Garden walking and art therapy for depression in older adults: a pilot study

The Effect of Walking on Depressive and Anxiety Symptoms: Systematic Review and Meta-Analysis

Background

Previous literature lacks summative information on the mental health benefits achieved from different forms of walking.

Objective

The aim of this study was to assess the effectiveness of different forms of walking in reducing symptoms of depression and anxiety.

Methods

This was a systematic review and meta-analysis of randomized controlled trials (RCTs) assessing the effects of walking on depressive and anxiety symptoms. MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, PsycINFO, Allied and Complementary Medicine Database (AMED), CINAHL, and Web of Science were searched on April 5, 2022. Two authors independently screened the studies and extracted the data. Random-effects meta-analysis was used to synthesize the data. Results were summarized as standardized mean differences (SMDs) with 95% CIs in forest plots. The risk of bias was assessed by using the Cochrane Risk of Bias tool.

Results

This review included 75 RCTs with 8636 participants; 68 studies reported depressive symptoms, 39 reported anxiety symptoms, and 32 reported both as the outcomes. One study reported the results for adolescents and was not included in the meta-analysis. The pooled results for adults indicated that walking could significantly reduce depressive symptoms (RCTs: n=44; SMD -0.591, 95% CI -0.778 to -0.403; I2=84.8%; τ2=0.3008; P<.001) and anxiety symptoms (RCTs: n=26; SMD -0.446, 95% CI -0.628 to -0.265; I2=81.1%; τ2=0.1530; P<.001) when compared with the inactive controls. Walking could significantly reduce depressive or anxiety symptoms in most subgroups, including different walking frequency, duration, location (indoor or outdoor), and format (group or individual) subgroups (all P values were <.05). Adult participants who were depressed (RCTs: n=5; SMD -1.863, 95% CI -2.764 to -0.962; I2=86.4%; τ2=0.8929) and those who were not depressed (RCTs: n=39; SMD -0.442, 95% CI -0.604 to -0.280; I2=77.5%; τ2=0.1742) could benefit from walking effects on their depressive symptoms, and participants who were depressed could benefit more (P=.002). In addition, there was no significant difference between walking and active controls in reducing depressive symptoms (RCTs: n=17; SMD -0.126, 95% CI -0.343 to 0.092; I2=58%; τ2=0.1058; P=.26) and anxiety symptoms (14 RCTs, SMD -0.053, 95% CI -0.311 to 0.206, I2=67.7%, τ2=0.1421; P=.69).

Conclusions

Various forms of walking can be effective in reducing symptoms of depression and anxiety, and the effects of walking are comparable to active controls. Walking can be adopted as an evidence-based intervention for reducing depression and anxiety. More evidence on the effect of low-intensity walking is needed in the future.

Effectiveness of horticultural therapy in aged people with depression: A systematic review and meta-analysis

Background

Depression, an increasing global crisis, has affected many people's daily life, especially for older adults. Horticultural therapy has been widely used in non-pharmacological treatment for patients with depression, with a body of studies demonstrating its therapeutic effects. However, a lack of systematic reviews and meta-analyses makes it difficult to get a holistic picture of this research field.

Objectives

We aimed to evaluate the reliability of the previous studies and the effectiveness of horticultural therapy (including the intervention of environmental settings, activities, and duration) on older adults with depression.

Methods

This systematic review was conducted under the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA) guidelines. We searched relevant studies in multiple databases, and the original search was finished on 25 September 2022. We included studies using randomized controlled trials (RCTs) or quasi-experimental designs.

Results

We yielded a total of 7,366 studies and finally included 13 which involved 698 aged people with depression. Results from meta-analysis indicated significant effects of horticultural therapy on reducing depressive symptoms for the older adults. Besides, we found different outcomes among various horticultural interventions (such as environmental setting, activities, and duration). Depression reduction was more effective in care-providing settings than in community settings; participatory activities were more effective in reducing depression than observational activities; intervention of 4–8 weeks might represent the optimal course of treatment compared to interventions more than 8 weeks in duration.

Conclusion

We came up with a comprehensive set of recommendations based on the meta-analysis: aged people in care-providing settings with depression could get the most benefit from horticultural therapy by participating in participatory activities for 4–8 weeks.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022363134, identifier CRD42022363134.

