mental health case study vignettes

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Suicide Risk: Case Studies and Vignettes

Identifying warning signs case study.

Taken from Patterson, C. W. (1981). Suicide. In Basic Psychopathology: A Programmed Text.

Instructions: Underline all words and phrases in the following case history that are related to INCREASED suicidal risk. Then answer the questions at the end of the exercise.

History of Present Illness

The client is a 65-year-old white male, divorced, living alone, admitted to the hospital in a near comatose condition yesterday because of an overdose of approximately thirty tablets of Valium, 5 mgm, combined with alcoholic intoxication. The client was given supportive care and is alert at the present time.

A heavy drinker, he has been unemployed from his janitorial job for the past three months because of his drinking. He acknowledges feeling increasingly depressed since being fired, and for the past two weeks has had insomnia, anorexia, and a ten pound weight loss. He indicates he wanted to die, had been thinking of suicide for the past week, planned the overdose, but had to “get drunk” because “I didn’t have the guts” [to kill myself]. He is unhappy that the attempt failed, states that, “nobody can help me” and he sees no way to help himself. He denies having any close relationships or caring how others would feel if he committed suicide (“who is there who cares?”). He views death as a “relief.” His use of alcohol has increased considerably in the past month. He denies having any hobbies or activities, “just drinking.”

Past Psychiatric History

Hospitalized in 1985 at Pleasantview Psychiatric Hospital for three months following a suicide attempt after his fourth wife left him. Treated with ECT, he did “pretty good, but only for about two years” thereafter.

Social History

An only child, his parents are deceased (father died by suicide when client was eight years old; mother died of “old age” two years ago). Raised in Boston, he moved to Los Angeles at twenty-one and has lived here since. Completed eighth grade (without any repeat) but quit to go to work (family needed money). Has never held a job longer than two years, usually quitting or being fired because of “my temper.” Usually worked as a laborer. Denies any physical problems other than feeling “tired all the time.” Currently living on Social Security income, he has no other financial resources. He received a bad conduct discharge from the army after three months for “disobeying an order and punching the officer.” He has had no legal problems other than several arrests in the past two years for public intoxication. Married and divorced four times, he has no children or close friends.

Mental Status Examination

65 y.o. W/M, short, thin, grey-haired, unkempt, with 2-3 day-old beard, lying passively in bed and avoiding eye contact. His speech was slow and he did not spontaneously offer information. Passively cooperative. Little movement of his extremities. His facial expression was sad and immobile.

Thought processes were logical and coherent, and no delusions or hallucinations were noted. Theme of talk centered around how hopeless the future was and his wishes to be dead. There were no thoughts about wishing to harm others.

Mood was one of depression. He was oriented to person, place, and time, and recent and remote memory was intact. He could perform simple calculations and his general fund of knowledge was fair. His intelligence was judged average.

Diagnostic Impression

• drug overdose (Valium and alcohol)
• Dysthymic Disorder (depression)
• Substance Use Disorder (alcohol)

Questions for Exercise

You have interviewed the client, obtained the above history, and now have to make some decisions about the client. He wants to leave the hospital.

• Is he a significant risk for suicide?
• discharging him as he wishes and with your concurrence?
• discharging him against medical advice (A.M.A.)?
• discharging him if he promises to see a therapist at a nearby mental health center within the next few days?
• holding him for purposes of getting his psychiatric in-client care even though he objects?
• Discuss briefly why you would not have chosen the other alternatives in question #2.

Identifying Warning Signs Case Study: Feedback/Answers

The client is a  65-year-old   white male ,  divorced ,  living alone , admitted to the hospital in a near comatose condition yesterday because of an overdose of approximately thirty tablets of Valium, 5 mgm, combined with alcoholic intoxication. The client was given supportive care and is alert at the present time. A  heavy drinker , he has been  unemployed  from his janitorial job for the past three months because of his drinking. He acknowledges feeling increasingly depressed since being fired, and for the past two weeks has had  insomnia  and a  ten pound weight loss . He indicates he wanted to die, had been thinking of suicide for the past week, planned the overdose, but had to “get drunk” because “I didn’t have the guts” [to kill myself]. He is  unhappy that the attempt failed , states that, “ nobody can help me ” and he sees no way to help himself. He  denies having any close relationships  or caring how others would feel if he committed suicide (“who is there who cares?”). He  views death as a “relief.”  His  use of alcohol has increased  considerably in the past month.  He denies having any hobbies or activities , “just drinking.”

Hospitalized in 1985 at Pleasantview Psychiatric Hospital for three months following a suicide attempt  after his  fourth wife left him . Treated with ECT, he did “pretty good, but only for about two years” thereafter.

An only child, his  parents are deceased  ( father died by suicide  when client was eight years old; mother died of “old age” two years ago). Raised in Boston, he moved to Los Angeles at twenty-one and has lived here since. Completed eighth grade (without any repeat) but quit to go to work (family needed money).  Has never held a job longer than two years , usually quitting or being fired because of “ my temper .” Usually worked as a laborer. Denies any physical problems other than feeling “tired all the time.” Currently living on Social Security income, he has  no other financial resources . He received a  bad conduct discharge from the army  after three months for “disobeying an order and punching the officer.” He has had no legal problems other than several arrests in the past two years for public intoxication.  Married and divorced four times , he  has no children or close friends .

65 y.o. W/M, short, thin, grey-haired, unkempt, with 2-3 day-old beard, lying passively in bed and avoiding eye contact.  His speech was slow and he did not spontaneously offer information . Passively cooperative. Little movement of his extremities. His facial expression was sad and immobile. Thought processes were logical and coherent, and no delusions or hallucinations were noted. Theme of talk centered around how  hopeless the future was and his wishes to be dead . There were no thoughts about wishing to harm others. Mood was one of depression . He was oriented to person, place, and time, and recent and remote memory was intact. He could perform simple calculations and his general fund of knowledge was fair. His intelligence was judged average.

• Is he a significant risk for suicide?  Yes. The client presents a considerable suicidal risk, with respect to demographic characteristics, psychiatric diagnosis and mental status findings.
• Discuss briefly why you would not have chosen the other alternatives in question #2.  The client appears to be actively suicidal at the present time,and may act upon his feelings. Nothing about his life has changed because of his attempt. He still is lonely, with limited social resources. He feels no remorse for his suicidal behavior and his future remains unaltered. He must be hospitalized until some therapeutic progress can be made.

Short-Term Suicide Risk Vignettes

*Case study vignettes taken from Maris, R. W., Berman, A. L., Maltsberger, J. T., & Yufit, R. I. (Eds), (1992). Assessment and prediction of suicide. New York: Guilford. And originally cited in Stelmachers, Z. T., & Sherman, R. E. (1990). Use of case vignettes in suicide  risk assessment. Suicide and Life-Threatening Behavior, 20, 65-84.

The assessment of suicide risk is a complicated process. The following vignettes are provided to promote discussion of suicide risk factors, assessment procedures, and intervention strategies. The “answers” are not provided, rather students are encouraged to discuss cases with each other and faculty. Two examples of how discussions may be facilitated are provided.

37-year-old white female, self-referred. Stated plan is to drive her car off a bridge. Precipitant seems to be verbal abuse by her boss; after talking to her nightly for hours, he suddenly refused to talk to her. As a result, patient feels angry and hurt, threatened to kill herself. She is also angry at her mother, who will not let patient smoke or bring men to their home. Current alcohol level is .15; patient is confused, repetitive, and ataxic. History reveals a previous suicide attempt (overdose) 7 years ago, which resulted in hospitalization. After spending the night at CIC and sobering, patient denies further suicidal intent.

16-year-old Native American female, self-referred following an overdose of 12 aspirins. Precipitant: could not tolerate rumors at school that she and another girl are sharing the same boyfriend. Denies being suicidal at this time (“I won’t do it again; I learned my lesson”). Reports that she has always had difficulty expressing her feelings. In the interview, is quiet, guarded, and initially quite reluctant to talk. Diagnostic impression: adjustment disorder.

49-year-old white female brought by police on a transportation hold following threats to overdose on aspirin (initially telephoned CIC and was willing to give her address). Patient feels trapped and abused, can’t cope at home with her schizophrenic sister. Wants to be in the hospital and continues to feel like killing herself. Husband indicates that the patient has been threatening to shoot him and her daughter but probably has no gun. Recent arrest for disorderly conduct (threatened police with a butcher knife). History of aspirin overdose 3 years ago. In the interview, patient is cooperative; appears depressed, anxious, helpless, and hopeless. Appetite and sleep are down, and so is her self-esteem. Is described as “anhedonic.” Alcohol level: .12.

23-year-od white male, self-referred. Patient bought a gun 2 months ago to kill himself and claims to have the gun and four shells in his car (police found the gun but no shells). Patient reports having planned time and place for suicide several times in the past. States that he cannot live any more with his “emotional pain” since his wife left him3 years ago. This pain has increased during the last week, but the patient cannot pinpoint any precipitant. Patient has a history of chemical dependency, but has been sober for 20 months and currently goes to AA.

22-year-old black male referred to CIC from the Emergency Room on a transportation hold. He referred himself to the Emergency Room after making fairly deep cuts on his wrists requiring nine stitches. Current stress is recent breakup with his girlfriend and loss of job. Has developed depressive symptoms for the last 2 months, including social withdrawal, insomnia, anhedonia, and decreased appetite. Blames his sister for the breakup with girlfriend. Makes threats to sister (“I will slice up that bitch, she is dead when I get out”). Patient is an alcoholic who just completed court-ordered chemical dependency treatment lasting 3 weeks. He is also on parole for attempted rape. There is a history of previous suicide attempts and assaultive behavior, which led to the patient being jailed. In the interview, patient is vague regarding recent events and history. He denies intent to kill himself but admits to still being quite ambivalent about it. Diagnostic impression: antisocial personality.

19-year-old white male found by roommate in a “sluggish” state following the ingestion of 10 sleeping pills (Sominex) and one bottle of whiskey. Recently has been giving away his possessions and has written a suicide note. After being brought to the Emergency Room, declares that he will do it again. Blood alcohol level: .23. For the last 3 or 4 weeks there has been sleep and appetite disturbance, with a 15-pound weight loss and subjective feelings of depression. Diagnostic impression: adjustment disorder with depressed mood versus major depressive episode. Patient refused hospitalization.

30-year-old white male brought from his place of employment by a personnel representative. Patient has been thinking of suicide “all the time” because he “can’t cope.” Has a knot in his stomach; sleep and appetite are down (sleeps only 3 hours per night); and plans either to shoot himself, jump off a bridge, or drive recklessly. Precipitant: constant fighting with his wife leading to a recent breakup (there is a long history of mutual verbal/physical abuse). There is a history of a serious suicide attempt: patient jumped off a ledge and fractured both legs; the precipitant for that attempt was a previous divorce. There is a history of chemical dependency with two courses of treatment. There is no current problem with alcohol or drugs. Patient is tearful, shaking, frightened, feeling hopeless, and at high risk for impulsive acting out. He states that life isn’t worthwhile.

