Effectiveness Not Established

Art Making/Art Therapy

for Depression

Art therapy encourages participants to express emotions through drawing and is aimed at triggering thoughts and feelings for communication. Trained art therapists assist participants to reflect on and explore the thoughts and feelings exposed in the creative expression. This activity is seen to promote the participant's understanding of him- or herself and the situation encountered. Art therapy has been studied in patients with cancer related to management of anxiety, depression, and fatigue.

Art making is the provision of the opportunity and materials for individuals to create various types of artistic items. Art making can be seen as a diversional activity. It differs from art therapy because it does not involve interaction with a trained art therapist and does not necessarily engage the participant in exploring thoughts and feelings through the creative expression.

Research Evidence Summaries

Altay, N., Kilicarslan-Toruner, E., & Sari, Ç. (2017). The effect of drawing and writing technique on the anxiety level of children undergoing cancer treatment. European Journal of Oncology Nursing, 28, 1-6.

Study Purpose

To determine the effect of drawing and writing technique on the anxiety level of children treated for cancer during hospitalization.

Intervention Characteristics/Basic Study Process

A five-day therapeutic program to reduce anxiety of children in treatment for cancer was implemented to understand the effect of continuous therapeutic play. Drawing, writing, and mutual storytelling techniques were pre-arranged in the child’s room. Drawing supplies were given to the children. The State Anxiety Inventory was administered on the first day. Drawing was implemented on the first and third days. Children were asked to draw a picture of a child in the hospital and to write a self-created story with a beginning, a middle, and an end about his or her drawing. Mutual storytelling was implemented on the second and fourth days. While listening to the story of the child, the researcher analyzes the themes and psychological meaning for the child. The researcher responds with a story that is similar but has a more positive ending. On the fifth day, the State Anxiety Inventory is administered for the second time.

Sample Characteristics

  • N = 30   
  • AGE: Mean = 12.56 years (range = 9-16)
  • MALES: 7 (23%)  
  • FEMALES: 23 (77%)
  • CURRENT TREATMENT: Chemotherapy, combination radiation therapy and chemotherapy
  • KEY DISEASE CHARACTERISTICS: Leukemia, solid tumor, lymphoma
  • OTHER KEY SAMPLE CHARACTERISTICS: Had received two or more courses of chemotherapy; child and parent consent to participation

Setting

  • SITE: Single site   
  • SETTING TYPE: Inpatient    
  • LOCATION: Gazi University, Ankara, Turkey

Phase of Care and Clinical Applications

  • PHASE OF CARE: Active anti-tumor treatment
  • APPLICATIONS: Pediatrics

Study Design

Quasi-experimental (pre- and postintervention evaluations of a single group)

Measurement Instruments/Methods

  • Descriptive data collection
  • State Anxiety Inventory
  • Wilcoxon test

Results

The five-day program was evaluated on the first and fifth day. The State Anxiety Inventory mean score (38.63 [SD = 4.38]) for children after the intervention decreased when compared to the mean beginning score (42.63 [SD = 4.64])  (Z = -4.57, p < 0.05). Only 2 of the 30 children wanted to keep the drawings after the intervention.

Conclusions

Drawing and writing and mutual storytelling techniques can be used to reduce the anxiety levels of children in treatment for cancer. The five-day program time interval and intervention could be implemented in future research.

Limitations

  • Small sample (< 30)
  • Risk of bias (no control group)
  • Risk of bias (no random assignment)
  • Unintended interventions or applicable interventions not described that would influence results
  • Other limitations/explanation: No information was provided on who implemented the writing and drawing program, although there is a mention of nursing staff or the "researcher" doing this but it was not made clear who this was and what training he or she had.

Nursing Implications

Writing and drawing can enable children to express their emotions and fears in an artistic format. Nurses should use these techniques to help uncover the hospitalized child’s anxiety. Training for interpretation and projective techniques in therapeutic communication with children would be helpful in hospital settings.

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Bar-Sela, G., Atid, L., Danos, S., Gabay, N., & Epelbaum, R. (2007). Art therapy improved depression and influenced fatigue levels in cancer patients on chemotherapy. Psycho-Oncology, 16, 980–984.

