural environments provides the
experience of a ‘soft fascination’ that allows the ability to pay attention without effort.
ART has been suggested to explain the results of some of the reviewed studies [
33
]. Other
clinical studies highlighted the importance of attention [
39
] or rumination [
26
] as factors
involved in mood improvement after exposure to natural environments.
Int. J. Environ. Res. Public Health 2022,19, 5094 8 of 17
Stress reduction theory (SRT) suggests that natural settings evoke an ‘automatic posi-
tive affective response’, which reduces stress and physiological activation [
16
,
47
]. It has
been suggested that stress relief after nature exposure can regulate the immunological
response [47]. Direct physiological mechanisms, such as exposure to microorganisms and
volatile organic compounds and microorganisms, would also enhance immune function-
ing [48].
Another major pathway linking nature and depression involves enabling of health-
promoting behaviors, such as social contacts and PA [
47
]. According to some controlled
studies of patients with depression, clinical improvement cannot be explained only by the
effects of PA or social interaction [
27
,
31
]. At the brain level, it has been suggested that
viewing images of nature can improve mood by reducing the activity of the orbitofrontal
cortex, which is hyperactive in patients with depression at rest [
49
]. Moreover, there is
evidence that nature exposure can reduce the activity of the subgenual prefrontal cortex
and rumination in healthy subjects [50].
3.2. Screen Time and Depression
The growing development and use of digital technology has accelerated people’s expo-
sure to screen-based devices [
51
]. A positive association between screen time (ST) and men-
tal health problems, including depressive and anxiety symptoms, has been
reported [52,53].
Most of this research has been conducted in young people from the general population (see
below), whereas fewer studies focused on adults. Thus, results are presented according to
age group.
3.2.1. Screen Time and Depression in Adults
Three large, nationally representative samples of adults from the general population
have examined the link between ST and depressive symptoms/disorders across cultures
and societies [
18
,
54
,
55
]. A large population-based, cross-sectional study of US adults
found a significant association between ST and moderate or severe levels of depression
after controlling for potential covariates [
54
]. Moreover, individuals who spent more
than six hours per day watching TV and using computers had higher odds of developing
depressive symptoms. In another study, Yu et al. [
18
] analyzed time spent by Chinese
adults in mentally passive (e.g., watching TV) and mentally active (e.g., using computer
and mobile devices) activities separately. Watching TV was associated with increased
depressive symptoms and the reverse was found for more mentally active modalities of ST.
Finally,
Werneck et al. [55]
compared the unhealthy lifestyles of adults with severe mental
illnesses with those of the general population in Brazil. MDD was associated with increased
TV watching, tobacco use, and consumption of sweets and soft drinks. Moreover, an
analysis of more than
84,000 adults
from the UK Biobank [
56
] found that multiple lifestyle
factors were associated with depressed mood. Increased ST as well as poor sleep and
dietary pattern were considered partly implicated in the development and aggravation of
depressed mood.
Social media use is a topic related with ST. In a nationally representative sample of
young adults from the United States, social media use was significantly associated with
increased odds for depression [
57
]. Strong and linear associations were found for all three
measures of social media use—total time per day spent on social media, visits per week,
and a global frequency score. In a national cohort study of young adults, among individuals
who were initially not depressed, baseline social media use was independently associated
with the development of depression over the following six months [
58
]. However, base-
line depression was not associated with an increase in social media use at follow-up in
that study.
Fewer studies have assessed adult patients with clinical depression. Two observational
studies with clinical samples have been published recently [
59
,
60
]. Tønning et al. [
59
]
assessed 74 adult patients with ICD-10 unipolar depressive disorder over six months
following discharge from psychiatric hospitalization. The daily number of times the screen
Int. J. Environ. Res. Public Health 2022,19, 5094 9 of 17
was switched on and the screen-on duration were used as proxy measures for smartphone
usage. Higher levels of depressive symptoms, measured with the Hamilton Rating Scale
for Depression (HRSD-17), were associated with fewer times the screen was switched on.