Vignette Discussion Examples

Vignette example 1.

Twenty-six year old white female phoned her counselor, stated that she might take pills, and then hung up and kept the phone off the hook. The counselor called the police and the patient was brought to the crisis intervention center on a transportation hold. Patient was angry, denied suicidal attempt, and refused evaluation; described as selectively mute, which means she wouldn’t answer any of the questions she didn’t like.

Facilitator: How high a risk is this person for committing suicide? Low, moderate or high? Student Answer 1: Maybe moderate because the person is warning somebody, basically a plea for help. Facilitator: Okay, so we have suicidal talk. That’s one of our red flags. What else? She said she might take pills, so we didn’t know if she does have the pills. So she has a plan. The plan would be to take pills, but we don’t know if we have means. Student Answer 2: High. She’s also angry. I don’t know if she’s angry often. Facilitator: A person in this situation who is really thinking about killing themselves tends not to deny it. They tend not to deny it. There are exceptions to everything, but most of the time, for some reason, this is one of the things where people tend to mostly tell you the truth. If you ask people, they tend to tell you the truth. It’s a very funny thing about suicide that way. That’s certainly not true about most things. If you ask people how much they drink…But, “Are you thinking about killing yourself?” “Well, yes.” If you ask a question, you tend to get a more or less accurate, straight answer. Student question: Is that because it doesn’t matter anymore? If they’re going to die anyway, who’s going to care about what anybody thinks or what happens? Facilitator: My hypothesis would be, when someone is at that point, they’re talking about real, true things. They’re not into play. This is where they are. If they’re really looking at it, then they’re just at that place. What’s to hide at that point? You don’t have anything to lose. It’s a state of mind. And then if you’re not in that place—it’s like, how close are you to the edge of that cliff? “I’m not there. I know where that is, and I’m not there.” “If you get there, will you tell me?” “Yeah, I’m not there.” So, people have a sense—if they’ve gotten that close, they know where that line is, and they know about where they stand in regard to it, because it’s a very hard-edged, true thing.

Twenty-three year old white male, self-referred. Patient bought a gun two months ago to kill himself and claims to have the gun and four shells in his car. Police found the gun but no shells. Patient reports having planned time and place for suicide several times in the past. States that he cannot live anymore with his emotional pain since his wife left him three years ago. This pain has increased during the last week, but the patient cannot pinpoint any precipitant. Patient has a history of chemical dependency but has been sober for 20 months and currently goes to AA.

Facilitator: How high a risk is this person for committing suicide? Low, moderate or high? On a scale from 0 to 7 (7 being very high). Student Answer 1: High. On a scale of 0 to 7? Student Answer: Six. Student Answer 2: I would say three. I think it would be lower because if he’s already bought the gun two months ago and he’s self-referring himself to get help, he wants to live. He has not made peace with whatever, and he’s more likely not give away his things, and he’s going to AA meetings. I think it’s lower than really an extreme…I would say a three or four. Student Answer 3: I would say a four or five, moderate. Student Answer 4: About a five..several times and hasn’t followed through, tells me he doesn’t really want to follow through with it. Facilitator: And there are no shells, right? So we can see some of the red flags are there, but some of them aren’t. He’s still sober… Student: He has a support group. Student: He’s not using, though he bought a gun—so that’s a concern. There is a lot there. Student: He may not have the shells so he doesn’t have the opportunity to. So does that make him more…? Student 2: Think I’ll change mine to a five. Facilitator: So the mean was 4.68, so 5 was the mode. If we’re saying this is a moderate risk, what things would we look for that would make this a high risk? Student: Take away AA. Student: If he falls off the wagon, he goes right to the top. Student: And if he finds the shells. Facilitator: Because it probably is not that hard to find shells. All these stores around here, you can get shells quicker than you can get a gun, so he’s only a five-minute purchase away from having lethal—in contrast to not having the gun. Student: Could there be a difference in the time? Let’s say his wife left him just four to six months ago rather than three years. Would that be something that would be more serious? Facilitator: Yes, or if his wife just left him. So, say his wife left him a month ago that would bump it up. So that’s unresolved. That’s taking a person that was worried and that’s pushing him higher. Student: It also raises the homicide rate. Facilitator: Yes, because these tend to be murder-suicides. How often have we seen that? Murder-suicide is a big deal. If she won’t be with me, she won’t be with anybody.

• Children's mental health case studies
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Explore the experiences of children and families with these interdisciplinary case studies. Designed to help professionals and students explore the strengths and needs of children and their families, each case presents a detailed situation, related research, problem-solving questions and feedback for the user. Use these cases on your own or in classes and training events

Each case study:

• Explores the experiences of a child and family over time.
• Introduces theories, research and practice ideas about children's mental health.
• Shows the needs of a child at specific stages of development.
• Invites users to “try on the hat” of different specific professionals.

By completing a case study participants will:

• Examine the needs of children from an interdisciplinary perspective.
• Recognize the importance of prevention/early intervention in children’s mental health.
• Apply ecological and developmental perspectives to children’s mental health.
• Predict probable outcomes for children based on services they receive.

Case studies prompt users to practice making decisions that are:

• Research-based.
• Practice-based.
• Best to meet a child and family's needs in that moment.

Children’s mental health service delivery systems often face significant challenges.

• Services can be disconnected and hard to access.
• Stigma can prevent people from seeking help.
• Parents, teachers and other direct providers can become overwhelmed with piecing together a system of care that meets the needs of an individual child.
• Professionals can be unaware of the theories and perspectives under which others serving the same family work
• Professionals may face challenges doing interdisciplinary work.
• Limited funding promotes competition between organizations trying to serve families.

These case studies help explore life-like mental health situations and decision-making. Case studies introduce characters with history, relationships and real-life problems. They offer users the opportunity to:

• Examine all these details, as well as pertinent research.
• Make informed decisions about intervention based on the available information.

The case study also allows users to see how preventive decisions can change outcomes later on. At every step, the case content and learning format encourages users to review the research to inform their decisions.

Each case study emphasizes the need to consider a growing child within ecological, developmental, and interdisciplinary frameworks.

• Ecological approaches consider all the levels of influence on a child.
• Developmental approaches recognize that children are constantly growing and developing. They may learn some things before other things.
• Interdisciplinary perspectives recognize that the needs of children will not be met within the perspectives and theories of a single discipline.

There are currently two different case students available. Each case study reflects a set of themes that the child and family experience.

The About Steven case study addresses:

• Adolescent depression.
• School mental health.
• Rural mental health services.
• Social/emotional development.

The Brianna and Tanya case study reflects themes of:

• Infant and early childhood mental health.
• Educational disparities.
• Trauma and toxic stress.
• Financial insecurity.
• Intergenerational issues.

The case studies are designed with many audiences in mind:

Practitioners from a variety of fields. This includes social work, education, nursing, public health, mental health, and others.

Professionals in training, including those attending graduate or undergraduate classes.

The broader community.

Each case is based on the research, theories, practices and perspectives of people in all these areas. The case studies emphasize the importance of considering an interdisciplinary framework. Children’s needs cannot be met within the perspective of a single discipline.

The complex problems children face need solutions that integrate many and diverse ways of knowing. The case studies also help everyone better understand the mental health needs of children. We all have a role to play.

These case has been piloted within:

Graduate and undergraduate courses.

Discipline-specific and interdisciplinary settings.

Professional organizations.

Currently, the case studies are being offered to instructors and their staff and students in graduate and undergraduate level courses. They are designed to supplement existing course curricula.

Instructors have used the case study effectively by:

• Assigning the entire case at one time as homework. This is followed by in-class discussion or a reflective writing assignment relevant to a course.
• Assigning sections of the case throughout the course. Instructors then require students to prepare for in-class discussion pertinent to that section.
• Creating writing, research or presentation assignments based on specific sections of course content.
• Focusing on a specific theme present in the case that is pertinent to the course. Instructors use this as a launching point for deeper study.
• Constructing other in-class creative experiences with the case.
• Collaborating with other instructors to hold interdisciplinary discussions about the case.

To get started with a particular case, visit the related web page and follow the instructions to register. Once you register as an instructor, you will receive information for your co-instructors, teaching assistants and students. Get more information on the following web pages.

• Brianna and Tanya: A case study about infant and early childhood mental health
• About Steven: A children’s mental health case study about depression

Cari Michaels, Extension educator

Reviewed in 2023

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Ethics and Psychology

Where ethics is more than a code

Welcome to the Nexus of Ethics, Psychology, Morality, Philosophy and Health Care

Vignette warehouse (39).

• Open access
• Published: 25 April 2024

The revision and factor analytic evaluation of the German version of the depression literacy scale (D-Lit-R German)

• Feyza Gökce 1   na1 ,
• Denise Jais 1   na1 ,
• Philipp Sterner 2 ,
• Antonius Schneider 1 ,
• Jochen Gensichen 3 &
• Gabriele Pitschel-Walz 1

For the POKAL-Group

BMC Psychology volume  12 , Article number:  235 ( 2024 ) Cite this article

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Depression is a common mental health disorder and the second leading cause of disability worldwide. In people with depression, low depression literacy, which could be characterized by a poor recognition of depressive symptoms and less knowledge about the availability of treatment options, can hinder adequate therapy for depression. Nevertheless, questionnaires measuring depression literacy in Germany are rare. Consequently, for the present study, the German Depression Literacy Scale (D-Lit) has been revised and evaluated.

First, a team of clinical psychologists revised the D-Lit German scale. Next, cognitive interviews were conducted with patients with depression to improve the comprehensibility of the scale items. Our revision of the D-Lit-R German scale was then subjected to an anonymous online study. Finally, the data went through an exploratory factor analysis, and sociodemographic subgroup analyses were performed.

N  = 524 individuals (age 18–80) completed the D-Lit-R German scale and a questionnaire on their sociodemographic data. Cronbach´s alpha was estimated as α = .72, and McDonald's Omega (categorical) was estimated as ω = .77. The mean Item difficulty was M  = .75 ( SD  = .15). An EFA was performed for a unidimensional model, a 5-factor-model and at last a 3-factor-model. The 5-factorial model showed a good model fit (χ 2 emp,WLSMV (131) = 92.424, p  > .05; CFI = 1, RMSEA = 0, SRMR = .07) but was rejected since the content of the potential 5 factors could not be determined. The 3-factor model showed an arguable model fit. The Chi 2 test was significant (χ 2 emp,WLSMV (168) = 199.912, p  < .05), but the CFI and the RMSEA met an acceptable model fit (CFI = .990, RMSEA of .019, 90% CI[.003, .029]). Substantively, the three factors were defined as (1) Distractors and other symptoms, (2) Depressive symptoms, and (3) Pharmacological and psychotherapeutic depression treatment. Furthermore, there were significant differences in sum scores regarding the subgroup's gender, treatment for mental health problems, depression treatment, experience with depression, and different career fields.

