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REVIEW ARTICLE
Art as a Therapeutic Tool in Depressive Disorders:
a Systematic Review of the Literature
Fernando Mateus Viégas Brandão
1
&Carolina Ventura Silva
2
&
Kleber Roberto da Silva Gonçalves de Oliveira
3
&Janari da Silva Pedroso
2
#Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract
Different alternative forms of therapy have been studied in relation to their applicability and
effectiveness. The use of art therapy in the treatment of depressive disorder is an example
frequently employed in several countries. The aim of this research was to identify and discuss
which artistic techniques have been applied most frequently in the treatment of depressive disorders
and what their main effects are. The research was conducted in the MEDLINE/PubMed, American
Psychological Association (APA) and Web of Science databases. The articles were selected
through the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA
protocol). 14 articles were selected, among which the main techniques of art therapy used were:
manual work (drawing, painting, and modeling), music, poetry, photography, theater and contem-
plation of art pieces. It was found that most of the researches are European and as a field of
knowledge they depart mainly from medicine. Of the 14 researches of this review, only two failed
in the use of art therapy techniques as a therapeutic tool. It can be understood that art therapy is a
safe and reliable tool for treatment not only of depression but also of other mental disorders.
Psychiatric Quarterly
https://doi.org/10.1007/s11126-019-09672-x
*Fernando Mateus Viégas Brandão
viegasmateus@hotmail.com
Carolina Ventura Silva
carolinaventura.psicologia@gmail.com
Kleber Roberto da Silva Gonçalves de Oliveira
drkrsgo225@gmail.com
Janari da Silva Pedroso
pedrosoufpa@gmail.com
1
Faculty of Medicine, State University of Pará, Angustura Street, 2219, 66087-310, Pedreira, Belém,
PA cep 66087-310, Brazil
2
Faculty of Psychology, Federal University of Pará, Augusto Corrêa Street, 1 –Guamá, Belém, PA cep
66075-110, Brazil
3
Faculty of Medicine, Federal University of Pará, Augusto Corrêa Street, 1 - Guamá, Belém, PA cep
66075-110, Brazil
Keywords Art therapy .Depression .Mental disorders
Background
The World Health Organization (WHO) estimates that today 350 million people worldwide are
living with depression [1]. The outlook is that by 2020, the disease is the second most
prevalent in the world, only surpassed by cardiovascular diseases [2]. In Brazil, it is estimated
that 9.7% of adults present some degree of this disease [3]. Suicide is the most tragic outcome
of this pathology and today, every 40 s, a person takes his or her own life [4].
Depression treatment is a challenge given the complexity of the disease and multivariate
approach it requires. This may involve psychotherapy, qualified hearing and/or use of psychotropic
drugs [5]. However, one of the major problems faced is non-adherence to treatment, on which main
reasons are: adverse effects of medications (nausea, vomiting, dry mouth, drowsiness, weight gain
and worsening depressive symptoms in the first days of medication use); fear of relying on
medicines; the poor communication with prescriber and lack of psychosocial support [6,7].
The search for therapeutic techniques that act as adjuvants of this therapy, as well as
facilitate the adhesion and social reintegration of patients with mental disorders is a major
challenge for those who work in the area. Among these tools, art has been one of the most
studied since the nineteenth century by psychiatrists such as Max Simon [8]inFrance,Carl
Gustav Jung [9] in Switzerland and Nise da Silveira [10] in Brazil, as well as other profes-
sionals who believe this is a form of therapy for patients with mental disorders [11].
Dance, music and theater are tools frequently used as an alternative treatment for psychi-
atric disorders [12–14]. With these techniques, patients become more resilient and can
understand better their disease, in order to understand and potentiate their treatment process,
so that the individual can modify as he or she experiences and faces illness [15–17].
We can see art as an important instrument in the promotion of well-being and clinical
improvement of patients. Nevertheless, a more detailed study of its specific repercussion in
certain pathologies such as depression is still necessary. Thus, the present research aimed to
identify and discuss, through a Systematic Review of literature, which artistic techniques are most
used as therapeutic tools in depressive disorder. Articles published between the years of 2013 to
2017 were analyzed in order to verify the main effects of therapies on the patients, as well as the
areas of knowledge and the countries which are producing more materials on the subject.
Methods
The study is a Systematic Review of Literature, in which advanced searches were conducted in
the electronic databases Medical Literature Analysis and Retrieval System Online (MEDLINE/
PubMed), APA and Web of Science, using the following descriptors of the Medical Subject
Headings (MeSH) and their synonyms: (Depress AND Art), (Depress AND Body Language)
and (Depress AND Clown).