"Human Flourishing with Dignity": A Meta-Ethnography of the Meaning of Gardens for Elderly in Nursing Homes and Residential Care Settings

This study aims to identify and synthesize qualitative research regarding residents' experiences of gardens while living in nursing homes and residential care facilities. To provide an optimal nursing environment inspired by nature, we need to derive knowledge from the residents' perspective. An interpretive meta-synthesis approach, a meta-ethnography, was chosen for this study. Altogether, six articles representing three continents and comprising 124 participants were included. The six articles that fulfilled the inclusion criteria were analyzed and synthesized according to Noblit & Hare's seven phases of meta-ethnography and the recent eMERGe guidelines. Four themes were identified: (1) The garden-a place to feel a connection with life, (2) the garden-a place to sense and find comfort, (3) the garden-a place to feel healthy and alive, and (4) the garden-a place to relate past and present. An overarching metaphor, "human flourishing with dignity," offers a deeper understanding of the meaning of the garden for older people in nursing homes and residential care. This meta-ethnography provides a reflective, systematic, data-driven synthesis based on literature spanning ten years. Rather than simply relying on retelling, the narration of experiences according to the primary researcher's descriptions and interpretations results in new knowledge. The significance of gardens for older people's health and well-being needs to be given greater attention and space in nursing practice, education, and health policies.

Effectiveness of neurobic exercise program on memory and depression among elderly residing at old age home

Objectives This study finds out the effectiveness of neurobic exercise program on memory and depression among elderly residing in old age homes. Methods The non-probability purposive sampling technique was used for sample selection. Wechsler's memory scale (WMS-IV) and Geriatric depression scale (GDS) were the instruments used to assess the memory and depression among elderly during the pretest and posttest, respectively and the researcher had developed data sheet to collect information about the background variables using interview technique. Results The neurobic exercise program was found to be effective in reducing depression among elderly residing in old age homes. There was a significant difference (p<0.001) in the level of depression had been found during the pretest and posttest in the interventional group. There was a statistically significant difference (p<0.001) found between the study group and in the control group. There was significant correlation (r=0.417, p<0.05) found between the memory and depression during the pretest in the study group among the elderly. A statistically significant association (p<0.05) found in the mean scores of depression and marital status of the elderly during the pretest in the study group and there was a significant association (p<0.01) found in the mean scores of depression and the gender of the elderly during the pretest and posttest in the non interventional group were found. Conclusions The findings suggested that neurobic exercise program is an effective intervention in improving memory and reducing depression.

Exploring the Effects of Guided vs. Unguided Art Therapy Methods

Art therapy has become known by its psychosocial and affective impact, but not so much by its effects on cognitive functioning. Based on a comparison between art therapy and music-making programs, we hypothesized that guided methods—dominant in music-making programs and characterized by an emphasis on execution (play the piece, produce the visual object) rather than ideation (conceive the visual object)—could boost the cognitive effects of art-making. We also hypothesized that removing ideation from the process with guided methods could decrease psychosocial/affective benefits. In order to test our hypotheses, we compared the effects of two art therapy methods on cognitive vs. psychosocial/affective domains. We implemented a short-term longitudinal study with patients with schizophrenia showing both psychosocial/affective and cognitive deficits. The sample was divided into two groups: unguided, instructed to ideate art pieces and execute them without external guidance, vs. guided, instructed to execute predefined art pieces following externally provided guidelines. There was no evidence that guided methods boost cognitive effects, since these were equivalent across groups. However, psychosocial/affective benefits were enhanced by unguided methods, suggesting that therapeutic methods can make a difference. Our study contributes to raising important new questions concerning the therapeutic mechanisms of art therapy.

