Art Therapy as a Therapeutic Intervention for Patients with Depression or Major Depression Disorder
Abstract
Depression is at this moment one of the most common diseases worldwide, affecting more than 264 million people. When this condition lasts for a long time and occurs with moderate to severe intensity it may become a serious health condition. This illness has a tremendous impact on a person’s health wellbeing, causing enormous suffering and an impaired performance and function at work, school and in the daily life with the family. And what is worst it may lead to commit suicide. Suicide is the second lead cause of dead in population 15-29 years old. About 800,000 people die to suicide every year.
Even Though there are established, efficient treatments for mental conditions, between 76% and 85% of people in low- and middle-income countries get no treatment for their illness (WHO, 2017). Obstacles to successful care involve a lack of resources, lack of skilled health-care providers and social stigma related with mental conditions. Another barrier to effective care is inaccurate assessment. In countries of all income levels, people who are depressed are every so often not properly diagnosed, and others who do not have the illness are too often misdiagnosed and given antidepressants.
Given the serious problem that depression represents for the modern world is that alternative therapies are needed as adjuvants for antidepressant medications. And is in this level where Art therapy could be considered an important tool that can be used to help to treat this mental condition. The research question in this proposal: What is the relationship between the participation in Art therapy and improvement of mood in patients who are diagnosed with Depression or Major Depression Disorder (MDD)? Try to stablish how effective is Art therapy to accomplish this purpose.
Keywords: Art Therapy, Depression, Major Depression Disorder
Art Therapy as a Therapeutic Intervention for Patients with Depression or Major Depression Disorder
Depression impact has grown worldwide on populations, and the condition has been identified as a global burden or worldwide crisis. The prediction is that the disease is becoming the second most illness that is disabling globally after the condition of the heart and its implications affect families, individuals, and societies as well as causing a negative impact in the economy. Depression is regarded as an illness that is complex and multifactorial affecting the whole individuals’ body processes, and its impact results in an effect on aspects such as psychological, biological, and social (Kim, 2017). Due to the complexity of depression presented, its treatment needs an appropriate holistic and personal approach that in most cases combines interventions that are psychological, pharmacological, and sociological in reflecting variations requirement for individuals experiencing the condition (Blomdahl et al., 2016).
The current recommendation of therapies has significantly resulted in effects that can be adverse, like antidepressant medications or does not provide solutions that are universal to those suffering from depression. Also, those individuals that are not able to engage in verbal communication can impose a problematic situation in addressing the depression symptoms. Therefore, to help address the issue of depression for patients having difficulty in oral communication or for whom medications are not or are partially effective a different approach can be done alternatively using different types of art therapy like therapy of dance movement, art mediums, therapy of music, and dramatherapy (Lee et al., 2017). Art therapies utilize creative expressions and communication that is non-verbal as their central therapeutic process (Laurer et al., 2015). Also, they help to fulfill certain universal needs for human beings such as the need for self-expression; Art therapies help in overcoming the issues of self-withdrawal that is embedded by depression and encourages sharing. Studies have confirmed art therapies to be extensively used for addressing depression (Kim, 2017). However, its effectiveness and intervention extend nature is still not apparent, and essential variations in known evidence are observed among disciplines of art therapies. When considering art therapies for depression, music therapy is among the most researched comparing with other types of treatments with dramatherapy for depression being very minimal (Lee et al., 2017).
The form of communication in art therapy is usually paintings and drawing when used for visual arts. Art therapy is a two-phase treatment such that it entails verbalization experiences in a therapeutic setting. Clinical skills are used in art therapy. Factors influencing depressed patients’ therapy practice includes therapy length, interventions, approaches, workplace of therapists, tools, and assignment of work (Laurer et al., 2015). Expert practitioners are used for making decisions and helping in developing adaptive conditions for patients suffering from depression. The research studies that have been done regarding art therapies have been linked to a smaller sample size but offering results that are promising such that therapies of art have led to the intervention that is inherently positive in changing the mood of individuals decreasing depression symptoms and improving the general wellbeing of patients (Zubala et al., 2017). Currently, there is an increasing number of research projects on art therapies, which are of high quality despite many of them are lacking scientific integrity. As art therapies are taking over conventional treatment for depression needs, an increase knowledge is necessary about the effectiveness, therefor more upper-quality studies are needed. The purpose of this study is to investigate what is the relationship between the participation in Art therapy and the improvement of mood in patients who are diagnosed with Depression or Major Depressive Disorder (MDD).
