http://jppbr.
DOI: 10.
21776/ub.
eISSN: 2723-083X pISSN: 2723-0821 Journal of Psychiatry Psychology and Behavioral Research Vol.
5 No.
March 2024
JPPBR
EXPLORING THE EFFICACY OF ART-RELATED
ACTIVITIES PARTICULARLY PAINTING AS ADJUVANT
THERAPY IN SCHIZOPHRENIA: AN EVIDENCE-BASED
CASE REPORT
Theresia Rini Krisniati Correspondence: theresiarini.
k@gmail.
Department of Mental Rehabilitation.
Grhasia Mental Hospital.
Yogyakarta.
Indonesia
CASE REPORT
OPEN ACCESS
ABSTRACT
Introduction Ae Schizophrenia is a condition that affects approximately one in 300 individuals across the globe, leading to the experience of both positive and negative symptoms.
While antipsychotic medication remains the primary treatment, some patients still contend with residual symptoms and relapses.
Art-related activities, particularly painting, are frequently used as potential adjuvant therapies for individuals with Therefore, this study aimed to critically assess the efficacy of art-related activities, specifically painting, as supplementary Methods Ae A comprehensive literature search was conducted on PubMed.
Google Scholar, and ScienceDirect, guided by clinical questions and strict inclusion or exclusion criteria.
The selected articles were critically evaluated to determine their validity, significance, and Results Ae The literature search identified 3 randomized controlled trials (RCT.
and 1 case series, each with varying validity and analysis Among the RCTs, 2 reported a positive effect of art therapy on the negative symptoms of schizophrenia, while the remaining 1 found no significant impact on patients.
In a case series study, a substantial difference was observed in the symptoms of schizophrenia patients who engaged in art activities.
Discuss Ae The 3 RCTs were done with the involvement of a licensed art therapist.
The practical application of the RCT study results was still limited by the case examined since there are no art therapists in the case observed.
However, in this case, the patient was observed to be more calm, cooperative and increase in ADL score after the art-related activity done in a rehabilitation program.
Conclusion: There is potential for art-related activities as adjuvant therapy for individuals with schizophrenia, but it still lacks sufficient and consistent evidence.
Keywords:art, painting, therapy, schizophrenia, art-related activity.
Article History:
Received: February 29, 2024.
Accepted: March 29, 2024.
Published: March 31, 2024.
Cite this as: Krisniati.
Exploring the Efficacy of Art-related Activities Particularly Painting as Adjuvant Therapy in Schizophrenia: an Evidence-based Case Report.
Journal of Psychiatry Psychology and Behavioral Research.
5:1.
Creative activities related to art have long held recognition as a valuable therapeutic method for individuals contending with mental disorders.
These activities can be facilitated by professionals including art therapists, occupational therapists, psychologists, or mental health nurses.
5 Studies consistently indicate the positive impact of art-related activities on the selfesteem, self-worth, and self-efficacy of individuals with mental disorders.
6,7,8 For those experiencing severe mental disorders, art-related activities often become an integral coping mechanism, offering respite from the psychoses they Activities such as drawing or painting still-life scenes are frequently recommended.
9 Most individuals with mental disorders describe experiencing a "flow-like" state during art activities, enabling these individuals to intensely focus and become absorbed in their creative pursuits.
INTRODUCTION
Schizophrenia is a severe mental disorder, affecting an estimated one in 300 individuals across the globe.
1 Individuals afflicted with this mental disorder often experience positive symptoms, including hallucinations and delusions, alongside negative symptoms such as attention disturbances, anergia, and limited speech.
2 The primary treatment modality comprises antipsychotic medication, which effectively reduces symptoms and minimizes the risk of relapse.
However, the efficacy of this medication remains limited when addressing the negative symptoms of schizophrenia.
3 Medication therapy is also challenged by low compliance rates, contributing to a 30-50% increase in inpatient admissions.
Additionally, some patients receiving treatment continue to experience residual symptoms, relapses, and a decline in social functioning.