We included studies in English published in the period from 2013 to 2017, with a sample
composed by humans and using the descriptors Art, Body Language and Clown in the evaluation of
the therapeutic effect in depressive disorder, being of the quantitative type and of empirical design.
Experimental studies in animals, literature reviews, purely qualitative evaluations, as well as studies
that do not analyze the therapeutic effects related to mentioned descriptors, were excluded.
Psychiatric Quarterly
Data was stored and tabulated in a spreadsheet application and in a word processor. The
follow up of searches was archived in a field diary that ensured the reliability in the selection of
articles and the fulfillment of inclusion and exclusion criteria. The following items were
cataloged for further evaluation: Title of article, keywords, year of publication, database in
which it was found, journal in which it was published, area of knowledge to which the article
belongs, research objective, context where was conducted (hospital, school, support house),
country, type of research, instruments used, main results, conclusion, statistical tests and
observations of authors of the systematic review about the article in question. These items
Fig. 1 PRISMA flow diagram of the screening process
Psychiatric Quarterly
were chosen based on what has been pointed out in literature as relevant to evaluate a scientific
publication, having as main base the protocol PRISMA [18], as can be seen in Fig. 1.
After being selected and tabulated, the articles passed, one by one, by analysis of three judges,
who evaluated whether the research met the criteria of reliability and scientific validity. To do so,
they answered a table with the following 5 items: “Is the research problem clear?”(Problem);
“Are the study objectives related to the question studied?”(Objective); “Is the method clearly
described and achieves objectives?”(Method); Are the results compatible with the method and
deserve credibility?“(Results); “Should the article be included? If not, what is the reason for the
exclusion?“(Included). Each of these questions was answered with “yes“or “no“by the judges,
being later converted into “one“for positive answers and “zero”for negative answers.
The answers of the judges were used for statistical calculations using the Kendall Tau-b
coefficient and Cronbach’s alpha, both performed in statistical software. Kendall’s tau-b
coefficient is a measure of agreement between two sets of classifications relative to a set of
objects or experiments, which evaluated the reliability of judges’analysis [19]. The correlation
was significant when the values were greater than or equal to 0.01, indicating the consistency
of evaluations among established attributes. Cronbach’s alpha is a coefficient to measure the
reliability of judges’choice [20]. As the result was classified as relevant, the reliability index
was greater than 0.7.
The structure of the literature review followed the criteria established in the PRISMA
protocol, which guides the organization of quantitative results in a flowchart composed of four
stages: identification, selection, eligibility, and inclusion. In Table 1, the flowchart for selection
of articles studied, which was concluded with the selection of 14 articles for analysis.
Except for the relationship between “Method”x“Objective”and “Problem”x“Method”,
both with 113, all other bivariate correlations were significant, indicating a consistency of
judges’evaluations among established attributes. Regarding the evaluation of Kendall Tau-b
coefficient, of 14 articles sent to the judges’review, all were included in the analysis of the
review, that is 100%. The reliability of the three judges’answers is positive in relation to 5
evaluated items since it assumes the value of 0.805, greater than 0.8.
Table 1 Kendall tau-b correlation coefficient
Problem Objective Method Results Included
Kendall tau-b Problem Coeficiente de correlação 1.000 .477 −.113 .548* .354
Sig (2 extremidades) .0 .077 .683 .048 .202
N1414141414
Objective Coeficiente de correlação .477 1.000 .152 .594* .813**
Sig (2 extremidades) .077 .0 .572 .028 .003
N1414141414
Method Coeficiente de correlação −.113 .152 1.000 .372 .240
Sig (2 extremidades) .683 .572 .0 .180 .386
N1414141414
Results Coeficiente de correlação .548* .594* .372 1.000 .645*
Sig (2 extremidades) .048 .028 .180 .0 .020
N1414141414
Included Coeficiente de correlação .354 .813** .240 .645* 1.000
Sig (2 extremidades) .202 .003 .386 .020 .0
N1414141414
* The correlation is significant at the 0.05 level (2 extremities)
**The correlation is significant at the 0.01 (2 extremities)
Psychiatric Quarterly
Results
Table 2corresponds to the summary of 14 articles, which were categorized in following items
for analysis: Study (Authors + research title), the country where research was carried out,
applied art therapy technique, the area of knowledge, main results and conclusions.
