Art therapy for people with non-psychotic mental disorders

Definition and prevalence of non-psychotic mental disorders

Among people under 65 years, nearly half of all ill health is mental illness, which accounts for 38% of all morbidity in the UK burden of disease. 1 Mental ill health is the largest single cause of disability in our society. 2 Mental disorders can be broadly categorised as either psychotic or non-psychotic, with non-psychotic disorders accounting for most (94%) mental health morbidity in adults. 1,3 Non-psychotic mental disorders include anxiety disorders such as phobias and obsessive–compulsive disorder, mood disorders such as depression and major depressive disorder, and other conditions such as eating disorders and personality disorders. Depression alone accounts for the greatest burden of disease among all mental health problems. 4,5 In addition, nearly one-third of all people with long-term physical conditions have a comorbid mental health problem such as depression or anxiety disorders, indicating an interaction between physical and mental illness. 6–8 Figures for mental illness quoted in the London School of Economics and Political Science report do not include dementia and alcohol and substance misuse, which are also important issues in their own right, and account for part of the outlay in mental health services in the UK NHS. 1

Costs to the NHS

Mental health receives a 13% share of the NHS expenditure despite mental health accounting for 23% in the burden of disease. 1 The largest part of this expenditure is on psychotic disorders, but these disorders account for less than 6% of people suffering with mental illness. One-quarter of all those with mental health problems are in treatment, compared with the vast majority of those with physical illnesses. 1 Research indicates that the costs of psychological therapy are low compared with general care admissions,9,10 and recovery rates are high. 11 Unlike most long-term physical conditions, much mental illness is curable. 11 For depression and anxiety the number needed to treat is estimated to be under 3. 1 Moreover, the same research used data from relevant National Institute for Health and Care Excellence (NICE) guidance compiled by the National Collaborating Centre for Mental Health and posits that ‘more expenditure on the most common mental disorders would almost certainly cost the NHS nothing’ because ‘when people with physical symptoms receive psychological therapy, the average improvement in physical symptoms is so great that the resulting savings on NHS physical care outweigh the cost of the psychological therapy’. 1

The NHS is under increasing pressure to provide cost-effective treatments to service users in a timely manner. The UK government initiative for Improving Access to Psychological Therapies (IAPT) for depression and anxiety disorders within the NHS offers evidence-based psychological therapies that are recommended by NICE. However, IAPT is facing increasing criticism that it is too limited to handle the mental health problems of people with long-term physical conditions or medically unexplained symptoms. 1 Recent evidence also suggests that only one-quarter of people with a mental illness receive treatment for it and that mental health is seriously undervalued, under-recognised and underfunded in the NHS. 1 It may be that more mental health treatment options are needed, which vary according to the type and severity of mental disorder, rather than a one-size-fits-all approach across professions. In addition, recent evidence suggests that psychological treatment may be a preferred treatment option over pharmacological treatment for many who are undergoing treatment for a psychiatric disorder. 12,13 Moreover, patient preference for treatment may impact on adherence and treatment outcome. 14,15 Therefore, evaluation of forms of psychological therapy other than cognitive–behavioural therapy (CBT) need to be conducted in addition to the evaluation of specific pathways within those psychological therapies, in order to create a strategic framework of pathways for managing the burden of mental health morbidity.

Evaluation of psychological therapies such as art therapy is therefore critical in order to inform future recommendations for its use. There is a small body of evidence to support the claim that art therapy is effective in treating a variety of symptoms and disorders in patients of different ages. 16 However, to date a full systematic review of the clinical effectiveness and cost-effectiveness of art therapy for non-psychotic mental disorders has not been undertaken. This project aimed to evaluate the current evidence for art therapy for people with non-psychotic mental disorders in order to inform researchers and commissioners about the value of future use of art therapy in the NHS.

Description of intervention

The intervention of interest is art therapy as might be delivered in the NHS. Art therapy involves using painting, clay work and other creative visual art-making (including creative digital media) as a form of non-verbal expression, in conjunction with other modes of communication within a therapeutic relationship in an appropriate therapeutic setting. Art therapy is a specific branch of treatment under the umbrella term ‘arts therapies’ used by the Health and Care Professions Council (HCPC) which includes drama therapy and music therapy. Dance movement therapy is also described as one of the arts therapies but is not yet regulated. For the purpose of this technology assessment these other forms of arts therapies, which do not centre on the creation of a sustainable physical piece of visual art, are excluded.

