ANTHROPOLOGICAL RESEARCHES AND STUDIES
No: 15

REDUCING DEPRESSION THROUGH ART THERAPY TECHNIQUES: A SYSTEMATIC LITERATURE REVIEW

Cristian-Nicolae CONSTANTIN (1), Elisabeta NIȚĂ (2), Camelia POPA (3)
Keywords: depression, art therapy, comorbidities, progress

DOI: https://doi.org/10.26758/15.1.17

(1) PhD student, School of Advanced Studies of the Romanian Academy. Institute of Philosophy and Psychology “Constantin Rădulescu – Motru”, Romanian Academy, Romania

(2) Fundeni Clinical Institute, Bucharest, Romania; e-mail: beti_iris@yahoo.com

(3) Institute of Philosophy and Psychology “Constantin Rădulescu – Motru”, Romanian Academy, Romania, UNATC “I. L. Caragiale” Bucharest; e-mail: popa_zaizon@yahoo.com

Address correspondence to: Cristian-Nicolae Constantin, School of Advanced Studies of the Romanian Academy, “Constantin Rădulescu-Motru” Institute of Philosophy and Psychology, Department of Psychology, Romanian Academy, 13 September Avenue, No. 13, 5th District, Bucharest, 050711, Romania. Ph.: +40-735182922; E-mail: cristian.constantin@crisact.ro

Abstract

Objective. The aim of the study was to identify art-therapeutic techniques effective in order to reduce the depression scores in patients with depressive disorders or depression associated with somatic diseases and therapeutic tools for measuring progress.

Material and methods. Information has been collected from scientific platforms such as Web of Science, Scopus, PubMed, ScienceDirect, ResearchGate, APA PsycNet and Google Scholar. Only quantitative studies from the last 10 years were selected, which have evaluated the progress of patients following the application of art-therapeutic techniques. Keywords such as: art therapy, depression, scores and rehabilitation were used. Of the 76 papers identified, 16 met the inclusion criteria.

Results. Studies have confirmed the usefulness of the art-therapeutic techniques in treatment schemes for patients with depression. The most used techniques were those in the field of visual arts (drawing, painting, modeling, collage) and music (musical auditions). Dance and art-media technologies were applied less often, and theatrical techniques were not used at all. All studies, with one exception, indicated a decrease in associated depression and anxiety, as well as improved emotional-cognitive coping. Outcomes were measured by questionnaires validated in a test-retest system, but only in the short term, immediately after the intervention, which was a common limitation.

Conclusions. Art therapy has a positive impact in reducing depression scores and increasing patients’ well-being, according to the analyzed studies. However, the future research should focus on evaluating the long-term effects of these techniques for a more in-depth understanding of the therapeutic benefits.

Keywords: depression, art therapy, comorbidities, progress

Suggested citation (APA)

Constantin, C.-N., Niță, E., & Popa, C. (2025). Reducing depression through art therapy techniques: A systematic literature review. Anthropological Researches and Studies, 15, 259-271. https://doi.org/10.26758/15.1.17

Introduction

Depression is an endemic disorder nowadays, with a multifactorial etiology and with a high incidence of onset between 20 and 40 years (Marinescu, Udriștoiu, Podea & Ciucu, 2008). It affects the mental well-being of the individual, and his ability to function in social and professional contexts.

Common symptoms of depressed patients include: slowed thinking, irritable or depressed mood, loss of pleasure, significant weight loss or gain, feelings of guilt and worthlessness, insomnia, suicidal ideation, and recurrent thoughts of death. The low rate of recovery from depression represents a public health problem (Popa&Ciobanu, 2013).

Other symptoms of depression include: feelings of inner emptiness and anger, constant restlessness, decreased libido (Gilbert, 2011); deficiencies in the desire for positive outcomes and in the avoidance of negative outcomes (Trew, 2011); decreased learning ability; poor social skills and difficulty reintegrating into society after discharge (Seligman, 2004; Morgan, Burns, Fitzpatrick, Pinfold & Priebe, 2007; Hopko, Lejuez, Ruggiero & Eifert, 2003).