According to Table 2, when reviewing the countries from which publications originated, it
could be seen that most of the research (n= 9) were carried out in European regions. A similar
result was found when evaluating the main areas of knowledge that published articles
on the subject during the period studied, in which medicine is highlighted in the
number of publications (n = 9). The most cited therapeutic tools (n=8) are manual
work, such as drawing, painting, sculpture and modeling, and second (n= 3) music.
Few studies (n= 2) did not have statistically significant results regarding the efficacy
of therapeutic techniques.
Discussion
The use of art as a therapeutic strategy originated in Europe, which also housed great
researchers like Carl Gustav Jung [9], Max Simon [8], Cesare Lombroso [35], among others,
as demonstrated by Ciasca [11] in her dissertation in which she made an extensive review of
the history of art as a therapeutic tool.
The trend of medical publications has lasted for many years and the popularity of the
application of art as a diagnostic and therapeutic tool, especially for mental disorders, has led
Lippin [36] to inaugurate the term medicine of arts and to propose this as a new medical
specialty.
In addition to the techniques used in art therapy, the most cited therapeutic tools (n=8)are
manual work, such as drawing, painting, sculpture and modeling [21–24,27–29,35]. Most of
the studies obtained positive results in their analyzed variables, being only the works of
Montag et al. [21] and Geue et al. [22] those who did not present satisfactory results in their
studies.
The research of Montag et al. [21], did not obtain a statistically significant reduction in the
parameters of depression, in other words, there was no significant decrease in initial values of
the scales in relation to the final ones. The evaluation process was based on Scale for the
Assessment of Negative Symptoms (SANS), Scale for Assessment of Positive Symptoms
(SAPS), Calgary Depression Scale for Schizophrenia (ECDE), and Overall Assessment of the
DSM Scale of Functioning-4-TR. Despite this, it achieved satisfactory results in the evaluation
of the secondary parameters of the disease, such as the levels of emotional awareness and in
the capacity of reflection on the mental states of others by the patients, which allowed to
conclude that therapeutic technique was satisfactory.
The study by Geue et al. [22], which also did not have statistical significance in the
parameters studied such as psychological stress and ability to deal with disease (evaluated
by Freiburg Questionnaire on Coping with Illness, Perceived Adjustment to Chronic Illness
Scale, Hospital Recognition and Depression Scale), recognizes that this result contradicts
several previous works. It also recommends that studies that are carried out in this line should
present randomized designs and concentrate on evaluating which interventions are most
effective and at what stage of treatment (hospitalization, outpatient, rehabilitation), art therapy
is most useful.
Psychiatric Quarterly
Table 2 Characteristics of included studies
Study Country Art therapy technique Area of
knowledge
Main results Conclusions of studies
Montag et al. [21] Germany Painting and sculpture with
clay
Medicine There were no differences between groups
regarding depressive symptoms. Patients in
the ART group showed significant
improvement in levels of emotional
awareness
Alternative forms of treatment were beneficial
for the treatment of depressive symptoms in
patients with schizophrenia
Geue et al. [22] Germany Drawing, painting, and
writing
Medicine No significant differences were found between
the “intervention”and “control”groups in
any of the studied moments nor on the
variants surveyed
The results contradict the preliminary studies.
Further research is needed that uses a
randomized controlled trial design and
focuses on assessing the efficacy of
intervention’sform
Crone et al. [23] United Kingdom Poetry, drawing, ceramics,
paintings, and mosaics
Psychology There was a greater participation of women
in the conclusion of the therapy and a
greater abandonment by the young
people. In the group that concluded
activities, there was a significant
improvement in well-being
The findings reveal that artistic interventions
were effective in promoting well-being
among women, the elderly, and people with
lower socioeconomic conditions
Lefèvre et al. [24] France Photograph, painting,
drawing, modeling, and
sculpture of clay
Psychology Art therapy sessions reduced patients’overall
distress by 7%. There was a significant
reduction in all of the symptoms: pain,
anxiety, evil, fatigue, sadness, and
depression. A study of significant
correlations indicated that technical
satisfaction, aesthetic beauty, and leisure are
involved to varying degrees in symptom
reduction
The benefits of art therapy in reducing suffering
in the palliative context are confirmed
Alfano et al. [25] Brazil Not reported Medicine The analysis of the association of quality
of life scores with specific alternative
medicine modalities revealed some
potential associations (especially for
dietary supplements, art therapy,
psychotherapy, and prayer)
Women with metastatic breast cancer often
use alternative medicine to treat cancer
and/or its symptoms. Biological-based
practices appear to be particularly im-
portant in Brazil
Psychiatric Quarterly
Table 2 (continued)
Study Country Art therapy technique Area of
knowledge
Main results Conclusions of studies
Kokavec et al. [26] Australia Not reported Psychology Group data revealed a significant reduction in
psychiatric morbidity and better
psychological adjustment. When divided
into degrees of psychiatric morbidity, a
significant reduction in the reporting of
symptoms of anxiety, depression and
irritability, mental confusion and somatic
symptoms
A structured community-based psychosocial
program is beneficial for women struggling
to come to terms with the emotional conse-
quences of breast cancer at all stages of
recovery
Kim et al. [27] Korea Music and manual works Medicine The mean score for the geriatric depression
scale showed a reduction after the
intervention (14.87 ± 7.69) versus the
previous score (16.31 ± 7.73)
The program reduced the levels of depression
in the elderly with Alzheimer’sdisease
Mandić-Gajićet al.
