Ask an answerable question (PICO)：
Patients with schizophrenia exhibit psychotic symptoms, and are more vulnerable to stress and anxiety, leading to mood disturbance or even suicidal tendencies. Through the process of planting, horticultural therapy can help patients learn self-management and stress coping skills. Therefore, the clinical question of the current program was as follows: Does horticultural therapy (Intervention) improve anxiety and stress (Outcome) among patients with schizophrenia (Patient)?
The Method and Analysis of Literature Review：
The programs were based on the EBN 5A steps. A literature search was conducted on the Cochrane Library, PubMed, Embase, CINAHL and CEPS from inception to April 2020. We set the key words and accompanying MeSH terms, performing a search with proper Boolean logic. The inclusion criteria were: (1) Systematic reviews or randomized controlled trials. (2) Patients with schizophrenia aged over 18 years (3) Application of horticultural therapy. (4) Outcome measures included anxiety or stress. One systematic review and one randomized controlled trial met the criteria.
Critical Appraisal：
According to the study design, the included studies were critically appraised with the CASP critical appraisal checklists. The level of evidence and grade of recommendation was based on the SIGN guidelines. The level of evidence of the included studies was rated as 1+ for the systematic review, and 1- for the randomized controlled trials, respectively. Thus the body of evidence resulted in grade B recommendation.
Clinical Application of Evidence：
Referencing the literature, the authors designed horticultural therapy programs. Patients with schizophrenia, who met the inclusion criteria, were recruited and randomly allocated to the experimental (n=21) or control (n=21) groups. The patients in the experimental group received horticultural therapy sessions for 80 minutes, twice weekly, for 4 weeks. The total length of intervention was 640 minutes. The patients in the control condition continued their usual care. All participants were evaluated at baseline and post-intervention.
Evaluation of Effectiveness：
At baseline, the experimental group had higher anxiety (t=2.053, p=.047) and stress (t=2.613, p=.013) than the control group. After intervention, ANCOVA revealed a significant main effect on group; the experimental group exhibited a greater improvement in anxiety (F=8.542, p=.006, η2=.180) and stress (F=6.506, p=.015, η2=.143), with large effect size. As for clinical success, the experimental group had more successful cases regarding anxiety, with an odds ratio of 7.13 (95%CI:1.31–38.77) and NNT of 3 (95%CI:1.7–11.5). For improvement of stress, the odds ratio was 10.000 (95%CI:1.10–90.59), favoring the experimental group, and NNT was 4 (95%CI:2.0–15.5).
Conclusions and Recommendations：
This report exemplifies knowledge translation from evidence to practice. The authors applied horticultural therapy to address mood disturbance. The results provide support for the execution of horticultural therapy on anxiety and stress among patients with schizophrenia. We recommend application of such programs continuously. However, future research with a larger sample size, more rigorous study design, and exploration of different outcomes of interest is warranted.