Intervention Characteristics/Basic Study Process

The intervention consisted of once weekly art therapy sessions to teach patients to act in a more conscious way by painting with water-based paints. The intervention was provided by an art therapist. The duration of the sessions varied. Those who completed four or more sessions (n = 19) were compared to those who participated for two weeks or less (n = 41).

Sample Characteristics

  • The sample was comprised of 60 adult ambulatory patients (77% female, 23% male) who were undergoing chemotherapy.
  • Mean age was 77 years (range 25–72).
  • Patients were excluded from the study if they had severe anemia; were treated with an epoetin; had changed their opiate, non-selective serotonin reuptake inhibitor (SSRI) antidepressant, or anxiolytic in the past three weeks; or had changed their SSRI antidepressant in the past six weeks.

Setting

The study was conducted in an ambulatory setting of a cancer center in northern Israel.

Study Design

The study used a single-arm, open-label design.

Measurement Instruments/Methods

  • Brief Fatigue Inventory (BFI), competed weekly before each session
  • Hospital Anxiety and Depression scale (HADS), competed weekly before each session

Results

  • Median BFI score decreased from 5.7 to 4.1 in the intervention group (p = 0.24).
  • Median HADS decreased from 9 to 7 in the intervention group (p = 0.21); anxiety was normal.

Limitations

  • The control group had greater fatigue and may not have been able to participate.
  • The study lacked randomization.
  • The study did not provide control data related to patient drop-out or chemotherapy.
  • Cycle or day-in-cycle assumptions regarding mediating the effect of decreased emotional distress were untested.

Nursing Implications

For treatment with art therapy, a patient requires referral to an art therapist.

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Bozcuk, H., Ozcan, K., Erdogan, C., Mutlu, H., Demir, M., & Coskun, S. (2017). A comparative study of art therapy in cancer patients receiving chemotherapy and improvement in quality of life by watercolor painting. Complementary Therapies in Medicine, 30, 67–72.

Study Purpose

To test the effect of painting art therapy, provided by a dedicated professional artist, on quality of life and anxiety and depression levels in patients receiving chemotherapy

Intervention Characteristics/Basic Study Process

Patients receiving treatment at an outpatient chemotherapy unit were recruited into the study for 12 weeks. Patients were classified by their exposure to the Painting Art Therapy Program (PATP). One group had prior exposure the the second did not. The third group were patients who declined participation and they were considered the control group. The study investigator who is an experienced art therapist conducted the therapy. Patients participated in watercolor painting and a discussion about the symbolic nature of the paintings, feelings, and thoughts. The investigator artist provided introduction to watercolor. During the chemotherapy infusion, the patient made watercolor paintings. After completions of the painting, patients discussed the meaning and subject of their painting. Patients in the intervention group were also given painting materials for home practice.

Sample Characteristics

  • N = 97 (65 in the PATP group and 32 in the control group)    
  • AGE: Mean = 50.6 years (range = 22-73)
  • MALES: 35%  
  • FEMALES: 56%
  • CURRENT TREATMENT: Chemotherapy
  • KEY DISEASE CHARACTERISTICS: 54% metastatic cancer
  • OTHER KEY SAMPLE CHARACTERISTICS: In the intervention group, 26 had prior exposure to PATP and 22 did not. The authors did not define what "prior expose" included.

Setting

  • SITE: Single site   
  • SETTING TYPE: Outpatient    
  • LOCATION: Antalya, Turkey

Phase of Care and Clinical Applications

PHASE OF CARE: Active anti-tumor treatment

Study Design

Comparative prospective study

Measurement Instruments/Methods

  • EORTC-QLQ-C30 questionnaire
  • Anxiety and depression scores (HADS)
  • Analysis of variance (ANOVA) with Bonferroni correction
  • Number of paintings finished by a patient (proxy motivation indicator)

Results

All patients reported liking the PATP to some extent. Change in global quality of life and depression scores differed significantly among the three groups (F = 7.87, p = 0.001; and F = 7.8, p = 0.001).  Correlates of change in depression were participation in PATP (F = 7.75, p < 0.001) and baseline depression scores (F = 17.71, p < 0.001). Predictors of the magnitude of change and change in depression were participation in PATP. Patients who had poorer well being showed better improvements by participating in PATP.  Previous exposure to PATP appeared to diminish the benefit obtained by PATP.