[28]
Serbian Drawing and painting Medicine The patient’s drawings and group protocols
show clinical improvement from the
reduction of depressive themes and an
increase in the frequency of human figure
drawings and self-confidence
The art therapy group enables visual
expressions of emotions, develops creative
potential, reduces depressive symptoms,
which facilitates integration into the
therapeutic process of schizophrenia
Hamre et al. [29] Germany Painting, drawing, and
sculpture of clay
Medicine There was a significant improvement in all
evaluated points (p< 0.001 for all pre-post
comparisons)
Outpatients who received anthroposophic
treatment for chronic diseases showed
improvement of symptoms and quality of life
McCabe et al. [30] Ireland Artistic exposure
observation at the
patient’s choice through a
remote camera
Medicine and
nursing
There was a reduction of anxiety after
transplantation. Data on depression were
similar, but only statistically significant
1 day after transplantation. Anxiety showed
a significant reduction at all points in the
study. The experience / helped patients to
know how to handle isolation better
There were positive effects of the introduction
of artistic interventions quality of life as well
as levels of anxiety, depression, and
experience of patients who had undergone
stem cell transplantation
Armstrong et al. [31] United Kingdom Painting, drawing, and
collage
Psychology The responses of the questionnaires were more
positive after the intervention, and 8 of the
10 mothers showed an improvement in
postpartum depression and in the
relationship with their children
The groups made a positive difference in the
lives of mothers and infants, which can be
demonstrated in positive quantitative
outcomes as well as positive feedback
Psychiatric Quarterly
Table 2 (continued)
Study Country Art therapy technique Area of
knowledge
Main results Conclusions of studies
Rawtaer et al. [32] Singapore Tai Chi, music and
contemplation of art
pieces
Medicine There were significant reductions in the scales
scores on depression and anxiety in the
single intervention phase, which remained
significant at week 52, after completion of
the combined intervention phase, relative to
the baseline
Participating in these psychosocial
interventions led to a positive improvement
in the symptoms of subsyndromal
depression and subsyndromal anxiety in
these elderly individuals over a year
Jani et al. [33] Ethiopia Music and theatre Medicine In women: Reduction of 60% of aggressive
behaviors and 50% of general mental health
problems (depression, anxiety, and attention
problems). For men: There were no significant
reductions in mental health problems
The psychosocial intervention was associated
with increased knowledge and acceptance
of HIV services. There was a reduction in
mental health problems in adolescents
Oklan & Henderson.
[34]
United States Music Psychology The intervention increased the use of adaptive
coping strategies, measured by the
Adolescent Coping Orientation to
Experienced Problems (A-COPE) and re-
duced the psychiatric symptoms measured
by the Symptom Checklist-90-R
The study suggests a promising strategy,
especially for the mental health of
adolescents who abuse inhalants. However,
one should consider the limitations of a case
study for a more generalized analysis
Psychiatric Quarterly
Among researches that obtained positive results in the study of the influence of manual
labor, we highlight the studies of Lefèvre et al. [24] e Crone et al. [23]which,inadditiontothe
technique already mentioned, also used photography and poetry, respectively, as therapeutic
instruments. The first, besides evaluating depressive symptoms, also evaluated other psycho-
logical components such as pain, anxiety, evil, fatigue, and sadness, obtaining a significant
reduction in all parameters.