In order to accomplish the purpose of this project, a proposal of literature review was presented. This proposal included the significance of the current practice. The Health Belief Model nursing theory was presented as the theoretical framework. A review of the literature was conducted based on the research question that was formulated. After the literature review, practice recommendations were suggested. At the end, the literature review was evaluated and the plan for dissemination was presented.
Significance of the Practice Problem
Depression has various impacts on patients, family, healthcare system, and society (Lee et al., 2017). Patients diagnosed with Depression or Major Depression display a lack of motivation with flat affect that negatively impact their recovery. Patient depression results in pain, loneliness, poor quality of life and reduction of income; this is because a person suffering from depression is mentally affected and feels guilty about almost everything, he or she is in despair and lacks self-motivation. Depression condition affects also families because it incurs in more cost in treating the patient, which also causes anxiety and more lack of motivation (Zubala et al., 2017).
Also, society becomes affected as much of the cost of care is spent on formulating better treatment methods that help in the prevention of the disorder (Lee et al., 2017). The community has to establish the best healthcare policies that govern the environment and provides a better service delivery for patients. Since depression is multifactorial and sophisticated, the patient suffering from it are more frequently readmitted in a healthcare facility or stays longer before they are adequately treated, which results in high-cost expenditure in order to improve the well-being of the patient.
Also, rapid advances in technology have extended the average lifespan of modern society with an increasingly aging population. Elderly individuals’ experience declined cognitive, social, and physical functioning due to changes that occur in their body tissues and degraded body organ functions. Cognitive decline is noticeable through the loss of attention, slow concentration, and little memory functioning. Due to these conditions of the elderly, symptoms of depression increase while the highest levels of cognitive functions result in decreased depression levels. Older adults are associated with increased risks for acquiring geriatric diseases and increased disposition of suffering Depression. Therefore, inducing an active social program among elderly can help in reducing Depression symptoms and improve cognitive functions. Art and recreational practices that entail individuals moving their body motivate elderly persons as it improves exceptional motor functions causing inner satisfaction, thus resulting in self-confidence recovery, promotion of problem-solving skills, and learning abilities (Zubala et al., 2017).
The research put in consideration the age and gender of the participants used for this study. The effect of depression was analyzed mainly on adult and elderly individuals because this age is more vulnerable to depression condition, unlike the younger one.
Elderly individuals usually require specialized care because, at this age, their body is weak and prone to other related diseases such as cardiovascular conditions, different types of cancer and degenerative diseases.
Although therapeutic use of art and occupational therapy as an intervention for behavioral health mental illness is well documented there is a paucity of studies that address the effectiveness of art and occupational therapy as a specific therapeutic intervention for Depression and Major Depression Disorder.
Research Question
The research question was formulated in order to provide the columns to support the literature review with the goal to obtain the latest information regarding the use of Art therapy in Depression and Major Depression. The research question was: What is the relationship between the participation in Art therapy and improvement of mood in patients who are diagnosed with Depression or Major Depression Disorder (MDD)?
Theoretical Framework
The Health Belief Model (HBM) was developed by Irwin Rosenstock in 1966 and has been identified as one of the earliest and most influential models in health promotion. It is a theoretical framework to explore the utilization of preventive health services and subsequently applied to the development of prevention-related interventions for asymptomatic health concerns. As such, it is an applicable theoretical framework for the organization of nursing health promotion services for the reduction of chronic disease in the community such as Depression or Major Depression Disorder (Glanz & Bishop, 2010). Treatment connection and adherence to psychotherapeutic interventions can be challenging with mental health patients. Health behavior theories, specifically the Health Belief Model (HBM) among others, focused on individuals′ beliefs, their readiness to change, their perceptions of illness severity and “threat,” their perceptions of significant others′ attitudes toward illness and treatment, and their behavioral intentions to change. (Gipson and king, 2012). The HBM is a value-expectancy theory that considers the value one assigns to maintaining wellness or seeking treatment in the face of an illness, and one’s beliefs about the effect of acting. Over time the HBM has extended, and in its present form is best articulated as six constructs or components that predict an individual’s readiness to enact change: perceived susceptibility; perceived severity; perceived benefits; perceived barriers; cues to action; and self-efficacy. (Janz, Champion, & Strecher, 2002)
Synthesis of the Literature
In a study which aim was to investigate the feasibility of the Mindfulness Art Therapy Short version for Japanese patients with advance cancer where patients learned mindfulness practices and then made art to express their feelings, investigators found that the results suggest that this intervention may be effective for increasing vigor and reducing fatigue, tension, confusion, Depression, and confusion; and for improving overall mood (Michiko et al, 2016). In another study where the purpose was to evaluate the effectiveness of art therapy based on appreciation of famous paintings on the distress of cancer patients receiving radiotherapy focusing on Depression and anxiety, the investigators found significant improvements on cancer related anxiety and Depression and reduced the prevalence of severe anxiety and Depression during cancer treatment (Lee et al, 2016).
