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Art therapy as an adjuvant treatment for depression in elderly women: A randomized controlled trial


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Objective: There are few quantitative studies on art therapy for the treatment of depression. The objective of this study was to evaluate if art therapy is beneficial as an adjuvant treatment for depression in the elderly. Methods: A randomized, controlled, single-blind study was carried out in a sample of elderly women with major depressive disorder (MDD) stable on pharmacotherapy. The experimental group (EG) was assigned to 20 weekly art therapy sessions (90 min/session). The control group (CG) was not subjected to any adjuvant intervention. Patients were evaluated at baseline and after 20 weeks, using the Geriatric Depression Scale (GDS), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and cognitive measures. Results: Logistic regression analysis adjusted for age revealed that women in EG (n=31) had significant improvement in GDS (p = 0.007), BDI (p = 0.025), and BAI (p = 0.032) scores as compared with controls (n=25). No difference was found in the cognitive measures. Conclusion: Art therapy as an adjunctive treatment for MDD in the elderly can improve depressive and anxiety symptoms. Clinical trial registration: RBR-2YXY7Z
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Art therapy as an adjuvant treatment for depression in
elderly women: a randomized controlled trial
Eliana C. Ciasca,
Rita C. Ferreira,
Carmen L.A. Santana,
Orestes V. Forlenza,
Glenda D. dos Santos,
Paula S. Brum,
Paula V. Nunes
Departamento de Psiquiatria, Instituto de Psiquiatria, Hospital das Clı
´nicas da Faculdade de Medicina da Universidade de Sa
˜o Paulo
˜oPaulo, SP, Brazil.
Escola Paulista de Enfermagem, Universidade Federal de Sa
˜o Paulo (UNIFESP), Sa
˜oPaulo, SP, Brazil.
Departamento de Neurologia, Faculdade de Medicina da Universidade de Sa
˜o Paulo (FMUSP), Sa
˜oPaulo, SP, Brazil.
Objective: There are few quantitative studies on art therapy for the treatment of depression.
The objective of this study was to evaluate if art therapy is beneficial as an adjuvant treatment for
depression in the elderly.
Methods: A randomized, controlled, single-blind study was carried out in a sample of elderly women
with major depressive disorder (MDD) stable on pharmacotherapy. The experimental group (EG) was
assigned to 20 weekly art therapy sessions (90 min/session). The control group (CG) was not
subjected to any adjuvant intervention. Patients were evaluated at baseline and after 20 weeks, using
the Geriatric Depression Scale (GDS), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI),
and cognitive measures.
Results: Logistic regression analysis adjusted for age revealed that women in EG (n=31) had signifi-
cant improvement in GDS (p = 0.007), BDI (p = 0.025), and BAI (p = 0.032) scores as compared with
controls (n=25). No difference was found in the cognitive measures.
Conclusion: Art therapy as an adjunctive treatment for MDD in the elderly can improve depressive
and anxiety symptoms.
Clinical trial registration: RBR-2YXY7Z
Keywords: Art therapy; depression; anxiety; elderly patients; clinical trial
Major depressive disorder (MDD) is not part of aging,
even though it is a common problem in the elderly. MDD
may have physical and mental consequences that worsen
general health condition and quality of life in elderly
Less than half of patients with depressive
disorders receive proper treatment.
This lack of access
to treatment is greater among elderly, low-income, and
minority populations.
Pharmacotherapy is frequently indicated in the manage-
ment of depression, especially in moderate to severe
cases. The combination of pharmacotherapy and psy-
chotherapy in elderly patients with MDD is often more
efficient than any of these approaches alone,
and is
associated with lower abandonment rates than pharma-
cotherapy alone; thus, this combination may be indicated
for patients with low medication adherence.
Several types of psychotherapy can be used in the treat-
ment of depression, with large variability in adherence
and response, depending, among other factors, on patient
characteristics. Although most studies on psychotherapy
for depression have involved the adult population, several
studies indicate that numerous types of psychotherapy
are also effective in elderly patients.
Cognitive-behavioral therapy, interpersonal psychotherapy,
and problem-solving therapy are considered first-line
treatments both for adult and elderly patients.
cence therapy, psychodynamic therapy, support therapy,
and nondirective counseling,
as well as self-esteem
life review therapy, and depression manage-
ment therapy,
can also be beneficial in the treatment of
depressive symptoms in the elderly.
Among these many therapies and approaches, evidence
suggests that active engagement in creative activities,
including art, can bring many benefits, including improved
well-being, quality of life, health, and socialization.
therapy is a creative approach used as a therapeutic
technique. It is intrinsically connected to artistic making,
which has been a human practice since time immemorial.
The therapeutic function of art is related to the possibility
of concretization of thoughts, feelings, desires, and the
facts of life using expressive resources. Art therapy uses
these resources, which mobilize several aspects of the
human mind: cognition, the sensorimotor system, emo-
tions, and intuition. Art therapy does not concern itself
only with the final product (visual arts, body expression,
and other forms of art per se), but also with the creative
process and the connection of artistic making and the
person who makes it.
Art therapy is suited to treat-
ing issues or themes that are also managed by other
Correspondence: Eliana C. Ciasca, Departamento de Psiquiatria,
Instituto de Psiquiatria, Hospital das Clı
´nicas da Faculdade de Medicina
da Universidade de Sa
˜o Paulo, Rua Ovı
´dio Pires de Campos, 78,
CEP 505403-010, Sa
˜o Paulo, SP, Brazil.
Submitted Feb 08 2017, accepted Jul 18 2017.
Revista Brasileira de Psiquiatria. 2018;00:000–000
Brazilian Journal of Psychiatry
˜o Brasileira de Psiquiatria
CC-BY-NC | doi:10.1590/1516-4446-2017-2250
well-known forms of psychotherapy, such as interpersonal
therapy, depression management therapy, and life review
Art therapy can be used in various populations. For
example, it may be particularly beneficial in individuals
who do not adapt to psychotherapeutic approaches that
are exclusively verbal. Art therapy can help establish
communication between patient and therapist and may
aid in the emergence of personality aspects or facts of
life to be dealt with in the therapeutic process.
art therapy session is often preceded by activities that
promote relaxation and introspection, such as mental
imagery. It can be used to link sensory perception and
and thus relieve the discomfort associated
with mood disorders.
Meta-analyses and systematic reviews of art therapy
are scarce. In a study of 15 randomized controlled trials
(n=777), meta-analysis was not possible because of clinical
heterogeneity and insufficiently comparable data on out-
come measures across studies. Although the quality of
the randomized trials was generally low, art therapy was
associated with significant positive changes in nonpsy-
chotic mental health symptoms relative to control groups
in 10 out of the 15 studies. Therefore, art therapy can be
an acceptable treatment and appears to be cost-effective
compared with wait-listing, but further studies are needed.
Thus, there is evidence that art therapy may contribute
to improvement of psychological parameters in different
disorders. However, controlled studies with quantitative
measures are still needed to establish its potential role in
MDD, a highly prevalent disorder. In this context, the
present study was designed to evaluate the effects of
20 sessions of adjunctive art therapy on mood, cognition,
and functionality in elderly women with MDD stable under
pharmacological treatment.
