The Covid-19 pandemic has had a huge psychological impact. The current evidence suggests that a psychiatric illness epidemic is co-occurring with the Covid-19 pandemic, which necessitates the attention of the global health community.¹ In Ireland, a study found significant increases in depression, anxiety and stress during restrictions (between March and June 2020) compared to before restrictions.² The College of Psychiatrists of Ireland also found an increase in psychiatric referrals for general anxiety, depression and panic.³ This does not only affect the general public but also patients who were infected with Covid-19, had post-traumatic stress and post-viral syndromes as well as healthcare workers who experienced psychological burnout.⁴

In primary care, we have seen an increase in cases of depression and anxiety since the beginning of the pandemic. We assess patients’ risks, refer them on for counselling and sometimes an antidepressant is warranted. There needs to be more focus on how to improve patients’ health rather than treating their illness with a ‘pill’. 

Patients should be empowered and given the autonomy to make healthy choices through the means of ‘social prescribing’. In Japan, if you find yourself with a mental health issue, the doctor may refer you to the local forest for forest bathing, also known as Shinrin-yoku.

The evidence of forest bathing (Shinrin-yoku)

Shinrin in Japanese means ‘forest’ and yoku means ‘bath’. So shinrin yoku means bathing in the woodland atmosphere, or taking in the forest through our senses. The idea is that when you open up your senses, you begin to connect with the natural world.⁵ A recent comprehensive systematic review (studies mostly from Asian countries) suggests beneficial therapeutic effects of forest-based interventions on: 

• The cardiovascular system, by lowering BP and reducing heart rate in healthy adults and in people with hypertension
• Lowering levels of cortisol, which is a biomarker for stress 
• Mental health disorders, such as depression and anxiety.Positive effects were seen in healthy children and adults, as well as adults with various pre-existing conditions.⁶

How to practise Shinrin-yoku

First, find a spot. Find a forest, which might only be a half hour drive from a city. Leave behind your phone, camera, music players and any other distractions. You do not need any devices. Leave behind any expectations. Find a spot and sit down. Then, engage your five senses

Listen: Listen to the birds chirping, the breeze rustling in the leaves of the trees and the calming sound of the river. Enjoy the natural silence of the forest; peace and quiet, free from noise pollution. Start by slowing down, focusing on your breath and as you breathe out, let any distractions float away. Listen in all directions to the sounds of nature or close your eyes to help you hear more intensely.

Look: Look at the beauty of the natural world. Look at the clouds and the sky, the water trickling in a stream or the way the branches in a tree divide. Go in close and look at the veins in a leaf or the petals in a flower and notice the patterns. Soon you will see patterns all around you. When you see how much of the world around you is patterned, you will begin to feel the splendour of the natural world.

Smell: Smell the fragrance of the forest and breathe in the natural aroma from the trees. Adopt a yoga pose. Breathe in as you raise your arms until your hands meet above your head and breathe out while you lower your arms.

Touch: Touch the trunk of a tree, feel the breeze on your face, dip your fingers or toes in a stream, lie on the ground. The aim is to restore the connection with nature. Have you noticed how good it feels?

Taste: Forests all full of food, such as berries and ‘mountain vegetables’ that Japanese people often use in cooking. Caution is needed here as there are plenty of poisonous plants; never eat anything that you are not 100% sure is safe. 

Many shops in forest-therapy trails in Japan provide forest-therapy meals that are prepared using ingredients that are grown locally so that you can taste the region you are walking in. Shinrin-yoku in Japan often ends with a tea ceremony, with tea brewed from the twigs, flowers and plants in the forest. This is a way of incorporating the forest, harmonising with the natural world. Why not bring a flask of tea in your car and enjoy it at the end of your walk? The optimal time to spend is around four hours, during which time you should aim to walk about 5km. But shorter bursts work too. Find a place in the forest you like, or even go for a one-night forest-bathing trip.

If you live in the city

Various studies have supported the notion that green space can provide a buffer against the negative health impact of stressful life events.^7,8 Green spaces provide a meeting place for users to maintain social ties, which in turn contributes to residents’ safety and adjustment.^9,10,11

Many of our cities have wonderful parks and gardens. They are relaxing and restorative places to be. Here are the five steps on how to do Shinrin-yoku in the park:

• Leave behind your gadgets and expectations
• Find a spot to sit: on the grass, beside a tree or on a bench
• Slow down and come into the present moment
• Engage your five senses and notice what you can hear, see, feel, smell and taste
• Stay as long as possible.

Our work environment

A study found that green micro breaks for as little as 40 seconds – eg. viewing a flowering meadow roof – can boost attention.¹² If you don’t have a window to look out of, how about bringing a plant for your windowsill or desk, or put them on a shelf. Have a picture of nature as a screensaver on your computer or the lock screen on your phone. Hang a picture of the countryside on your wall. Take a green micro break. 

We are lucky. We can see the beautiful scenery of the large garden at the back of our practice and the 10-acre grass field next to it. You can look out through the window and wonder how you could have missed the change in season. The leaves on the pear tree are growing. 

A forest bathing prescription

 (click to enlarge)

Table 1 gives an example of a forest bathing prescription that could be given to patients as a social prescribing tool.¹³ How about trying it out yourself? If you feel enthusiastic, do visit the official international Shinrin-yoku website at www.natureandforesttherapy.earth/ for more information on becoming a certified forest therapy guide. 

References 

1. Hossain MM, Tasnim S, Sultana A, et al. Epidemiology of mental health problems in COVID-19: A review. F1000Res 2020; 9: 636 
2. Burke T, Berry A, Taylor LK, et al. Increased psychological distress during Covid-19 and quarantine in Ireland: A National Survey. J Clin Med 2020; 9(11): 3481
3. Covid-19 impact on secondary mental healthcare services in Ireland. Dublin: College of Psychiatrists of Ireland 2020
4. Kelly BD. Impact of Covid-19 on Mental Health in Ireland: Evidence to Date. Ir Med J 2020; 113(10): 14 
5. Li Q. Shinrin-Yoku: The art and science of forest bathing, how trees can help you find health and happiness. Penguin Life 2018 
6. Stier-Jarmer M, Throner V, Kirschneck M, et al. The psychological and physical effects of forests on human health: A Systematic Review of Systematic Reviews and Meta-Analyses. Int J Environ Res Public Health 2021; 18(4): 1770 
7. van den Berg AE, Maas J, Verheij RA, et al. Green space as a buffer between stressful life events and health. Soc Sci Med 2010; 70(8): 1203-10 
8. Stigsdotter UK, Ekholm O, Schipperijn J, et al. Health promoting outdoor environments-associations between green space, and health, health-related quality of life and stress based on a Danish national representative survey. Scand J Public Health 2010; 38(4): 411-7 
9. Kweon B-S, Sullivan WC, Wiley AR. Green common spaces and the social integration of inner-city older adults. Environment and Behavior 1998; 30(6): 832-858 
10. Kuo FE, Sullivan WC, Coley RL, et al. Fertile ground for community: inner-city neighbourhood common spaces, Am J Community Psychol 1998; 26(6): 823-51 
11. Maas J, van Dillen SME, Verheij RA, et al. Social contacts as a possible mechanism behind the relation between green space and health. Health Place 2009; 15(2): 586-595
12. Lee KE, Williams K, Sargent L, et al. 40-second green roof views sustain attention: The role of micro-breaks in attention restoration. Journal of Environmental Psychology 2015; 42: 182-189
13. www.shinrin-yoku.org