According with Laurer and van der Vennet (2015) a study trying to investigate whether art production or viewing and sorting art reproductions would be more effective in reducing negative mood like Depression and anxiety for 28 adults with substance abuse disorder found that the hypothesis that art production would have a greater reduction in these symptoms was initially supported by the mean scores and the t-test analyses; however it was not supported by two of three ANOVAs, which indicated that time over treatment made as difference rather than the intervention.
In the study “Therapeutic theatre: an experience from a mental health clinic in Yaoundé-Cameroon”, Animbom Ngong (2017) found that by engaging in this collective production, the participants attained deeper understanding of their psychological states and developed coping mechanisms and re-adaptation skills vis-à-vis Depression, anxiety and stress.
Maujean, Pepping and Kendall (2014) in their review article examined current knowledge about the efficacy of art therapy based on the findings of 8 randomized controlled trials conducted with adults’ populations from 2008-2013 that met high standard of rigor. Of these studies all but one reported beneficial effects of art therapy. They found that art therapy may benefit a range of individual, including older adults, war veterans and prison inmates who suffer mood problems among of them depression.
On the other hand, Boehm et al (2014) in a review article called “Arts Therapies for Anxiety, Depression and Quality of life in breast Cancer patients: A systematic Review and meta-Analysis” addressed that the results suggested that art therapies seem to positively affect patients’ anxiety but not depression or quality of life. No conclusion could be drawn regarding the effects of art therapy on pain, functional assessment, coping and mood states such as depression.
Art therapy is based mainly on clinical experience and is rarely described and evaluated significantly. There is a need for further exploration of its use in patients with depression. Experts on the field of art therapy considered that the main aspect of clinical practice in art therapy for patients with depression is that art themes should promote expression related to both to depression and personal history (Blomdahl et al., 2016). On this study the aim was to explore what experts consider to be the main aspects of art therapy in clinical practice for patients with depression. The main aspects of art therapy were agreed to be themselves verbally and through making art. It was equally important that art tasks provided an opportunity to address depressive thoughts, feeling, life experiences and physical symptoms.
In a randomized-control-trial study that investigated the effects of manual-based phenomenological Art Therapy for individuals living with depression in addition to treatment as usual compared with only treatment as usual for individuals diagnosed with moderate to severe depression, investigators got to the following conclusions and implications for practice: Manual-based works as expected, being an effective treatment and contributes to recovery for individuals with moderate to severe depression. This outcome needs to be confirmed and its long-term effects examined in further studies. (Blomdhal, Rusner, Guregard and Wijk, 2018)
Current therapies do not offer universal solutions for the “global burden” of depression. By focusing on non-verbal communication and creativity, arts therapies might present a relevant treatment option, but their effectiveness remains unclear. A pilot study was undertaken to evaluate a brief art therapy group for adults suffering from depression. Adults experiencing mild to moderate depression took part in art therapy and completed questionnaires at three points in time, the intensity of depression, levels of anxiety and general well being were measured. Semi structured interviews focused on participants expectations and experience of therapy. A decrease in depressive symptoms was observed immediately after the therapy and at the follow up and a trend for improvemet of subjectively perceived wellbeing was recorded. The statistically significant results and participants’ experience indicate that art therapy may offer a valuable
When developing a project about the influence of Art therapy on depression symptoms it’s important to know all the related projects that have the same purpose; to improve patients depression among other mood disorders. In the article “Arts on prescription”, Caroline Wendling et al (2018) described a social prescribing project that engaged sufferers of anxiety and depression in creative process. They described the philosophy for Arts and minds, a Cambridge shire-based charity that has been providing “Arts on Prescription” (AoP) – a form of social prescription- since 2009, that as they stated, it is not Art therapy. Art therapy is a form of psychotherapy delivered by qualified arts therapists and the therapist knows the patient’s medical condition and history and plans the art as therapy in response. In contrast, AoP focuses on the artistic process rather than therapeutic outcomes. It provides an opportunity to work on something creative and stimulating within the aim of increasing wellbeing, AoP are facilitated by artists rather than arts therapist. AoP is not a replacement of drugs or cognitive behavioral therapy (CBT) in the treatment of depression, but it works alongside them to enhance the recovery process.
