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• ‘They give me joy as I proceed.’ So wrote the 19th century poet John Clare of the footpaths and byways he traversed during his troubled life of mental illness and grinding rural poverty. Clare was the son of a farm labourer; nature – the land – was his everyday working context but also his emotional sustenance in an increasingly industrialised world.
  
  ‘… [T]ravel does not merely broaden the mind. It makes the mind,’ wrote travel writer and author Bruce Chatwin in an essay ‘It’s a Nomad, Nomad World’. Chatwin’s hypothesis was that humans are essentially nomadic and that our increasingly immobile existence is the cause of most of the mental, physical and social ills that plague us today.
  
  Walking and the natural landscape have a long association with mental health and wellbeing. But medical, public health and, most recently, neuroscientific research has in recent decades created a growing body of robust evidence attesting to the benefits of physical activity for mental health.
  
  But not just any physical activity and not just anywhere. This is something that researchers are increasingly discovering. Published in the British Medical Journal in early June, a randomised controlled trial by researchers at Bristol and Exeter universities, in collaboration with Peninsula Medical School, created consternation when it appeared to show that exercise doesn’t help mental ill health.¹ The findings of the TREAD study, widely misreported in the mainstream media, were much more subtle and specific. ‘What the trial actually tells us is that a particular kind of physical activity intervention, alongside normal GP treatment, makes no added difference to mental health outcomes,’ says lead researcher Melanie Chalder, Research Fellow in the university’s Academic Unit of Psychiatry.
  
  Participants in the intervention group were offered the support of a trained physical activity facilitator (PAF) for eight months to help them devise an individualised programme of activities that they felt they could maintain long-term. This was not a formal exercise programme, Chalder emphasises: ‘The physical activity could be almost anything that could be easily incorporated into the person’s everyday routine – dancing, gym, walking, swimming, gardening, running, cycling.
  
  ‘TREAD’s intervention group did report higher levels of physical activity. To that extent, the intervention was a success. What was surprising was that this increase in physical activity made no impact on participants’ depression. Both the intervention and the control group showed considerable improvement in their symptoms; there was no significant difference between the two. So there’s a disconnect there,’ Chalder says.
  
  Future research might usefully explore the levels of intensity at which physical activity does benefit mental health, she believes. ‘It may be that the physical activities participants chose weren’t sufficiently intensive to give a benefit for depression.’
  
  What, where and how?
  What you do, where you do it and the mechanisms at work are where research needs to focus, says Nanette Mutrie, Professor of Exercise and Sport Psychology at the University of Strathclyde. Increasingly, research suggests that the form of exercise needs to be tailored to the individual and that not all physical activity is good for everyone’s mental health. Mutrie’s own research has found, for example, that 20 minutes of vigorous leisure activity up to five times a week is linked with reduced depression scores in men and women.² But, importantly, vigorous physical activity for seven days a week made men more depressed. And there was a very clear link between depression and housework in women – the more housework women did, the more likely they were to be depressed. Interestingly, there was no link between levels of depression and physical activity in the workplace.
  
  ‘We found that each mode of activity had a different relationship with depression scores. What we don’t know from this research, of course, is why,’ Mutrie says. She conjectures that the link between depression and housework may reflect the fact that women who do more housework are spending more time alone at home. Higher frequency of vigorous activity in men may signal a tipping over into compulsive behaviour that carries its own burden of mental distress.
  
  The link between exercise and mental health is, Mutrie argues, the somatopsychic effect: ‘The body in motion has positive effects on how you feel.’ This may be for numerous reasons: endorphin and serotonin levels in the brain that are activated by physical activity; improved confidence and self-esteem from feeling better about your body; a greater sense of control from taking exercise to improve mood rather than just taking an antidepressant; improved physical health or, quite simply, as Bruce Chatwin argued and Mutrie also believes, because that is how we are designed by Mother Nature (or evolution). ‘Technology – cars, trains, labour-saving household appliances – and modern architecture and environmental planning and design are increasingly removing natural activity from our daily lives. I am convinced that is related to the increases we see in depression. Our bodies are not active enough in the course of our everyday lives to trigger these chemical mechanisms in our brains. Just putting walking back into daily life would make a big difference to mental health,’ Mutrie argues.
  