Conclusions

The D-Lit-R German scale is a time-efficient scale to assess some aspects of the depression literacy construct that can be easily applied. Since there was no perfect model fit, it is recommended to continue to revise the scale. Further evaluation studies could ask for knowledge of the etiological factors of depression. Future studies could then use this instrument to convey depression literacy. This instrument could assess the growth of knowledge after psychoeducational interventions in different settings.

Trial registration

This trial was preregistered at the platform osf.io ( https://osf.io/49xdh ).

Registration number: https://doi.org/10.17605/OSF.IO/49XDH

Date of registration: 28 April 2022.

Peer Review reports

With a prevalence rate of 28.9%, depression is now a worldwide mental disorder [ 1 ]. This disorder is characterized by the main symptoms of a depressed mood, decreased energy, and lack of interest for at least two weeks. Several other, partly somatic symptoms include sleep disturbances and loss of appetite [ 2 ]. In Germany, even though effective treatments for depression already exist and are commonly used, e.g., cognitive behavioral psychotherapy, interpersonal psychotherapy, or antidepressant medication [ 3 ], more than half of the people with depression don´t use the available health services [ 4 ]. In addition to access barriers, e.g., inability to get an appointment or long waiting times, individual barriers also play an essential role in explaining this [ 5 ]. One barrier can be the fear of being stigmatized. Another barrier can be dysfunctional cognitions, e.g., believing that treatment will not be helpful or wanting to deal with the problem on their own. Tomczyk et al. (2018) found that informal help-seeking was negatively associated with depression literacy, meaning that people with high depression literacy were less likely to seek informal help and vice versa [ 6 ]. In the literature, depression literacy or depression knowledge is defined as a sub-construct of mental health literacy (MHL) [ 7 ]. Depression literacy includes knowledge about depressive symptoms, depression-relevant support services, and competence in applying this knowledge. MHL, in general, refers to the knowledge of how to identify a specific mental disorder, how to access health information, what the risk and etiological factors are, and what self-help and treatment options are available [ 8 ]. MHL also comprises attitudes that promote appropriate treatment. Greater MHL is shown to predict the readiness to take up treatment [ 9 , 10 ]. In Contrast, lower depression literacy is associated with poor recognition of depressive symptoms and less knowledge of the availability of treatment options [ 11 ]. Sociodemographic factors such as age, gender, and general education can also influence MHL. Studies show that MHL is lower in older adults, in people with lower education, and in men compared to women [ 12 , 13 , 14 ].

Regarding depression literacy, Makowski et al. (2021) conducted a national telephone study and found that 55% of the participants recognized depression as the health problem depicted in a case vignette [ 15 ]. Although this seems to be a moderate level of depression literacy, it is of great importance to increase depression literacy in society, in view of the growing number of people with depression worldwide [ 16 ]. More services should be offered to particularly vulnerable groups to improve the course of depressive disorders and reduce barriers to access. This could be achieved, for example, through a psychoeducational intervention in General practices, as most patients with depression first consult their GP and are also treated by them [ 17 , 18 , 19 ]. Instruments used to assess MHL are mainly case vignettes that ask for disease-specific declarative knowledge [ 20 ]. Those vignettes focus on the knowledge of terminology, risk factors, diagnosis, and prognosis, which are captured by recognition tests [ 8 ]. In addition, there are also several standardized knowledge questionnaires on MHL [ 20 ]. Wei et al. (2018) identified a total of 69 knowledge questionnaires in a review of available MHL measurement instruments from 401 studies, most notably the Mental Health Literacy Scale (MHLS) [ 21 , 22 ]. However, questionnaires measuring specific disease-related knowledge about depression in Germany are insufficient. One example is a knowledge questionnaire by Görnitz et al. (1998), which has not yet been evaluated [ 23 ]. Since there is a lack of evaluated questionnaires in the field of depression knowledge, Freitag et al. (2018) translated the depression literacy scale (D-Lit) by Griffiths et al. (2004) [ 24 ] into German and conducted an evaluation study [ 7 ]. The original scale consists of 22 items, and the translated German scale had the same properties as the original scale and reached an internal consistency of Cronbach's alpha = 0.747, which can be regarded as satisfactory [ 25 ]. However, the authors state that there may have been problems with the content or language of some items in terms of comprehension.

Furthermore, it should be noted that the sample used in the study consisted of individuals with depressive symptoms. Therefore, the authors recommend evaluating the scale on a subclinical sample. Consequently, the present study aimed to optimize the D-Lit German scale as a measure of depression knowledge and to test its psychometric properties and factor structure. Furthermore, it aimed to investigate the differences in depression literacy regarding subgroups based on psychosocial variables (e.g., Gender, Age) to select those with a greater need for interventions that increase depression literacy. Overall, this study was conducted to develop a validated instrument that can be used in another subsequent study to assess depression knowledge in patients with depression. In this planned study, a psychoeducation program for patients with depression [ 26 ] will be tested in general practices. Since one of the variables of interest will be depression literacy, it was also aimed to optimize the compatibility of the D-Lit German scale as a measuring instrument for such an intervention.

Study design

This study was preregistered at the platform osf.io (Registration link: https://osf.io/49xdh , registration number: https://doi.org/ https://doi.org/10.17605/OSF.IO/49XDH ). The study consisted of two parts. The first part included the revision of the scale. Part two comprised the online survey to investigate psychometric properties, analyze the scale's factor structure, and compare differences in the sum score depending on sociodemographic subgroups. Before data collection, the study was assessed and approved by the ethics committee of the Technical University of Munich (TUM). All methods were carried out in accordance with relevant guidelines and regulations. All participants confirmed their informed consent before taking part in the study.

Adaptation and revision

First, the existing D-Lit German scale [ 7 ] was revised by an expert team of two clinical psychologists to improve the comprehensibility of the scale items as recommended by Freitag et al. (2018) [ 7 ]. Four items were found to be misleading or not in accordance with the current S3 guidelines for depression. These items were replaced by four new items, thematizing other aspects of depression and depression treatment. This first draft of the revised D-Lit-R German scale [ 27 ] was developed for the present study, has not been published before, and is available in the online supplements. The scale then underwent a pretest with cognitive interviews with the technique of “thinking aloud” [ 28 ] to identify possible comprehension and response problems. In accordance with the recommendation of Prüfer & Rexroth (2005) [ 28 ], we aimed to recruit at least 5 participants for the interviews. Due to difficulties in the recruitment, the final number of participants was N  = 5, consisting of patients with depression (two women and three men; Ages: 24, 28, 43, 49, and 66) staying at the private ward of the Clinic for Psychiatry and Psychotherapy of the University Hospital Rechts der Isar of the Technical University in Munich (TUM). The Interviews were conducted by one of the first authors of the present study (DJ) in April 2022. They were audio recorded and transcribed. After transcription, the audio records were deleted. Participants gave informed consent before taking part in the interviews.

The registered problems in the transcripts were rated following the Question Rating System of Faulbaum et al. (2009) [ 29 ]. Then, the altered items were again discussed and reviewed by the clinical psychologists and the study team.

Online survey

In a subsequent online survey, a convenient sample of participants answered the modified D-Lit-R German scale [ 27 ] and a sociodemographic questionnaire. All interested individuals (18–80 years) who did not meet exclusion criteria were eligible to participate and thus included. The exclusion criteria comprised cognitive impairment, language barriers, an academic degree in psychology, or another expertise in psychology or psychiatry. Interested persons were only invited to participate in the study if they did not meet any exclusion criteria. Expertise in psychology or psychiatry was further assessed by asking questions about their profession in the sociodemographic questionnaire at the beginning of the online survey. The survey was conducted via the internet platform www.sosci-survey.de . The period for participation was 6 weeks (May–June 2022). The time required to complete the survey was suggested to be 5–10 min. Subjects were asked to give their informed consent at the beginning of the survey by clicking a button since data collection was anonymous. Participation was voluntary and unpaid. By closing the survey web page, participants could end the survey at any time if they no longer wished to participate.

Sample size and recruitment

Schönbrodt and Perugini (2013) recommend a minimum sample size of N  = 250 since stable estimates of correlations with manifest variables can only be expected with this sample size [ 30 ]. For stable estimates regarding the correlations of latent variables, a sample size of 490 persons is recommended [ 31 ]. Therefore, a target sample size of N  = 490 individuals was aimed for.

Recruitment was conducted via analog and digital advertisement through flyers at universities, clinics, other educational institutions, and institutions of daily life (e.g., supermarkets) in Munich, Germany, and Innsbruck, Austria.

Measurement tools

Sociodemographic questionnaire.

The questionnaire included items with questions on the following domains: Age, gender, experience with treatment for mental health problems, experience with depression (self, acquaintance), current treatment for depression, level of education, and career field. We further assessed how the participants found out about the study.

D-Lit-R German scale [ 27 ]

A revised version of the German translation of the Depression Literacy Scale (D-Lit German) by Freitag et al. (2018) [ 7 ] was used to assess depression literacy. The original version was constructed by Griffiths et al. (2004) [ 24 ]. In total, the revised D-Lit-R German scale [ 27 ] that we developed for this study contains 22 items with a three-part response format ("true," "false," "I don't know"). One point is given for each correct answer; no point is awarded for questions answered incorrectly or with "I don't know.". A higher sum score indicates a greater depression knowledge [ 7 ]. Freitag et al. (2018) [ 7 ] report a Cronbach’s α of 0.747 for the D-Lit German scale. Four items of the D-Lit German scale were replaced by reformulated items (see Table  1 ). However, the revised scale still had the same response format as the D-Lit German scale and was evaluated and interpreted in the same way. The authors of both the original and the translated version of the D-Lit scale, Kathleen Griffiths and Simone Freitag, have kindly given their permission to use their versions for the further development of the scale.