The NICE clinical practice guideline (2014) mentions art therapy as a non-pharmacological treatment strategy for psychoses, including depression, starting in the acute phase of the disorder and continuing without interruption after discharge. According to this guideline, art therapies should be provided by an art therapist with previous experience of working with people with psychosis. It is recommended that art therapy interventions should  be provided in groups when there are no difficulties related to acceptability, access and engagement. Art therapies, which also work for patients with negative symptoms, should combine psychotherapeutic techniques with activities aimed at promoting creative, often unstructured expression (NICE, 2014).

In general, art therapy is proposed to complement the medical treatment, as it facilitates the different experience of reality by patients, the organization of their life experience, the understanding and acceptance of feelings that arise during the creative process, the development of relationships with others, the recovery of mental health and increasing their well-being. Hänninen & Valkonen (2019) showed that depressed people are often extremely dissatisfied with themselves, angry, lacking energy and patience; these people have abandoned their previous hobbies and leisure activities. However, if they participated in group art therapy, they could share their thoughts and emotions throughout the entire process of creating their own artworks and benefit from the support of the art therapist and group mates (Zhang, Cheng, Huang & Xu, 2021).

In depression, art-therapeutic techniques reduce the intensity of symptoms, prevent the onset of major episodes and relapses, studies in the field have revealed (Yalom & Leszcz, 2008; (Zhang, Cheng, Huang & Xu, 2021). When art therapy is carried out in a group , it has an increased capacity to inoculate hope. Art therapists can actually help the patients to actually participate in activities, to immerse themselves in creation, to find solutions to the situations they face, producing positive changes in their emotions and behaviors.

Also, the art therapy reduces care costs, prevents readmission of patients and compensates for drug resistance. Romila (2019), Martin et al. (2018) showed that art-therapeutic techniques using music, dance, acting, painting are means of stress management in psychosis, which directly influence episodes of the disorder, remissions and prevent future episodes.

Purpose and objectives of the study

The aim of this paper was to review the quantitative studies on art therapy for the treatment of depression, from the last 10 years, to reveal, on the one hand, the art-therapeutic techniques that may reduce the depression scores of patients with depressive disorder and of patients with depression secondary to some somatic diseases, and, on the other hand – the psychometric instruments used in order to quantify the clinical progress.

The research questions formulated in order to achieve the goal were:

  1. What are the art-therapeutic techniques most frequently used in research on reducing the depression scores?
  2. What is the worldwide distribution of these researches?
  3. What are the psychometric instruments used in these specific researches?
  4. What are the limits of using the art-therapeutic techniques?

Starting from these researches questions, were stated the following objectives:

O1: The identification of the most used art-therapeutic techniques in reducing depression.

O2: The need in order to identify the tools which are used to measure the patient’s progress by the clinical teams with art therapists.

Methodology

Data source. We searched on the Web of Science : Scopus, PubMed, ScienceDirect, ResearchGate, APA PsycNet and Google Scholar platforms for quantitative studies from the last 10 years concerning the art therapy and depression. The search was carried out between June and September 2024, using the keywords art therapy, depression, scores, rehabilitation.

Inclusion and exclusion criteria. We opted for those studies which has measured test-retest therapeutic progress after the application of the art-therapeutic techniques, with the help of validated instruments. 91 papers were found, of which 76 papers from credible sources (scientific literature) were retained in a first stage. Of those 76, 16 were chosen, as being relevant for the objectives of the review (PRISMA flow diagram). PRISMA flow diagram for new systematic reviews which included searches only of databases and registers: (Page et al., 2021).

Figure 1

PRISMA flow diagram (to see Figure 1, please click here).

Data analysis and extraction

It was found that there were few quantitative studies about art therapy in the treatment of depression during the period covered. For the articles that met the inclusion criteria in the systematic review, the following indicators were extracted: the participants and the inclusion criteria in the studies, the art-therapeutic methods used, the measurable effects of the art-therapy and the study limits. This information has been systematized by patient groups in Tables 2, 3 and 4, found after the conclusions.