Coloring Activities for Anxiety Reduction and Mood Improvement in Taiwanese Community-Dwelling Older Adults: A Randomized Controlled Study

To investigate the effect of mandala coloring, plaid pattern coloring, and free-form drawing activities on anxiety and mood in older Taiwanese adults. A total of 120 older adults aged 55 years to 75 years were recruited from 18 community-based learning centers for older adults in southern Taiwan. They were randomly assigned to engage in one of the following four activities for 20 minutes: (1) mandala coloring group, (2) plaid pattern coloring group, (3) free-form drawing group, and (4) reading group (control). Information on sociodemographic, lifestyle, and perceived health status was collected at the baseline. In addition, anxiety levels, measured using the 20-item State-Trait Anxiety Inventory–State Anxiety Scale (STAI-S), were ascertained at the baseline (T1), after a brief anxiety induction (T2), and at the end of the assigned activity (T3). The mean anxiety levels among the four groups at T3 were analyzed using analysis of covariance, followed by Šidák multiple comparison test, as appropriate. The mean age of the 120 study participants was 65.1 years and 73.3% were females. A significantly lower anxiety level was observed only in the mandala coloring group (least square mean = 28.2; 95% confidence interval = 24.7–31.7) compared with the control group (least square mean = 36.0; 95% confidence interval = 32.9–39.2) (P=0.004, partial eta-squared = 0.113). Furthermore, when the STAI-S was analyzed at the item level, the mandala coloring group was significantly different from the control group in the following six feelings: calmed down, safe, at ease, rested, satisfied, and I feel good. In conclusion, short-term mandala coloring activity could significantly alleviate self-induced anxiety in community-dwelling older adults. Further studies on the long-term effects of mandala coloring activity in improving the emotional well-being of older adults are warranted.

Neurological Changes and Depression: 2020 Update

This article covers current research on the relationship between depression and cognitive impairment in older adults. First, it approaches the clinical assessment of late-life depression and comorbid cognitive impairment. Cognitive risk factors for suicide are discussed. Research is then provided on neuropsychological changes associated with depression, discussing subjective cognitive impairment, mild cognitive impairment, and dementia profiles. In addition, literature regarding neuroimaging and biomarker findings in depressed older adults is presented. Finally, therapeutic models for treatment of late-life depression are discussed, including psychotherapy models, holistic treatments, pharmacologic approaches, and brain stimulation therapies.

A Scoping Review Mapping Research on Green Space and Associated Mental Health Benefits

BACKGROUND

There is a growing interest in research investigating the association between green space (GS) and mental health and wellbeing (HWB), in order to understand the underlying mechanisms. Accordingly, there is a need to map the literature and create an overview of the research.

METHODS

A scoping review approach was used to map literature on GS, including context and co-exposures (the GS exposome), and their associations with mental HWB. The review considers mental HWB definitions and measurements and how GS is characterized. Furthermore, the review aims to identify knowledge gaps and make recommendations for future research.

RESULTS

We identified a great diversity in study designs, definitions, outcome measures, consideration of the totality of the GS exposome, and reporting of results. Around 70% of the 263 reviewed studies reported a positive association between some aspect of GS and HWB. However, there is a limited amount of research using randomized controlled crossover trails (RCTs) and mixed methods and an abundance of qualitative subjective research.

CONCLUSIONS

The discords between study designs, definitions, and the reporting of results makes it difficult to aggregate the evidence and identify any potential causal mechanisms. We propose key points to consider when defining and quantifying GS and make recommendations for reporting on research investigating GS and mental HWB. This review highlights a need for large well-designed RCTs that reliably measure the GS exposome in relation to mental HWB.

Creative art therapy for mental illness

Creative art therapy (CAT) for severe mental illness (SMI) represents an extremely heterogenous body of literature that encompasses the use of a large variety of creative mediums (i.e. visual art, music, dance, drama, writing) in the treatment of mental disorders. The present review provides a narrative summary of the findings on the use of CAT for the selected SMI, being: schizophrenia, trauma-related disorders, major depression, and bipolar disorder. A database search of PubMed and the Cochrane Library was conducted related to the use of CAT in the treatment of mental disorders published between January 2008 and March 2019. A total of 9697 citations were identified to match the search criteria and 86 full-texts were reviewed. Although literature suggests CAT to be a potentially low-risk and high benefit intervention to minimize symptoms and maximize functioning in individuals living with SMI, the lack of methodological rigor, and inconsistency in study methods and outcome measures have prevented the advancement of CAT for use in SMI. Although creation of a single CAT regimen for all psychiatric disorders stands neither practical nor advisable, greater standardization of methods would improve evaluation of CAT interventions. Future research should elucidate biological mechanisms underlying CAT methods.