These findings support that smartphone-based self-monitoring is feasible and associated
with clinical ratings in patients with depression. Another recent study [
60
] examined the
use of social media in outpatients with unipolar depression and bipolar disorder. After
controlling for age and sex, both clinical groups and the healthy control group spent a
similar amount of time on social media. The use of social media followed a mood-congruent
pattern, with decreased and more passive use during depressive episodes. Interestingly,
more participants reported detrimental than beneficial effects on mood symptoms during
depressive episodes [
60
]. Finally, to the knowledge of authors, no experimental research to
date has involved ST in patients with depression.
3.2.2. Screen Time and Depression in Young Populations
Young people, e.g., children and adolescents, are especially exposed to ST and ado-
lescence is a period of high risk for the onset of depression [
61
]. In adolescents, excessive
ST has been associated with mental health outcomes such as psychological problems and
greater risk for depression or anxiety [
51
]. Overall, results regarding the relationship
between ST and depressive symptoms are inconsistent [53,6264].
The high heterogeneity and the small overall effect size observed suggest that other
factors likely moderate the relationship between depressive symptoms and ST in adoles-
cence [
65
]. The type of screen-based activity seems to be one such moderator. For instance,
mentally active activities, such as video gaming, may even have protective associations
with depressive symptoms in adolescents [
66
]. As noted by Kim et al. [
67
], most studies
have not differentiated between active and passive forms of ST. In a representative sample
of adolescents aged 12–17 years, past six-month incidence of DSM-IV-TR defined major
depressive episode was associated with passive ST but not with active ST [
67
]. Conversely,
in a large Swedish cohort study, self-reported hours spent in passive, sedentary behaviors,
including screen use, were not significantly associated with the incidence of MDD over a
13-year follow-up [
68
]. Still, other studies found positive associations between active ST
and depressive and anxiety symptoms in adolescents [
69
]. Individual characteristics might
represent another important moderator. In a large cross-sectional study with children and
adolescents, the association between ST and depression varied with screen type and indi-
vidual characteristics, such as gender and developmental stage [
70
]. During adolescence,
heavy screen media use was more strongly associated with mental health issues, among
girls compared to boys, especially for social media and Internet use [
71
]. On the other
hand, sleep and PA are consistently replicated correlates of excessive ST use in adolescents.
Indeed, there is growing awareness that increased ST and insufficient sleep and PA are
co-dependent and may have synergistic effects to impair mental health [
72
]. These three
lifestyle behaviors should be considered simultaneously when examining their relationship
with depressive symptoms in adolescence [67,73].
Moreover, the associations between ST and depression are largely based on the find-
ings of cross-sectional studies. Longitudinal studies suggest that the dynamic interplay
between excessive ST and depressive symptoms appears to be complex and bidirectional in
nature [
74
,
75
]. A recent systematic review of longitudinal studies found small to very small
but significant associations between total ST and subsequent depressive symptoms, but not
anxiety, in young people [
75
]. This relationship was stronger than the reverse association
between depressive symptoms and subsequent ST.
4. Discussion
There is growing research interest in the role of nature and screen time in depressive
symptoms/disorders. This overview gathers promising evidence that several NBIs may
improve depression outcomes. Specifically, in studies with mixed clinical samples, walks
in rural settings and green spaces showed positives changes in mood [
26
,
30
], whereas PA
Int. J. Environ. Res. Public Health 2022,19, 5094 10 of 17
in both green and blue spaces improved mood [
34
]. Moreover, a multimodal program
developed in nature improved emotional wellbeing [
35
] and forest therapy improved
depressive symptoms in inpatients with affective disorders [
32
]. A significant reduction in
depressive symptoms was observed after therapeutic horticulture [
33
,
39
] and WAT [
38
].
More consistent findings emerged from the few studies of patients with clinical depression
only. Psychotherapy delivered in a forest significantly reduced depressive symptoms and
increased rates of clinical remission [
25
]. Moreover, a virtual reality program was effective
to ameliorate symptoms in elder women with treatment-resistant depression [
29
]. Inter-
estingly, four studies found that walking in natural environments was associated with
benefits on depression-related measures [
24
,
27
,
28
,
31
]. Compared to control interventions,
walks in nature decreased depressive symptoms [
24
,
28
] improved positive affect [
31
] and
showed a trend to improve mood states [
27
]. This concurs with meta-analytic evidence that
PA conducted in natural settings is associated with greater positive effects on depression
compared to indoor exercise [
76
]. Previous evidence showing the benefits of NBIs for
depressive symptoms mostly relied on studies with healthy subjects and clinical popula-
tions of patients without a formal diagnosis of depression [
12
16
,
77
]. The present review
builds upon that literature and expands that knowledge to the few intervention studies
comprising patients with clinical depression.