This randomized, controlled, single-blind study was car-
ried out at the Instituto de Psiquiatria, Hospital das Clı
da Faculdade de Medicina da Universidade de Sa
˜o Paulo
(IPq-HCFMUSP), Brazil. All participants signed an infor-
med consent form approved by the local ethics committee
before enrolling in this study. The study was approved
and authorized by the FMUSP ethics committee (protocol
no. 211.133/13), and was registered with the World Health
Organization International Clinical Trials Registry Plat-
form (WHO ICTRP; UTN U1111-1192-1365) and the
Brazilian Registry of Clinical Trials (Registro Brasileiro
de Ensaios Clı
´nicos [ReBec]; RBR-2YXY7Z).
Elderly outpatients attending IPq-FMUSP were invited
to take part in the study. Ninety-four patients were initially
contacted by telephone and underwent pre-screening
(see the flow diagram in Figure 1).
The inclusion criteria were: a lifetime DSM-5 diagnosis
of MDD,
female gender, age 60 years or older, ability to
read and write, and agreement to take part in the study.
Besides, participants had to be stable on pharmaco-
therapy for depression, i.e., with no change in medication
regimen (agent or dosage) throughout the study period.
The decision to keep patients on their current medication
regimen was made by each participant’s attending psychi-
atrist, based on the perception that the best improvement
Figure 1 Flow diagram of participant selection. CG = control group. EG = experimental group. MDD = major depressive
disorder. T1 = time point 1. T2 = time point 2.
Rev Bras Psiquiatr. 2018;00(00)
2EC Ciasca et al.
in symptoms was already being achieved with the cur-
rent dose with the least side effects possible. Patients
with depression scale scores above the cutoff were
acceptable, and all had to be available to take part in all
evaluations and interventions.
The exclusion criteria were cognitive difficulties sug-
gestive of dementia, defined by a Mini-Mental State
Examination (MMSE)
score below 25 for people with
1 to 4 years of formal schooling or below 27 for people
with 5 years or more of schooling. We also excluded drug
users, those with degenerative diseases, and those with
any systemic disorders associated with high morbidity
and mortality, such as cancers with poor prognosis or
progressive renal impairment.
Ninety-four patients were initially screened. Twenty-
eight did not meet the inclusion criteria. A psychiatrist
interviewed the remaining 66 patients, using the Struc-
tured Clinical Interview (SCID) to confirm MDD diagnosis
according to the DSM-5 criteria. No patient met the exclu-
sion criteria. To randomize the participants, the order
of study entry was obeyed for each group of 22 people
per semester. Odd-numbered entrants were allocated to
the CG (11 patients), and even-numbered entrants con-
stituted the experimental group (EG) (11 patients).
The CG and EG were thus formed of 33 participants
each. At the end of the study, 25 participants were still
present in the CG and 31 in the EG.
EG participants received 20 art therapy workshops,
while the CG did not receive any type of psychotherapy
during the study period. After the study, however, patients
in the CG could take part in the art therapy workshops if
they so wished.
Evaluation tools
Patients in the CG and in the EG were subjected to the
same battery of standardized tests, carried out by the
same team of neuropsychologists, at the start of the study
(time point 1) and at the end of the 20-week study period
(time point 2). The mean duration of the test battery was
45 minutes. For the EG, tests were carried out at the end
of the 20 art therapy weekly sessions. For CG, they were
carried out the same 20-week interval, in which patients
were not subjected to any intervention.
Sociodemographic questionnaires were administered
that included information on age, educational attainment,
marital status, and income level. Questionnaires about
medications used, number of previous depressive episodes,
and presence of other diseases besides depression were
also applied.
Depression was evaluated with the Geriatric Depres-
sion Scale (GDS-15).
This diagnostic instrument is
designed to detect depressive symptoms in the elderly
and consists of 15 affirmative/negative questions regard-
ing satisfaction and hope in life, fatigue, and memory. The
cutoff point for depression is 5. Scores between 1 and 5
are considered subsyndromal depression; scores between
6 and 10 are considered depression; and scores between
11 and 15 are considered severe depression. Depressive
symptoms were also evaluated with the Beck Depression
Inventory (BDI),
which consists of 21 questions about how
the individual has felt in the preceding week regarding depres-
sive symptoms such as hopelessness, irritability, guilt, or
feelings of being punished, as well as physical symptoms
such as fatigue, weight loss, and decreased libido. Each
question is scored on a scale of 0 to 3; therefore, the
maximum BDI score is 63. The cutoff point for depres-
sion is 12, and scores between 1 and 11 are considered
subsyndromal depression.
As the GDS is validated for the study of depression in
the elderly
and the BDI is widely used for adults and it
is more comprehensive in several aspects of depression,
we also checked for correlation between these scales.
Anxiety was evaluated by the Beck Anxiety Inventory
which consists of 21 questions about how the
individual has felt in the preceding week regarding
common anxiety symptoms, such as sweating, tremor,
fear, and feelings of distress. The cutoff point for anxiety
is 12, and scores between 1 and 11 are considered sub-
syndromal anxiety.
A cognitive assessment battery was also administered,
consisting of the MMSE,
the Verbal Fluency Test –
animal category,
the Trail Making Test A,
and the Rey
Complex Figure (Rey CF) task.
In the Verbal Fluency
Test – animal category,
normal performance was defined
as the ability to remembering more than 12 animals
(for participants with 1 to 7 years of formal schooling) or
more than 13 animals (for participants with 8 years or
more of schooling). The Trail Making Test A
was used
to evaluate cognitive functions involving sustained atten-
tion, cognitive flexibility, executive functions, sequencing
ability, and motor speed. The Rey CF
is a visuospatial
task that requires visual attention and memory. First, the
participant copied a complex drawing while observing it.
This first step analyzes visuospatial processing and
strategy development. After 30 minutes, the patient was
asked to draw the figure again, without seeing it. This step
of the test is known as the Rey Delayed Recall (Rey DR)
task, and was used to assess visual and operational
memory. The lower the score, the worse the participant’s
visuospatial aptitude.
Study intervention
Art therapy sessions were carried out at the IPq-HCFMUSP
workshop facility. EG patients participated in 20 art
therapy sessions lasting 90 minutes each, all led by the
same art therapist. Although the art therapy intervention
involved three groups of 11 participants each, the work-
shops had an individual focus, that is, each participant
was instructed to work on her own artistic output during
the session.
The workshops produced a therapeutic context in
which nonverbal expression was used to facilitate self-
knowledge, self-esteem, and self-acceptance. The tech-
niques used involved themes that led to reflection on
adaptation to difficult life circumstances, such as losses,
death, finitude, resentment, solitude, and feelings of impotence.
All sessions were divided into four parts:
1) Welcome: patients entered the room and got ready to
start working.
Rev Bras Psiquiatr. 2018;00(00)
Art therapy for depression 3
2) Relaxation and guided imagery: the art therapist asked
patients to disconnect from their daily thoughts and
breathe gently. With the aid of a specific song selected
for each session, relaxation and guided imagery activities
were carried out, usually by inducing the participants to
imagine a nature setting of their choice. Then, the topic for
artistic creation during the session was proposed. The art
therapist’s spoken guidance during the guided imagery
activity was conceived as an introduction to the artistic
work itself, so that the participants would get in touch with
images and emotions related to the topic to be addressed
during the session.
