A high percentage of patients with cancer receive a comorbid diagnosis of anxiety, depression, or another psychological disorder. However, research evaluating the efficacy of art therapy as an intervention to alleviate these symptoms is limited. Art therapy can offer psychosomatic symptom relief among patients with cancer, but more rigorous and randomized controlled clinical trials are warranted to strengthen evidence-based research supporting its clinical utility.
AT A GLANCE
- Art therapy uses creative processes to enrich and enhance the lives of patients experiencing psychosomatic symptoms.
- Based on a literature review of eight studies, art therapy improved patients’ anxiety in seven studies, depression in five studies, and overall quality of life in four studies.
- Additional research on the benefits of art therapy are needed to fully understand its efficacy in improving symptoms of anxiety and depression and overall quality of life in patients with cancer.
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The National Cancer Institute (NCI, 2018) estimates that 439.2 new cancer diagnoses and 163.5 cancer-related deaths occur annually per 100,000 people in the United States. A cancer diagnosis is not easily accepted, and with incidence occuring more and more frequently in the United States, patients may require additional support to cope with their diagnosis. Patients who do not receive psychological support following a cancer diagnosis or while undergoing treatment for cancer are more likely to experience various states of mental distress (Gliznak, 2016). According to the NCI (n.d.), psychological disorders are common among patients with cancer and can lead to decreased overall quality of life, with 25% of patients with cancer being affected by major depression. The high incidence of anxiety and depression in patients with cancer presents an opportunity for the use of complementary and alternative therapies in relieving the psychosomatic symptoms that many patients experience (Jang et al., 2016).
Art therapy is an integrative mental health intervention involving creative processes, application of psychological theories, and human experiences within a psychotherapeutic relationship (American Art Therapy Association, 2017). The use of imagery, as well as the verbal and cognitive aspects of therapy sessions, provide an opportunity to promote improved mental and physical health. Although a diagnosis of cancer can bring about feelings of defeat and despair, patients’ perceptions of the disease and its trajectory may be transformed into a more positive experience through the creative process of art therapy (McNutt, 2016). This literature review provides a scholarly foundation for oncology clinical care by supporting art therapy as an intervention to reduce patients’ psychosomatic symptoms (anxiety and depression) and improve patient perceptions of quality of life.
A literature search was conducted using CINAHL®, PubMed®, and PsycINFO®. Multiple combinations of the following search terms were included: art therapy, cancer, neoplasm, oncolog*, myeloma, leukemia, breast cancer, depression, anxiety, fear, quality of life, and psych*. Boolean operators were also used, and search terms were truncated to help to facilitate the search.
Inclusion and Exclusion Criteria
The search was limited to peer-reviewed articles published from 2011 to 2018. Full-text articles were obtained through the DePaul University Library database or the ILLiad® interlibrary loan management system. Included articles were written in English; were focused on the nursing, medicine, or psychology disciplines; and discussed the effects of art therapy in patients with cancer. Articles were excluded if they focused on other forms of therapy; had a non-oncology patient population; and were integrative reviews, systematic reviews, or literature reviews.
Data Synthesis and Analysis
Of the 193 articles that were eligible for the review, 84 were excluded based on the title, and 95 did not meet the remaining inclusion criteria. Fourteen full-text articles were reviewed; eight articles met the inclusion criteria and were included in the data analysis. To synthesize the data, the information from the articles was coded, categorized, and summarized to give the reader a thorough overview of the available evidence in the literature (Grove et al., 2015). The data were then examined to determine any patterns that were present within the articles that helped to answer the initial research question on the effects of art therapy as an intervention for anxiety, depression, and overall quality of life among patients with cancer.
During the data reduction step, pertinent data from each article were divided into subgroups for simplified analysis. The subgroups included the psychosomatic symptom being evaluated, such as anxiety and depression, as well as quality of life. Relevant data regarding measurement tools and participant demographic information were also obtained from each study (see Table 1).
Data were grouped together and converted into a comprehensive data table using subgroups and variables. Table 2 presents a summary of the results from each study, including the effect of the intervention on patients’ anxiety, depression, and quality of life via mean scores and standard deviations.
Based on the literature review, eight studies have evaluated the efficacy of art therapy as an intervention to alleviate psychosomatic symptoms in patients with cancer. The total sample consisted of 394 patients with cancer (65 men, 256 women, 73 undisclosed). Three studies focused specifically on patients with breast cancer (Jang et al., 2016; Singer et al., 2010; Vella & Budd, 2011), whereas the remaining five studies evaluated the use of art therapy in patients with varying cancer types. Because the majority of studies included patients with breast cancer, the study samples were primarily comprised of female patients.