Despite art therapy being an established and practised form of psychological therapy for decades, only more recently have researchers in the field of art therapy addressed the need to integrate art therapy into a model of evidence-based practice. Therefore, an abundance of literature exists consisting of single case studies or theoretical concepts in art therapy. Proponents of art therapy17–19 and of the arts therapies20,21 only relatively recently have come to realise that randomised controlled studies of art therapy are needed in order to create a pluralistic body of evidence. As a consequence there has been limited formal synthesis of evidence16,22 for the clinical effectiveness and cost-effectiveness of art therapy in order to assess its relevance as a treatment for the most common mental disorders in the NHS.

Current use of art therapy in NHS

Currently, CBT is the most widely recommended psychological therapy for most mental health problems. However, NICE has identified that the arts therapies (including art therapy) may have specific benefits for people with psychosis and schizophrenia and, therefore, recommends art therapy to be considered for these patients, above counselling and supportive psychological therapy. 23 There are a number of non-psychotic mental health problems that are typified by service users’ reluctance or inability to communicate their feelings verbally. Art therapy is currently being used in the NHS for many non-psychotic mental disorders. For example, arts therapies are included in the autistic spectrum disorder (ASD) Strategic Plan for Wales20 as an accessible and appropriate form of psychotherapy for those with ASD. For these and other service users, it may be that art therapy is a more appropriate treatment than standard talking therapies, but the evidence base for the use and acceptability of art therapy in non-psychotic mental disorders has yet to be formally evaluated. There are clinical guidelines by art therapists for working with elderly people,24 working with prisoners,25 working with children, adolescents and families,26 and working with people with a diagnosis of personality disorder,27 indicating movement in the profession towards more specific systematic practice and research. There are currently no national guidelines in the UK specifically for the use of art therapy for non-psychotic mental disorders.

Art therapy is a widely used psychological therapy which has HCPC approval, higher education Quality Assurance Agency for Higher Education subject benchmarks and a professional organisation for its practitioners – the British Association of Art Therapists (BAAT). While testimonials and case studies occupied much of the evidence for art therapy in the past, there has been less focus on producing rigorous randomised controlled trials (RCTs) of art therapy. The purpose of this review is to assess systematically the evidence that is relevant to whether or not art therapy is effective, how it may be clinically effective and whether or not it is cost-effective in people with non-psychotic mental health disorders.

The results of the 2014 BAAT Workforce Survey represented one-third of members from the professional association; with 70 responses from Scotland and 567 responses from England, Wales and Northern Ireland. The survey results suggested that:

• In England, Wales and Northern Ireland, the NHS employs around half of art therapists who responded. Other large employers are third-sector organisations (charities, voluntary and independent organisations), educational institutions, private practices and local authorities.

• Over half of art therapists who responded use generic skills in their work, such as assessments and key working, possibly reflecting a change towards delivering other services in addition to providing art therapy.

• The majority of client groups served are adults, children and young people. Elderly people and families account for smaller proportions.

• The range of mental health difficulties dealt with by art therapists who responded includes complex trauma and abuse, learning disabilities, alcohol and substance use, forensic mental health, criminal justice, elderly people and palliative care.

There are likely to be regional variations in the availability and practice of art therapy in the UK not captured by this survey.

There is no definitive criterion for who is routinely referred for art therapy, and at what point in their care pathway. 28 The only standardised guidelines for its use are in relation to schizophrenia. 29 However, discernible clusters of people undergo art therapy according to published literature, including people who have been abused and traumatised, who are on the autistic spectrum, who have addictions, dementia, eating disorders or learning difficulties, who are offenders, who are in palliative care, who have depression or personality disorders or who were displaced as a result of political violence. Therefore, adults are referred from a broad range of diagnostic categories, but they tend not to be referred on the basis of diagnosis alone. They may be referred on the basis of behavioural problems, including problems with engaging with services or problems with putting distress into words, for which talking therapies would not be the preferred option. Other clinicians making referrals to art therapy are often looking to widen the range of treatment options for people who, in addition to having complex, severe and enduring mental health problems, face emotional and socioeconomic deprivation. As seen in the use of art therapy for service users in palliative care, people facing the emotional consequences of serious physical health may also be referred.