Art therapy in the form of painting or expressive drawing is a commonly used approach, both individually and within groups of psychosocial interventions.
There exists an ongoing debate surrounding whether art therapy truly has a positive impact on individuals with schizophrenia, as expressive drawings aimed at self-discovery may contain emotionally charged content that can overwhelm patients.
2 Therefore, this evidence-based case report aims to critically analyze whether art therapy, particularly painting, when integrated with standard therapy, can yield a positive impact on those with this mental disorder.
METHOD
Clinical Question Mrs.
N, a 38-year-old individual, had been suffering from schizophrenia for the past 4 years.
The patient was found participating in activities at a Mental Rehabilitation facility when encountered.
Mrs.
N had been admitted to the hospital three weeks before the encounter with complaints of confusion, self-conversation, and auditory hallucinations instructing her to leave without bidding farewell.
She had poor adherence to treatment before being admitted for an inpatient Mrs.
N was diagnosed with unspecified schizophrenia, and there were no comorbidities.
During her inpatient stay, the patient received standard therapy from a psychiatrist.
Throughout her engagement in the mental rehabilitation program.
Mrs.
N remained calm, and cooperative, and had limited verbal communication.
Additionally, the patient engaged in painting activities once a week for 2 consecutive weeks within the Department of Mental Rehabilitation.
In the case of patients diagnosed with schizophrenia, did the incorporation of art-related activities, particularly painting, alongside standard therapy yield a positive impact on the mental condition of these individuals? Searching Method The search for relevant articles was conducted on PubMedA.
Google ScholarA, and ScienceDirectA on August 17, 2023, using the following keywords, including "painting," "paint," "art," "therapy," "schizophrenia," and "psychosis.
" The search strategy, results, and inclusion-exclusion criteria are shown in Figure 1 and Table 1.
The selection of articles began with the scrutiny of titles and abstracts based on inclusion criteria, followed by the elimination of duplicates discovered across different A subsequent screening was performed based on exclusion criteria, and finally, articles equipped with complete manuscripts were selected for review, including 3 Randomized Clinical Trials (RCT.
and 1 case series.
Critical assessment was performed, including evaluations of validity, significance, and applicability based on the criteria established by the Centre for Evidence-Based Medicine.
University of Oxford, tailored for studies about therapy.
RESULT
Following the comprehensive search strategy, 4 original articles met the criteria for inclusion in this evidence-based case report.
Details regarding the design, procedures, and measurements were presented in Table 2, while the critical appraisal for validity, significance, and applicability was shown in Table 3.
Critical appraisal was conducted on 4 articles, and 3 of these constituted RCTs categorized at level 2b of evidence, and the remaining 1 was a case series study categorized at level 4.
Among the studies.
Crawford et al.
had the largest sample size in comparison to the others.
2 Meanwhile, the investigation by Richardson et al.
had the highest rate of loss to follow-up, reaching up to 18%.
10 All studies were considered to have average validity.
A total of 3 RCT articles had largely similar sample characteristics, while the case series presented different sample characteristics, with schizophrenic patients 1% of the total sample.
5 Richardson et al.
not use blinding, whereas in the other two other RCTs, blinding was implemented on the side of assessors, although achieving patient blinding was not feasible.
All included studies featured painting and drawing as the core art activities.
In the context of the 3 RCT articles, these activities were conducted within an art therapy group under the guidance of a registered art therapist.
The duration of art activities extended to a minimum of 6 weeks, with Crawford et al.
offering the longest intervention period, providing these activities for an extensive 12 months.
DISCUSS
In 2 of the Randomized Clinical Trials (RCT), specifically the studies by Richardson et al.
and Montag et al.
significant effect of art therapy on alleviating negative symptoms when compared to standard care alone.
10,11 Montag et al.
further showed the efficacy of art therapy in reducing positive symptoms.