Conclusions

The authors showed improved quality of life and relief from depression in patients with the utilization of PATP. They authors demonstrated that watercolor can be an important form of art therapy in maintaining quality of life in patients with cancer. The application is feasible in the outpatient clinic. Patients demonstrated benefit of PATP in close relationship with basal global quality of life and depression scores. Because art is subjective, other forms of art therapy may target different patients more specifically.

Limitations

  • Small sample (< 100)
  • Baseline sample/group differences of import
  • Risk of bias (no random assignment)
  • Unintended interventions or applicable interventions not described that would influence results

Nursing Implications

Art therapy can be an important and feasible intervention for patients on active treatment. Participation in art therapy while receiving chemotherapy treatment can improve quality of life and contribute to decreased depression.

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Thyme, K.E., Sundin, E.C., Wiberg, B., Öster, I., Åström, S., & Lindh, J. (2009). Individual brief art therapy can be helpful for women with breast cancer: A randomized controlled clinical study. Palliative and Supportive Care, 7, 87–95.

Study Purpose

To explore the responses, in terms of self-image and psychiatric symptoms, of women with breast cancer to an art therapy intervention

Intervention Characteristics/Basic Study Process

The art therapy intervention consisted of five sessions in which participants were encouraged to express feelings and thoughts. Participants’ pictures were used as a mode of expression, followed by reflective dialog. Two experienced art therapists conducted interventions and patient interviews, so that the therapist did not function as both interviewer and therapist for the same patient. Art therapy sessions were provided during adjuvant radiation therapy. Study data were collected at baseline, after two months, and after four months.

Sample Characteristics

  • The study reported on a sample of 41 patients.
  • Median patient age was 59 years, with a range of 37–69 years.
  • All the patients had breast cancer (100% female sample) and had received adjuvant radiation therapy. No other specific diagnostic information was provided.
  • No demographic data were reported (other than age). A few patients in both groups were receiving antidepressants. About 50% of patients had received chemotherapy prior to radiation therapy, and 41% had received hormone therapy.

Setting

  • Single site
  • Outpatient setting
  • Sweden

Phase of Care and Clinical Applications

  • Phase of care: active treatment
  • Clinical applications: late effects and survivorship

Study Design

Randomized controlled trial with longitudinal analysis

Measurement Instruments/Methods

  • Structural analysis of social behavior
  • Symptom Checklist-90 (provides symptom-subscale scores and measures of general severity)
  • Interview

Results

At baseline, all participants had similar self-image scores and scores for depression, anxiety, and general symptom severity as a group of females undergoing radiation therapy for breast cancer who are otherwise healthy. Those who received art therapy showed a decrease in symptoms of anxiety and depression (p < 0.01). Control patients’ symptom levels remained essentially stable. Regression analysis showed that surgery, chemotherapy, parenthood, and study group were significant predictors of depression and anxiety as measured at the end of the study (p < 0.05). Axillary surgery and hormonal treatment predicted higher ratings of anxiety. Subjects’ positive and negative self-image scores were not different between study groups and did not differ significantly from healthy controls.

Conclusions

Participation in art therapy was related to lower patient ratings of depression, anxiety, and somatic symptoms. Axillary surgery and hormonal treatment were predictive of higher levels of anxiety and depression.

Limitations

  • The study had a small sample, with fewer than 100 participants.
  • No attentional control was provided.
  • It is unclear whether art therapy sessions were provided individually or in groups, a factor that could have affected results.
  • There was an overall drop-out rate of 24% from the initial randomized sample.
  • Baseline scores relating to depression and anxiety were actually lower in study patients than those of a healthy comparison group, leading one to question the clinical relevance of study findings overall.
  • Measurement methods used in the study did not include those commonly used in other research.
  • Authors reported minimal demographic informatio, a factor that may limit generalizability.

Nursing Implications

Findings suggest that art therapy might be helpful in management of symptoms of depression and anxiety in women with breast cancer; however, the clinical relevance of findings is unclear. Further well-designed research is needed to confirm these preliminary findings.

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