Available via license: CC BY-NC 4.0
Content may be subject to copyright.
ORIGINAL ARTICLE
Art therapy as an adjuvant treatment for depression in
elderly women: a randomized controlled trial
Eliana C. Ciasca,
1
Rita C. Ferreira,
1
Carmen L.A. Santana,
2
Orestes V. Forlenza,
1
Glenda D. dos Santos,
1
Paula S. Brum,
3
Paula V. Nunes
1
1
Departamento de Psiquiatria, Instituto de Psiquiatria, Hospital das Clı
´nicas da Faculdade de Medicina da Universidade de Sa
˜o Paulo
(HCFMUSP), Sa
˜oPaulo, SP, Brazil.
2
Escola Paulista de Enfermagem, Universidade Federal de Sa
˜o Paulo (UNIFESP), Sa
˜oPaulo, SP, Brazil.
3
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
Introduction
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
patients.
1,2
Less than half of patients with depressive
disorders receive proper treatment.
3-8
This lack of access
to treatment is greater among elderly, low-income, and
minority populations.
2,9
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,
9
and is
associated with lower abandonment rates than pharma-
cotherapy alone; thus, this combination may be indicated
for patients with low medication adherence.
10
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.
9,11-14
Cognitive-behavioral therapy, interpersonal psychotherapy,
and problem-solving therapy are considered first-line
treatments both for adult and elderly patients.
9
Reminis-
cence therapy, psychodynamic therapy, support therapy,
and nondirective counseling,
3,5,12,13
as well as self-esteem
therapy,
14
life review therapy, and depression manage-
ment therapy,
6
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.
15,16
Art
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.
16
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.
E-mail: elianaciasca@uol.com.br
Submitted Feb 08 2017, accepted Jul 18 2017.
Revista Brasileira de Psiquiatria. 2018;00:000–000
Brazilian Journal of Psychiatry
Associac¸a
˜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
therapy.
17
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.
16,18,19
An
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
emotions,
20
and thus relieve the discomfort associated
with mood disorders.
21,22
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.
16
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.
Methods
This randomized, controlled, single-blind study was car-
ried out at the Instituto de Psiquiatria, Hospital das Clı
´nicas
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).
Sample
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,
23
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)
24,25
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).
26,27
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),
28
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
26,27
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
(BAI),
29
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,
24,25
the Verbal Fluency Test –
animal category,
30
the Trail Making Test A,
31
and the Rey
Complex Figure (Rey CF) task.
32
In the Verbal Fluency
Test – animal category,
30
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
31
was used
to evaluate cognitive functions involving sustained atten-
tion, cognitive flexibility, executive functions, sequencing
ability, and motor speed. The Rey CF
32
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
control.
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.
Results
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
Characteristics
CG
(n=25)
EG
(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
w
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
w
Antidepressant and
psychotropic
9 (36.0) 14 (45.2)
Data presented as mean 6standard deviation, unless otherwise
specified.
*Mann-Whitney U;
w
Fisher’s exact test;
=
chi-square test.
Rev Bras Psiquiatr. 2018;00(00)
4EC Ciasca et al.
CG participants only exhibited improvement in BDI
scores.
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.
Discussion
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
therapy.
17
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
elderly,
17
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
significance.
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.
20,21
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.
33
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.
22
The
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
symptoms.
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.
34
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.
35
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
factors.
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,
26,27
and the BDI
28
is
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.
1,2
Besides, women
are generally more likely to seek healthcare; among the
elderly, women are more socially active than men,
6,36
and
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.
3-5,7,8
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
studies.
5,9
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.
35
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.
37
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.
35
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.
38
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.
39
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
well.
40
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.
35
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.
6
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.
Disclosure
The authors report no conflicts of interest.
References
1 Taylor WD. Clinical practice. Depression in the elderly. N Engl J Med.
2014;371:1228-36.
2 Park M, Unu
¨tzer J. Geriatric depression in primary care. Psychiatr
Clin North Am. 2011;34:469-87.