Defining the use of art therapy for children and adolescents is also problematic. This is because children’s problems tend to be grouped as ‘emotional’ or ‘behavioural’ in the absence of diagnosed disorders. 30 Published outcome data are scarcer for children and adolescents, with more qualitative descriptions of art therapy occurring in the literature. However, BAAT reports that, in November 2010, of the approximately 1800 full members of BAAT, 878 described themselves as working with children, young people and/or families. Seemingly, therefore, art therapy is currently being widely practised with children and young people and should be duly considered in this review.

The art therapist’s role in the mental health service pathway

In service contexts where art therapists are working more briefly with service users, they may also refer on to other services. This is particularly important for clients who have long-term conditions, as it leaves the way open for clients to return for more art therapy at a later stage. Accordingly, art therapists have a professional responsibility to consider carefully referrals that they receive and that they make. Figure 1 indicates the mental health service pathway open to art therapists who are working in a multiagency context. This diagram is adapted from a presentation at the BAAT annual general meeting in 2010,31 in which a two-way bridge was highlighted as a potentially important relationship for art therapists who are working, clinically, with service users for relatively short periods of time.

FIGURE 1.

Mental health service pathway for art therapists working in a multiagency context.

Art therapy as a clinical intervention: definition

Although art therapy is a HCPC-approved form of psychological therapy in the UK, there is currently a lack of a clear single definition of art therapy. The BAAT describes art therapy as a form of psychological therapy that uses the art-making process as its primary mode of communication and can therefore be particularly helpful to people who find it hard to express their thoughts and feelings verbally. Clients who are referred to an art therapist do not need to have previous experience or skill in art, and the overall aim of its practitioners is to enable the client to explore and express their feelings in a safe and facilitating environment. Art therapy can be regarded as a three-way process between the client, the therapist and the image or artefact. 33

The concept of art therapy may sometimes be confused with creative arts movements or strategies designed to improve well-being through art (often called ‘arts in health’ approaches) which, although potentially beneficial, are not specific formal therapeutic interventions to target mental health conditions in individual service users. In order to distinguish the psychotherapeutic use of art therapy as is under investigation in this research question, a criterion to define art therapy as a form of psychological therapy has been formulated. This pragmatic definition was developed as a screening tool and a guide for assessing papers for inclusion into the systematic review. It is not intended to be an exhaustive definition and needed to be sufficiently flexible to include practices in the UK and abroad.

Definition of art therapy in this review:

• The procedure includes establishing therapeutic boundaries appropriate for art therapy interventions (such as clarity about the start and finish of therapy and the frequency and length of sessions).

• The intervention takes places in the presence of a therapist with whom there is an appropriate therapeutic relationship.

• The intervention includes the therapeutic use of art materials.

• The description of art therapy is appropriate to the cultural and service context.

Art therapy as a complex intervention

Non-pharmacological treatments such as psychotherapies are often considered to be complex interventions. The key features of complex interventions have been described (Craig et al. 200834) as:

• having a number of interacting components

• having a number and difficulty of behaviours required by those delivering or receiving the intervention

• having a number of groups or organisational levels targeted by the intervention

• having a number and variability of outcomes

• requiring a degree of flexibility or tailoring of the intervention permitted (non-standardisation/reproducibility).

Art therapy can be regarded as a complex intervention according to each of these features for the following reasons:

• Art therapy may often be used in service users with complex clinical presentations who may or may not have responded to several other treatments in mental health services. It is frequently delivered as part of a wider package of treatment and sometimes as a last resort when other treatments have failed.

• Art therapy is not delivered for any one specific health condition or symptom. It is used in a variety of patient populations. In addition, art therapy is not alone in lacking a clear single definition; psychological therapy more generally is open to heterogeneity through its delivery by different individuals.

• Art therapy is frequently used in service users with comorbid physical long-term conditions which may actually be their primary health diagnosis. There is no set clinical pathway for who should receive art therapy and at what stage of treatment. Therefore, it is difficult to define or exhaustively list comparators for art therapy.

• There is currently no standard outcome measure for defining ‘successful’ treatment through art therapy in clinical practice.