3) Artistic output. After the guided imagery activity, the art
therapist instructed the participants to work out the topic
that had been proposed, using the art supplies available.
Techniques such as painting, drawing, clay modeling,
weaving, and collage were used. For the workshop
devoted to the topic of ‘‘self-esteem,’’ for instance, parti-
cipants were instructed to fashion a mandala out of grains
and seeds glued onto a piece of cardboard, and were
told that each grain or seed was to represent a quality
they recognized in their personality. The topic ‘‘sense of
loss’’ was worked through by having participants stop
while their artworks were still unfinished and switching
works with another participant. ‘‘Difficulty in dealing with
difficult situations’’ was worked through by providing
participants with rocks, which they were instructed to
‘‘place in a more beautiful context’’ within their artworks,
thus helping them change their outlook on the situation.
The topic ‘‘controlling tendencies’’ was worked through by
having participants blow paint through a soda straw; the
fact it is very difficult to control the direction of the paint
was intended to show participants that life is difficult to
4) Once the artworks were completed, each participant was
invited to verbally express her reflections and any feelings
that surfaced during the activity. This verbalization step
was important for participants to elaborate on what emerged
during their production, while the group and the art
therapist listened; the art therapist then helped each
patient understand her artistic output. The participants
took their artworks home at the end of each session.
On average, the relaxation and guided imagery step
lasted 7 minutes; the artistic output step lasted 60 min-
utes; and the verbalization step lasted 15 to 20 minutes.
Statistical analysis
Quantitative data were analyzed in SPSS version 20 for
Windows. The Kolmogorov-Smirnov method was used to
test for normality of data distribution. As the assumption of
normality was rejected, nonparametric tests were used
to evaluate participant scores. The Mann-Whitney Utest
was used to compare sociodemographic data, number
of depressive episodes, and cognitive and psychiatric
variables between the EG and CG. The chi-square test
and, as necessary, Fisher’s exact test were used to test
for associations between group allocation and the cate-
gorical variables. The Wilcoxon test was used to compare
differences (baseline vs. follow-up) in scale scores for
each of the groups (EG and CG, separately). The Mann-
Whitney Utest was also used to verify homogeneity
between groups at baseline; as a significant difference in
age between groups was observed (p = 0.033), all
subsequent analyses were designed to control for age.
Age-adjusted logistic regression analysis was used to
assess differences between groups (EG and CG, as the
dependent variable) in change in psychometric instrument
scores (delta = time point 2 - time 1, as explanatory
variables). Spearman correlation coefficients were calcu-
lated to assess potential relationships among changes in
the different psychometric instruments, and the correla-
tion between delta GDS and delta BDI was found
relevant. The significance level was set at p o0.05 for
all analyses.
At baseline (time point 1), EG (n=31) and CG (n=25) were
homogeneous for all variables, except age (p = 0.033), as
seen in Table 1. There were no differences in educational
attainment, marital status, depression onset after age
60 years, or number of previous depressive episodes.
Groups were also similar in terms of pharmacological
treatment (classified as an antidepressant alone, an anti-
depressant plus anxiolytics, or an antidepressant plus
other psychotropic drugs; p = 0.60).
Furthermore, there were no between-group differences
in psychiatric or cognitive variables of interest at baseline
(Table 2).
Table 3 presents a longitudinal analysis of variables in
each group. Baseline data (time point 1) were compared
with data from the end of the study (time point 2) for each
group. EG participants exhibited improvement in MMSE,
GDS, BDI, BAI, and Rey DR scores, i.e., a reduction
in depression and anxiety scores and an increase in
cognition and visuoconstructive performance scores.
Table 1 Sociodemographic and clinical features of the
control (CG) and experimental (EG) groups at baseline
(n=31) p-value
Age (years) 69.866.4 66.165.7 0.033*
Schooling 12.764.2 11.664.3 0.40*
Marital status, n (%)
Single 10 (40.0) 9 (29.0) 0.096
Married 8 (32.0) 6 (19.4)
Widowed 6 (24.0) 7 (22.6)
Divorced 1 (4.0) 9 (29.0)
First episode after 60 years, n (%) 5 (15.2) 6 (18.2) 0.741
Number of depressive episodes 3.061.2 3.661.7 0.225*
Geriatric Depression Scale p5963.4 665.3 0.162
Medication, n (%)
Antidepressant only 14 (56.0) 15 (48.4)
Antidepressant and anxiolytic 2 (8.0) 2 (6.4) 0.598
Antidepressant and
9 (36.0) 14 (45.2)
Data presented as mean 6standard deviation, unless otherwise
*Mann-Whitney U;
Fisher’s exact test;
chi-square test.
Rev Bras Psiquiatr. 2018;00(00)
4EC Ciasca et al.
CG participants only exhibited improvement in BDI
Comparison of improvement/variation (delta) in psy-
chometric scale scores between groups EG and CG was
performed by age-adjusted logistic regression analysis
(Table 4). EG participants exhibited a greater reduction
(delta) in GDS, BDI, and BAI scores than controls. There
was no significant difference between EG and CG in
terms of the change in cognitive battery scores.
In the EG, a X50% reduction in depression scores
was achieved by 32.3% of participants (n=10) in the GDS
and 41.9% of the participants (n=13) in BDI. None scored
0 in either scale at the end of the experiment. In the CG,
only one participant (4%) had a 50% reduction in scores
in both scales, and none remitted.
As an additional analysis, we tested for correlation
between GDS and BDI. A significant, moderate to strong
correlation was found for both groups, both at baseline
and at the end of the study (CG, time point 1: p = 0.001,
rho = 0.629; time point 2: p o0.001, rho = 0.663; GE,
time point 1: p o0.001, rho = 0.731; time point 2:
po0.001, rho = 0.696). This correlation shows evidences
that the two scales corroborate the statistical analysis.
The art therapy intervention for elderly women with stable,
pharmacologically treated MDD described in this rando-
mized, single-blind study led to improvement in depres-
sion and anxiety symptoms. This was demonstrated both
on comparison of the EG versus the CG and by the
response rates observed in the EG, ranging from 32.2
(GDS) to 41.9% (BDI). The intervention was a preset
program of art therapy workshops consisting of a brief
relaxation exercise through guided imagery, followed by
artistic output and, finally, sharing of feeling and thoughts
with the group and therapist. The decrease in depressive
and anxiety symptoms observed after this intervention
is consistent with that observed following other forms
of nonpharmacological treatment, such as other types
of psychotherapy with a scope similar to that of art
The themes addressed by this art therapy intervention
resemble those dealt with in other psychotherapies known
to lead to improvement in depressive symptoms in the
such as interpersonal therapy (as it stimulated
social interaction in the group, as well as interaction with
the therapist when patients shared their feelings and
thoughts); depression management therapy (as it enabled
reflection on depression-related issues, such as losses,
physical disability, and solitude, correcting dysfunctional
beliefs); and life review therapy (because past situations
Table 2 Psychiatric and cognitive variables in the control
(CG) and experimental (EC) groups at baseline
Cognitive and
psychiatric variables CG (n=25) EG (n=31) p-value*
MMSE 28.261.6 27.462.2 0.16
Fluency 17.065.4 16.863.3 0.87
Trail Making A 35.4613.7 32.5611.7 0.58
Rey CF 76.0620.9 65.5629.4 0.20
Rey DR 47.4626.4 48.6627.1 0.87
GDS 7.563.7 8.663.3 0.24
BDI 15.968.4 20.9610.8 0.07
BAI 13.7615.8 18.5613.6 0.08
Data presented as mean 6standard deviation.
BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory;
Fluency = Verbal fluency test; GDS = Geriatric Depression Scale;
MMSE = Mini-Mental State Examination; Rey CF = Rey Complex
Figure Test; Rey DR = Rey Delayed Recall Task.
*Mann-Whitney U.
Table 3 Longitudinal analysis of the data of each group
separately: time 1 (T1) compared to time 2 (T2)
T1 and T2 CG (n=25) p-value* EG (n=31) p-value*
MMSE 1 28.261.6 0.80 27.462.2 0.034
MMSE 2 28.361.6 28.062.4
Fluency 1 17.065.4 1.00 16.863.3 0.950
Fluency 2 17.264.1 16.964.4
Trail Making A1 35.4613.7 0.27 32.5611.7 0.150
Trail Making A2 37.3612.8 35.8612.2
Rey CF 1 76.0620.9 0.29 65.6629.4 0.570
Rey CF 2 72.0626.7 68.1623.7
Rey DR 1 47.4626.5 0.19 48.6627.1 0.002
Rey DR 2 52.1625.8 60.2630.0
GDS 1 7.563.65 0.12 8.663.3 o0.001
GDS 2 6.963.53 5.563.4
BAI 1 13.7615.79 0.32 18.5613.6 0.004
BAI 2 10.8610.26 9.668.3
BDI 1 15.968.37 0.04 20.9610.8 o0.001
BDI 2 14.468.73 12.3610.2
Data presented as mean 6standard deviation.
BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory;
CG = control group;
EG = experimental group; Fluency = Verbal fluency test; GDS =
Geriatric Depression Scale; MMSE = Mini-Mental State
Examination; Rey CF = Rey Complex Figure Test; Rey DR = Rey
Delayed Recall.
*Wilcoxon test. Bold font indicates statistical significance.
Table 4 Improvement (variation) in variables of interest in
the control (CG) and experimental (EC) groups between time
points 1 and 2
Delta CG (n=25) EG (n=31) p-value*
MMSE 0.160.8 0.661.7 0.090
Fluency 0.163.1 0.162.6 0.930
Trail Making 1.9610.1 3.3611.9 0.360
Rey CF 4.0616.4 2.5618.6 0.160
Rey DR 4.7617.8 11.6620.1 0.380
GDS -0.662.32 -3.263.4 0.007
BAI -2.9611.36 -8.9614.5 0.032
BDI -1.664.86 -8.6612.8 0.025
Data presented as mean 6standard deviation.
BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory;
Fluency = Verbal fluency test; GDS = Geriatric Depression Scale;
MMSE = Mini-Mental State Examination; Rey CF = Rey Complex
Figure Test; Rey DR = Rey Delayed Recall.
*Logistic regression adjusted for age. Bold font indicates statistical
Rev Bras Psiquiatr. 2018;00(00)
Art therapy for depression 5
were revisited, providing the patient with the opportunity
to work out these situations using expressive techniques).
Anxiety scores were reduced at the end of this study,
which is in accordance with the therapeutic objective of
the sessions. This finding was also reported in other
studies of guided imagery.
In the present interven-
tion, guided imagery was used with the aim of helping
participants relax, move their thoughts away from worries
or unpleasant situations, and bring their attention to the
topic of the workshop.
Visualization of positive and
pleasant images during guided imagery may also have
contributed to decreasing the negative thoughts and
feelings of sadness that are characteristic of depression.
These results are similar to those reported in previous
studies on guided imagery using projected images.
most unique part of the model proposed in this study –
artistic making through art therapy sessions – stimulated
and increased the possibility of observation and revalua-
tion of patients’ feelings, values, and even attitudes.
This is possible especially because, during artistic output,
emotions and feelings are concretized through art, becom-
ing more active than rational thoughts. This can promote
insight, leading to changes in how a given situation or
problem is viewed by the patient; this, in turn, may have
contributed to a reduction in anxiety and depressive
Searching for the meaning of life is a coping strategy
during stressful events, which are numerous during old
age and are worsened by awareness of the approach and
inexorability of death.
In the art therapy intervention
used herein, themes such as the finiteness of existence,
fear of death and disease, and solitude were addressed
nonverbally. The benefit of this approach is that patients
can become aware of these issues without having to
tackle them rationally and defensively. Artworks can
represent the concretization of emotions, enabling the
patient to gain insight into problems that can then be
changed, which is the main objective of psychotherapy.
Art therapy can allow the individual to enter a plastic,
expressive universe that is different from her daily routine,
facilitating new perceptions. Patients are encouraged to
share this process with the art therapist, who sees,
listens, and supports the patient, making transformation
of the patient’s reality possible.
Improvement in depressive and anxiety symptoms was
also reported in a meta-analysis of art therapy for patients
with breast cancer.
Even though depression and anxiety
were probably effects of the disease itself and not the
primary issue in this meta-analysis, it may be inferred
that both patients with cancer and those with MDD
may benefit from art therapy, given the fact that the
two disorders have common precipitating or perpetuating
The results of the GDS corroborate the results of the
BDI scale, with a significant, moderate to strong correla-
tion for both groups. The GDS has been validated for the
study of depression in the elderly,
and the BDI
widely used for adults. The advantages of the BDI are its
more comprehensive coverage of several aspects of
depression and the wider range of scores (up to 63 points
instead of 15 in the GDS), which may make the BDI more
appropriate to measure slight changes. The fact that it is
widely used worldwide also makes comparison between
studies easier. Therefore, both scales seem adequate to
evaluate depression and its treatment in older adults.
To create a more homogenous group, recruitment was
restricted to female participants. The literature shows that
depression is more prevalent and often more chronic
and recurrent in women than in men.
Besides, women
are generally more likely to seek healthcare; among the
elderly, women are more socially active than men,
may therefore adhere better to treatment. The age group
chosen in the study (60 years or older) also has particular
characteristics, such as greater social difficulties, increased
risk of several diseases, faster loss of function, and greater
risk of depression.
The use of group sessions made it possible to increase
the number of people seen by the therapist, enabled the
exchange of experiences among the participants, and
allowed mediation of interpersonal relationships by the
therapist, which decreased social isolation (a possible
consequence of depression). This important benefit of
group psychotherapy has also been reported in other
The duration of psychotherapy is an important issue,
and has been considered in many studies. As the objec-
tive of the present study was to test art therapy as an
adjunct to pharmacotherapy for treatment of MDD, a
duration of 20 sessions was chosen, as it enables a better
grasp of the concepts and establishment of well-being.
In previous studies of art therapy, at least 12 sessions
were recommended for treatment of depression and
anxiety symptoms.
A systematic review and meta-
analysis of psychosocial interventions for depression in
elderly patients found more positive results with at least
3 months of therapy.