11 In contrast, a distinct RCT article conducted by Crawford et al.
presented divergent results, indicating that the therapy did not yield a significant impact on the measured symptoms.
Patients participating in the art therapy group significantly experienced less improvement in the positive symptom subscale when compared to those in the activity group within the trial, with an adjusted difference of 3 .
= 0.
2 Caddy et al.
also reported a significant difference in average symptom scores within the art activity group, although a direct comparison with a control group was absent, raising questions regarding its relevance.
Based on the validity component, it was evident that 3 of the RCTs under scrutiny could be deemed valid.
The duration of interventions in these RCTs varied, ranging from a minimum of 6 weeks to a maximum of 12 months, with corresponding follow-up evaluations commencing at a minimum of 12 weeks and extending up to 12 months after treatment.
It was crucial to acknowledge that the extended intervention and follow-up timelines introduced an elevated risk of loss to follow-up.
According to Richardson et al.
, a substantial 18% loss to follow-up was documented, potentially affecting the validity of the analysis.
The risk of unequal patient outcomes at baseline, exemplified in the study by Richardson et al.
Baseline measurements on the SANS scale .
egative symptom scal.
indicated lower values in the art therapy group.
However, the mean change scores of the SANS scale between the Standard Psychiatric Care (SPC) group and the Art Therapy (AT) group at baseline and 6 months of follow-up suggested reduced values in the AT group, with a mean difference in change scores of 0.
7, 95% CI .
2 - 4.
The study by Montag et al.
introduced limitations arising from the lack of standardization in the frequency of psychotherapy contact provided to both groups during the intervention, an aspect omitted from the analysis yet potentially influencing the analysis results.
Additionally, the treatment-as-usual group received supplementary therapies including occupational therapy, sports, music, relaxation, cognitive training, and social skill training.
The activities of the art therapy group remained exclusive to art therapy, omitting any mention of additional interventions.
The study conducted by Crawford et al.
became the most robust in terms of validity and has the largest sample size among the 4 selected articles.
However, its weakness lay in the substantial absenteeism observed among the patients during both art therapy and activity group sessions, with nearly 40% missing from the art therapy and almost 50% from the activity This phenomenon was primarily attributed to low motivation and organizational challenges among the Meanwhile, the instrumental variables analysis failed to establish a significant association between the participant's attendance at these sessions and the primary outcomes, it was crucial to recognize that this analysis was constrained by the assumption of a linear relationship between the session attendance and treatment effect.
The 4 studies mentioned above showed the prevailing limitations and paucity of investigations about the potential of art-related activities in the context of schizophrenia treatment.
The effects of these activities on schizophrenia patients remained challenging to quantify.
Furthermore, the assessed long-term effects failed to show significant and consistent benefits from art-related activities.
A study directly proving the immediate impacts of these activities remained absent.
The practical application of the study results was still limited by the specific cases examined.
The availability of human resources, particularly art therapists with formal education in art therapy, was significantly lacking in the areas where these cases were observed.
In the case of Mrs.
N, she participated in a mental rehabilitation program by doing individual painting activities with the help of a mental health nurse, but with no licensed art therapist.
The approach in painting activities was nondirective and appreciative of the progress the patient made in drawing.
After participating in the mental rehabilitation program, in maintenance wards.
Mrs.
N appeared to be more calm, and cooperative.
There was also an increase in her ADL She was also found to be looking forward enthusiastically to the next painting session.
In the Caddy et study, art-related activity interventions were carried out without the presence of art therapists, including individual art Furthermore, a study by Caddy et al found significant mean differences on all symptom scales measured between admission and discharge .
<0.
on the patient receiving art therapy, but there is no comparable control group, hence the effect of art therapy intervention remains unclear The 3 RCT articles, however, incorporated art therapy with painting activities, all guided by a licensed art therapist.
Furthermore, differences were found in the form of intervention used within these 3 RCTs, with art therapy group-sharing psychotherapy feedback provided by art therapists.
exploration of the potential of art-related activities as adjuvant therapy for individuals suffering from schizophrenia could serve as a catalyst, encouraging the development of further studies and augmenting existing art therapy programs.