• Art therapists do not offer a set package but tend to tailor the course of treatment, as well as each individual session, to the client.

Thus, confidence in building a coherent network of evidence for a mixed treatment comparison that would contain all possible comparators, comparable study designs and homogeneous participants was low. The use of substantial resources to construct a comparison with potentially low internal validity, in terms of the relative dearth of relevant art therapy evidence, was not deemed appropriate.

Non-psychotic mental health population: definition

The population under consideration is people undergoing treatment for mental health symptoms that do not include psychosis. However, one of the complexities of this population is that not everyone who is being treated for mental health symptoms has a mental health diagnosis. The target population can be described as:

1. Mainstream mental health clinical samples with or without formal diagnoses.

The primary health diagnosis for many people who are service users in mental health may be for a long-term physical health condition or illness that impacts on their mental health. A second group who are also relevant to the research question can be defined as the study population:

1. b(i) Reversible or fluctuating physical conditions where the treatment goals of art therapy include reduction of mental health symptoms (such as depression, anxiety or trauma) as demonstrated by the outcome measures used.

In addition, service users may be in receipt of mental health services for conditions where the primary goal of treatment cannot be considered solely as ‘recovery’ from symptoms, but may be to cope with the symptoms of chronic conditions such as dementia. Therefore, a third group which can also be regarded as relevant to the research question can be defined as the study population:

1. b(ii) Irreversible AND/OR deteriorating physical conditions for which mental health outcomes (such as reduction in depression, anxiety or trauma symptoms) were explicitly targeted and measured.

The use of a more flexible definition for the population, while unconventional in the majority of health technology assessments, is employed here in order to ensure that, while adhering to the research question, the review is also providing a complete picture of the literature relevant to the research question.

Positive outcomes and ‘success’ in mental health treatment

In the field of mental health there is a movement to accept the term ‘recovery’ rather than ‘cure’. This is because recovery can be seen as an ongoing experience which may not be comparable to end points in pharmacological trials. The term ‘recovery’ accommodates the concept that the journey of transitioning from a negative mental health state may be non-linear and may include setbacks as well as progress. 21,35 Essential elements of the recovery approach are reported to be those that facilitate the rebuilding of a meaningful life despite the continuing presence of mental health problems. 36

In addition, the measurement of recovery from a mental health disorder requires the use of a user-validated outcome measure. 37,38 In this sense, the majority of service users would need to agree that the measure makes sense and evaluates human factors that are important to them. Crucially, the outcome measure selected to evaluate treatment needs to be valid, reliable and sensitive to change over time. Mental health disorders can be chronic, recurring and multistage, and it is important that formal evaluation of mental health states is able to capture these complexities.

Time points for measuring recovery should also receive consideration. Individual differences may account for some variation in response to treatment but programmes of psychological treatment themselves vary in duration and frequency. Interventions may or may not be tailored to the individual service user according to service provision. Measurement of patient response to treatment using long-term follow-up, as well as within the time period of the intervention, are essential to determine sustained benefit of psychological interventions.

Bibliographic database searching

Comprehensive literature searches were used to inform the quantitative, qualitative and cost-effectiveness reviews. A search strategy was developed to identify reviews, RCTs, economic evaluations, qualitative research and all other study types relating to art therapy. Methodological search filters were applied where appropriate. No other search limitations were used and all databases were searched from inception to present. Searches were conducted from May to July 2013. The full search strategies can be found in Appendix 2.

To ensure that the full breadth of literature for the non-psychotic population was included, it was pragmatic to search for all art therapy studies and then subsequently exclude studies manually (through the sifting process) that were conducted in people with a psychotic disorder or a disorder in which symptoms of psychosis were reported. It is therefore possible for the reviewer to view all potentially relevant records available and manually exclude studies of samples with psychotic disorders. This method of searching through the literature is in contrast to an approach that uses a search strategy listing all possible mental health disorders that are considered to be ‘non-psychotic’ in the search terms. The latter method may not retrieve all relevant studies from populations that are not indexed under the named mental health disorders.