Positive effects of art therapy on depression and self-esteem of older adults in nursing homes

Depression and self-esteem affects the health and quality of life of older adults who live in nursing homes. This study tested the effectiveness of art therapy activities on reducing the depression and improving the self-esteem of elderly living in long-term care institutes. This was a quasi-experimental study. A purposive sampling strategy was used to select 55 subjects who were aged 65 and above with intact mental functions and depression tendencies and currently residing in nursing homes in Kaohsiung, Taiwan. 29 subjects who participated in a selection of 12 artistic activities were assigned to the experimental group and 26 subjects who adhered to their ordinary activities were allocated to the control group. Structured questionnaires of the artistic group were used for data collection. The art therapy programs showed promising effects in improving the depression and self-esteem of older adults living in nursing homes. Art therapy activities benefit the mental health of older adults. Incorporating artistic activities into social work care may help develop long-term care into a more diverse, unique, and innovative direction.

Effectiveness of Art Therapy With Adult Clients in 2018-What Progress Has Been Made?

In the year 2000, an important art therapy literature review addressed an essential question-does art therapy work? It discussed 17 articles dealing with the issue of the effectiveness of art therapy. Two decades later, this research field has extended its scope and is flourishing. Several current reviews of research work have described the broad range of methods implemented today, which includes qualitative and quantitative studies; other reviews have focused on art therapy with specific populations, or by age group. The aim of this systematic literature review is to contribute to the ongoing discussion in the field by exploring the latest studies dealing with the effectiveness of art therapy with a broad scope of adult clients. We conducted a comprehensive search in four databases and review of every quantitative article that has addressed outcome measures in the art therapy field from 2000 to 2017. This paper presents the latest 27 studies in the field that examine the effectiveness of art therapy with adult clients and divides them into seven clinical categories: cancer patients, clients coping with a variety of medical conditions, mental health clients, clients coping with trauma, prison inmates, the elderly, and clients who have not been diagnosed with specific issues but face ongoing daily challenges. It underscores the potential effects of art therapy on these seven clinical populations, and recommends the necessary expansions for future research in the field, to enable art therapy research to take further strides forward.

Neurologic Changes and Depression

This article covers current research on the relationship between depression and cognitive impairment in older adults. First, it approaches the clinical assessment of late-life depression and comorbid cognitive impairment. Cognitive risk factors for suicide are discussed. Research is then provided on neuropsychological changes associated with depression, discussing subjective cognitive impairment, mild cognitive impairment, and dementia profiles. Additionally, literature regarding neuroimaging and biomarker findings in depressed older adults is presented. Finally, therapeutic models for treatment of late-life depression are also discussed, including psychotherapy models, holistic treatments, pharmacologic approaches, and brain-stimulation therapies.

The Effectiveness of Combining Visual Art Activities and Physical Exercise for Older Adults on Well-Being or Quality of Life and Mood: A Scoping Review

Visual art activities and physical exercise are both low-intensity and low-cost interventions. The present study aims to comprehensively describe published literature on the effectiveness of a combination of these interventions on well-being or quality of life (QoL) and mood of older adults. Embase, CINAHL, Ovid Medline (R), PsycINFO, and Web of Science databases were searched for studies published between 1990 and 2015 that evaluated interventions combining visual art therapy and exercise for people aged 50 years or older with at least one resultant well-being or QoL or mood outcome. We found 10 studies utilizing different combination programs and outcome measures, and most had small sample sizes. Seventy percent of the studies reported that combining both interventions was effective in improving well-being or QoL and mood in older adults. Future studies are, however, requisite to investigate whether in the respective population such a combination is more effective than either of the interventions alone.

Systematic review and economic modelling of the clinical effectiveness and cost-effectiveness of art therapy among people with non-psychotic mental health disorders

BACKGROUND

Mental health problems account for almost half of all ill health in people under 65 years. The majority are non-psychotic (e.g. depression, anxiety and phobias). For some people, art therapy may provide more profound and long-lasting healing than more standard forms of treatment, perhaps because it can provide an alternative means of expression and release from trauma. As yet, no formal evaluation of art therapy for non-psychotic mental health disorders has been conducted.

AIM

This review aimed to evaluate evidence for the clinical effectiveness and cost-effectiveness of art therapy for non-psychotic mental health disorders.