In modern society, the average lifespan has been extended with rapid advances in medical technology and science, and the aging population is thus quickly increasing. The proportion of the elderly population tends to rise every year. Programs that combine physical activities, arts and crafts and recreational program on the activities of daily living (ADL) have positive effects on the health of the elderly and provide evidence for managing their health, specially depression. (Kim, 2017).
In a very interesting investigation where art therapy intervention was applied to alleviate the symptoms of post-traumatic stress, depression and anxiety among Syrian refugee children, Ugurlu, Akca and Acartuk, (2016) found that trauma, depression and trait anxiety symptoms of children were significantly reduced at the post-assessment. Therefore, they concluded that art therapy may be an effective method to reduce the mentioned symptoms among refugee children.
Khai Ling Lee, M.S Mustaffa and S.Y. Tan (2017) developed a study where they tried to understand better the use of visual arts in counseling adults with depressive disorders. Applying both qualitative and quantitative research methods they explored the adult participants counseling experiences. Their findings showed that through the therapeutic use of visual arts the participants were able to explore and express various emotions, face their problems, communicate better with themselves and the counselor, achieve a deeper self-understanding, and make meaningful progress in counselling, even though some of them experienced a sense of uncertainty at the beginning of some art-making activities.
In a study where the structure of a coloring task influences anxiety, mood and perseverance was tested, eighty-five undergraduate students were randomly assigned to 1 of 2 coloring conditions: free choice, where they could color an image. Anxiety and mood including depression were measure before and after coloring; in addition, perseverance was measured after coloring. The results showed positive effects of coloring, wit greater anxiety reductions and evidence of higher perseverance in the free choice group. This suggests that well being might be facilitated by a coloring task that balances structure and engagement (Eaton and Tieber, 2017).
Most mental health problems are non-psychotic (e.g. Depression, anxiety, and phobias). For some people, art therapy may be more acceptable alternative form of psychological therapy than standards form of treatment, such as talking therapies. From the limited available evidence art therapy was associate with positive effects compared with control in several studies in patients with different clinical profiles. The included trials were generally of poor quality and are therefore likely to be at high risk of bias. Art therapy appeared to be cost -effective versus wait lists. There was insufficient evidence to make an informed comparison of the cost-effectiveness of group art therapy with group verbal therapy. (Uttley et al, 2015)
Practice Recommendations
According with the literature review, the therapeutic use of art and occupational therapy as an intervention for behavioral health mental illness was well documented. There was scarcity of studies addressing art and occupational therapy as a specific therapeutic intervention for Major depressive disorder and Depression. Patients diagnosed with MDD display a nonexistence motivation with flat affect which negatively affects their recovery. Art therapies seemed to affect positively the extent of patients who suffer from depression. Therefore, patients who had depression, especially those who suffered from a secondary chronic health problem such as cancer patients were benefit receiving recommendation to opt-in participating in therapies of art and occupational therapies as they seemed to effectively control mood disorders like anxiety and depression. Some of the art therapies caused a positive impact on patients and therefore, it may be a good recommendation to apply the type of art therapy that best suits the patient to provide and adjuvant to appropriate medication or treatment plan and improve healthy living. Patients who suffer chronic physical illnesses feel a sense of isolation and to reduce their pain and suffering art therapy appeared to be the best therapy for treatment and reducing its impact as the patient becomes jovial and forgets the wrong thinking.
Project Description
This project was intended to evaluate what was the relationship between the participation in Art therapy and improvement of mood in patients who were diagnosed with Depression or Major Depression Disorder (MDD). The main purpose was to investigate the latest information regarding the application of Art therapy as a therapeutic intervention for patients suffering from depression and MDD. Peer review and English only articles from 2014 to 2019 were considered for this investigation.
This project was developed by the careful reading of the current investigations related to the mentioned topic with the purpose to find what is the relationship between art therapy and Depression and MDD. The sources were obtained from Ana G. Mendez virtual library, Cochrane, Google Scholar, EMBASE, PubMed and CINAHL. To identify the mentioned topic problem, key words were used to find the articles: Art therapy, Art therapy means, Depression, Major Depression Disorder. The literature review obtained from the mentioned sources will be kept for 5 years, locked in the primary investigator home office, and after 5 years will be destroy by paper shredder and discarded. The primary investigator and his mentor have had access to the data obtained for this purpose. The results of this study helped to clarify what was the relationship between art therapy and patients suffering from depression or MDD.