  There is also hard evidence that physical activity protects against brain neuron death and can actually restore cells in the hippocampus – the area of the brain connected with short and long-term memory. The hippocampus shrinks in later life, leading to memory loss and increased risk of dementia. But in one US randomised controlled trial with 120 older adults, participation in an aerobic exercise programme increased hippocampal volume by two per cent, effectively reversing age-related shrinkage, with accompanying improvements in memory.³
  
  Green therapy
  Proponents of ‘green’ exercise and ‘ecotherapy’ would add to this the benefits of being outdoors, in nature itself. Another piece of very new research, also from Glasgow University, has recently confirmed conclusively the benefits of regular exercise in green spaces.⁴ The study used general population data, from the Scottish Health Survey 2008, to explore the associations between exercise in woodlands, parks, swimming pools, the gym, urban streets and the home and risk of depression. It showed that exercising in woodlands and parks had the overwhelmingly greatest benefits for mental health. Lead researcher Rich Mitchell, Professor of Health and Environment at the university’s Institute for Health and Wellbeing, says even he was surprised by the margin of difference between the beneficial effects of the natural and urban, built environments.
  
  Says Mitchell: ‘Environmental psychology has shown us that our bodies and brains like being in a natural environment. Physical activity in a natural environment gives you a double dose – both a biological and psychological response that protects against mental ill health.’ But he wouldn’t want to see GPs ‘prescribing’ natural exercise. ‘Exercise and being in a natural environment is a wonderful thing. It can and does make people feel better about themselves. But don’t think about it in terms of exercise,’ he advises. ‘Think about it as somewhere to go to escape for a while.’
  
  Virtual worlds
  New technology may be the cause of many 21st century ills, but it can also be harnessed for good. At the University of Birmingham Bob Stone, Professor of Interactive Multimedia Systems and a psychologist by background, has been pioneering the use of virtual natural environments with people unable physically to get out into the countryside. ‘The research shows that the real thing is definitely better’, Stone says, but for people with physical disabilities or in hospital or in care homes, a virtual green environment can provide the same mentally restorative effects as nature.
  
  ‘We have research from the past 20 years showing you can restore attentional and cognitive deficits by exposure to nature. What the restorative environment seems to be doing is providing our brains with relaxing natural distractions that don’t require significant cognitive processing,’ Stone says. ‘If you walk around a busy urban scene, with man-made features, man-made sounds, traffic noise and high-level structures, you have to keep your attention directed and focused just to counteract their effects. But when you put people in a natural world, it reduces levels of arousal so their cognitive processes can catch up.’
  
  This is what Stone’s team is aiming to capture in the two virtual ‘restorative environments’ they have created for a pilot study, based on the South Devon Coastal Path and Burrator Reservoir on Dartmoor. Sound is an essential element. ‘As soon as you add bird song, babbling brooks, insects buzzing by, particularly the sounds of waves on the shore, the whole virtual experience is transformed. The “wow” effect captures people’s attention immediately. I have these virtual scenes on a 50-inch screen as background in my office and it’s like a window on an alternative reality that I can turn to – after a challenging student seminar, for example,’ Stone says.
  
  The work is attracting interest from a wide range of sectors, including residential care homes, intensive care and neuropathy units, and the Ministry of Defence. Stone’s team has devised a system of contact-free controls based on games technologies that make it possible for Armed Forces amputees to ‘walk’ through the virtual natural environment and undertake simple activities to exercise to maintain muscle tone.
  
  ‘It has so much potential for elderly people too. It has what I call the “coal fire effect”,’ Stone says. ‘Looking at the virtual scenes seems to relax people, draw them in and promote memories in that same way. As we add in different sounds, smells and other stimuli, it will really start to have an immersive and restorative effect.’
  
  Workplace benefits
  Essex University’s Centre for Environment and Society has pioneered research into ‘green exercise’ and mental health and is currently exploring the benefits for workplaces.
  
  Jo Barton, Lecturer in Sports and Exercise Science, says we should take seriously the concept of ‘nature deficit disorder’. ‘The need for nature is hard-wired into our genes. There are studies showing that lack of contact with the natural world has a clear impact on cognitive functions, especially among young people. Our work has shown that being active in green spaces gives you more energy and greater vigour than equivalent exercise in built environments or indoors.’
  
  Translated to the workplace setting, green exercise may have benefits for staff wellbeing and productivity. ‘We’ve been working with one company, trying out a range of interventions to promote green physical activity, including lunchtime walks, giving staff activity monitors to encourage them to walk more, and walk-and-talk meetings.’ The benefits of walk-and-talk meetings are, she says, striking. ‘The evidence is so far purely anecdotal, but people tell us they find these meetings much more productive. They either reach their conclusions much more quickly, or they inspire more creative thinking.’
  