Although the main characteristic of art therapy is its
use of expressive resources, verbal communication was
also favored in this study. An artwork that mirrors the
individual, and about which she may talk, is an important
communication facilitator between the patient, the therapist
and, in this case, the group. Nevertheless, a systematic
review and meta-analysis suggested that, as art therapy
interventions are powerful techniques for psychic mobiliza-
tion, some painful or distressing contents may surface to
the conscious mind. Thus, art therapy sessions should be
conducted carefully by the therapist, who must pay close
attention to the emotional status of the patients.
EG participants experienced improvement in GDS,
BDI, and BAI scores, which were the focus of the inter-
vention. The EG also showed significant improvement in
cognition, as assessed by the MMSE and Rey DR. One
factor that might have contributed to this improvement in
cognition is stimulation through artistic making, as well
as the therapeutic process of art therapy itself and the
improvement in mood. However, on comparison with the
CG, the improvement in cognition disappears. Several
explanations for this are possible. One factor is the rela-
tively small sample size; moreover, a nonsignificant improve-
ment was also found in the CG, perhaps because of
a learning effect regarding the test tasks. CG partici-
pants showed only a slight improvement in BDI without
Rev Bras Psiquiatr. 2018;00(00)
6EC Ciasca et al.
receiving any intervention. The reason for this improve-
ment cannot be stated; perhaps the fact that these parti-
cipants received some care (through the application of
tests) influenced this reduction in symptoms. Therefore,
no cognitive improvement was observed in the present
study. These findings contradict those of a pilot study that
investigated the efficacy of 12 art therapy sessions in
improving cognitive performance.
One possible expla-
nation is that, in this pilot study, cognitive aspects were
better explored during the sessions, whereas the main
focus of the art therapy intervention described herein was
emotional improvement rather than cognitive aspects,
such as memory and executive functions. Future studies
could better explore this important issue.
The present intervention included high-income, highly
educated elderly patients and low-income women with
few years of schooling in the same group. This hetero-
geneity did not seem to have any negative impact on
understanding, participation, or involvement in the study
intervention. It should be emphasized that artistic ability is
not a requirement for participation in art therapy sessions.
Therefore, the applicability of art therapy in different situa-
tions, contexts, and populations, as well as its cost-
effectiveness, are also relevant aspects to be explored in
future studies.
Research on art therapy is still incipient,
especially in the field of medicine, where quantitative
validation is in high demand. Furthermore, the term ‘‘art
therapy’’ is somewhat imprecise, as ‘‘art’’ refers to visual
art and ‘‘art as therapy’’ is related to a broader category
that includes music, dance, and drama therapy as
It bears stressing that, given the heterogeneity of
approaches, expressive techniques, and ways in which
workshops are conducted by art therapists, leading to a
wide range of strategies, concepts, and modalities, it is
difficult to compare studies and assess the overall effects
of art therapy.
This study has several limitations. The integration of a
brief relaxation and guided imagery step during the art
therapy sessions, in addition to artistic production per se,
means we cannot know which component was respon-
sible for the effects observed. Another limitation was the
duration of the intervention, as patients abandoned
treatment in both groups. Only two patients dropped out
of the EG, but in the no-intervention CG, eight patients
abandoned the study. It is also important to consider
the size and quality of the sample. Recruitment was
limited to elderly women living in the city of Sa
˜o Paulo,
and, although the group showed heterogeneous socio-
economic and cultural characteristics, it was not repre-
sentative of the Brazilian elderly female population. The
fact that only women participated in this study means that
entirely different results may be observed in a study of
male participants alone or of both genders. A sham
therapy would also be of great value. However, the
number of patients recruited was relatively small; the
addition of a sham group would have diluted the sample
even further. The absence of a multiple-baseline design is
also a limitation, because it precludes assessment of
whether the positive effects of art therapy were long-lasting.
The type of intervention itself is also a limitation. The
workshops and the technique of relaxation with guided
imagery, although described in detail, may be carried out
differently by another art therapist, with different results.
Another limitation of the study was the fact that dif-
ferent antidepressants were used by the participants,
even though allocation was random and all participants’
medication regimens remained unchanged during the
experiment. In our sample, medication was well tolerated,
as no major cognitive side effect was seen according to
the cognitive tests. Future studies could better explore if,
for instance, antidepressants with superior neurotropic or
cognitive-enhancing effects could lead to better respon-
ses to therapy.
Additional studies of art therapy may be carried out to
discuss impact on quality of life, well-being, and decreas-
ing obsessive reminiscences, as has been done with
other psychotherapeutic interventions.
Finally, it is impor-
tant that other well-designed, quantitative studies be
conducted before art therapy can be indicated as an
adjunctive healthcare service.
In conclusion, despite some limitations, the present
study contributes to the recognition of art therapy as
an adjunct to pharmacotherapy in improving depressive
symptoms in patients with MDD. The intervention model
used art therapy and relaxation through guided imagery –
three approaches have great potential to modify mental
states – to enhance the possibility of transforming the
patient’s world view and to enable resignification of past
events. Furthermore, while most research on art therapy
has been qualitative, this study provides quantitative
information on the effects of this modality.
The authors report no conflicts of interest.
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... Art making has been shown to reduce symptoms of anxiety and depression and improve well-being, self-esteem, and confidence (Ciasca et al., 2018;Crone et al., 2013;Sandmire et al., 2016). In fact, 20-30 minutes of art making has been shown to significantly decrease state and trait anxiety in college students (Drake et al., 2014;Sandmire et al., 2016). ...
... Improvements in PA after participating in an art making session also support results from previous research (Ciasca et al., 2018;Crone et al., 2013;Sandmire et al., 2016). Moreover, an open studio setting in which participants can choose how they participate has demonstrated significant increases in PA and decreases in NA (Bell & Robbins, 2007;Kaimal et al., 2017). ...
... Based on the suggestions and recommendations from the therapist at an elderly care centre, 13 elderlies fit the inclusion criteria and were selected to participate in the experiments together with another two subjects from the nearby area. The criteria for selecting the subjects include age of more than 60 (Koris et al., 2017), showing early symptoms of memory disorder, having regular or corrected-to-standard vision and hearing, and being able to obey test directions (Ciasca et al., 2018). For experimental research with tight experimental controls, successful research is possible with samples as small as 10 to 20 in size (Sekaran & Bougie, 2003). ...
Full-text available
Game-based psychotherapy intervention is a promising alternative to non-pharmacological approaches in treating memory disorders. Nevertheless, the game-based approach is yet to be included systematically in existing intervention models for treating memorydisorders. Hence, this article discusses how a proposed gamebased psychotherapy intervention is developed and validated usingneurofeedback approach. The proposed model consists of nine exogenous and six instantaneous factors as the main components. Toensure its applicability, a validation procedure has been carried out through a series of psychotherapy experiments involving the elderly with memory disorder symptoms. Electroencephalogram (EEG) data captured from the experiments are thoroughly analysed to validate relationships among factors in the model. Experimental findings have proven that all relationships are successfully validated and supported except for the belief component with the cut-off point of 56.6%. The novelty of this study can be attributed to the integration of digital games and neurofeedback in psychotherapy for memory disorders. The model is believed to be a guideline in planning suitable cognitive training and rehabilitation for people with memory disorders towards improving the quality of the elderly life.
... In an observational study, Gussak (2007) found that art therapy dramatically decreased the depressed symptoms. Likewise, single-blind and randomized controlled studies also proved that art therapy was effective for psychological distress (Ciasca et al., 2018). Very popular among students, art therapy has been shown in numerous studies (Hongtao, 2021) to dramatically lessen stress and symptoms of depression. ...