In addition to the range of conditions covered by the population, the evidence from the studies being generated was frequently not a clear-cut diagnosed ‘mental health disorder’ and the populations retrieved were not the clinical populations of common mental health problems that were first anticipated. At this point in the study identification process it would have been easy to exclude any study that did not include patients with a clinically diagnosed mental health disorder. If this approach had been taken, there would have been three studies in the quantitative review. Instead a pragmatic approach was taken by identifying, including and describing the populations that art therapy is being studied in, with reference to targeting mental health symptoms (see Chapter 1, Non-psychotic mental health population: definition).

Databases searched

• MEDLINE and MEDLINE In-Process & Other Non-Indexed citations (OvidSP).

• EMBASE (OvidSP).

• Cochrane Database of Systematic Reviews (The Cochrane Library).

• Cochrane Central Register of Controlled Trials (The Cochrane Library).

• Database of Abstracts of Review of Effects (The Cochrane Library).

• NHS Economic Evaluation Database (The Cochrane Library).

• Health Technology Assessment Database (The Cochrane Library).

• Science Citation Index (Web of Science via Web of Knowledge).

• Social Sciences Citation Index (Web of Science via Web of Knowledge).

• CINAHL: Cumulative Index to Nursing and Allied Health Literature (EBSCOhost).

• PsycINFO (OvidSP).

• AMED: Allied and Complementary Medicine Database (OvidSP).

• ASSIA: Applied Social Sciences Index and Abstracts (ProQuest).

Sensitive keyword strategies using free-text and, where available, thesaurus terms using Boolean operators and database-specific syntax were developed to search the electronic databases. Date limits or language restrictions were not used on any database. All resources were searched from inception to May 2013.

Grey literature searching

A number of sources were searched to identify any relevant grey literature. Relevant grey literature or unpublished evidence would include reports and dissertations that report sufficient details of the methods and results of the study to permit quality assessment. Conference proceedings without a corresponding final report (published or unpublished) would not qualify for inclusion, as they are unlikely to contain sufficient information to permit quality assessment and can often be different to results published in the final report. 39,40

Sources searched

• NHS Evidence (Guidelines): www.evidence.nhs.uk/.

• The BAAT: www.baat.org/index.html.

• UK Clinical Research Network Portfolio Database: public.ukcrn.org.uk/Search/Portfolio.aspx.

• National Research Register Archive: www.nihr.ac.uk/Pages/NRRArchive.aspx.

• Current Controlled Trials: www.controlled-trials.com/.

• OpenGrey: www.opengrey.eu/.

• Google Scholar: scholar.google.co.uk/.

• Mind: www.mind.org.uk/.

• International Art Therapy Organisation: www.internationalarttherapy.org/.

• National Coalition of Arts Therapies Associations: www.nccata.org/.

Additional search methods

A hand search of the International Journal of Art Therapy (formerly Inscape) was conducted. The additional search methods of reference list checking and citation searching of the included studies were utilised. Other complementary search methods were considered such as pearl growing; however, because the search method employed was considered to be very inclusive, such additional methods were unlikely to generate additional relevant records.

Screening and eligibility

The operational sifting criteria (eligibility criteria) were defined and verified by two reviewers (LU and AS). Titles and abstracts of all records generated from the searches were scrutinised by one assessor and checked by a second assessor to identify studies for possible inclusion into the quantitative review. All studies identified for inclusion at abstract stage were obtained in full text for more detailed appraisal. Non-English studies were translated and included if relevant. For conference abstracts or clinical trial records without study data, authors were contacted via e-mail; however, no additional data were retrieved by contacting study authors. There was no exclusion on the basis of quality. If closer assessment of studies at full text indicated that eligible studies were not RCTs, then the studies were excluded. Agreement on inclusion, for 20% of the total search results (n = 2015), was calculated at title/abstract sift demonstrating 0.93 agreement using the kappa statistic. If there was uncertainty regarding the inclusion of a study, the reviewers sought the opinion of the team members with the relevant clinical, methodological or subject expertise to guide the decision.

Accumulation of results

All references were accumulated in a database using Reference Manager Version 12 (Thomson Reuters, Philadelphia, PA, USA), enabling studies to be retrieved in categories by keyword searches and duplicates to be removed.

Study appraisal

Two reviewers (LU and AS) performed data extraction independently for all included papers and discrepancies were resolved by discussion between reviewers. When necessary, authors of the studies were contacted for further information. Data were input into a data extraction template using Microsoft Excel (Microsoft Corporation, Redmond, WA, USA), which was designed for the purpose of this review and verified by two reviewers. Information related to study population, sample size, intervention, comparators, potential biases in the conduct of the trial, outcomes including adverse events, follow-up and methods of statistical analysis was abstracted from the published papers directly into the electronic data extraction spreadsheet.