Another technique of art therapy that gained prominence in this study was music,
which was the second most used technique (n= 3) in the articles [27,32–34]. This
technique has also been shown to be an excellent therapeutic option, including for
the control of other mental disorders such as chemical dependence [34]. The study
by Jani et al. [33] points out that, since the positive results were limited to the
female population studied, the men who participated in the study were not included,
which was attributed mainly to greater difficulties they face in terms of work and
housing.
Another important fact is that in almost all studies, music was used along with
other artistic interventions, such as manual work [27], theater [33] and even Tai Chi
[32]. This last study also brought the observation of works of art as a therapeutic
tool, which is presented separately as an art therapy technique by McCabe et al.
[30]
The study of McCabe et al. [30] presents a differentiated perspective in relation
to others in this review, both in relation to application method and data analysis. In
this research, participants hospitalized for transplantation could choose from a menu
of nine art channels that transmitted real images from partner museums through
remote cameras with themes of nature, places of personal meaning, abstract visual
or classic works of art that were exhibited in these galleries. The results were
excellent, mainly showing a significant reduction in anxiety and depression levels,
however, long-dependent effects were not maintained for long periods of hospital-
ization, lasting from 1 to 7 days after transplantation, on anxiety and only 1 day on
depression.
In view of the results presented, it can be seen that art therapy is an effective tool
for the treatment of depressive disorders, as well as other psychological and psychi-
atric disorders such as anxiety disorders and chemical dependence. It can be pointed
out that this is a safe tool to be used in the treatment of depression, being its choice
made in an individualized and conscious way by the health professional along with
the patient.
Conclusions
Through this study, it was possible to verify and discuss the main artistic techniques
that are used in the treatment of depressive disorder. Medicine is the area of
knowledge that has most searched for art therapy as a form of treatment for depres-
sion and Europe is still the great pole of knowledge and research on the subject. In
addition, among the main techniques of art therapy used today are manual works
(drawing, painting, and modeling, usually with ceramics and clay), music, poetry,
photography, theater and contemplation of art pieces.
Psychiatric Quarterly
The lack of methodological uniformity and lack of valuable information about the
analyzed characteristics (Problem, Objective, Method, Results, Included) of the studies
made it difficult to deepen the investigation, which could result in a possible limit to
this article. Nevertheless, it was possible to understand by reading and analyzing the
data, that art therapy is a safe and reliable tool for the treatment not only of
depression but also of other mental disorders.
Data Availability Please contact the author for data requests.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of interest.
Ethical Approval This article does not contain any studies with human participants or animals performed by
any of the authors.
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Fernando Mateus Viégas Brandão is a graduated in Medicine at the State University of Pará, 10th period.
Member of the Health Development Laboratory of the Federal University of Pará. Member of Psychiatry
Academic League. He currently conducts research in the areas of: art therapy and mental disorders; personality
structure and attachment.
Psychiatric Quarterly
Carolina Ventura Silva is a graduated in Psychology at the Federal University of Pará, 9th period. She is a
scholarship holder of the Institutional Program of University Extension Scholarships at the Bettina Ferro de
Souza Hospital, within the Ambulatory of Anxiety and Depression. Member of the Health Development
Laboratory, where the areas of research are temperament of babies in institutional contexts, psychological
evaluation, psychopathology and art therapy work.
Kleber Roberto da Silva Gonçalves de Oliveira is an assistant professor of the Medicine Course at the Federal
University of Pará and University Center of Pará and Medical Psychiatrist at the State Public Foundation Hospital
de Clinicas Gaspar Vianna. Doctorate at the Graduate Program in Clinical Psychology. Currently is Psychiatry
Paraense Association president.
Janari da Silva Pedroso is an associate professor III of the Federal University of Pará; Productivity fellow
teacher CNPq, carries out his academic activities at the Faculty of Psychology, Graduate Program in Theory and
Behavior Research and Graduate Program in Psychology. Adviser of masters and doctorate. It develops
researches with the themes: human development in biopsychosocial aspects, psychotherapeutic interventions,
family and mental health studies, psychopathological processes and diagnostic evaluation of developmental and
personality disorders with the different methods of psychodiagnostic evaluation (psychological tests, interviews,
development scales and intelligence). Coordinates the development and health laboratory where research is
centered on human development (childhood, elderly and family), extension activities are developed in the
program of Ambulatory Anxiety and Depression at Bettina Ferro Hospital of the Federal University of Pará
and teaching in undergraduate and postgraduate teaching activities, academic orientation and internship
supervision.
Psychiatric Quarterly
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