In contrast, the relationship between ST and depression is more equivocal at the
time of writing. As reviewed above, very few observational studies and no experimental
research on ST have been conducted in patients with clinical depression. Most studies
are cross-sectional and have been focused on youth from the general population. The
relationship between increased ST and depression may be moderated, at least in part, by
screen type, participants’ demographic features, and other lifestyles, such as sleep and
PA/sedentary behavior. Based on the available longitudinal studies, the nature of this
relationship is likely complex and bidirectional.
4.1. Study Shortcomings and Recommendations for Future Research
In this section, the major methodological limitations of the reviewed studies are
summarized together with research recommendations to overcome study shortcomings.
Much of the current evidence on the role of NBIs in depression is based on studies
with small samples, mixed clinical samples, and heterogeneous designs. Studies with
small samples are prone to type II error and may hinder the identification of subgroups
of patients that benefit the most. Related to this, recruiting only patients with depression
has proven to be difficult [
30
], which often leads to mixed samples in most experimental
studies (see Section 3.1.3).
Study designs are largely variable from observational studies to randomized controlled
randomized trials (RCTs). Randomization is not always feasible, ethical, or acceptable
in natural environments [
78
]. Similarly, NBIs cannot be blind because participants and
healthcare providers experience the treatment environment [
14
,
25
]. Failing to blind the
researchers can lead to placebo effects in participants [
12
]. Moreover, many of the reviewed
studies are subject to selection bias because participants are not fully randomized, and
assignation to the NBI is based on individual preferences. Self-referred participants might
be expected to have an interest in natural environments and NBIs, which may lead to a
potential ‘nature-positive’ bias [79]. In sum, RCTs are difficult to apply to NBIs.
Studies are also heterogeneous regarding treatments. Participants received stand-alone
NBI or additional interventions, such as antidepressant medication, psychotherapy, and
occupational therapy [
25
,
32
,
34
]. In many studies, depressive symptoms were assessed with
self-report questionnaires instead of more reliable measures, such as clinician-rated scales.
The control of confounding factors is also difficult in NBIs, either due to the absence
of control groups or the difficulty in controlling some covariates. Variables such as time;
social interaction; familiarity with locations; pollution or seasonal variations; and sun-
light, vitamin D, temperature, humidity, or type of PA have been suggested as potential
biases [30,31,34].
Int. J. Environ. Res. Public Health 2022,19, 5094 11 of 17
Some benefits were observed after a single session of NBI in two studies [
31
,
32
].
This concurs with evidence supporting that short-term exposure to nature can improve
mood [
16
]. However, the long-term effects of NBIs on clinical depression are largely
unknown. Three of the reviewed studies followed patients up to three months after the
intervention [
28
,
38
,
39
] and all found that improvement in depressive symptoms were
maintained at follow-up. More longitudinal research is warranted to establish the potential
sustainability of these effects.
The quality of risk of bias of the included studies was not assessed in this overview.
Overall, the aforementioned shortcomings suggest a low quality of many NBI studies in
this area [12,14,16].
Regarding research about depression and screen time, the major limitations involve
cross-sectional designs and self-assessment of ST and depressive symptoms. Firstly, causal
relationships cannot be derived from cross-sectional studies. More longitudinal studies
and RCTs are warranted to establish the directionality of the associations observed between
ST and depression [
64
]. Secondly, ST is usually assessed with retrospective self-reports,
which may be affected by to recall bias and measurement error. Therefore, a combination
of validated objective measures, such as accelerometers, and real-time self-reports, such as
EMA, is highly recommended [
53
,
64
]. Thirdly, the next generation of studies should use
diagnostic psychiatric interviews to examine depressive symptoms instead of self-reported
questionnaires.