The current research was planned to investigate the efficacy of integrated Islamic Art Interventions on stress and resilience among undergraduate university students. After screening on Stress levels with Students Stress Inventory, 10 participants were selected with moderate to severe stress from a public sector university. Furthermore another questionnaire were also used to measure the resilience which was a Brief Resilience Scale. The responses on questionnaires were taken before intervention and also post intervention. The results were generated and analyzed through SPSS (26 Version). The results of paired sample t-test indicate that Islamic Art Interventions significantly decrease the stress levels and significantly increasing the resilience levels among undergraduate university students. This carries implications for psychologists and educationists for using Islamic Art Interventions for improving the academic and personal life issues in the student population
... Finland, Italy, Mexico, Taiwan, Thailand and the USA) and used a variety of quantitative designs, six involving randomised group allocation (online supplemental file 6). [29][30][31][32][33][34] Studies were published from 2004 to 2022 and involved a total of 669 participants with anxiety and/ or depression. The number of participants (across all arms) ranged from 14 to 200 per study (median sample size 32.5). ...
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Objectives: This systematic review examined the potential benefit of all group-based performing arts interventions for primary anxiety and/or depression. Setting: Scholarly literature from any country or countries globally. Data sources: Three key bibliographic databases, Google Scholar and relevant citation chasing. Primary and secondary outcome measures: Depression and/or anxiety symptom severity, well-being, quality of life, functional communication or social participation. Results: Database searches returned a total of 63 678 records, of which 56 059 remained following dededuplication. From these database searches, a total of 153 records proceeded to full-text screening. These were supplemented by 18 additional unique full-text screening records from Google Scholar searches and citation chasing (12% of total). From a total of 171 records at the full-text screening stage, 12 publications (7%) were eligible for inclusion in this systematic review, each reporting on a separate study. Published from 2004 to 2021, these studies involved a total of 669 participants with anxiety and/or depression from nine countries and covered five broad artistic modalities: dance, music therapy, art therapy, martial arts and theatre. Dance was the most studied artistic modality (five studies), while there were three studies on art therapy, two on music therapy and one each on martial arts and theatre. The evidence was clearest for a benefit of arts therapies on depression and/or anxiety symptoms. Conclusions: This systematic review addresses all group-based active arts interventions in a focused population of primary anxiety and/or depression. The evidence suggests that the arts may be a useful therapeutic medium in this population. However, a substantial limitation of the evidence base is the lack of studies directly comparing different artistic modalities. Moreover, not all artistic modalities were assessed for all outcome domains. Therefore, it is not currently possible to determine which artistic modalities are most beneficial for which specific outcomes.
... Regarding psychiatric comorbidities, the only included study that measured their symptoms found no significant results for them (obsessive compulsive, anxiety and depressive symptoms) when using visual art-based intervention in AN outpatients (Lock et al., 2018), differently from studies with other clinical populations (Abbing et al., 2018;Ciasca et al., 2018). Furthermore, two included studies found significant ED psychopathology results, but they are fragile, as the groups were different at baseline where the visual art group had higher levels of AN psychopathology than the comparison group (Lock et al., 2018), and the snack offered during the museum visit makes it impossible to infer whether the reduction in urge-to-eat levels is an effect of visual art-based intervention or of the food intake in that uncontrolled study (Thaler et al., 2017). ...
Aim: To assess the effect of visual art- and music-based interventions in the treatment of eating disorders. Methods: This study was registered in PROSPERO (CRD42020161503). Six databases (CINAHL, EMBASE, Lilacs, PsycINFO, PubMed and The Cochrane Library) were consulted. The searches were performed on 19 June 2019, and updated on 18 March 2022. No restriction on language, date, or publication status was applied. Methodological quality was assessed using Joanna Briggs Institute's instruments. All steps were performed by two independent reviewers and a third participated in the event of disagreement. Results: Eight studies were included. Few statistically significant results were found. Overall, both interventions might help to reduce negative emotional states. Conclusion: Visual art- and music-based interventions present limited and inconclusive scientific evidence in patients with eating disorders and therefore their effectiveness is currently unknown. A theoretical model is proposed to guide future research. Further studies are needed to clarify their clinical relevance.
Dementia cases are rising along with the elderly population. Thus, alternative methods to pharmacological treatment are increasingly sought to improve the quality of life of these people. Among these interventions, the effects of music-based therapies (MBT) on the symptoms of dementia and the use of digital technologies to mediate and enhance non-pharmacological therapies are being increasingly studied. The use of MBT contributes to the reduction of neuropsychiatric symptoms of dementia and is associated with the stimulation of specific cognitive functions. Meanwhile, digital technologies aim to support people living with dementia throughout their illness and are cited as a facilitator of non-pharmacological approaches to treat the non-cognitive aspects of dementia and stimulate cognitive functions. The authors discuss the aging process, and the use of digital technologies to enhance the use of music as a therapeutic resource in the non-pharmacological treatment of dementia syndromes, presenting the advantages and possibilities of bringing these two resources together.
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BACKGROUND Acute cerebral infarction (ACI) is characterized by a high incidence of morbidity, disability, recurrence, death and heavy economic burden, and has become a disease of concern in global researchers. As ACI has serious effects on patients’ physical status, life and economy, often causing anxiety, depression and other psychological problems, these problems can lead to the aggravation of physical symptoms; thus, it is very important to understand the factors affecting the mental health of these patients. AIM To understand the elements that affect the mental health of patients who have suffered an ACI. METHODS A questionnaire survey was conducted among patients with ACI admitted to three tertiary hospitals (Quanzhou First Hospital, Fuqing City Hospital Affiliated to Fujian Medical University, and the 900 Hospital of the Joint Service Support Force of the People’s Liberation Army of China) in Fujian Province from January 2022 to December 2022 using the convenience sampling method. ACI inpatients who met the inclusion criteria were selected. Informed consent was obtained from the patients before the investigation, and a face-to-face questionnaire survey was conducted using a unified scale. The questionnaire included a general situation questionnaire, Zung’s self-rating depression scale and Zung’s self-rating anxiety scale. All questionnaires were checked by two researchers and then the data were input and sorted using Excel software. The general situation of patients with ACI was analyzed by descriptive statistics, the influence of variables on mental health by the independent sample t test and variance analysis, and the influencing factors on psychological distress were analyzed by multiple stepwise regression. RESULTS The average age of the 220 patients with ACI was 68.64 ± 10.74 years, including 142 males and 78 females. Most of the patients were between 60 and 74 years old, the majority had high school or technical secondary school education, most lived with their spouse, and most lived in cities. The majority of patients had a personal income of 3001 to 5000 RMB yuan per month. The new rural cooperative medical insurance system had the largest number of participants. Most stroke patients were cared for by their spouses and of these patients, 52.3% had previously smoked. Univariate analysis showed that gender, age, residence, course of disease, number of previous chronic diseases and smoking history were the main factors affecting the anxiety scores of patients with ACI. Age, living conditions, monthly income, course of disease and knowledge of disease were the primary variables influencing the depression score in patients with ACI. The findings of multivariate analysis revealed that the course of disease and gender were the most important factors influencing patients’ anxiety scores, and the course of disease was also the most important factor influencing patients’ depression scores. CONCLUSION Long disease course and female patients with ACI were more likely to have psychological problems such as a high incidence of emotional disorders. These groups require more attention and counseling.
