Subthreshold depression represents a state of psychological sub-health between normal individuals and clinical depression. It constitutes a high-risk stage for developing clinical depression and a critical phase for alleviating depressive symptoms. However, current research predominantly focuses on treating depression in the elderly, with insufficient attention to interventions for high-risk populations or limited to cross-sectional investigations of subthreshold depression risk factors. Therefore, prioritizing subthreshold depression in the elderly and implementing early interventions is essential. A 2024 article in The Lancet suggests that subthreshold depression treatment should prioritize psychotherapy and lifestyle adjustments over medication. Horticultural therapy, an interdisciplinary approach integrating horticulture, medicine, and psychology, demonstrates unique advantages over traditional medical treatments. In practical application, however, limited resources may hinder adequate support for horticultural activities, compromising activity quality, reducing therapeutic efficacy, and restricting the widespread adoption of horticultural therapy. Integrating VR technology with horticultural therapy can provide patients with more comprehensive, personalized, and effective mental health treatment plans, empowering them toward healthier, more positive lives. Therefore, the research team designed a VR horticultural intervention system for elderly individuals with subthreshold depression based on the Social Participation Competence Framework.
Age ≥ 60 years
Meets subthreshold depression diagnostic criteria: CES-D score ≥ 16 on the Center for Epidemiological Survey, Depression Scale (CES-D) used in epidemiological surveys (this criterion is widely adopted in comparable studies)
No communication barriers in vision, hearing, or speech
Informed consent
Insulin dependent diabetes
Thyroid disease
Recent exposure to a major traumatic stress event, with no risk of suicide
Currently participating in other similar studies
Parallel
Virtual Reality Garden System
Other interventionThe system comprised six tasks. Task One was an individual task involving planting tomatoes by completing eight subtasks (tilling, sowing, fertilizing, watering, secondary fertilization, secondary watering, pest control, harvesting) in a virtual garden. Tasks Two through Five were two-player online cooperative tasks. Task 2 involves corn cultivation, with one participant planting while the other observes; Task 3 requires two participants to simultaneously plant strawberries in parallel within the virtual garden; Task 4 involves collaborative sunflower planting between two participants; Task 5 has experienced elderly participants assisting less experienced individuals in completing planting tasks; Task 6 enables three participants to share the joy of planting together in the virtual garden.
Routine Care
Other interventionThis arm of seniors maintains their daily routines and participates regularly in the nursing home's daily activities.
Subthreshold Depression
The Center for Epidemiological Surveys Depression Scale (CES-D) was developed by Rirodiff at the National Institute of Mental Health in the United States. It is designed for screening depressive symptoms in older adults, comprising 20 items. Each question assesses one symptom, covering 20 distinct symptoms in total. The total score ranges from 0 to 60 points. A score ≤15 indicates no depressive symptoms, 16-19 suggests possible depressive symptoms, and ≥20 confirms depressive symptoms. The Cronbach's alpha coefficient for the Chinese population is 0.90. It is one of the most commonly used subthreshold depression epidemiological survey tools, with existing studies defining CES-D ≥16 as subthreshold depression. Translated with DeepL.com (free version)
General cognitive function
The Montreal Coanitive Asessment Scale,developed by Nasreddine in 2004 to assess participants'general cognitive function, covers eight areasof cognitive assessment, including visuospatial and executive function, naming, memory, attention, speech, abstraction, delayed recall, andorientation. The Changsha version of the Montreal Cognitive Assessment Scale was used in this study, and its Cronbach's a coeficient was 0.846,retest reliability was 0.974, and investigator reliability was 0.969. The score of the Montreal Cognitive Assessment Scale ranges from 0 to 30points. The higher the score,the better the cognitive function ofthe study subjects. The iliterate group s13, the primary school group s19 and thejunior high school and above group s24 can be judged as impaired cognitive function to correct the bias caused by education level.
Anxiety Condition
The self-rating anxiety scale (SAS) was designed and developed by Zung in the United States in 1971 to assess the severity of anxiety symptoms in individuals. It demonstrates good reliability and validity, with a split-half reliability coefficient of 0.696, test-retest reliability of 0.777, and internal consistency of 0.82. Additionally, it exhibits good construct validity . The scale comprises 20 items, with items 5, 9, 13, 17, and 19 scored in reverse. The scale employs a 1-4 rating scale (1 = never or rarely; 2 = a small portion of the time; 3 = a considerable portion of the time; 4 = most or all of the time). Individuals complete the scale based on their experiences during the past week. The total score is multiplied by 1.25, rounded to the nearest whole number to obtain a standardized score, which serves as the statistical indicator. A higher standardized score indicates more severe anxiety levels
Activities of Daily Living
This study employs the Activities of Daily Living (ADL) scale developed by Lawton and Brody in 1969 to assess an individual's self-care abilities and functional status in daily life. The version selected for this study, adapted into Chinese by Zhang Mingyuan et al., comprises 20 items using a 4-point Likert scale. The total score ranges from 20 to 80 points, with higher scores indicating poorer ability to perform activities of daily living. The Cronbach's α coefficient for this scale is 0.92.
Social Support
Social Support Rating Scale (SSRS) This study employed the SSRS developed by Xiao Shuiyuan in 1986 to assess patients' levels of social support. The scale comprises three dimensions: objective support (3 items), subjective support (4 items), and utilization of support (3 items), totaling 20 items. Items 1, 4, 5, 6, 8, 9, and 10 are single-choice questions. Options (1), (2), (3), (4) are scored as 1, 2, 3, and 4 points respectively. For items 2 and 3, the "No sources at all" option scores 0 points, while the "The following sources" option scores points corresponding to the number of sources selected. In item 7, options A, B, C, D, and E are scored from 1 to 4 points, ranging from 'None' to "Full support," respectively. The total score ranges from 12 to 66 points. Higher scores indicate greater levels of social support for the patient. The Cronbach's α coefficient for this scale ranges from 0.89 to 0.94.
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