Finally, why address nature exposure and ST at the same time? These environmental
lifestyles can interact at different levels. Growing urbanization and technological develop-
ments have favored an increase in ST and a parallel reduction in time spent in nature [
9
].
It has been suggested that as individuals spend more time with screens, it is likely that
they engage less in other activities, such as in-person social interactions, physical activity,
and/or time spent in natural environments [
9
]. Moreover, technology and nature have
been suggested to exert opposing influences on human brain and cognitive functions [
80
].
The possibility exists that nature exposure might buffer psychological impacts of excessive
ST. According to a recent scoping review, very few studies have assessed time spent with
screens and nature simultaneously and their likely interactive psychological effects in chil-
dren and adolescents [
10
]. Further research on this area may pave the way to multimodal
lifestyle-based interventions in depression.
4.2. Implications for Practice
The importance of lifestyle in the management of depression is gaining momentum.
Indeed, for milder cases of depression, recent clinical guidelines recommend addressing
lifestyle behaviors before starting conventional treatments [
81
]. Moreover, several recom-
mendations on diet/nutrition [
82
,
83
] and physical activity [
84
] aimed to prevent and treat
depression have been issued.
Health care providers are in a key position to recommend and prescribe nature expo-
sure to patients with depression [
85
]. A replicated finding emerging from studies of patients
with clinical depression concerns the benefits of exercise in natural environments for depres-
sive symptoms. This relates to the field of ‘green exercise’. There is growing evidence that
being physically active or exercising within a natural environment or green space (‘green
exercise’) provides greater mental health benefits than PA or nature contact alone [
86
]. The
efficacy of exercise to prevent and treat depression has been demonstrated [
7
] and prescrib-
ing PA/exercise is endorsed in guidelines [
84
]. Further high-quality research is needed to
confirm the efficacy of green exercise in patients with clinical depression before establishing
its prescription in clinical practice. In the future, the potential efficacy of other NBIs, such
as therapeutic horticulture and forest therapy, can be also considered regarding specifically
clinical depression. Interestingly, the existing literature does not seem to make specific
recommendations in terms of exposure time addressed to people with clinical depression.
This could be due, among other reasons, to the lack of a standardized method to measure
time spent in nature or nature contact [
87
] as well as the broad diversity of NBIs [
88
]. In
Int. J. Environ. Res. Public Health 2022,19, 5094 12 of 17
our opinion, the nature-based perspective would be applicable at different levels of clinical
practice, from the modification of depressed patients’ lifestyles to the setting in which
treatments are developed or the creation of specific protocols for therapeutic programs.
Virtual reality (VR) is a new method of accessing nature with a potential interest for
patients with disabling, chronic conditions [
89
], such as psychiatric disorders. In this regard,
a recent meta-analysis showed the efficacy of VR to reduce anxiety levels in patients with a
wide range of anxiety disorders [
90
]. VR was also shown to improve depressive symptoms,
although at that time none of the studies focused on patients with MDD [
90
]. The positive
results of a more recent study [
29
] await replication with independent samples of clinical
depression. In healthy subjects, VR has been suggested to be associated with less intense
benefits for mood compared to authentic nature contact [91].
Regarding ST, there is limited evidence to guide recommendations on advisable
or safe exposure to screens [
63
]. For instance, the Canadian guidelines for sedentary
activity [
92
] recommend that adolescents engage in no more than two hours of ST per
day. The findings of original studies are quite heterogeneous in this regard. For instance,
adolescents reporting four or more hours of passive screen time per day were three times
more likely to develop a major depressive episode compared to those reporting less than
two hours [
67
]. In other studies, individuals who spent at least two hours per day of
ST-based sedentary behavior were more likely to have depression [
53
]. Further studies are
clearly needed to better estimate the dose–response relationship between ST and depression
and tentatively establish appropriate time limits for ST [
62
]. It is important to note that
the thresholds at which ST becomes detrimental for mental health may differ according to
screen type [
93
]. Accordingly, both screen modality and the amount of time spent should
be considered when developing more tailored recommendations for young people.