The evidence generated from the comprehensive searches highlighted that the majority of research in art therapy is conducted by or with art therapists. This indicates potential researcher allegiance towards the intervention in that art therapists are likely to have a vested interest in the output of the study. For this reason it was deemed important to focus on the highest quality evidence available from the study literature. Trials that were non-randomised (i.e. in which the researcher was able to select and allocate participants to treatment arms) were considered to be too low in methodological rigour to be included in this review. The consequence of including data from non-randomised studies into the review is that the resulting data are biased and therefore not robust or sufficient to inform and contribute to the evidence base. 41,42 The inclusion and exclusion criteria for the quantitative review are shown in Figure 2.

FIGURE 2.

Eligibility criteria for the quantitative review.

Setting

Studies could be conducted in any setting, including primary, secondary, community based or inpatient.

Sessions

Study selection was not limited by the number of sessions, and studies that provided the intervention in a single session were included.

Timing of outcome assessment

Post-treatment outcomes and outcomes at reported follow-up points were extracted and summarised when reported.

Quality assessment strategy

Quality assessment of included RCTs was performed for all studies independently by two reviewers using quality assessment criteria adapted from the Cochrane risk of bias,44 Centre for Reviews and Dissemination (CRD) guidance45 and Critical Appraisal Skills Programme (CASP)46 checklists to develop a modified tool for the purpose of this review. The modified tool was developed to incorporate relevant elements across several tools to allow comprehensive and relevant quality assessment for the included trials. Judgements and corresponding reasons for judgements for each quality criterion for all studies were stated explicitly and recorded. Risk of bias was assessed to be low, high or unclear. Where insufficient details were reported to make a judgement, risk of bias was stated to be unclear and authors were not contacted for further details. Discrepancies in judgements were resolved by discussion between the two reviewers.

Heterogeneity of the included studies

The study populations are heterogeneous (Figure 4), highlighting the wide application of art therapy in this small number of included RCTs but also demonstrating the difficulty in obtaining a pooled estimate of treatment effect. In this respect the clinical profile of patients can be regarded as a potential treatment effect modifier.

FIGURE 4.

Patient clinical profiles in the 15 included RCTs.

The control groups across the included studies are heterogeneous (Figure 5); therefore, there may be different estimates of treatment effects depending on what art therapy is compared against. Creating a network meta-analysis, which would incorporate all relevant evidence for all the comparators, for all non-psychotic mental health disorders, would be beyond the remit for this research project.

FIGURE 5.

Comparator arms in the 15 included RCTs.

In addition, despite common mental health symptoms being investigated across the included RCTs, the majority of studies were using different measurement scales to assess these outcomes (Table 7). Therefore, as there are insufficient comparable data on outcome measure across studies, it is not possible to perform a formal pooled analysis.

Potential treatment effect modifiers in the included studies

As well as the patient’s clinical profile, several other treatment effect modifiers can be identified from the included studies.

Study summaries

This section provides short overviews of each study with reference to statistically significant differences between groups that were reported in each of the studies.

Findings of the included studies

The directions of statistically significant results from the 15 included RCTs are summarised in Table 8.

As can be seen in Table 8, in 14 of the 15 included studies there were improvements from baseline in some outcomes in the art therapy groups. However, both the intervention and the control groups improved from baseline in four studies, with no significant difference between the groups. 47,49,50,53 The control groups across these four studies were verbal psychodynamic psychotherapy,47 treatment as usual,49 CBT50 and garden walking,53 and verbal psychodynamic psychotherapy, respectively.

In eight studies, art therapy was significantly better than the control group for some but not all outcome measures. Table 9 shows the results according to the mean change from baseline between groups in these eight studies.

In one study,52 all outcomes were significantly better in the art therapy intervention group than in the control group. Table 10 shows the results from the Kim52 study.