Results                                                                                                                                                                                                          

In these 16 studies there were included in the systematic review, the effect of art therapy on decreasing depression scores and the functioning of various art therapy techniques for patients diagnosed with clinical depression or depression associated with other psychological or somatic conditions were revealed.

The total number of participants in art therapy sessions in these studies was 739 (excluding control groups used in some studies).

Studies were conducted in: China (2), Canada and China, Tunisia, Indonesia, USA (2), United Kingdom, Iran, Brazil, South Korea (2), Israel, Sweden, Philippines, Jordan. Europeans’ interest in this area of ​​research was low.

The included studies are from the last 10 years. There has been an increase in interest in art therapy in the treatment of patients diagnosed with depression, although research in this area has suffered a decline during the pandemic. One study was conducted online and directly involved pandemic effects—depression and grief related to the death of family members with Covid (Park & ​​Cha, 2023).

The study participants, all age groups being included, came from diverse clinical and non-clinical backgrounds. Only two studies had more than 100 participants (Zhang, Cheng, Huang & Xu, 2021; Nan&Ho, 2017), the others worked with much smaller samples. The participants were patients under medical treatment or not.

Depression as a main, stand-alone disorder was addressed by art-therapeutic techniques in only three studies (Tuazon, 2022; Zhang, Cheng, Huang & Xu, 2021; Blomdahl, Wijk, Guregård & Rusner, 2018). The rest of the studies looked at depression as associated with other medical conditions, such as stroke, cancer, kidney disease and burns.

The art-therapeutic methods chosen outlined an overview of the techniques frequently used by practitioners. Thus, mainly techniques specific to the visual arts has been accessed by the means of: – drawing, painting, modeling, collage, music and musical auditions. Art therapy using clay modeling was applied by Nan and Ho (2017). A study that used art-media technologies was innovative (Blomdahl, Wijk, Guregård, & Rusner, 2018). No studies were identified as using theater techniques or drama therapy in the treatment of depression, which represents an important potential for research in this area.

The instruments used, alone or in combination with other instruments, were: Beck’s Depression Inventory (BDI II), Hamilton Scale (HAMD), Childhood Depression Scale (CDI), Depression Anxiety Stress Scales (DASS), Maria Kovacs Children’s Depression Inventory Questionnaire ( CDI), Geriatric Depression Scale (GDS-15) and Depression Screening (CES-D). As it is seen in Table 1, the BDI II was preferred for the assessment of depression scores in the test-retest system, followed by the Hamilton Scale and the DASS Scales.

Regarding the study’s methodology, test-retest studies were chosen, either with a single group of participants or with an experimental group and a control group. There was not a predetermined duration for the art therapy sessions and no unitary extension of them over time. The sessions were planned as follows: 4 sessions in 2 weeks (Alwledat et al., 2023); 10 weekly one-hour sessions (Blomdahl, Wijk, Guregård, & Rusner, 2018); 20 sessions (Ciasca et al., 2018); art therapy workshops during 8 weeks (Czamanski-Cohen et al., 2019); 50-minute sessions once a week for 6 weeks (Lee et al., 2023); 12-week painting groups (Moriarty et al., 2022); 10 sessions of 45 minutes, daily (Rezazadeh et al., 2020); 8 sessions of 1 hour each, once a week (Park & ​​Cha, 2023); one session over 8 weeks (Park & ​​Cha, 2023); sessions over 24 weeks (Zhang, Cheng, Huang & Xu, 2021).

Speaking about the people who carried out the art therapy sessions, we may remember that they were: psychologists, art therapists, medical assistants specialized in the application of art therapy in clinical settings, occupational therapists with additional basic training in psychotherapy or art therapy, other health professionals, arts professionals, music therapists, health management interventional visitors, etc.

Regarding the measurable effects of the art therapy on participants, only one study found no post-art therapy improvements of the experimental group compared to the control group (Park&Cha, 2023). In all the other studies, in addition to the decrease in depression, there was also an improvement in other measured parameters, as appropriate – anxiety, cognitive-emotional coping strategies or an increase in the quality of life.