Table 1.
Search strategy Database PubMedA .
th August 2.
Search Terms .
ainting or ar.
AND ( therap.
AND (.
chizophrenia OR GooglescholarA .
th August 2.
ainting or ar.
AND ( therap.
AND (.
chizophrenia OR ScienceDirectA .
th August 2.
TITLE-ABSTR-KEY.
ainting or ar.
AND ABSTRKEY(AutherapyA.
AND TITLE-ABSTR-KEY(AuschizophreniaAy OR AupsychosisAy ) Figure 1.
Flowchart of the Search Strategy Results Table 2.
Design.
Procedure, and Measurement of the Selected Articles Article Year
Design
Procedure Outcome Measurement Richardson et
, 10
RCT
Caddy et al.
Case series Crawford et
RCT
Montag et
,11
RCT
Research Subjects Patients with schizophrenia are diagnosed for at least 2 years.
HoNOS.
Health of the Nation Outcome Scales12 Brief Psychiatric Rating Scale (BPRS) for observer-rated symptoms.
Total Sample:
Social Functioning Scale (SFS) 14 SPC (Standard Psychiatric Car.
group: A Inventory of Interpersonal Problems 47.
AT (Art Therap.
group: 43.
(IIP-.
The AT group received standard A Scale for the Assessment of Negative therapy from a psychiatrist and artSymptoms (SANS)16 related group activities.
A Lancashire Quality of Life Profile (Perc Art activities were conducted once a QoL)17 week for @90 minutes for 12 weeks.
A Brief Symptom Inventory (BSI) 18 involving expressive painting/drawing The assessment was conducted at:
and group sharing guided by a licensed A Initial research art therapist, with follow-up.
Post-intervention A Follow-up after six months A Research Subjects:
The Depression and Anxiety One sample group.
CA (Creative Activity Stress Scale (DASS-.
19 Grou.
, included 403 samples, consisting A The Quality of Life Enjoyment of inpatients who received standard and Satisfaction Questionnaire psychiatric care .
eriod 2004-2.
and (Q-LES-Q)20 participated in art therapy group activities A The Medical Outcomes Short for a minimum of 6 sessions, each lasting Form Questionnaire (SF-.
@90 minutes, without participating in shortened version of the SF-.
21 other group activities.
The Health of the Nation The sample included:
Outcome Scale (HoNOS)12 A 8% of patients with a diagnosis of Measurements were carried out during mood .
admission and inpatient discharge.
schizophrenia spectrum diagnosis.
4% of patients with a neurotic or anxiety diagnosis.
The remaining percentage had diagnoses of substance abuse, organic disorders, and other A Art-related activities included various activities such as handicrafts, including painting, printmaking, clay making, knitting, and more.
Research Subjects A Global Assessment Functioning Subjects were divided into 3 groups:
(GAF scal.
The group received standard Positive Negative therapy and art therapy .
Syndrome (PANNS) scale23 Dosage i.
The group received standard medication using the Morisky therapy and group activity therapy .
Health-related quality of life .
The group received only standard using European Quality of Lifetherapy .
5 Dimensions (EQ-5D)25 A Social Function Questionnaire A Art activities in the art therapy group
(SFQ)14
were guided by a licensed art therapist General Well-Being Scale and conducted in small groups .
-8 developed by US health and individual.
once a week for @90 nutrition survey.
minutes, for 12 months.
Activities The assessment was conducted by a blind included expressive and spontaneous assessor at:
painting/drawing.
Initial research (Baselin.
A Post-treatment .
A Follow-up .
A Research Subjects A Primary A total of 58 patients diagnosed with assessment of psychotic and depressive schizophrenia according to DSM-IV symptoms through structured interviews, were randomized into two groups.
TAU encompassing scores from the following .
reatment as usua.
and AT .
rt therap.