In one study57 of a sample of people with dementia, outcomes were worse for the art therapy group than for the control group, which was an activity control group. An unusual pattern of results is presented, including a significant increase in anxious/depressed mood (p < 0.01) at 40 weeks which was not present at the 10- or 20-week time points and dissipated by 44 and 56 weeks. The authors discuss several reasons for this result including the high level of attrition; the reliance on observer ratings in the frail and elderly sample (and subsequent potential impact of observer bias); the increased depression as a response to the sessions ending; and the possibility that art therapy was contraindicated in this sample.

Narrative subgroup analysis of studies by mental health outcome domains

Table 11 presents the results for effectiveness of art therapy across relevant mental health outcome domains.

Critical appraisal of the potential sources of bias in the included studies

Critical appraisal of other potential sources of confounding

Discussion of the quantitative review

The aim of the quantitative systematic review was to assess the evidence of clinical effectiveness of art therapy compared with control for treating non-psychotic mental health disorders. The limited available evidence showed that patients receiving art therapy had significant positive improvements in 14 out of 15 RCTs. In 10 of these studies, art therapy resulted in significantly more improved outcomes than the control, while in four studies art therapy resulted in an improvement from baseline but the improvement in the intervention group was not significantly greater than in the control group. In one study, outcomes were better in the control group than in the art therapy group. Relevant mental health outcome domains that were targeted in the included studies were depression, anxiety, mood, trauma, distress, QoL, coping, cognition and self-esteem. Improvements were frequently reported in each of these symptoms except for cognition.

Limitations of the quantitative evidence

Despite every possible effort to identify all relevant trials, the number of studies that qualified for inclusion was small. Despite a large number of records on art therapy yielded from the searches, very few studies were RCTs, demonstrating a slow uptake of the evidence-based medicine model in this field. The study samples are heterogeneous and few samples can be regarded strictly as the target population for this review – people diagnosed with a mental health condition. The limited selection of mental health disorders in the included study samples means that the external validity to the population with non-psychotic mental health disorders is limited. In addition, the sample sizes are small, and as yet there are no large-scale RCTs of art therapy in non-psychotic mental health disorders. The paucity of RCT evidence means that it is not possible to make generalisations about specific disorders or population characteristics.

The risk assessment of bias highlighted that, although all studies were reported to be RCTs, few studies reported how patients were randomised, and in the majority of studies there were several instances of high risk of bias. Areas of potential confounding frequently associated with the studies included attrition, concomitant treatment and treatment fidelity. Consequently, the internal validity of the included studies is threatened. Owing to the low quality of the 15 RCTs, the results included in the quantitative review should be interpreted with caution. As this systematic review did not search for and include direct evidence about other interventions for non-psychotic mental health disorders, it has not been possible to identify indirect evidence for the effect of art therapy in a mixed treatment comparison within the scope of this research. Therefore, the effectiveness of art therapy compared with other commonly used treatments that have been shown to be effective is unknown. In addition, the underlying mechanisms of action in art therapy remain unclear from this evidence. The qualitative systematic review that is presented in the next chapters will explore the factors that may contribute to the therapeutic action in art therapy.

Bibliographic database searching

As the searches for the clinical effectiveness were comprehensive for art therapy literature, the same database was used for both the quantitative and qualitative reviews (see Chapter 2, Literature search methods).

Screening and eligibility

All abstracts, and then full papers, were read by two reviewers (AS and LU) who made independent decisions regarding inclusion or exclusion, and consensus, where possible, was obtained by meeting to compare decisions. In the event of disagreement, a third reviewer (EK) read the paper and made the decision. Study types included were:

• qualitative research reporting the perspectives and attitudes of people with non-psychotic mental health disorders who have received art therapy in order to examine issues of acceptability

• qualitative data embedded in trial reports or in accompanying process evaluations, to inform an understanding of how issues of acceptability are likely to affect the clinical effectiveness of art therapy

• qualitative data either from separately conceived research or embedded within quantitative study reports, reporting the acceptability of art therapy to health care practitioners.

The inclusion and exclusion criteria for the qualitative review are reported in Figure 6. Studies in all settings were included, although the community was the main setting of interest.

FIGURE 6.

Eligibility criteria for the qualitative review.

Quality assessment strategy

Studies meeting the inclusion criteria were evaluated by two reviewers using the CerQual approach. CerQual (certainty of the qualitative evidence67) aims to assess how much certainty can be placed in the qualitative evidence for the review finding, or, in other words, how reliable the review finding is. This approach relies on assessing both the methodological quality of the individual included studies and the coherence of the review finding as defined by the extent to which a clear pattern across the individual study data is identifiable.