3 Andreescu C, Reynolds CF 3rd. Late-life depression: evidence-based
treatment and promising new directions for research and clinical
practice. Psychiatr Clin North Am. 2001;34:335-55.
4 Cooper C, Katona C, Lyketsos K, Blazer D, Brodaty H, Rabins P,
et al. A systematic review of treatments for refractory depression in
older people. Am J Psychiatry. 2011;168:681-8.
5 Kiosses DN, Leon AC, Are
´an PA. Psychosocial interventions for
late-life major depression: evidence-based treatments, predictors of
treatment outcomes, and moderators of treatment effects. Psychiatr
Clin North Am. 2011;34:377-401.
6 Gameiro GR, Minguini IP, Alves TCTF. The role of stress and life
events in the onset of depression in the elderly. Rev Med (Sa
˜o Paulo).
2014;93:31-40.
7 Diniz BS, Nunes PV, Machado-Vieira R, Forlenza OV. Current
pharmacological approaches and perspectives in the treatment of
geriatric mood disorders. Curr Opin Psychiatry. 2011;24:473-7.
8 Samad Z, Brealey S, Gilbody S. The effectiveness of behavioural
therapy for the treatment of depression in older adults: a meta-analysis.
Int J Geriatr Psychiatry. 2011;26:1211-20.
9 Cuijipers P. Psychotherapies for adult depression: recent develop-
ments. Curr Opin Psychiatry. 2015;28:24-9.
10 Guidi J, Tomba E, Fava GA. The sequential integration of pharma-
cotherapy and psychotherapy in the treatment of major depressive
disorder: a meta-analysis of the sequential model and a critical review
of the literature. Am J Psychiatry. 2016;173:128-37.
Rev Bras Psiquiatr. 2018;00(00)
Art therapy for depression 7
11 Serfaty MA, Haworth D, Blanchard M, Buszewicz M, Murad S, King
M. Clinical effectiveness of individual cognitive behavioral therapy for
depressed older people in primary care: a randomized controlled trial.
Arch Gen Psychiatry. 2009;66:1332-40.
12 Are
´an PA, Raue P, Mackin RS, Kanellopoulos D, McCulloch C,
Alexopoulos GS. Problem-solving therapy and supportive therapy in
older adults with major depression and executive dysfunction. Am J
Psychiatry. 2010;167:1391-8.
13 Pinquart M, Forstmeier S. Effects of reminiscence interventions on
psychosocial outcomes: a meta-analysis. Aging Ment Health. 2012;
16:541-58.
14 Yassuda MS, Nunes PV. Innovative psychosocial approaches in old
age psychiatry. Curr Opin Psychiatry. 2009;22:527-31.
15 Bungay H, Clift S. Arts on prescription: a review of practice in the U.K.
Perspect Public Health. 2010;130:277-81.
16 Uttley L, Scope A, Stevenson M, Rawdin A, Taylor Buck E, Sutton A,
et al. Systematic review and economic modelling of the clinical
effectiveness and cost-effectiveness of art therapy among people
with non-psychotic mental health disorders. Health Technol Assess.
2015;19:1-120, v-vi.
17 Reynolds CF 3rd. Prevention of depressive disorders: a brave new
world. Depress Anxiety. 2009;26:1062-5.
18 O
¨ster I, Svensk AC, Magnusson E, Thyme KE, Sjo
˜din M, Astro
¨mS,
et al. Art therapy improves coping resources: a randomized, con-
trolled study among women with breast cancer. Palliat Support Care.
2006;4:57-64.
19 Puig A, Lee SM, Goodwin L, Sherrard PAD. The efficacy of creative
arts therapies to enhance emotional expression, spirituality, and
psychological well-being of newly diagnosed stage I and stage II
breast cancer patients: a preliminary study. Arts Psychother. 2006;
33:218-28.
20 Lea
˜o ER, Silva MJP. Mu
´sica e dor cro
ˆnica musculoesquele
´tica: o
potencial evocativo de imagens mentais. Rev Latinoam Enferm.