No studies were identified that analyzed the long-term results of art therapy. All studies reported immediate, post-intervention outcomes, which was a common limitation of a research of this type.

Table 1

Psychometric instruments used in measuring therapeutic progress in a test-retest system (to see Table 1, please click here)

Table 2

Art therapy for children, teenagers and young people (to see Table 2, please click here)

Table 3

Art therapy for adults and the elderly (to see Table 3, please click here)

Table 4

Art therapy for psychiatric patients (to see Table 4, please click here)

Discussions

In general, reviews of the scientific literature on the effects of art therapy on depression have looked at both to the quantitative and qualitative research evidence, documenting overall participant benefits, but in the present study only the quantitative evidence was selected. The quantitative studies inventoried, although few in number, represent as much valid research evidence for the effect of art therapy in depression as a primary disorder or as a disorder associated with somatic conditions.

The clinical results were encouraging for the introduction of the art therapy in clinical care routines. Thus, Lee, Choi, Shin & Suh (2023) investigated the effects of the art therapy on depressive disorder (moderate and severe) and found that patients treated with art psychotherapy and pharmacotherapy showed slightly greater improvement compared to those who were treated only with antidepressant drugs. There were no differences in progress between those with moderate depression and those with severe depression. Liao et al. (2022) tested the reduction of depression scores due to the art therapy through Western music and Chinese music and also obtained favorable results.

The concrete mechanisms by which the decrease in depression scores occurs were deepened by Blomdahl, Wijk, Guregård, & Rusner (2018), through their intensive research on 10 hospitalized depressed patients. Thus, the recovery from the disease would be achieved by facilitating the dialogue of the psychiatric patient with the therapist, but also by stimulating the inner dialogue, which takes place by involving the patient in working with the image, with art materials and in the process of making art. In the view of the quoted authors, the external dialogue with the therapist elucidates and deepens the internal dialogue – the created image (more precisely its content) acts as a mirror that can not only be seen and understood by the viewers, but also it allows answers. Creating art not only awakens emotions, but also increases awareness of those emotions and thoughts.

Blomdahl, Wijk, Guregård, & Rusner (2018) emphasized that the art therapists have a very important role, more precisely that of supporting the patient to meet himself through the image. Furthermore, his inner dialogue changes his way of thinking, and from this point his concepts may be reevaluated.

Depression in the third age was also approached art-therapeutically, in order to increase the quality of life of elderly people.

Thus, Ciasca et al. (2018) assessed whether if the art therapy is beneficial as an adjunctive treatment for depression in older adults with pharmacotherapy-resistant major depression and found that it may improve depression and anxiety scores. In working with 33 elderly women, the cited authors preferred drawing, clay modeling, weaving and making collages. Once the work was completed, each participant was invited to verbally express their reflections and feelings that arose during the activity. The verbalization step was important for detailing the experiences during the artistic production, while the group and the art therapist listened. Then, the art therapist helped each patient to understand her production, because the therapeutic function of art is related to the possibility of materializing thoughts, feelings, desires and facts of life, using expressive resources.

Ciasca et al. (2018) pointed out that the art therapy may be particularly beneficial for patients who do not adapt to the exclusively verbal psychotherapeutic approaches. Thus, it helps to establish a patient-therapist communication and contributes to the emergence of personality’s aspects or facts of life which must be addressed in the therapeutic process. In the cited study, the use of group sessions made it possible to increase the number of people seen by the therapist, facilitated the exchange of experiences between the participants, and allowed the mediation of interpersonal relationships by the therapist, which decreased the social isolation of the depressed elderly women.

In the same segment of the successful process of art therapy for the depressed elderly, Dunphy et al. (2019) conducted a systematic review of studies and found 75 articles with positive quantitative and qualitative results. They depicted the following effects of visual arts, music, dance and drama therapy: physical (increased muscle strength), neurochemical (release of endorphins), intrapersonal (improving self-image, strengthening self-control, communication of emotions), cultural ( aesthetic pleasure), cognitive (memory stimulation) and social (increased social skills and connection).