, with each group consisting of A 29 patients.
Both groups received standard psychiatric therapy.
In the AT group, art-related activities were conducted in small groups .
-6 individual.
for 12 sessions lasting 90 minutes each, spanning over 6 weeks.
These sessions were guided by a licensed art therapist.
The activities involved expressive and non-directive painting and drawing using various mediums, followed A by group sharing based on patient Scale for the assessment of negative symptoms (SANS) 16 Scale for the assessment of positive symptoms (SAPS), 27 Calgary depression scale for schizophrenia (CDSS), 28 Global functioning scale of the DSM-IVTR (GAF)22 Secondary outcomes comprised the evaluation of:
Mentalizing function parameters, including cognitive empathy assessed through the Reading the Mind in the Eyes (RME) test and Levels Emotional Awareness Scale (LEAS)29,30 A Self-efficacy and locus of control, assessed using the Questionnaire for Competence and Control (Fragebogen zu Kompetenz- und Kontrollyberzeugungen.
FKK)31 A Quality of life during follow-up after therapy, assessed using the Modular System for Quality of Life (MSQoL)32 Measurements were conducted by blind assessors at:
At the beginning of therapy .
A Post-intervention A Follow-up at 12 weeks Table 3.
Critical appraisal of validity and applicability of the four studies based on criteria.
Importance Patient similarity (%) loss follow up Applicability Blinding Standardization Setting Randomization Sample size Level of evidence Article, year Validity A There was a statistically significant impact of Art therapy on negative symptoms measured with the SANS scale, p=0.
02, with Richardson et al.
,10
little or no significant result on other symptom scales.
A The difference in mean change scores for the SANS scale between the SPC group and the AT group at baseline and 6-month followup indicates a lower value in the AT group.
The change in means difference is 0.
7, with a 95% confidence interval of 0.
2 to 4.
A There were significant mean differences on all symptom scales Caddy et ,5 .
measured between admission and discharge .
<0.
on the patient receiving art therapy, but there is no comparable control group, hence the effect of art therapy intervention remains A Differences in outcomes at 12 and 24 months were not found A The adjusted mean difference between those randomized to art therapy and standard care alone was Ae0.
9 on the GAF Scale .
% confidence interval (CI) = Ae3.
8 to 2.
1, p = 0.
Crawford et ,2 .
7 on the PANSS Scale .
% CI = Ae3.
1 to 4.
6, p = A The adjusted mean difference between those randomized to art therapy and activity groups was Ae1.
1 on the GAF Scale .
% CI = Ae4.
0 to 1.
8, p = 0.
1 on the PANSS Scale .
% CI = Ae0.
7 to 6.
9, p = 0.
A On post-treatment results, there is a significant effect of AT .
rt therap.
compared with TAU .
reatment as usua.
group on the SAPS (Scale assessment of positive symptom.
score after controlling the effects of verbal IQ F.
= 11.
38, p<0.
Montag et ,11 .
carried out in per-protocol analysis, and F.
, 37.
=4.
462, p <0.
carried out in intention-to-treat analysis.
A On 12 weeks follow-up results, there is a significant effect of AT compared with TAU group on SANS (Scale Assessment of negative sympto.
score after controlling the effects of verbal IQ F.
=7.
820, p<0.
0125 carried out in per-protocol analysis.
*single blinding: assessor blind.
stated clearly in the article.
- not being done.
/- partially.
levels of evidence based on Centre for Evidencebased Medicine.
CONCLUSION
In conclusion, the efficacy of art-related activities in improving the condition of individuals suffering from schizophrenia remained inconclusive, lacking sufficient definitive evidence.
Several studies showed that art therapy, when administered over a certain period, might yield a positive impact on reducing negative symptoms in patients with this mental disorder.
However, further comprehensive investigations in this domain were needed to provide a more definitive understanding of the potential benefits of art therapy as an adjunctive treatment for individuals contending with schizophrenia.
REFERENCES