Statistical analysis

Statistical analyses were performed using SPSS statistical software version 27 (IBM SPSS Statistics) and R (version 4.2.0 R Core Team, 2022) and the packages Jmv (Version 2.3.4;), Lavaan (Version 0.6–12; Rosseel, 2012), MBESS (Version 4.9.1; Kelley, 2017), nfactors (Version 2.4.1; Raiche, 2010), psy (Version 1.2; Falissard & Falissard, 2022), psych (Version 2.2.5; Revelle, 2022), and RE- daS (Version 0.9.4; Maier, 2022). The significance level was set at α = 0.05 for two-sided significance tests. For multiple tests, the significance level was corrected according to Bonferroni. Multiple imputations (chained equation) [ 32 ] of missing values of the dependent variable (D-Lit-R German data) were not performed since the small number of three data points (0.03%) did not follow a systematic pattern and were classified as MCAR values (missing completely at random) [ 33 , 34 ].

Descriptive item statistics (means, standard deviations, selectivity, item skewness) were calculated, and distributional analyses (scale skewness and scale kurtosis) were performed. The scale's reliability was assessed using Cronbach´s alpha and McDonald's Omega (categorical). To check the suitability of the present data for the factor analysis, we examined Bartlett's test for sphericity [ 35 ] with the Kaiser–Meyer–Olkin coefficient (KMO) [ 36 ] and the correlations of the anti-image matrices (MSA coefficients). This was followed by a factor analytic examination of the D-Lit-R German scale with determination of the number of factors to be extracted using parallel analysis [ 37 ] and MAP test [ 21 , 38 ]. Because of the categorical response format and the fact that the factors would correlate, a WLSMV (Weighted Least Squares Mean Variance – adjusted; rotation: oblimin) factor analysis was calculated [ 39 , 40 ]. Measurement models were evaluated using the following fit indices: global model fit (Chi2 test), RMSEA (Root Mean Square Error of Approximation), CFI (Comparative Fit Index), and SRMR (Standardized Root Mean Square Residual) [ 41 ]. We want to point out that we used these fit indices to compare models with varying numbers of factors. In this, we tried to find a trade-off between model fit and model interpretability. Finally, subgroup analyses were performed using t-tests (Welch tests for missing prerequisites), nonparametric tests (Mann–Whitney U test), and the univariate analyses of variance complemented by Dunnett T3 post hoc tests.

In sum, 10 original D-Lit German scale items were replaced by reformulated items and modified. Table 1 shows the modified items and their original versions. There were several reasons for the modification or replacement of the items. Items 1, 3, and 12 were slightly modified to improve the comprehensibility. Item 18, which initially had to be answered with “correct”, is a question on the treatment of depression that is not in line with the current recommendations of the S3- guidelines. Therefore, we replaced it with a more accurate item regarding depression treatment based on the guidelines' recommendations. Items 13, 16, and 19 were found to be misleading and display implausible comparisons. These items were replaced by new items, which were chosen in accordance with the content of the psychoeducational program of the subsequent study, for which the revised scale is thought to be one of the measuring tools. The same reasoning was crucial for the replacement of item 15. The original item 15 was found to be too easy based on the feedback in the cognitive interviews. Since the original item possibly aimed to decrease stigma, we chose to replace it with an item about the causes of depression that could also have a destigmatizing effect.

Descriptive statistics

630 subjects participated in the study. Before data analysis, 103 data entries were excluded since only the link had been clicked on and no data had been entered. Additionally, 3 subjects were excluded from the analysis because they met an exclusion criterion. Table 2 shows the descriptive statistics of the sociodemographic characteristics of the final sample ( N  = 524). Most participants stated that they became aware of the study through their university or college (53.2%), and some have been approached by friends, family, or acquaintances (28.6%). Other participants were asked to participate through the Institute of General Practice and Health Services Research (10.9%) and some through social media (6.9%). Regarding the gender of the participants, the sample included 370 (70.6%) women and 142 (27.1%) men, 7 (1.3%) participants choosing the option “diverse” and 5 (1%) participants selecting the response option "I do not wish to provide information". The sample's age ranged from 18 to 79 years (M = 32.38; SD = 14.69).

Data from N  = 524 subjects could be included in the statistical analysis; the mean sum score was M  = 16.52 ( SD  = 3.40), the selectivity of the items ranged between r it  = -0.02—0.50, with 15 of the 22 items (68.2%) having a selectivity < 0.30, which can be considered as a moderate degree [ 39 , 42 ]. Since Cronbach´s alpha was α = 0.72 and McDonald's Omega (categorical) was ω = 0.77, the scale's reliability was found to be acceptable. Table 3 shows the descriptive statistics.

The mean completion time of the online survey was M  = 4.36 ( SD  = 1.95) minutes. Since participants could have looked up some of the answers online, a spearman correlation analysis of the completion time and the sum score was conducted. A significant, negative correlation of r  = -0.153, p  < 0.001 showed that a longer completion time was associated with a smaller sum score.

Factor analysis

Based on the Kaiser–Meyer–Olkin coefficient (KMO = 0.77), the data was considered suitable for the factor analysis. In addition, the anti-image matrices of the inter-item correlations had high MSA coefficients (0.51—0.86). The Bartlett's test of sphericity showed that all correlations were significantly different from zero (χ 2  = 1584.35; p  < 0.001; df = 231). Horn's (1965) parallel analysis suggested extracting 5 factors for which eigenvalues are reported above the 95% percentile [ 37 ]. However, because the MAP test extracted only one factor for the minimum mean squared partial correlation (0.01) and since it was assumed that the scale measured the construct depression knowledge, an EFA (algorithm: WLSMV, rotation: oblimin) was first performed for a unidimensional model.

Unidimensional model

Table 4 shows the factor loadings (λ) and commonalities ( h 2 ). The unidimensional structure accounted for 28.5% of the total variance.

A total of 19 loadings were significant at a significance level of p  < 0.001 and two loadings ( λ 2 , λ 16 ) at a significance level of p  < 0.05. The chi 2 test calculated for the general model fit was significant (χ 2 emp,WLSMV (35) = 173.252, p  < 0.001), the model is therefore rejected. Similarly, the fit indices of the single-factor model (CFI = 0.930, RMSEA = 0.087, SRMR = 0.146) failed to meet the cut-off values defined by Hu and Bentler (1999) [ 41 ]. Due to the rather poor model fit, the single-factor- congeneric model was rejected based on the fit indices and the chi2 test.

5-factor-model

Based on the parallel analysis, an EFA was calculated for a multidimensional τ-congeneric model. The 5-factorial structure explained 52.61% of the total variance. The chi 2 test was not significant (χ 2 emp,WLSMV (131) = 92.424, p  > 0.05). The fit indices also indicated a good model fit (CFI = 1, RMSEA = 0, SRMR = 0.07). Although the 5-factorial model seemed to explain the data statistically best, the content of the factors could not be sufficiently depicted, respectively.

3-factor-model

As a result, the model was discarded in favor of a 3-factor model based on theoretical post-hoc considerations regarding the content of the factors. The explained total variance of the 3-factorial model was 42.62%. The proportion of correct answers varied between the factors. The global hypothesis test was significant, χ 2 emp,WLSMV (168) = 199.912, p  < 0.05. The CFI is 0.990, arguing for acceptance of the model, followed in the output, by the RMSEA of 0.019, 90% CI[0.003, 0.029], which meets an acceptable model fit. The SRMR of 0.093 failed to meet the common cut-offs by Hu and Bentler (1999) [ 41 ]. Six items had higher loadings on factor 1, nine items on factor 2, and six on factor 3 (Table  5 ). Item 15 had the lowest loading (λ 15  = 0.04), which did not become significant on any of the factors. This item did not seem to belong to any factor, so it should be removed from the scale in the long term. However, the remaining 21 loadings were significant on at least one factor. Other modified items (1, 3, 12, 13, 16, 18, 19) had factor loadings and communalities of λ = 0.18—0.75 and h 2  = 0.10—0.71. The three highest loadings were on item 8 (λ 8  = 0.89), item 10 (λ 10  = 0.85) and item 22 (λ 22  = 0.80). Item 3 had a double loading on the first (λ 3  = 0.18) and second factors (λ 3  = 0.19).

3-factor-model after removing Item 15

After removing Item 15, which did not have a significant loading on any factor, the analysis was conducted again for the 3-factor model, resulting in a better model fit with χ 2 emp,WLSMV (150) = 156.062, p  > 0.05, CFI = 0.998, RMSEA = 0.009, SRMR = 0.088. The explained total variance of the 3-factor model without item 15 increased to 44.78% and the items still loaded on the same factors as before. The individual factor loadings can be found in the online supplements.

Content identification of the potential factors

Factor 1: distractors and other symptoms.

Factor 1 is composed of items that are predominantly not associated with the construct depression and mainly address symptoms of other mental illnesses. Items 1, 3, 5, 6, 10 and 14 therefore discriminate incorrect from correct knowledge about depressive symptoms.

Factor 2: depressive symptoms

This factor represents items that primarily ask about depressive symptoms (2, 4, 7, 8, 9, 11, 13, 16, 19). Item 16 had the lowest communality and more likely corresponds to the treatment of depression.

Factor 3: pharmacological and psychotherapeutic depression treatment

This factor contains items regarding the pharmacological or psychotherapeutic treatment of depression (12, 17, 18, 20, 21, 22). Item 15 did not seem to be connected to any factor.

Sociodemographic subgroup analyses

There was no significant influence of age on the number of correct answers. Due to the very small number of cases in the gender groups ‘divers’ and ‘no information’, only the gender groups of women and men were compared. There were statistically significant differences between the two gender categories (t Welch (237,45) = 4.37, p  < 0.001, d = 0.45), with females averagely scoring 1.5 more correct responses than males. Differences in the sum score depending on the level of education were analyzed by a t-test for the two most predominant groups of education, Abitur and secondary school. The results of the Welch test showed no statistically significant differences between the groups. Using the Mann–Whitney U-test, a significantly higher sum score was found for people who had already sought treatment for mental health problems compared to people without treatment experience (U = 21,494, Z = -6.771, p  < 0.001, r  = 0.30). Also, using the Mann–Whitney U-test, a significant difference was found between the group that had been in depression treatment before and the group without previous depression treatment, with higher scores in the first group (U = 14,494, Z = -5.71, p  < 0.001, r  = 0.25). Additionally, another Welch test revealed statistically significant differences between the group that had already been affected by depression themselves or had someone close to them who was affected and the group without any experience depression (t Welch (175,81) = 6.54, p  < 0.001, d  = 0.74). Individuals who had experience of depression, scored on average 2.4 more correct responses than those without experience. Significant mean differences were also found between the different career fields (technical, social, economic, health sciences, humanities, natural sciences, law, other field of activity, not specified) using a one-factor ANOVA with post-hoc tests (Dunnett-T3) (F(8, 515) = 132.28, p  < 0.001, η 2  = 0.174, 95% CI[0.108, 0.221] and are depicted in Table  6 .