In another area of ​​clinical intervention, Moriarty et al. (2022) applied art therapy to 11 expectant mothers with mild to moderate postnatal depression (as measured by the Beck Depression Inventory-II), recruited from the economically disadvantaged suburban areas in the UK. They found the following: a decrease in depression scores, an increase in perceived self-efficacy and the appearance of a sense of achievement in the participants. Moreover, other authors had also shown that the art therapy improves the self-perception, the degree of the personal efficacy and the level of the resilience to stress (Haeyen et al., 2015; Crone et al., 2010).

However, the greatest interest in the application of art-therapeutic techniques was aroused by the depression associated with other somatic conditions. Thus, Alwledat et al. (2023) found that in stroke patients art therapy could be used in the management of the comorbid depression by helping them to communicate with each other, express their emotions, ideas, thoughts and feelings. The associated depression is a major and debilitating complication in stroke, and its reduction, through non-pharmacological therapies (without side effects), would improve the therapeutic results of neurological conditions and restore the psychological balance of patients, concluded the authors cited in their study of 85 people with a history of stroke.

Cancer-related depression has been a fertile ground for two studies (Czamanski-Cohen, Wiley, Sela, Caspi, &Weihs, 2019; Naveed&Masoud, 2018).

Czamanski-Cohen et al. (2019) applied mandala coloring techniques in 20 Israeli women with breast cancer, then they discovered a decrease in depression scores and they showed that processing emotions during art therapy is a mechanism for reducing the depression and the somatic symptoms in cancer patients.

Previously, Hanser et al. (2016) showed that in women with advanced (metastatic) breast cancer, the art therapy through drawing, dance and music reduces depression, increases relaxation, induces feelings of happiness, lowers heart rate and increases the personal comfort.

Puig, Lee, Goodwin, Sheerard had, in their turn explored, in 2006, the effectiveness of a complementary creative art therapy intervention in order to improve the emotional expression, the spirituality, and the psychological well-being in 39 newly diagnosed breast cancer patients. The 16 painting sessions of 60 minutes each, carried out in the cited study, managed to reduce their depression scores, decreased their negative emotional states and increased their psychological well-being (measured by the POMS profile of mood states) .

In the same registry, Naveed and Masoud (2018) has examined the effectiveness of therapeutic group art therapy in reducing depression scores in 15 children with leukemia. They found that it is effective, it may be done with trained mental health professionals, and is likely to maintain positive cancer treatment outcomes.

In another area of ​​the pediatric issue, Rezazadeh, Froutan, Ahmad, Mazloum, & Moghaddam (2020) measured the effects of art therapy through music and drawing to reduce anxiety and depression in 60 burned children aged 6 to 12 years . In this study, depression was considered a post-traumatic psychological injury. Anxiety was measured with the parental version of the Spence Children’s Anxiety Scale, and depression with the Maria Kovacs Depression Inventory for Children. Art therapy using painting and music led to reduced anxiety and depression in all of these burn children included in the study.

Art therapy has also proven prolific in bereavement depression. Park and Cha (2023) examined the effects of online group art therapy (art telehealth therapy) on 20 adults who lost family members during the pandemic using three instruments to measure depression, grief, and quality of life. At the end of the study (randomized controlled) there was an improvement in the psychological distress of all participants, but there were no statistically significant differences in the change scores between the experimental group and the control group in terms of depression, pain and the quality of life.

The instruments used, alone or in combination with other instruments, were: Beck’s Depression Inventory (BDI II), Hamilton Scale (HAMD), Childhood Depression Scale (CDI), Depression Anxiety Stress Scales (DASS), Maria Kovacs Children’s Depression Inventory Questionnaire ( CDI), Geriatric Depression Scale (GDS-15) and Depression Screening (CES-D).