2004;12:235-41.
21 Apo
´stolo JLA, Kolkaba K. The effects of guided imagery on comfort,
depression, anxiety, and stress of psychiatric inpatients with depres-
sive disorders. Arch Psychiatr Nurs. 2009;23:403-11.
22 Skeie TM, Skeie S, Stiles TC. The effectiveness of pleasant imagery
and a distraction task as coping strategies in alleviating experimen-
tally induced dysphoric mood. Cogn Behav Ther. 2010;18:31-42.
23 Associac¸a
˜o Americana de Psiquiatria. Manual Diagno
´stico e Estatı
´stico
de Transtornos Mentais, 5
a
edic¸a
˜o (DSM-5). Porto Alegre: Artmed; 2014.
24 Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A prac-
tical method for grading the cognitive state of patients for the clinician.
J Psychiatr Res.1975;12:189-98.
25 Brucki SM, Nitrini R, Caramelli P, Bertolucci PH, Okamoto IH.
[Suggestions for utilization of the mini-mental state examination in
Brazil]. Arq Neuropsiquiatr. 2003;61:777-81.
26 Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M, et al.
Development and validation of a geriatric depression screening scale:
a preliminary report. J Psychiatr Res.1982-1983;17:37-49.
27 Almeida OP, Almeida SA. [Reliability of the Brazilian version of
the ++abbreviated form of Geriatric Depression Scale (GDS) short
form]. Arq Neuropsiquiatr. 1998;57:421-6.
28 Beck AT, Steer RA. Manual for the revised Beck depression inventory.
San Antonio: Psychological Corporation; 1987.
29 Beck AT, Steer RA. Manual for the Beck anxiety inventory. San
Antonio: Psychological Corporation; 1990.
30 Newcombe F. Missile wounds of the brain: a study of psychological
deficits. Oxford: Oxford University; 1969.
31 Army Individual Test Battery. Manual of directions and scoring.
Washington: War Department, Adjutant General’s Office; 1944.
32 Rey A. L’examen clinique en psychologie. Paris: Universitaire de
France; 1958.
33 Holmes EA, Mathews A. Mental imagery in emotion and emotional
disorders. Clin Psychol Rev. 2010;30:349-62.
34 Pompili M, Innamorati M, Di Vittorio C, Sher L, Girardi P, Amore M.
Sociodemographic and clinical differences between suicide ideators
and attempters: a study of mood disordered patients 50 years and
older. Suicide Life Threat Behav. 2014;44:34-45.
35 Boehm K, Cramer H, Staroszynski T, Ostermann T. Arts therapies for
anxiety, depression, and quality of life in breast cancer patients: a
systematic review and meta-analysis. Evid Based Complement
Alternat Med. 2014;2014:103297.
36 Pledger MJ, Cumming JN, Burnette M. Health service use amongst
users of complementary and alternative medicine. N Z Med J. 2010;
123:26-35.
37 Forsman AK, Nordmyr J, Wahlebecck K. Psychosocial interventions
for the promotion of mental health and the prevention of depression
among older adults. Health Promot Int. 2011;26:i85-107.
38 Alders A, Levine-Madori L. The effect of art therapy on cognitive
performance of Hispanic/Latino older adults. Art Ther (Alex). 2010;
27:127-35.
39 Patel V, Weiss HA, Chowdhary N, Naik S, Pednekar S, Chatterjee S,
et al . Effectiveness of an intervention led by lay health counsellors for
depressive and anxiety disorders in primary care in Goa, India (MANAS):
a cluster randomised controlled trial. Lancet. 2010;376:2086-95.
40 Wood MJ, Molassiotis A, Payne S. What research evidence is there
for the use of art therapy in the management of symptoms in adults
with cancer? A systematic review. Psychooncology. 2011;20:135-45.
Rev Bras Psiquiatr. 2018;00(00)
8EC Ciasca et al.