In the present study, we revised and examined the German Depression Literacy Scale [ 7 ] regarding its factoranalytic and psychometric values. As recommended by Freitag et al. (2018) [ 7 ], we conducted the revised German Depression Literacy Scale [ 27 ] in a convenient sample.

The parallel analysis within the EFA revealed a 5-factorial structure of the D-Lit-R German scale, contrary to the assumption that depression knowledge could be a unidimensional construct as it had been extracted by the MAP test. After examining the unidimensional model and reviewing the fit indices, the assumption of a single-factorial structure was rejected. Although the 5-factor model fitted the data better than the unifactorial model, we could not make sense of the content of a 5-factor model. We chose the 3-factor model because it is a good trade-off between interpretability and model fit. Freitag et al. (2018) postulated that the original German version contained items regarding depressive symptoms and knowledge of other psychological symptoms [ 7 ]. These two categories were also reflected by the results of the present study. Jorm (2012) defines mental health literacy as a composition of many factors:1. knowing how to prevent mental disorders, 2. recognizing when a disorder is developing, 3. knowing what help-seeking options and treatments are available, 4. knowing which effective self-help strategies for milder problems exist, and 5. having first aid skills to support others who are developing a mental disorder or are in a mental health crisis [ 43 ]. Two of these domains could be identified in the 3-factorial model in the present study. One factor (factor 2) contained items testing knowledge about depression symptoms. The other factor (factor 1) also entailed items that tested symptom knowledge but related to symptoms of other mental disorders. As mentioned above, the third factor asked for items related to treatment knowledge. Treatment knowledge (factor 3) and symptom knowledge (factors 1 and 2) are only two of the essential components of depression knowledge [ 7 , 43 ]. The other constructs subsumed under depression knowledge, such as prevention knowledge, help-seeking knowledge, and informal support options [ 43 ], were not represented in the modified D- Lit-R German scale.

These findings complement the literature on studies that translated and validated the original D-Lit scale into other languages. The factors extracted by the factor analysis we conducted are similar to the results of Jeong et al. (2017) [ 44 ], which also retained 3 factors for their revised 21-item Korean version of the D-Lit scale: 1) misperceptions about depression and its treatment; 2) knowledge about depression; and 3) knowledge about the treatment of depression. Other studies have detected either a 5-factor model [ 45 ] with factor domains similar to what we suggested or a 1-factor model, covering depression literacy as a one-dimensional construct [ 46 , 47 ].

In the present study, we aimed to adapt and revise the scale to increase the comprehensibility and correct items that were not aligned with the S3 guidelines. Furthermore, we tried to match the items of the scale to the topics that will be presented in a psychoeducation program in a subsequent study, which concerns improving depression care in general practices. Since most translations had been adapted for cultural aspects [ 44 , 45 , 46 , 48 ], the different versions might, in fact, represent different domains of depression literacy. To create a scale that represents all of the domains of depression literacy based on the MHL definition by Jorm (2012), further studies should adapt the D-Lit scale according to his definition.

For our final version of the D-Lit-R German scale, we recommend excluding Item 15 since it shows a low selectivity, and excluding it increased the explained total variance. Compared to the reliability of the original German version of the D-Lit-German scale (α = 0.75) [ 7 ], the reliability of our scale in the present study (α = 0.72; ω = 0.77) was similar. The reliability analysis of the English version revealed a Cronbach's alpha of 0.70 with a test–retest reliability of 0.71 [ 24 ] and is slightly below the reliability of the D- Lit-R German scale [ 27 ]. A majority of almost 75% of the respondents answered the questions correctly, which is notably higher than the 50% correct response rate detected by Freitag et al. (2018) [ 7 ]. Respectively, the percentage of correct answers for symptom knowledge, which excludes incorrect symptoms (factor 1) and identifies correct symptoms (factor 2), was 71% and 91%. This means that the sample has a high level of symptom knowledge. Compared to that, only 38% correctly answered questions regarding the possible third factor, which is depression treatment (pharmacological and psychotherapeutic treatment). This supports findings from previous studies on depression knowledge [ 7 , 49 , 50 ] and implies that the present sample seems to have less knowledge regarding guideline-based treatment.

To our knowledge, the present study is the first attempt to analyze the factor structure of the German D-Lit scale. Having an instrument to measure depression literacy without using case vignettes is important to enable standardized research since most studies use different kinds of case vignettes, which often leads to results that are difficult to compare [ 51 , 52 ]. Although it was possible for researchers like Makowski et al. (2021) [ 15 ] to gain representative results on depression literacy by using case vignettes, this approach requires many resources. By revising the German D-Lit scale, we promote the extensive usage of this short and time-saving scale in German mental health research. Furthermore, we replaced misleading items with items that matched to a cognitive-behavioral depression psychoeducation [ 26 ]. Therefore, it could be expected that the scale can also be useful to measure the growth in depression literacy after other interventions to increase depression literacy since most interventions are based on cognitive-behavioral therapy concepts [ 53 ]. According to the stage model of Wright et al. (2015), involving patients in the adaptation process of a questionnaire can be classified as a preliminary stage of patient and public involvement (PPI) [ 54 ]. By conducting cognitive interviews with patients, we aimed to promote a participatory research approach, which cannot yet be regarded as standard in Germany [ 55 ].

Limitations

The study has some limitations, one of which is due to the online nature of the study. Because the study was online, subjects could search for the correct answers while completing the scale to achieve a better test result. Due to this limitation, we calculated a correlation between the processing time and the total score. Processing time correlated negatively with the total score. This could mean that participants who knew less about depression spent more time thinking about the answers and had a longer processing time. However, it might be that those who knew less would have scored even worse if they had not used the processing time for research. In the future, a time limit should be implemented to prevent this possible bias. Despite the achievement of the minimum sample size, the sample was not representative (young average age, high level of education). Since we conducted the scale on a convenient sample, due to the online nature of the study, younger participants might have had easier access to the study. Furthermore, women are shown to participate in online surveys more often than men [ 56 ]. This was also the case in our study, which might have led to higher depression knowledge since women have higher depression knowledge and mental health literacy in general [ 6 , 7 , 57 , 58 ]. The high proportion of correct answers could also be traced back to the educational level of the sample, which was above average. In addition, 77% of individuals reported having depression experience, and 43% reported having treatment experience. Overall, 21% of the respondents were undergoing treatment for their own depression at the time they participated in the study. This aligns with the results from insurance fund routine data in Germany [ 4 , 59 ], but could also have been favorable for a higher depression knowledge. To summarize, the results of this study are not representative of the general population, as the people included in the study were predominantly young, highly educated, and female.

Nevertheless, our results can suggest a preliminary factor structure that should be tested again using a representative sample. Further studies should focus on more inclusive strategies to recruit participants and consider implementing the scale in a paper-based format. Instead of focusing on universities or other educational institutions for recruitment, health care centers, e.g., general practices, community health care centers, or clinics, should be considered. Also, to avoid only attracting people who have already experienced depression, the topic of the research project should not be revealed until the end of the survey. Considering the moderate selectivities of the items, the absence of an analysis of the test–retest reliability, and the limitations regarding the study population, the German D-Lit-R scale [ 27 ] still has to undergo further development and evaluation.

In the present study, we revised the Geman Depression Literacy scale and evaluated the psychometric values and factor structure of it in a convenient sample. The results indicate that the D-Lit-R German scale measures knowledge of 1) symptoms of depression, 2) symptoms of other psychological disorders that have to be distinguished from depression, and 3) the treatment of depression (pharmacological and psychotherapeutic). The scale conveys satisfactory reliability and can be easily applied since it is very time-saving and standardized. Due to several limitations, such as the limited generalizability resulting from our convenient sample, the scale should be conducted again in a more representative population. Also, further revision is needed to construct a scale that can capture all aspects of depression literacy as defined in the literature and can be used for follow-up measures.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author upon reasonable request.

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Acknowledgements

The authors acknowledge and thank all participants of the study. Furthermore, we also acknowledge and thank Prof. Dr. Barbara Juen for supervising this work. Also, we would like to thank Kathleen Griffiths and Simone Freitag for giving her permission to use their versions of the depression literacy scale.

*** The POKAL-Group (PrädiktOren und Klinische Ergebnisse bei depressiven ErkrAnkungen in der hausärztLichen Versorgung (POKAL, DFG-GrK 2621)) consists of the following principle investigators: Markus Bühner, Tobias Dreischulte, Peter Falkai, Jochen Gensichen, Peter Henningsen, Caroline Jung-Sievers, Helmut Krcmar, Kirsten Lochbühler, Karoline Lukaschek, Gabriele Pitschel-Walz, Barbara Prommegger, Andrea Schmitt and Antonius Schneider. The following doctoral students are members of the POKAL-Group: Katharina Biersack, Constantin Brand, Vita Brisnik, Christopher Ebert, Julia Eder, Feyza Gökce, Carolin Haas, Lisa Hattenkofer, Lukas Kaupe, Jonas Raub, Philipp Reindl-Spanner, Hannah Schillok, Petra Schönweger, Clara Teusen, Marie Vogel, Victoria von Schrottenberg, Jochen Vukas and Puya Younesi.

Open Access funding enabled and organized by Projekt DEAL. Open Access funding enabled and organized by Projekt DEAL. The research reported in this publication was supported by the German Research Foundation (DFG-GrK 2621/POKAL-Kolleg).

Author information

Gökce Feyza and Jais Denise contributed equally to this work and share the first authorship.

Authors and Affiliations

School of Medicine and Health, Department of Clinical Medicine, Technical University Munich, Institute of General Practice and Health Services Research, Orleansstraße 47, 81667, Munich, Germany

Feyza Gökce, Denise Jais, Antonius Schneider & Gabriele Pitschel-Walz

Department of Psychology, LMU Munich, Leopoldstr. 13, 80802, Munich, Germany

Philipp Sterner

Institute of General Practice, LMU Munich, Nußbaumstraße 5, 80336, Munich, Germany

Jochen Gensichen

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• Markus Bühner
• , Tobias Dreischulte
• , Peter Falkai
• , Jochen Gensichen
• , Peter Henningsen
• , Caroline Jung-Sievers
• , Helmut Krcmar
• , Kirsten Lochbühler
• , Karoline Lukaschek
• , Gabriele Pitschel-Walz
• , Barbara Prommegger
• , Andrea Schmitt
• , Antonius Schneider
• , Katharina Biersack
• , Constantin Brand
• , Vita Brisnik
• , Christopher Ebert
• , Julia Eder
• , Feyza Gökce
• , Carolin Haas
• , Lisa Hattenkofer
• , Lukas Kaupe
• , Jonas Raub
• , Philipp Reindl-Spanner
• , Hannah Schillok
• , Petra Schönweger
• , Clara Teusen
• , Marie Vogel
• , Victoria von Schrottenberg
• , Jochen Vukas
•  & Puya Younesi

Contributions

FG and DJ contributed equally to this work and thus share the first authorship. FG, GPW and DJ designed the study; DJ acquired and analyzed the data; PS assisted in analyzing the data; PS, GPW and FG assisted in the interpretation of the data. FG drafted the manuscript. FG, GPW, PS, AS and JG were involved in revising it critically and all authors have read and approved the final manuscript.