Excessive ST has been suggested to displace physical activity, getting adequate sleep,
in-person social interactions, and academic activities [
10
]. It is not our contention that
the increased use of screens is without benefits for mental wellbeing and health. Indeed,
moderate screen time may provide opportunities to reinforce actual relationships, forge
new social interactions, and enhance academic performance [
94
] Beyond social support,
smartphones and other screen-based technologies are currently used to foster physical
activity, sports, and aerobic exercise through Youtube videos and online tutorials. Apps
can be used to improve dietary patterns and stress management. Notably, all these healthy
lifestyles are protective behaviors for mental health [7,95].
Given that no experimental research involving ST has been conducted in patients with
depression so far, practice recommendations may be extrapolated from indirect evidence.
A recent prospective cohort study of adolescents in the UK explored whether replacing
any type of ST with exercise at age 14 could reduce emotional distress at age 17 [
93
]. Only
replacing watching TV or using social media with team sports, but not individual exercise,
was associated with lower emotional symptoms at follow-up. However, depressive symp-
toms were not specifically assessed in that study. On the other hand, digital detoxification
is one strategy to promote healthy digital habits and minimize the negative impact of ST on
health [
96
]. Conducting RCTs in patients with clinical depression are expected to advance
the field.
Taken together, the available evidence is limited to formulate practice guidelines and
prescription of these environmental lifestyles to individuals with depression.
4.3. Strengths and Limitations of Review
This overview is subject to several limitations. Relevant studies may have been
overlooked due to several reasons. First, this was a non-systematic review, which was
limited to three databases. Second, owing to the broad and diverse vocabulary used for
NBIs [
88
], significant search terms may have been omitted. Third, only articles written in
English were included. Moreover, the risk of bias of included studies was not examined.
In narrative reviews such as the present one, the included studies may be biased, relevant
literature may have been missed, and the search is not replicable by other authors. However,
Int. J. Environ. Res. Public Health 2022,19, 5094 13 of 17
our study also has some strengths. We adopted a wide approach aimed to gain an overall
understanding of how nature exposure impacts the clinical outcomes of patients with
depression. To the best of the authors’ knowledge, this is the first time that nature exposure
and screen time have been simultaneously reviewed in relation to clinical depression.
5. Conclusions
This overview examined the role of nature exposure and screen time in depression,
with a special focus on clinical samples of patients with well-defined depression. Scientific
knowledge about the role of natural environments and NBIs targeting depression seems to
be allocated in different silos. Undertaking a wide perspective can be useful to join the dots
in cross-disciplinary fields. There is promising evidence suggesting that nature and screen
time are related to clinical depression. Several interventions involving nature exposure have
shown positive effects on depressive symptoms and mood-related measures. The most
consistent finding suggests that walks in natural environments may decrease symptoms
in patients with clinical depression. Less researched interventions, such as psychotherapy
delivered in a forest or access to natural environments via virtual reality, may also be
effective. In contrast, the relationship with screen time remains more equivocal as very
few observational studies and no experimental research have been conducted in patients
with clinical depression. Overall, evidence on these topics is scarce, sparse, and presents
several limitations. At this stage, drawing firm conclusions is challenging due to the
diversity of interventions and methodological designs. An agenda for practice and research
is also suggested. More high-quality experimental research is needed to better establish the
efficacy of NBIs in clinical depression. The joint study of nature exposure and screen time
in depressed individuals can clarify their likely interactive effects. Collectively, it is too
early to formulate practice guidelines and advise the prescription of these environmental
lifestyles to individuals with depression.
Author Contributions:
Conceptualization and supervision, V.B.-M.; investigation, writing, review,
and editing, V.B.-M. and J.C.-M. All authors have read and agreed to the published version of
the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Acknowledgments:
VB-M acknowledges the national grant PI16/01770 from the Instituto de Salud
Carlos III, ISCIII (The PROBILIFE study). The authors gratefully acknowledge Ciara E. Balanzáfor
her careful proofreading of the manuscript. The authors would also like to express their gratitude to
the anonymous referees, whose comments helped to improve the quality of the manuscript.
Conflicts of Interest:
VBM received grants and served as consultant, advisor, or continuing medical
education (CME) speaker during the last 5 years for the following entities: Angelini Spain, Angelini
Portugal, Bristol-Myers-Squibb, Ferrer, Janssen, Juste, Lundbeck, Nutrición Médica, and Otsuka.