The expansion of art therapy in hospitals, as an adjunct to pharmacological treatment, could favor the faster rehabilitation of patients, their therapeutic compliance (especially in the case of those with depression associated with somatic diseases) and it would reduce the costs of treatments. The cost of depression is very high and long-lasting, due to the decrease in the working capacity of individuals, sick leave and the price of drug treatment (Popa & Ciobanu, 2013). In 2019, about 7.2% of EU residents suffered from depression, which attracted annual costs of over 6 billion euros (average cost was 3,402 euros/patient – ​​Eurostat, 2021).

In 2022, the state medical system in Romania settled 344.84 lei/day for the hospitalization of a patient with depressive and/or anxious symptoms, according to the Order of the Minister of Health and the president of the National Health Insurance House no. 1068/627/2021. In Spain, the hospitalization cost of a patient with depression was, in 2019, 420.9 euros/day, to which were added laboratory tests (32.3 euros/day), specialist care (65 euros/day) and other investigations/treatments medications during hospitalization (Vieta et al., 2021). In the USA, where the depression is one of the most common mental disorders, it has seen constant increases in the costs of the depressed patients. So, only between 2010 and 2018 the costs increased by more than 35%, up to 236 billion dollars (Greenberb et al ., 2021), and the growth trend continues (Lerner, 2021).

But depression entails not only major social and economic costs, but also avoidable loss of life, as its main complication is the suicide. According to the World Health Organization, more than 700,000 deaths by suicide were recorded in 2019 (WHO, 2021). Suicide was the third leading cause of death among European adolescents, after accidents and cancer (Tudose, Tudose&Dobranici, 2002).

Limits

The present study is only a part of an exploratory research aimed at selecting the best art-therapeutic approaches for the rehabilitation of depressed psychiatric patients and the tools that can measure therapeutic progress.

The limits of this study derive from those of the selected studies. Thus, a common limitation of the selected papers is the small number of the participants. The other limits concern: the non-representativeness of the samples (the lots come from the same communities); the necessity of allocating more time for art therapy sessions and longitudinal follow-up of cases (several sessions, in a longer interval); the short duration of the workshops (about one hour); the difficulties of integrating art therapy into hospital routines, in the case of patients with somatic conditions comorbid with depression (burned, on dialysis, etc.); technical difficulties (choice of materials); the pronounced local cultural character of some art-therapeutic methods (Chinese flowers); the limited number of art therapists who could apply rehabilitation methods; the need to use some combined art-therapeutic methods, which stimulate both verbal and non-verbal expression; difficulty controlling some symptoms associated with comorbid depression (for example, the impulsivity of burned children); the exclusion of chronic depressives from studies and the difficulty of adapting art-therapeutic techniques to the uniqueness of the participants.

The knowledge of these limits, revealed by the exploratory research, helps the methodological precision of a future research with the subject of the rehabilitation of patients with different psychiatric pathologies through art therapy.

Conclusions

In the past 10 years there have been few quantitative studies concerning the art therapy in the treatment of depression. It has been shown to be effective in reducing the psychological burden of the depression in some psychiatric patients and some patients with serious illnesses (cancer, stroke and kidney disease). The techniques used in the studies included, – in this review, – the way of reduced the stress of the participants in the sessions, encouraged communication with each other, the free expression of emotions, feelings and ideas, thus reducing their depression scores. The group sessions also increased patients’ access to therapists.

Quantitative research on art therapy is still in its infancy, and the techniques are limited. In the inventoried studies, mainly techniques specific to the visual arts were accessed – drawing, painting, modeling, collage, music and musical auditions. One study used the art therapy with the help of using the clay modeling, and another used media art technologies. Practitioners have made the most use of visual art therapy, although art also includes dance, theater, film, and drama therapy. No studies were identified using theater techniques or drama therapy in the treatment of depression, which may represent an important potential for researches in this area. As a result, unlike other psychotherapies, art therapy participate as an adjunct in the rehabilitation of depressed patients, its inclusion in clinical guidelines not being accidental at all.

Competing interests

The authors declare no competing interests.

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