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Correspondence to Feyza Gökce .

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Before data collection, the study was assessed and approved by the ethics committee of the Technical University of Munich (TUM). All methods were carried out in accordance with relevant guidelines and regulations.

Internal reference number of the Ethics Approval: 2022-84_1-S-SR.

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All participants confirmed their informed consent before taking part in the study.

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Gökce, F., Jais, D., Sterner, P. et al. The revision and factor analytic evaluation of the German version of the depression literacy scale (D-Lit-R German). BMC Psychol 12 , 235 (2024). https://doi.org/10.1186/s40359-024-01730-9

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A qualitative study of the barriers to commissioning social and therapeutic horticulture in mental health care

• Carly J. Wood 1 ,
• Georgina Morton 1 ,
• Kathryn Rossiter 2 ,
• Becs Baumber 2 &
• Rachel E. Bragg 1 , 3  

BMC Public Health volume  24 , Article number:  1197 ( 2024 ) Cite this article

Metrics details

Social and Therapeutic Horticulture (STH) is a process where trained practitioners work with plants and people to improve an individual’s physical and psychological health, communication and thinking skills. Evidence suggests that STH can support individuals with mental ill-health, however, current commissioning of STH within mental health care is limited. This study aimed to understand the barriers to commissioning STH in mental health care and to identify potential solutions to barriers, to support more widespread availability of services. 

Individuals with a role in mental health care commissioning from across the UK were invited to take part in semi-structured interviews via zoom. Interviews explored factors influencing the mental health services they commission or refer to, their perception of the role of STH in mental health care and the barriers to commissioning STH, together with potential solutions to any barriers identified.

Commissioners identified a lack of knowledge of STH and evidence of its effectiveness, and a culture which prioritises traditional medical models, as barriers to commissioning. Challenges for STH providers in responding to large-scale commissioning requirements were also highlighted as a barrier.

Conclusions

To upscale commissioning of STH in mental health care, STH interventions need to be embedded within NHS priorities and information on STH services and their effectiveness needs to be easily accessible to practitioners. The sector should also be supported in working collaboratively to enable commissioning of services at scale.

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Mental health is defined as “a state of well-being in which every individual realises their own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” [ 1 ]. Mental illness or mental ill-health is characterized by a clinically significant disturbance in an individual’s cognition, emotional regulation, or behaviour, that is associated with distress or impairment in important areas of functioning, such as work, daily activities, or personal relationships [ 2 ]. The NHS identify five mental health levels which capture both mental health and mental illness on a continuum [ 3 ], moving from Level 0, where a person can take their own decision to independently improve their mental health and wellbeing, through to level 4, a person who is experiencing acute mental health crisis or who has a long-term serious mental illness. It is expected that people move through the different mental health levels either on a recovery pathway, or during times when mental health worsens and an increased level of intervention is required.

Common treatment approaches for mental health levels 2 and above include medication and psychological therapies [ 4 ]. However, medications such as anti-depressants may only provide significant positive effects for severe depression (level 4) [ 5 ] and have side effects or withdrawal symptoms [ 6 ]. Recent clinical trials also indicate that the efficacy of psychological therapies such as cognitive behavioral therapy (CBT) has diminished [ 7 ] whilst long waiting lists [ 4 ], can leave individuals without treatment for significant periods of time.

Social and Therapeutic Horticulture (STH), a process where trained practitioners work with plants and people to improve an individual’s physical and psychological health, communication and thinking skills [ 8 ], is one type of nature-based intervention (NBI) that is used to support individuals with mental ill-health. Although often used as an umbrella term for all gardening activities that target health and wellbeing, STH represents more targeted gardening activities that support individuals at mental health levels 2 and 3, typically provided by the voluntary, community and social enterprise (VCSE) sector. More specialised provision (termed ‘horticultural therapy’) for level 4 mental health needs where patients are typically in hospital or in-patient settings, and less specialised social gardening for level 1 needs is also available.

To date, multiple systematic reviews and meta-analyses have been conducted on the benefits of gardening and STH activities, reporting reductions in symptoms of depression and anxiety, reduced stress and mood disturbances, and improved quality of life, life satisfaction and community belonging for a range of groups, including the general public, patients with a range of physical illnesses, those with poor mental health, symptoms or diagnoses of mental illness [ 9 , 10 , 11 , 12 , 13 , 14 , 15 ]. In a recent review of randomised controlled trials (RCTs), Briggs, Morris, and Rees [ 16 ] revealed an overall positive effect of STH interventions for depression and wellbeing, with half of the included studies involving individuals with a diagnosis or symptoms of mental illness. Despite the positive findings from this review, much of the existing evidence of the benefits of STH is focused on gardening and gardening activities for individuals at mental health level 0 and 1. There are fewer published scientific studies specifically focusing on individuals at mental health levels 2–4 who would need to be referred to STH interventions. Furthermore, most published studies use pre-post design methodologies without control groups, and incorporate a variety of outcome measures, thus making it difficult to combine findings across studies.

Despite evidence of the benefits of STH for a range of populations, and an increased interest from the Government and NHS [ 17 ] in the health and wellbeing benefits of engaging with nature, referrals to STH are not widespread from the NHS or within social prescribing schemes [ 18 ]. Current commissioning of NBI such as STH are primarily from the local authority, social services, self-referrals, special education, and Community Mental Health Teams [ 18 , 19 ], rather than routinely from general practitioners (GPs) or other clinicians. The NHS commissioning cycle involves a continual process of (i) strategic planning (to identify needs, review provisions and decide priorities); (ii) procurement of services and (iii) monitoring and evaluation [ 20 ]. Given that the NBIs have been highlighted as a key priority for improving mental health [ 17 ], wider commissioning might be expected. However, Shaw et al. [ 21 ] highlighted that commissioning for long term conditions is labour intensive for commissioners, with the scale and intensity of the work often not being proportionate to the service gains. It was also reported that commissioners were less comfortable with the transactional elements of their role, such as decommissioning services or seeking new providers [ 21 ]. These factors might act as barriers to commissioning of STH for mental health.

There has recently been a fundamental shift in the way that the health and care system is organized in the UK. In July 2022, Integrated Care Systems (ICS) were given statutory status, with Integrated Care Boards (ICBs) being set up to take on the NHS planning functions previously held by clinical commissioning groups, enabling joined up working and partnerships between health and social care and VCSE organisations [ 22 , 23 ]. It was hoped that this shift might result in increased commissioning of services based in VCSE sector, however, there also may be unique and unknown challenges experienced within this new structure. The aims of this study were therefore to (i) understand the barriers to commissioning STH in mental health care and (ii) identify potential solutions to these barriers to support more widespread availability of services.

To understand barriers to commissioning STH in mental health care, a combined deductive and inductive qualitative approach was used [ 24 ]. Semi-structured interviews, a common qualitative method, were conducted to obtain in-depth information about the experiences and perspectives of individuals with a role in mental health care commissioning. The interviews were conducted by a research assistant trained in qualitative data collection techniques and analysis.

Study context

Potential participants were identified by the research team and members of the Therapeutic Horticulture Stakeholder Group (THSG), a group established by Natural England in March 2022 with support from The National Academy of Social Prescribing (NASP), to explore how to grow the Therapeutic Horticulture offer and to support the scaling up of Green Social Prescribing (GSP) [ 25 ]. The group (currently chaired and convened by Thrive with support from Natural England) brings together leading organisations and professionals in this field with representation from Natural England, The National Academy of Social Prescribing (NASP), NHS England, academics, health care professionals, and organisations who support the provision of STH. With permission, THSG members provided the research team with the email addresses for individuals with a role in mental health care commissioning who might be interested in taking part in the research.

Recruitment

Individuals were purposively selected for participation in the research based on their job role to ensure representation across mental health ‘commissioning’ roles, including individuals who refer individual patients to mental health services through to those in senior positions with responsibility for commissioning regional mental health services. Participants were also selected to incorporate the perspectives of individuals both with and without experience of commissioning or referring to STH interventions and from across multiple regions of the UK. All potential participants were contacted via email by a member of the research team and provided with information about the study via a participant information sheet. Potential participants also shared information about the research with their colleagues who were also invited to take part in the study. A combined purposive and snowballing sampling approach was therefore used, two sampling techniques that are commonly combined [ 26 ]. In total 22 participants were invited to participate in the study.

Prior to participation in the research, participants were sent the definition of STH [ 8 ] and the mental health levels [ 3 ] to aid discussion of the role of STH in mental health care and to ensure consistency in their understanding of both STH and the NHS mental health levels. All participants provided informed consent prior to participation in the study and reconfirmed their consent at the start of the interview. Ethical approval was granted by Ethics Sub-committee 2 at the University of Essex (ETH2223-0519). Regulations regarding data management and storage were adhered to throughout the research.

Characteristics of participants

Nine participants provided consent to take part in an online semi-structured interview via zoom, including five males and four females. Participants were from a range of roles related to mental health care, with some participants referring individual service users to local services and others commissioning services for an entire region. Participants were a link worker, a GP, a consultant psychiatrist, a clinical psychologist, a commissioner of mental health services for children and young people, a community mental health team project manager, director of adult mental health, head of commissioning and policy, and a mental health programme lead. Most participants ( n  = 5) reported having a general awareness of GSP and NBI but no expertise in STH, whilst the remaining participants ( n  = 4) reported extensively researching STH and commissioning or supporting STH-type services. Participants were from multiple regions across the UK (with two participants spanning two regions), including Essex ( n  = 4), Suffolk ( n  = 1), Lancashire ( n  = 1), South Cumbria ( n  = 2), Somerset ( n  = 1), Kent ( n  = 1) and Manchester ( n  = 1).

Semi-structured interviews were conducted between February-April 2023. Interviews were conducted electronically in a private space at the participants and researcher’s place of work or in their homes. Interviews lasted between 17 min and 47 min, with this variation in duration resulting from the mixed experiences of STH amongst participants. Interviews were recorded using Zoom software and automated transcripts downloaded, checked, and corrected by the research assistant prior to analysis. All participants were asked about their job role, the factors that influence the mental health services they commission or refer to, their perception of the role of STH and the barriers to commissioning STH, together with potential solutions to any barriers identified. The topic guide used in the interviews is included in Appendix 1 . This guide was developed by the authors, in line with the study aims, with feedback provided by the THSG to refine the final interview guide.