JC-M received grants and served as continuing medical education (CME) speaker during the last
5 years for Otsuka, Lundbeck, and Angelini Spain. None is related to the contents of this manuscript.
The funders had no role in the writing of the manuscript or in the decision to publish the results.
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Background :Screen-based device use could increase the risk of adolescent depression. Distinct modalities of screen-use may have differential effects on mental health. We used compositional data analysis to examine how theoretically replacing different screen-uses with exercise might influence future adolescent emotional distress. Methods : In 4,599 adolescents (55% female) from a nationally-representative, prospective cohort, we used time-use diary data at age 14 to estimate daily screen use (television, social media, video game, general computer use) and exercise (team sport and individual exercise). The outcome was emotional distress at age 17, assessed using the emotional symptoms subscale of the Strengths and Difficulties Questionnaire. Results : Theoretically replacing 60 minutes of total screen time with exercise at age 14 was associated with a 0.05 (95%CI -0.08, -0.02) score reduction on the emotional symptoms’ subscale at 17 in fully-adjusted models. Replacing 60 minutes of television or social media use with team sports was associated with a reduction of 0.17 (95%CI, -0.31, -0.04) and 0.15 (95%CI, -0.29, -0.01) in emotional symptom scores, respectively. We found no change in emotional symptom scores when replacing video game or general computer use with team sport, or when replacing any screen time with individual exercise. Limitations : No direct measure of depressive symptoms at follow-up. Conclusions :Replacing any screen time with exercise could reduce emotional distress, but the largest effect sizes were associated with replacing time in television watching and social media with team sports. Recommendations to limit screen-use in adolescents may require a nuanced approach for protecting mental health.
Article
Background This study aimed to compare self-reported changes on lifestyle behaviors during two phases of the COVID-19 pandemic in Spain, and to evaluate clinical and sociodemographic factors associated with lifestyles. Methods Two cross-sectional web surveys were conducted during lockdown (April 15-May 15, 2020) and seven months later (November 16-December 16, 2020). Lifestyle behaviors were self-reported by a multidimensional scale (SMILE-C). Two separate samples of respondents were analyzed. A multivariate regression model was performed to evaluate the association of SMILE-C scores with demographic and clinical variables. Results The sample comprised, 3,412 participants from the first survey (S1) and in the S1 and 3,635 from the second (S2). SMILE-C score decreased across surveys (p <0.001). The rates of positive screenings for depression and anxiety were similar between the surveys, whereas those for alcohol abuse decreased (p<0.001). Most participants in S2 reported that their lifestyle had not changed compared to those before the pandemic. Variables independently associated with an unhealthier lifestyle were working as an essential worker, lower educational level, previous mental disease, worse self-rated health, totally/moderate changes on diet, sleep or social support, as well as positive screenings for alcohol abuse, anxiety and depression. Limitations The cross-sectional design and recruitment by non-probabilistic methods limit inferring causality and the external validity of the results. Conclusions Overall lifestyle worsened seven months after the lockdown in Spain. Several demographic and clinical factors were associated with lifestyle scores. The contribution of common mental disorders to unhealthier lifestyles should be considered in order to prevent the negative impact of the pandemic.
Article
For most people, telework during the COVID-19 pandemic necessitates the increased use of digital tools. Although working from home can enhance flexibility, it comes with various psychological challenges, all of which can be substantially exacerbated for people during the COVID-19 pandemic. The increased need to use digital tools can create cognitive overload that may negatively impact work productivity and well-being. The idea of digital detox has received increasing attention in the last few years as a means for recovering from stress caused by the use of digital media. This paper presents an analysis of the relationships between the use of digital work tools, the feeling of cognitive overload, digital detox measures, perceived work performance, and well-being. Results from an online survey (N = 403) conducted during the period of strict lockdown measures in Germany in April and May 2020 indicate that the relationship between the use of text-based tools and well-being, but not perceived job performance, is mediated by cognitive overload. These relationships were not found for the use of videoconferencing tools. However, for users of these tools, the number of digital detox measures moderates the relationship between cognitive overload and the perception of work demands.