All eight studies examined art therapy as an intervention for patients with cancer with measurement outcomes focused on anxiety, depression, or quality of life. The majority of the studies reviewed (n = 6) used weekly art therapy sessions ranging from 5 weeks to 24 weeks, with sessions lasting an average of 45–90 minutes (Bozcuk et al., 2017; Geue et al., 2012, 2013, 2017; Jang et al., 2016; Thyme et al., 2009). The art therapy sessions used in each study varied from watercolor painting to drawing with colored pencils; however, variations in interventions were not factored into the results of this review. In a study by Vella and Budd (2011), a four-week retreat was used to deliver the intervention, and Gliznak (2016) held two sessions per month, with each lasting for five and a half hours. The study period in the Gliznak (2016) study was undisclosed. Across all studies, the number of patients included in the interventions ranged from 24 to 73. Outcome measures in the studies reviewed included anxiety (n = 8 studies), depression (n = 7 studies), and quality of life (n = 5 studies). The following instruments were used in the reviewed studies to measure levels of anxiety and depression in patients: the Hospital Anxiety and Depression Scale (n = 4), the National Comprehensive Cancer Network Distress Thermometer and Problem List (n = 1), the Personality Assessment Inventory (n = 1), the Symptom Checklist-90 (n = 1), and the Brief Symptom Inventory-18 (n = 1). The European Organisation for the Research and Treatment of Cancer Quality-of-Life Questionnaire–Core 30 was used in four studies, and the Functional Assessment of Cancer Therapy–General was used in one study to measure quality of life.
All eight studies examined the efficacy of art therapy as an intervention to improve patients’ levels of anxiety. From baseline to postintervention, patients’ anxiety scores improved from 8% to 64% (Geue et al., 2012; Gliznak, 2016). In the seven studies that reviewed the effects of an art therapy intervention on depression in patients with cancer, patient scores for depression improved from 6% to 72% (Geue et al., 2013; Vella & Budd, 2011). From baseline to postintervention, quality-of-life scores improved from 8% to 68% following an art therapy intervention (Geue et al., 2017; Jang et al., 2016).
This literature review identified eight studies that examined the efficacy of art therapy as an intervention to alleviate psychosomatic symptoms, such as anxiety and depression, and quality of life in patients with cancer. The studies included in this review reported that art therapy can modestly decrease patients’ anxiety and depression and increase patients’ perception of quality of life.
Of the eight studies reviewed, only two studies had outcomes with less than a 10% improvement in any of the psychosomatic symptoms. In a study by Geue et al. (2012), anxiety improved 8% and depression improved 7% following an art therapy intervention. Similarly, in a follow-up study, quality-of-life scores improved 8% in patients who received art therapy (Geue et al., 2017). In studies where the benefits of art therapy could not be confirmed, patients still reported a positive subjective experience with art therapy; however, the efficacy of art therapy could not be identified as beneficial because other variables (e.g., disease progression, treatment) also affected the psychosomatic outcomes of patients. Overall, art therapy was found to have a modest positive effect on psychosomatic symptoms in patients with cancer and no negative effects in all studies.
The total sample size for the eight included studies was fewer than 400 patients during an eight-year period. With a relatively small sample size, the results of these studies may not be a representative of the overall number of patients with cancer. Because studies with only adult patients were included in this review, the findings must be interpreted carefully within this context.
Implications for Practice
This literature review suggests that art therapy is modestly effective as an intervention to alleviate psychosomatic symptoms in patients with cancer, such as anxiety and depression. In addition, based on the results of the literature review, art therapy may also improve the overall quality of life of patients with cancer. Therefore, nurses should be aware of the potential efficacy and benefits of art therapy so that they can recommend it as a component of holistic patient care. Licensed art therapy professionals can best provide interventions that can be integrated into patients’ care plans.
This literature review provided a scholarly foundation for art therapy as an intervention that can potentially decrease symptoms of anxiety and depression in patients with cancer and improve patient perceptions of quality of life. Because randomized controlled clinical research trials supporting these findings are limited (Jang et al., 2016; Thyme et al., 2009), additional research examining the benefits and potential negative outcomes of using art therapy is warranted to better determine the long-term efficacy of art therapy.
About the Author(s)
Denise LaPenna, MSN, RN, is an RN at Northwestern Memorial Hospital and Joseph D. Tariman, PhD, RN, ANP-BC, FAAN, is an assistant professor of nursing and codirector of the doctor of nursing practice program in the School of Nursing at DePaul University, both in Chicago, IL. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. Tariman can be reached at email@example.com, with copy to CJONEditor@ons.org.
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