Data were managed and coded using NVivo software version 12 (QSR International Pty Ltd., Doncaster, Australia, 2018). Transcripts were coded using reflexive thematic analysis, following the phases of Braun and Clarke [ 27 , 28 ]. Initially, two interview transcripts were coded independently by two authors (CJW, GM) and following discussion, a coding framework was developed and used to code the remaining transcripts. The coding framework was revised as coding continued. Themes were actively produced through exploration of the data and codes, and subsequent discussions between the wider research team.

As data analysis progressed and themes developed, the researchers discussed their own assumptions of the codes and themes. The researcher with the least experience in the mental health benefits of STH carried out the primary analysis to ensure that there was the least bias in the coding of the data. In the final stage of the analysis, four overarching themes were identified, each of which are described in detail below and include funding and workforce (theme 1), commissioning culture (theme 2), knowledge of STH (theme 3) and evidence of effectiveness (theme 4). Within these themes both the barriers to commissioning STH in mental health care (aim 1) and potential solutions to the barriers raised (aim 2) are discussed.

Theme one: funding and workforce

A lack of funding available for mental healthcare in the NHS was referred to as a key challenge for commissioning by most participants. Participants referred to a reduction in investment in mental health services over the last decade and reflected that a consequence of the reduced investment was that the NHS was “ trying to do more with less ”. Commissioning decisions were therefore suggested as being based around what can be delivered given the finances available and ensuring that commissioned services are “ cost effective ”. Commissioners were reported as being left in a position where they must commission based on what they can afford to provide rather than based on what they perceive to be best for their population.

In relation to STH specifically, most participants reported that the limited budgets available for mental health care result in sustainable and longer-term funding being a persistent problem for VCSE organisations. This was thought to result in the short-lived nature of STH services and high staff turnover. The lack of consistency in the offer across regions was also thought to compound this problem. Participants commented on the need to commission services that can cater for the entire population for which they commission, with “ pockets of services” making it difficult to do so. These “ pockets of services ” were deemed as not always being in areas where they were most needed, being less cost-effective, not being accessible for all and potentially requiring transportation to reach, which may pose financial issues for both individuals and organisations.

“They don’t want to be having just one project in one corner of their patch. They want to be able to say we’re doing this across the whole county.” (General Practitioner)

It was suggested that partnership working within the VCSE sector would enable a more consistent offer and a larger “ footprint” across regions, which would support access to larger funding streams, the growth of smaller VCSE organisations and subsequently wider scale commissioning of services.

Similar to a shortage of funding, most participants referred to a lack of workforce and resources within mental health services. One participant referred to a “revolving door of personnel” , resulting in continued staff shortages, whilst another referred to the constant juggling of resources. These issues were suggested to be a barrier to commissioning of new services such as STH.

“...new idea is...something they've not got time for as they’re so bogged down, it’s just kind of surviving day to day really. It’s almost too much to start thinking about something new, like a new nature-based therapy group.” (Clinical Psychologist)

One participant reported that the loss (and lack of replacement) of staff in particular roles essential to furthering the NHS Trusts green plans and working with the VCSE sector, further limited commissioning of STH. It was felt that embedding sustainability roles into Trusts would save money and that having directors and ‘champions’ who have a personal interest in sustainability, would help to influence commissioning boards and push the sustainability and STH agenda forward. However, the association between sustainability roles and commissioning of STH was only made by one participant, making it unclear to what extent these are reliant upon each other.

It was also reflected by one participant that the underfunding and understaffing issues within the NHS might present a key opportunity for the VCSE sector to assist in providing mental health care if it is given the chance, with another participant referring to the “missed opportunity” within their Trust to use small pots of funding to support the VCSE sector.

Theme two: commissioning culture

Several participants suggested that commissioned mental health services are driven by national requirements set out by the NHS and in the long-term plan [ 29 ] and that services such as STH are “not really embedded in national must dos…” Rather than facilitating a holistic approach to commissioning, the NHS guidelines (combined with the underfunding and under-resourcing of mental health care) were thought to limit the capacity of commissioners to allocate funding for services within the VCSE sector. Participants emphasised the need to see “ green initiatives ”, “ efforts ” and “ schemes ” within these national plans to support the commissioning of STH.

The commissioning culture of a “focus on reactive treatments rather than prevention” , was also reflected as a barrier to commissioning STH, with several participants discussing prevention of mental illness in relation to STH. Traditional approaches and therapies (i.e., talking/cognitive and drug therapies) were suggested as being prioritised, with a need to shift towards more preventative and holistic treatment in order for services like STH to be fully embedded.

“I think what we’re trying to do is stop the knee-jerk reaction to ‘we have to plug a gap over here’ and thinking about it more creatively and that’s what we’re trying to do. But it’s a big shift for the system, and it’s really easy to just keep throwing money at something that is a traditional approach to fixing something”. (Commissioner of mental health services for Children and Young People)

Some participants also suggested that STH should be embedded at every level of mental health care, allowing patients at all levels of mental health need to be referred to VCSE sector services and via a number of different referral pathways.

“It’s obvious, you build it in at all levels of referral...before GP, at GP, at IAPT [Increasing Access to Psychological Therapies], at secondary care. You just open the doors, and it would be successful. Reduce the demand on the NHS” (Consultant Psychiatrist).

It was felt that this approach would support individuals in accessing STH services, but that in order for it to be embedded at every level there would need to be “buy-in” from commissioners.

Theme three: knowledge of STH

Whilst all participants felt that there was a role for STH in mental health care, a lack of knowledge of STH by individuals with roles in referrals and commissioning was reported as a barrier to commissioning. While some participants within the study demonstrated or reported good knowledge of what STH is, the services available, and the range of mental and physical health benefits it could provide, this was cited as not being the case for all individuals within their organisations, where there was a mixture of different levels of knowledge. Some study participants also reported (or demonstrated) that they personally had limited knowledge of what STH is, who it is for and/or the evidence base surrounding the health benefits. There were some perceptions that STH would only appeal to certain groups and that it could only play a role in mental ill-health prevention or maintenance rather than in treatment, which contradicts the evidence supporting the use of STH in health care.

“This type of activity probably appeals to people in a particular demographic...I'm not necessarily convinced that people in their twenties and thirties would think of that as a go-to for leisure, pleasure, or seeing that as something that would benefit them..”. (Head of Commissioning and Policy)

The limited knowledge of STH was largely attributed to a lack of available information from providers of STH about the benefits of their services, who they are targeting, and how risk is managed. Most participants reported not receiving information or it not being readily available or easily accessible amongst the large volume of information that commissioners already receive. Some participants also referenced the need for the VCSE sector to promote or ‘champion’ their services and directly approach the NHS to highlight what they were doing within the community and to identify how this might align with ongoing NHS agendas.

“We need to be able to understand what the offer is, and it’s not always clear what community assets are available, and so I think the sector could do a better job for sure of collating those offers. But we need to understand what it is, what the needs are, what the value is, and how we can support it in a financially challenged environment.” (Community Mental Health Team Project Manager)

Overall, participants felt that greater and more effective sharing of information on STH and communication with commissioners was needed for STH to be commissioned more widely.

“Why are we not doing it? We don’t really know what they’re doing”. (Link Worker)

This was felt to be particularly important given that commissioners do not typically get training in STH.

Theme four: evidence of effectiveness

Evidence was highlighted as a factor influencing commissioning by all participants involved in the study, but to varying degrees and in varying contexts, perhaps reflecting differences in the knowledge of participants. Evidence of the effectiveness of STH was perceived by several participants as lacking in quantity and quality, with some reference to the need for high quality studies. Some participants also referred to a lack of awareness of evidence of the benefits of STH, in line with a lack of knowledge of STH broadly (Theme 3). However, one participant with extensive experience of STH, said that lack of evidence in relation to the benefits of STH was not the issue but rather a lack of evidence of how STH can “ structurally work within government commissioned services ”, alluding to potential difficulties in embedding services such as STH throughout the healthcare system.

Some participants also referred to the differences in evidence between levels of mental health need and how it was not necessarily effective for all mental health conditions, with one participant stating that it is not a “universal panacea” . One participant referred to the evidence of STH for severe and enduring mental illness and that whilst there was evidence to support its use, it was not widely publicised. Participants felt that evidence of the benefits of STH needed to be shared widely, easy to access and regularly updated.

“..the longer you work as a doctor, the less you become an academic because you become a clinician, so it’s less easy to access all that information. So, it’s a bit difficult to kind of prove to people that there is some decent evidence.” (Consultant Psychiatrist)

Several participants also referred to key performance indicators that the NHS are measured against and the need for STH services to have measurable outcomes that align with these indicators, for example the Warwick Edinburgh Mental Wellbeing Scale. A number of participants also commented that these outcomes should be focused on the effect STH has had on the individual patient, instead of statistics like waiting, access and discharge rates, which do not identify whether the patients’ condition has improved. However, there were also contradictory points highlighting that commissioning decisions were typically based around referral and discharge rates, the longer-term impacts on the healthcare system, and cost savings for the NHS, with these statistics being easier to examine than the impacts on patients.

As a result of challenges over measurement of outcomes and impact, some participants suggested changes to the ways that STH providers collect and provide evidence. Participants recommended that the sector focuses on providing qualitative evidence such as “ case studies ”, “ vignettes ” or “ user experience voices ” that tell “ the positive story ” of the impact their service has for the individual.

“...Health has a high bar for reporting, and we need to be able to prove that something has had an impact.. We can’t do the same thing really, with some of the green investments that we make. And so, I think we need to understand how we can evidence the impact it’s had, and it doesn’t always need to be data driven ...There are number-driven discussions, or data driven discussions. What is missing in that room is the patient’s story and the impact. And I think that’s where the third sector could really help us bring this to life.” (Community Mental Health Team Project Manager)

However, this type of evidence was acknowledged as being difficult to accomplish and often limited by the infrastructure of the organisations who may not have the capacity to collect this information. One participant suggested that if this evidence was available, the use of a video to demonstrate the impact on patients might be a technique that would “sell” the service to commissioners.

The aims of this study were to (i) understand the barriers to commissioning STH in mental health care and (ii) identify potential solutions to these barriers to support more widespread commissioning of STH services. The key themes that were produced from the data were issues around funding and workforce which prevented widespread commissioning of STH, a commissioning culture which makes it difficult to commission ‘non-traditional’ treatments, a lack of knowledge of what STH is and how it can be used, the services available, and a lack of [awareness of] evidence to support its effectiveness. There were a number of suggestions as to how these barriers could be overcome, most of which are likely to require systems-level change by both the NHS and VCSE sector.