  You’ll never walk alone
  With July’s Olympic Games imminent, the Department of Health seems to have finally woken up and smelled the left-over pizza from the night before. The most exercise many of us will take this summer will be to switch the TV on. In June the Department of Health launched Games4Life, a national campaign offering free family fun activity packs to ‘encourage millions of people to get involved and get active’.
  
  But couch athletes may be cheered by Alan Pringle’s research with football fans. Pringle, who describes himself as a ‘long-suffering’ Mansfield Town supporter, says football fans derive huge emotional benefits from the comradeship and consistency that supporting their football team provides – even if it never wins. ‘We live in a world of constant change. Constant change provokes anxiety. One lad told me that watching Mansfield Town play was the only thing in his life that was reliably there for him. He said he’d lost his job, his house, his marriage – “but the club is there. I know they’re rubbish, but they’re my club”.’
  
  Going to a match can also provide the benefits of social contact without having to talk to anyone face to face. ‘No one’s looking at you. No one’s going to want to have a conversation with you. You can get the human connection without having to give anything of yourself and without feeling you are under scrutiny,’ Pringle says.
  
  But, perhaps above all, football fans (and men in particular) get a tremendous emotional release from going to matches. Pringle likens it to a Renaissance Carnival where behaviours that are normally socially unacceptable are licensed for that short period of time. ‘They can get drunk, swear at the referee, scream, taunt, chant abusive songs and behave in an antisocial way and it’s acceptable, it’s sanctioned within the confines of the stadium. There’s this negative view that football fans are just hooligan thugs but I interviewed lawyers, police officers, road sweepers, factory workers – it was the same story. They sang the same songs and threw the same abuse at the referee. People told me that the only time they get road rage is when the football season is over. For men in particular, it offers an important outlet for emotional discharge.’
  
  Running wild
  Health and social care agencies are using the natural environment to work therapeutically with young and old alike. The Wilderness Foundation UK (www.wildernessfoundation.org.uk) offers group and individually tailored programmes for vulnerable young people with behavioural, emotional and mental health problems. The programmes combine psychotherapy and group therapy with experiential group work in natural, wild and remote settings. The Foundation argues that exposure to the challenges presented by the natural environment can promote flexibility, self-awareness and a sense of self-efficacy and achievement.
  
  Helen Payne is one of their consultant outdoor facilitators. She works mainly with young people aged 16–19 referred by pupil referral units (PRUs). She says just walking with a young person can have an amazing effect. ‘I walk miles and miles with them, in the rain, sunshine, thunder and lightning, just getting to know them. Walking is good for talking intimately because it isn’t face to face. The scents and sounds of the countryside are calming and you can also walk in silence very happily in a way that you can’t sit in silence in a room with a counsellor – or in Starbucks, for that matter. I love it when a young person is OK about heading off somewhere without a map and just seeing where we end up. It’s an adventure.’
  
  At the other end of the age range, Dementia Adventure (www.dementiaadventure.co.uk) specialises in organising green therapy programmes and adventure holidays for people with dementia and their carers. The company recently won the ‘Risky Business’ category in the International Dementia Excellence Awards.
  
  Says Neil Mapes, founder and co-director: ‘Residential care homes can be very protective and unwilling to take risks. It’s safer and easier just to keep everybody indoors. But people have lost sight of the importance to the individual of being outdoors and in direct contact with nature. It’s not just the physical exercise; it’s about having a life worth living,’ he argues. ‘Risk assessments are worth nothing without also looking at the benefits of taking those risks and what the person will gain.’
  
  There is, as yet, no ‘hard’ evidence of the benefits of exposure to nature specifically for people with dementia. But Mapes firmly believes it can help reduce use of antipsychotics and counteract the mental and physical effects of the illness. ‘People in residential care are often desperately unhappy. We lead walking groups in a local park. It’s a very simple thing but you can see the benefits in people’s faces. Their mood changes from apathy and anxiety to pure joy.’

• References:
  

  1. Chalder M, Wiles NHJ, Campbell J et al. Facilitated physical activity as a treatment for depressed adults: randomised controlled trial. British Medical Journal 2012; 344: e2758.
  2. Mutrie N, Hannah MK. The importance of both setting and intensity of physical activity in relation to non-clinical anxiety and depression. International Journal of Health Promotion and Education 2007; 45: 24–32.
  3. Erickson KI, Voss MW, Prakash RS et al. Exercise training increases size of hippocampus and improves memory. PNAS 2011; 108(7): 3017–3022.
  4. Mitchell R. Is physical activity in natural environments better for mental health than physical activity in other environments? Social Science & Medicine 2012; http://dx.doi.org/10.1016/j.socscimed.2012.04.012