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Background. Research is directed towards female suicides and the solution of the postvention problems in Lithuania. Suicidal behavior of women is conditioned by their psychological sensitivity to different psycho-social factors. The-psycho-emotional state of women who have attempted suicide is worsened, different negative emotions prevail, they lack self-esteem and are disappointed. The methods used in the research aim to answer the same question: does art therapy have an effect on the psycho-emotional state of women who have attempted suicide? It uses different methods of data analysis, i.e. quantitative and qualitative analysis of a small sample. Research aim. The aim of the research is to present effects of art therapy on changes in the psycho-emotional state of women who have attempted suicide. The aim of the research is supported by the following tasks and questions. Tasks: 1) to determine changes of depression symptoms; 2) to determine change of anxiety symptoms. Questions: 1) how do visually dominant iconographic motifs in patients’ drawings change during art therapy? 2) how do visually dominant formal motifs in patients’ drawings change during art therapy? 3) does the change of iconographic and formal motifs relate to changes of the emotional state of a selected group of women? 4) how interrelated are results of quantitative and qualitative research methods? Methods. Mixed research was conducted using the HADS scale, with analysis of visually dominant iconographic and formal elements. Results. The art therapy intervention significantly reduced the level of depression in the subjects. Art therapy had no significant effect on subjects’ anxiety levels. Selected iconographic motifs in the subjectsʼ drawings during the process of art therapy changed: from visually unindentifiable to recognizable objects; from an abstract symbolic meaning to a more concrete and clearly defined meaning; from a smaller to a larger number of iconographic elements; from an iconographically blurred to a more explicit plot. Selected formal motifs in the patients’ drawings during the process of art therapy changed: from incomplete to more detailed depiction of the object; from closed to more open silhouette type; from an isolated object opposed to the surrounding space to an object increasingly infiltrating into that space; from a closed to a progressively more open composition; from linearity to pictoriality; from darker to lighter color scale; from poorer to richer color palettes. The change of iconographic and formal motifs is related to the change of the emotional state of the subjects: the reduced isolation of the depicted objects and the strict separation from the surrounding space show a reduced opposition of the subjects, and the beginning of the social and psychological connection with the surrounding world. The shift from an incomplete to a more detailed depiction of an object shows that the former uncontrollability of the subjects’ self, their feelings, and their connection with the environment turns into clear and rational controllability; more concrete and realistic drawings show the increased awareness of the subjects and better connection with the surrounding world. Conclusions. The change in depression levels after art therapy intervention is statistically significant (p<0.05). The change in anxiety levels after art therapy intervention is not statistically significant (p>0.05). The shift of the drawings is from abstract to specific iconography. The formal motifs of the drawings become more detailed and their type of representation become more varied; the depiction of the objects have become more integrated in the composite space, and the composition become more open; the paintings became more artistic, and the color range became wider. The psycho-emotional state of the subjects in the sessions varied from detachment, withdrawal, hiding, fear of looking at oneself, to opening up, trying to notice and make sense of all one’s own negativity, to manage negative emotions and to project one’s future. Keywords: art therapy, woman suicide, anxiety, depression.
Art therapy is an effective method of treating behavioral and psychological issues in individuals with dementia and Alzheimer's disease, and has been tested amongst patients as early as the 1980s. Although similar benefits have been seen in populations of people who are not at risk for this disease, studies have shown art therapy to be effective at lowering levels of depression, improving social skills, supplementing verbal communication, enhancing quality of life, and maintaining fine motor skills in participants with dementia and Alzheimer's disease. Additionally, some research has suggested that art therapy may play a role in improving cognition, delaying neuronal decay, and inspiring autobiographical memories, though further research is needed to support these arguments. This chapter will dissect the many studies that suggest various cognitive and psychological benefits, analyze current interventions, examine art's role in a therapeutic setting, and advocate for future studies.
Background Art therapy is increasingly being used as a nonpharmacological form of therapy for older people, but there is still a great need for further research.Objective The effects of art therapy on the quality of life, pain intensity and well-being of multimorbid patients in a geriatric day hospital.Material and methodsOlder patients with dementia and/or depression and/or chronic pain received structured art therapy in addition to comprehensive geriatric clinical care. Documentation of geriatric assessment parameters at admission, discharge and follow-up.ResultsThe parameters of the assessment, the verbal rating scale of pain intensity (VRS), the depression in old age scale (DIA-S), the World Health Organization‑5 well-being index (WHO-5) and the European quality of life 5 dimensions 3‑level version (EQ-5D-3L), did not show any statistically significant effects. A secondary analysis showed positive tendencies for well-being (WHO-5) and pain intensity (VRS). The pre-post comparison of art therapy showed a highly significant positive influence on well-being (p < 0.001).Conclusion Art therapy has a positive effect on the well-being and pain intensity of multimorbid geriatric patients. Further research is urgently required.
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Mental health problems account for almost half of all ill health in people under 65 years. The majority are non-psychotic (e.g. depression, anxiety and phobias). For some people, art therapy may provide more profound and long-lasting healing than more standard forms of treatment, perhaps because it can provide an alternative means of expression and release from trauma. As yet, no formal evaluation of art therapy for non-psychotic mental health disorders has been conducted. This review aimed to evaluate evidence for the clinical effectiveness and cost-effectiveness of art therapy for non-psychotic mental health disorders. Comprehensive literature searches for studies examining art therapy in populations with non-psychotic mental health disorders were performed in major health-related and social science bibliographic databases including MEDLINE, EMBASE, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Allied and Complementary Medicine Database (AMED) and Applied Social Sciences Index and Abstracts (ASSIA) from inception up to May 2013. A quantitative systematic review of clinical effectiveness, a qualitative review to explore the acceptability, relative benefits and potential harms, and a cost-utility analysis of studies evaluating cost-effectiveness of art therapy were conducted. In the quantitative review, 15 randomised controlled trials (RCTs) were included (n = 777). Meta-analysis was not possible because of clinical heterogeneity and insufficient comparable data on outcome measures across studies. A narrative synthesis reports that art therapy was associated with significant positive changes relative to the control group in mental health symptoms in 10 out of the 15 studies. The control groups varied between studies but included wait-list/no treatment, attention placebo controls and psychological therapy comparators. Four studies reported improvement from baseline but no significant difference between groups. One study reported that outcomes were more favourable in the control group. The quality of included RCTs was generally low. In the qualitative review, 12 cohort studies were included (n = 188 service users; n = 16 service providers). Themes relating to benefits of art therapy for service users included the relationship with the therapist, personal achievement and distraction. Areas of potential harms were related to the activation of emotions that were then unresolved, lack of skill of the art therapist and sudden termination of art therapy. The quality of included qualitative studies was generally low to moderate. In the cost-effectiveness review, a de novo model was constructed and populated with data identified from the clinical review. Scenario analyses were conducted allowing comparisons of group art therapy with wait-list control, group art therapy with group verbal therapy, and individual art therapy versus control. Art therapy appeared cost-effective compared with wait-list control with high certainty, although generalisability to the target population was unclear. Verbal therapy appeared more cost-effective than art therapy but there was considerable uncertainty and a sizeable probability that art therapy was more clinically effective. The cost-effectiveness of individual art therapy was uncertain and dependent on assumptions regarding clinical benefit and duration of benefit. From the limited available evidence, art therapy was associated with positive effects when compared with a control in a number of studies in patients with different clinical profiles, and it was reported to be an acceptable treatment and was associated with a number of benefits. Art therapy appeared to be cost-effective compared with wait-list but further studies are needed to confirm this finding as well as evidence to inform future cost-effective analyses of art therapy versus other treatments. The study is registered as PROSPERO CRD42013003957. The National Institute for Health Research Health Technology Assessment programme.