In relation to funding and workforce, the continued reductions in funding for mental health care were identified as a key barrier to commissioning STH. This finding is mirrored in the recent evaluation of the Government’s GSP pilot, which identified unstable short-term funding and lack of system level support for the sector as a barrier to embedding GSP within statutory systems [ 22 ]. Furthermore, the recently established, ICBs, which were designed to support greater partnership working with the VCSE sector, have been asked to make a further 30% reduction in their running costs [ 30 ]. As a result, funding and resources for mental health services are likely to become even more stretched, further restricting commissioning of new services.

In the UK most NBIs, including STH, sit within the VCSE sector and are typically delivered by small-scale providers, allowing for a more bespoke, person-centred service [ 22 , 31 ]. However, this approach makes it difficult for STH providers to respond to large-scale commissioning requirements and combined with the funding and resources issue, is likely to result in commissioners continuing to consider STH as a less viable option for mental health care. Thus, it is essential that STH providers work in partnership to demonstrate the ‘offer’ for services they can provide on a regional scale [ 32 , 33 ]. This collaborative approach could be supported and facilitated through the use of regional nature-based VCSE networks such as the Norfolk Green Care Network [ 34 ] and the Reading Green Wellbeing Network [ 35 ]. These networks can promote partnership working between providers, become potential commissioning hubs and could enable providers to work together to apply for larger funding opportunities. Voluntary networks such as these could also help ICBs proactively engage with VCSEs but would need investment and support at the system-wide level to ensure sustainability.

Commissioning culture within the health service was also identified as a key barrier to commissioning of STH. Despite a commitment to increase use of personalised care, social prescribing, and community centred approaches for health and wellbeing across multiple Government and health organisations [ 36 , 37 ], the NHS long plan [ 29 ], which outlines the key priorities from 2019 to 2024, does not embed the use of these approaches as priorities. Instead, it prioritises helping people to get easier access to therapy for common mental disorders such as anxiety and depression; despite evidence to suggest diminishing effectiveness over time and poor outcomes for some groups [ 7 ]. Without community-based approaches being embedded within national plans, participants felt they had limited capacity to commission the VCSE sector.

The recently published NHS major conditions strategy case for change and strategic framework [ 38 ] calls for a focus on integrated working with community-based partners as part of the future long term conditions strategy, and a commitment to accelerating research to understand how mental, physical, and social conditions interlink and how they can be treated. Given that services such as STH can target mental, physical, and social needs simultaneously [ 39 ], it is possible that this focus may result in increased use of holistic services such as STH. However, until the full long-term conditions strategy is released, it is unclear how these approaches will be embedded and prioritised. As highlighted by participants, for interventions such as STH to be successful, they need to be embedded at every level of mental health care, allowing multiple entry points into the VCSE sector. The trend for prioritisation of traditional approaches to mental health care, as also reported by Shanahan et al. [ 40 ] and Tambayah et al. [ 41 ], alongside the suggested reluctance of commissioners in decommissioning services and seeking new providers [ 21 ], also needs to be overcome to promote greater variability in treatment options.

Lack of knowledge and awareness of STH, in a variety of contexts, was highlighted as a key barrier to service commissioning. There were some perceptions that STH would not appeal to all individuals or that it was not suitable for particular groups, for example younger people. A lack of knowledge about what STH interventions entail and the level of mental health need they can be appropriate for, was also highlighted by participants, with some interviewees referring to STH as solely a preventative health measure as opposed to a treatment option for acute and chronic mental illness. Furthermore, a lack of knowledge and awareness of what STH provision is available was identified as a barrier to commissioning. Lack of knowledge of local services has also been identified as a barrier to commissioning NBIs via GSP [ 22 ] and for commissioning STH by clinicians [ 42 ]. As commissioning of new services requires significant partnership working between both commissioners and service providers [ 21 ], this lack of awareness of what STH services are available locally is likely to be problematic.

Shanahan et al. [ 40 ] and Fixsen and Barrett [ 43 ] highlighted that referral and commissioning of NBI is influenced by the knowledge and interest of the GP, termed “GP buy-in” . Thus, individuals may not be offered interventions such as STH unless their health care provider has a particular interest in, knowledge of, or belief in its value. This need for ‘practitioner buy-in ’ is not aligned with traditional approaches where treatments are prescribed as ‘normal practice’ regardless of whether the practitioner has a particular interest in the approach. Providing a means by which practitioners can easily access information about STH services, such as regional or national directories of STH services, which enable identification of interventions across the UK and detail what they involve and who they are for, may facilitate increased awareness, knowledge and ‘ buy- in’ of STH interventions. However, any directory would need to be fully embedded in healthcare treatment, referral, and commissioning systems.

An interesting observation that emerged from the data was also the tendency of participants to refer to STH as green “schemes” , “therapies” or “initiatives” , indicating a perception that all nature-based activities are equivalent as reported by Sempik, Hine and Wilcox [ 44 ]. This is problematic and is likely to compound issues around what types of STH services are appropriate for different levels of need. To address this barrier, a framework for aligning STH provision with the NHS’ five mental health levels has been produced, identifying what types of activities, support, evaluation, and quality assurance are needed at each level, along with examples of beneficiaries across the UK [ 45 ]. To support partnership working, increased understanding and commissioning of STH, this framework should be adopted widely by both the health care sector and STH organisations and utilised in the suggested service directory.

Evidence of the effectiveness of STH was mentioned by all study participants as a factor that influences commissioning. Whilst some referred to a lack of awareness and publicisation of the evidence, as echoed in Tambayah et al. [ 41 ], others reported a lack in quality and quantity, or a lack of evidence for specific mental health levels or conditions. For individuals at mental health levels 0 and 1, there are a range of systematic reviews and meta-analyses demonstrating the benefits of gardening activities [ 11 , 12 , 14 , 15 ]. There are also numerous studies and reviews reporting the benefits for STH for individuals with symptoms of mental illness or diagnosed mental illness, aligning with mental health levels 2–4. However, in many cases this data is combined with data from individuals without mental ill-health, or for a range of mental health disorders [ 13 , 16 , 46 ], making it more difficult to isolate the evidence for specific conditions and those who require mental health intervention. Whilst studies focused on individuals at levels 2–4 with mild to severe mental illness have demonstrated positive effects for depression, wellbeing, quality of life and activities of daily living [ 16 , 47 ], many studies fail to incorporate comparison groups or randomisation procedures. To further enhance the evidence base, well-designed, high quality RCTs are therefore needed, along with sufficient funding to support this level of scientific evaluation.

Whilst there is undoubtedly room for high quality RCTs to further advance the STH evidence base, other accepted interventions in health and policy fields in the UK have not been based on RCT evidence [ 48 ]. There is also a wealth of quantitative and qualitative evidence from the scientific and VCSE sector advocating the effectiveness of STH, much of which utilises measurable outcomes and describes the impact on the patient (as suggested by the study participants). Furthermore, an independent report by the Kings Fund [ 48 ] suggested that gardening-based interventions can have numerous benefits for individuals as an adjunct to their existing mental health treatment, whilst the Wildlife Trusts [ 49 ] demonstrated significant cost savings to the NHS if they were to invest in a ‘natural’ health service, with an estimated an annual cost of £534.1 million per year for delivery against a gross annual cost saving of £635.6 million. Thus, whilst there is need to strengthen the evidence base in specific areas, there is clear evidence of the potential benefit of NBIs such as STH to the health care system and patients. Furthermore, Wye et al. [ 50 ] reported that commissioners experience multiple barriers to using academic research to inform commissioning. As a result, they often utilise NICE guidelines, local evaluations, local clinicians’ knowledge, and service users experiences to inform their commissioning decisions. To support commissioning of STH, existing evidence and knowledge should be integrated into mental health care policy and practice, NICE guidelines, and be more clearly publicised and communicated to commissioners via effective dissemination methods such as infographics and via professional journals aimed at commissioners.

The findings of this study present the perspectives of nine individuals, from a range of commissioning roles and regions across the UK. However, the full range of barriers experienced by individuals with roles in mental health care commissioning may not have been captured. Further research in this field should aim to incorporate the perspectives of individuals involved in the development of mental health policy and NHS senior leaders who have a direct influence on funding decisions, to understand the barriers to prioritising approaches such as STH at a national level. It should also prioritise high quality RCTs for mental health levels 2–4 and for specific conditions, to develop a clearer and more focused evidence base to support commissioning of STH in mental healthcare. The potential solutions to the commissioning barriers highlighted in this research should also be actioned by individuals in health and VCSE sectors to further support the growth and commissioning of STH. This is essential for ensuring a more sustainable mental health system whereby service users can access support when it is needed.

Overall, the findings of this study highlight a range of barriers to the commissioning of STH, including a commissioning culture which priorities traditional medical models, a lack of knowledge of STH broadly (including the services available, levels of mental health need it can cater for and the existing evidence of its effectiveness, particularly for specific mental health conditions), and the challenges for STH providers in responding to large-scale commissioning requirements. To support commissioning of STH in mental health care, the VCSE sector should be supported in developing higher quality evaluation methodology accepted by the NHS and in working collaboratively to enable commissioning of services at scale. Information on STH services and their effectiveness also needs to be easily accessible to practitioners, and STH interventions should be fully embedded within NHS priorities to enable a more holistic health care approach, which has the potential to improve patient outcomes, reduce the strain on mental health services and result in considerable cost savings.

Availability of data and materials

The datasets generated during the current study are available in the REShare repository, with restricted access via https://reshare.ukdataservice.ac.uk/856812/ .

Abbreviations

Cognitive Behavioural Therapy

General Practitioner

Green Social Prescribing

Integrated Care Board

Integrated Care System

Nature-based Intervention

National Health Service

Randomised Controlled Trial

Social and Therapeutic Horticulture

Voluntary, Community and Social Enterprise

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Acknowledgements

The authors like to acknowledge the funder who enabled this study to take place and the participants for their valuable insights. We would also like to thank the THSG for their help with recruitment of participants to the study.

This work was funded by Research England (grant number FN02200).

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CW, KR and RB conceived and designed the study. GM collected, analysed, and interpreted the data. CW also analysed and interpreted the data and drafted the manuscript. GM, KR, BB and RB substantially revised the manuscript. All authors have approved the submitted version.

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Wood, C.J., Morton, G., Rossiter, K. et al. A qualitative study of the barriers to commissioning social and therapeutic horticulture in mental health care. BMC Public Health 24 , 1197 (2024). https://doi.org/10.1186/s12889-024-18621-8

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• Social and therapeutic horticulture (STH)
• Nature-based intervention (NBI)
• Green social prescribing (GSP)
• Mental illness
• Mental ill-health
• Commissioning
• Mental health
• Health care

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