METHODS

Comprehensive literature searches for studies examining art therapy in populations with non-psychotic mental health disorders were performed in major health-related and social science bibliographic databases including MEDLINE, EMBASE, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Allied and Complementary Medicine Database (AMED) and Applied Social Sciences Index and Abstracts (ASSIA) from inception up to May 2013. A quantitative systematic review of clinical effectiveness, a qualitative review to explore the acceptability, relative benefits and potential harms, and a cost-utility analysis of studies evaluating cost-effectiveness of art therapy were conducted.

RESULTS

In the quantitative review, 15 randomised controlled trials (RCTs) were included (n = 777). Meta-analysis was not possible because of clinical heterogeneity and insufficient comparable data on outcome measures across studies. A narrative synthesis reports that art therapy was associated with significant positive changes relative to the control group in mental health symptoms in 10 out of the 15 studies. The control groups varied between studies but included wait-list/no treatment, attention placebo controls and psychological therapy comparators. Four studies reported improvement from baseline but no significant difference between groups. One study reported that outcomes were more favourable in the control group. The quality of included RCTs was generally low. In the qualitative review, 12 cohort studies were included (n = 188 service users; n = 16 service providers). Themes relating to benefits of art therapy for service users included the relationship with the therapist, personal achievement and distraction. Areas of potential harms were related to the activation of emotions that were then unresolved, lack of skill of the art therapist and sudden termination of art therapy. The quality of included qualitative studies was generally low to moderate. In the cost-effectiveness review, a de novo model was constructed and populated with data identified from the clinical review. Scenario analyses were conducted allowing comparisons of group art therapy with wait-list control, group art therapy with group verbal therapy, and individual art therapy versus control. Art therapy appeared cost-effective compared with wait-list control with high certainty, although generalisability to the target population was unclear. Verbal therapy appeared more cost-effective than art therapy but there was considerable uncertainty and a sizeable probability that art therapy was more clinically effective. The cost-effectiveness of individual art therapy was uncertain and dependent on assumptions regarding clinical benefit and duration of benefit.

CONCLUSIONS

From the limited available evidence, art therapy was associated with positive effects when compared with a control in a number of studies in patients with different clinical profiles, and it was reported to be an acceptable treatment and was associated with a number of benefits. Art therapy appeared to be cost-effective compared with wait-list but further studies are needed to confirm this finding as well as evidence to inform future cost-effective analyses of art therapy versus other treatments.

STUDY REGISTRATION

The study is registered as PROSPERO CRD42013003957.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The clinical and cost effectiveness of group art therapy for people with non-psychotic mental health disorders: a systematic review and cost-effectiveness analysis

BACKGROUND

The majority of mental health problems are non-psychotic (e.g., depression, anxiety, and phobias). For some people, art therapy may be a more acceptable alternative form of psychological therapy than standard forms of treatment, such as talking therapies. This study was part of a health technology assessment commissioned by the National Institute for Health Research, UK and aimed to systematically appraise the clinical and cost-effective evidence for art therapy for people with non-psychotic mental health disorders.

METHODS

Comprehensive literature searches for studies examining art therapy in populations with non-psychotic mental health disorders were performed in May 2013. A quantitative systematic review of clinical effectiveness and a systematic review of studies evaluating the cost-effectiveness of group art therapy were conducted.

RESULTS

Eleven randomised controlled trials were included (533 patients). Meta-analysis was not possible due to clinical heterogeneity and insufficient comparable data on outcome measures across studies. The control groups varied between studies but included: no treatment/wait-list, attention placebo controls and psychological therapy comparators. Art therapy was associated with significant positive changes relative to the control group in mental health symptoms in 7 of the 11 studies. A de novo model was constructed and populated with data identified from the clinical review. Scenario analyses were conducted allowing comparisons of group art therapy with wait-list control and group art therapy with group verbal therapy. Group art-therapy appeared cost-effective compared with wait-list control with high certainty although generalisability to the target population was unclear; group verbal therapy appeared more cost-effective than art therapy but there was considerable uncertainty and a sizeable probability that art therapy was more cost effective.

CONCLUSIONS

From the limited available evidence art therapy was associated with positive effects compared with control in a number of 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-list but further studies are needed to confirm this finding in the target population. There was insufficient evidence to make an informed comparison of the cost-effectiveness of group art therapy with group verbal therapy.

TRIAL REGISTRATION

HTA project no. 12/27/16; PROSPERO registration no. CRD42013003957.