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Background. Breast cancer is one of the most common types of cancer. However, only a few trials assess the effects of arts therapies. Material and Methods. We searched the Cochrane Central Register of Controlled Trials, PubMed, and Google Scholar from their start date to January 2012. We handsearched reference lists and contacted experts. All randomized controlled trials, quasi-randomized trials, and controlled clinical trials of art interventions in breast cancer patients were included. Data were extracted and risk of bias was assessed. Meta-analyses were performed using standardized mean differences. Results. Thirteen trials with a total of 606 patients were included. Arts therapies comprised music therapy interventions, various types of art therapy, and dance/movement therapies. The methodological quality ranged from poor to high quality with the majority scoring 3 of 4 points on the Jadad scale. Results suggest that arts therapies seem to positively affect patients' anxiety (standardized mean difference: -1.10; 95%, confidence interval: -1.40 to -0.80) but not depression or quality of life. No conclusion could be drawn regarding the effects of arts therapy on pain, functional assessment, coping, and mood states. Discussion. Our review indicates that arts interventions may have beneficial effects on anxiety in patients with breast cancer.
Objective: A number of randomized controlled trials in major depressive disorder have employed a sequential model, which consists of the use of pharmacotherapy in the acute phase and of psychotherapy in its residual phase. The aim of this review was to provide an updated meta-analysis of the efficacy of this approach in reducing the risk of relapse in major depressive disorder and to place these findings in the larger context of treatment selection. Method: Keyword searches were conducted in MEDLINE, EMBASE, PsycINFO, and Cochrane Library from inception of each database through October 2014. Randomized controlled trials examining the efficacy of the administration of psychotherapy after successful response to acute-phase pharmacotherapy in the treatment of adults with major depressive disorder were considered for inclusion in the meta-analysis. Results: Thirteen high-quality studies with 728 patients in a sequential treatment arm and 682 in a control treatment arm were included. All studies involved cognitive-behavioral therapy (CBT). The pooled risk ratio for relapse/recurrence was 0.781 (95% confidence interval [CI]=0.671-0.909; number needed to treat=8), according to the random-effects model, suggesting a relative advantage in preventing relapse/recurrence compared with control conditions. A significant effect of CBT during continuation of antidepressant drugs compared with antidepressants alone or treatment as usual (risk ratio: 0.811; 95% CI=0.685-0.961; number needed to treat=10) was found. Patients randomly assigned to CBT who had antidepressants tapered and discontinued were significantly less likely to experience relapse/recurrence compared with those assigned to either clinical management or continuation of antidepressant medication (risk ratio: 0.674; 95% CI=0.482-0.943; number needed to treat=5). Conclusions: The sequential integration of CBT and pharmacotherapy is a viable strategy for preventing relapse in major depressive disorder. The current indications for the application of psychotherapy in major depressive disorder are discussed, with special reference to its integration with pharmacotherapy.
Much has been learned from the 400 randomized trials on psychotherapies for adult depression that have been conducted, but much is also still unknown. In this study some recent attempts to further reduce the disease burden of depression through psychotherapies are reviewed. In the past, many new psychotherapies have promised to be more effective than existing treatments, usually without success. We describe recent research on two new therapies, acceptance and commitment therapy and cognitive bias modification, and conclude that both have also not shown to be more effective than existing therapies. A growing number of studies have also focused on therapies that may be successful in further reducing the disease burden, such as treatments for chronic depression and relapse prevention. Other studies are aimed at scaling up psychological services, such as the training of lay health counselors in low-income and middle-income countries, telephone-based, and internet-based therapies. Psychotherapies are essential tools in the treatment of adult depression. Randomized trials have shown that these treatments are effective, and by focusing on key issues, such as chronic depression, relapse, and scaling them up, psychotherapies contribute more and more to the reduction of the disease burden of depression.
Key Clinical Points Care of the Asplenic Patient Late-life depression (occurring in persons 60 years of age or older) is common and is often associated with coexisting medical illness, cognitive dysfunction, or both. Depressed older adults are at increased risk for suicide. Asplenic patients in whom fever develops should receive empirical antimicrobial therapy immediately. Screening for depression is important, but positive screening results should be followed by a thorough evaluation to assess patient safety and ensure that treatment is warranted. Either pharmacotherapy or psychotherapy may be used as first-line therapy. Currently available antidepressants show efficacy in depressed older populations, but older adults may be at increased risk for medication side effects. Selective serotonin-reuptake inhibitors (SSRIs) are considered first-line pharmacotherapy. Standardized psychotherapy techniques are also effective for depression in older adults.
Our study sought to characterize mood disordered suicide ideators and attempters 50 years and older admitted to a psychiatric ward either for a recent suicide attempt or for ongoing suicidal ideation. We enrolled 50 patients with suicide ideation consecutively admitted to an inpatient department and 50 patients admitted for a suicide attempt made in the last 48 hours. Suicide attempters more frequently had low social support and an age of onset of mood disorder of 46 years and older, and less frequently had a history of suicidal behaviors in the family members and pharmacological treatment, despite the fact that the groups did not differ with regard to antidepressants prescribed. The groups were not distinguishable based on several variables assumed to be risk factors for suicide behavior, such as proximal life events and stressors or alcohol use disorders. In both samples, comorbidity with organic diseases, the presence of stressful life events in the past 12 months, and a diagnosis of major depression were frequently reported. In conclusion, the presence of low social support and the absence of a pharmacotherapy may increase suicidal behaviors in patients at risk.
This article presents the results of a pilot study investigating the efficacy of art therapy to enhance cognitive performance in a sample of 24 elderly Hispanic/Latino members of a community center who participated in a weekly structured thematic therapeutic arts program. A 12-week, quasiexperimental, pretest/posttest, nonrandomized, controlled design evaluated outcomes using the Clock Drawing Test (CDT) and the Cognitive Failures Questionnaire (CFQ). Participants who attended the art therapy sessions outperformed those who did not on both cognitive evaluation tests. The findings suggest that the combination of self-initiated art making with art therapy session attendance may be most beneficial for enhancing a person's perception of cognitive ability, which in turn may positively affect overall cognitive performance.
The present study was designed to test the hypothesis derived from Beck's cognitive theory that decreased negative thinking alleviates depression in experimentally depressed subjects. In order to reduce the frequency of negative thinking, two types of cognitive coping strategies were used, namely pleasant imagery and a distraction task. According to Beck's theory, both strategies should be effective in altering depression. However, the results indicated a clearcut difference in effect as measured on the DACL. Pleasant imagery was successful in alleviating depression, while the distraction task was not.