Project Evaluation Results
The evaluation criteria were primarily determining the literature that best fits the research. The present project was evaluated after performing the literature review; the results were analyzed by the data collected through the literature review of the related investigations. Articles 5 years old or less were considered and analyze with the purpose to validate the research question of the project. Once the data was collected the analysis was completed to come up with right information that was included in the ultimate report. The goal of analyzing data was to eliminate the errors that might had happened during data collection. Several processes aroused during data analysis, and they comprised data coding and data editing. At the end it was expected that this study was able to answer the research question which was: What is the relationship between the participation in Art therapy and improvement of mood in patients who are diagnosed with Depression or Major Depression Disorder (MDD)?
Tables with summarization of all citations were offered in both appendix A & B. appendix A was used for the summary of primary research evidence and was comprised the citation, question or hypothesis, theoretical foundation, research design and sample size, key finding, recommendations or implications and level of evidence of each article. Appendix B was used for the summary of the systematic reviews and contained the citation, question, search strategy, inclusion and exclusion criteria, data, extraction and analysis, key findings, recommendations, implications and level of evidence of each article.
Each of the presented articles was evaluated as relevant or not to answer the research question. All the information was computed by an excel database and some of the results were summarized using the SPSS statistic package.
Discussion and Implications for Nursing and Healthcare
Depression is a multifactorial disease that requires proper ways of treatment. Considering this statement, the findings of this study were useful as a practical reference for healthcare practitioners since the use of art therapy caused a positive impact on patients that experience anxiety and depression. Art therapy involves either dance movements, pictorial presentations inform of visual, cinematherapy, the use of art means and other related therapies (Animbom Ngong, 2017). Based on these types of therapies, they may cause different impact to patients and may be preferred differently by a patient receiving depression treatment. For instance, older adults are considered to be prone to various disease complications due to their reduced body physiological processes. In these cases, elderly individuals may prefer art therapy rather than medical treatment. Art therapy may be useful to reduce depression and to promote healthiness of individuals who are distressed by taking away their thoughts about pain (Ando et al., 2016).
The project caused a significant impact in nursing and healthcare field such that nurse practitioners had expounded knowledge regarding art therapy and its application as a therapeutic intervention for the treatment of depression. Since significant distress results from chronic diseases such as cancer, this project aspired to provide detailed information regarding depression and chronic diseases and tried to provide all the possible solutions for the betterment of this condition through a better treatment plan.
From the project evaluation results, it was expected that a conclusion could be inferred that art therapy would be a suitable method of therapeutic intervention for treating patients that were suffering from depression or Major Depression as an adjuvant to the use of medications.
The project had the expectation to be able to cause a positive impact to despair patients including the chronically ill such that art therapy interventions would be able to improve the treatment plan and enhance a quicker recovery of the patient.
Plans for Dissemination
From past research evidence I found that the best and effective way how research works are disseminated is by using various type of media available. In the present study, peer to peer interaction were an important milestone to achieve this purpose. A thirty minutes group presentation using Power point provided a summary of the study to my classmates and the mentor of the Research class. Also, it allowed me to receive written feedback from my classmates. A poster was created and exhibited in one of the halls of Ana G Mendez University, South Florida Campus (SFC). The mentioned poster displayed a summary of the complete research study and its results. Also, it was provided a copy of the complete research to the Ana G Mendez University library (South Florida Campus) in order to be available for anyone that is interested to access the information of my research project. From the present research project, we concluded that art therapy was a good intervention as an adjuvant for patients suffering from depression or Major Depressive Disorder. The present project was envisioned for my master’s degree program in fulfillment of the necessities for a research project with the intention of helping to improve the wellbeing of the targeted population; therefore, there was no preliminary intention to publish this research project. Nevertheless, it was my desire that it would meet the specifications in order to be printed in the publications of my Nursing school.
Summary and Conclusion
From the study, it was concluded that art therapy may be used as a therapeutic intervention for patients suffering from depression or Major Depression. Depression, as depicted, entails illness that is complex and multifactorial affecting the whole individuals’ body and cognitive processes, and its impact results in effect on aspects such as psychological, biological, and social. The study revealed that the use of art therapy may lead to the improvement of the health life of patients, reducing severe distress, enhancing mood, and cultivating a sense of hope. Depression degraded both the healthcare system, community, and individuals by increasing their treatment cost and other expenditures. It was the intention of this project to have an important significance to the healthcare and a positive impact on patients suffering from depression or MDD. It was concluded that art therapy is the best adjuvant intervention for relieving the symptoms of depression, especially those suffering concomitant chronic illnesses promoting their well-being as well as healthy living.
References
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