To assess methodological quality individual studies were appraised using an abbreviated version of the CASP quality assessment tool for qualitative studies. 68

Two reviewers (AS and LU) independently applied the set of quality criteria to each included study. In the event of a disagreement, a third reviewer (EK) was consulted. Studies were included in the review regardless of study quality.

Whereas study quality applies to each individual included study, ‘coherence’ relates to the review finding which is subsequently developed through the synthesis of the individual studies. Therefore, the coherence of each review finding was then assessed by looking at the extent to which a clear pattern across the data was identified and was contributed by each individual study. This was assessed by looking to see if the review finding was consistent across multiple contexts and if the review finding incorporated explanations for any variation across individual studies. Coherence was further strengthened when the individual studies contributing to the finding were drawn from a wide range of settings. Using the assessment of methodological quality and assessment of coherence together, the certainty of each review finding was rated as high, moderate or low.

Data extraction strategy

Data extraction from included qualitative studies was undertaken independently by AS using a data extraction tool adapted and tailored for the precise purpose of the qualitative review. All data extractions were checked by LU, with any discrepancies being discussed by both data extractors. Where data for included studies were missing, reviewers attempted to contact the authors at their last known e-mail addresses.

For the purpose of data extraction, two principal approaches to decide what counts as qualitative evidence have been proposed. 69 In the first, only data from primary studies which are illustrated by a direct quotation from the respondent are extracted, whereas in the second all qualitative data identified in the primary studies and relevant to the review question are extracted. Given the anticipated paucity of evidence, the latter, more inclusive, approach to data type was adopted, together with a selective approach to extract data relevant to the specific research question. A framework for extraction was developed which focused specifically on data relating to the review question, including how art therapy helped (relative benefits); how art therapy was unhelpful (potential harms); neutral effects (neither benefits or harms); barriers to participation [acceptability (a)]; and recommendations for service delivery [acceptability (b)] from patients and health practitioners. Table 18 illustrates the data extraction elements.

Data synthesis strategy

Qualitative meta-synthesis was undertaken to provide added value to the quantitative analysis by indicating patient issues around the acceptability of art therapy as a treatment for non-psychotic mental health disorders. Specifically, thematic synthesis was used to aggregate the findings. 70 The framework developed for data extraction was used to shape the synthesis of the findings.

Combining the quantitative and qualitative data

Methodological work to date has been unable to establish the superiority of conducting the qualitative and quantitative synthesis in parallel or of conducting quantitative followed by qualitative, qualitative followed by quantitative or some more iterative approach. Our choice of method of combining data was determined by the needs of this particular review, in which the quantitative data were the main focus and the qualitative data were used for their explanatory potential. We, therefore, employ methods similar to those described by Noyes et al. 71 to explore the effectiveness review in the light of supporting qualitative research data.

Included studies: qualitative review

From the 10,270 citations identified from the initial searches (see Chapter 2), 290 were considered following abstract sift and 42 papers were considered at full paper sift for the qualitative review. Figure 7 shows the flow chart of studies included in the qualitative review. The sifting process resulted in the inclusion of 12 studies (13 sources) at full paper sift. All included full papers were published between 2002 and 2013 (although one study was an unpublished manuscript linked to a published abstract within this time scale72). Two were theses,73,74 and one of these had an associated peer-reviewed paper75 which reported the same study.

FIGURE 7.

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow chart of studies included in the qualitative review.

Study respondents

Eleven studies assessed patients’ attitudes and two studies assessed health practitioner attitudes to the intervention [general practitioners (GPs) = 1; art therapists = 1]. The studies contained qualitative data from 188 patients and 16 health practitioners. The primary diagnoses of the patient populations studied included cancer (n = 6), depression/anxiety/stress (n = 3), PTSD (n = 1) and obesity (n = 1). The symptoms being treated by art therapy included depression, stress, anxiety, psychological distress, low self-esteem, fatigue and fear.

Six studies did not report the age of the participants. Where age range was reported,73,76–78 ages ranged from 26 to 82 years. Five studies77,81–84 did not report the gender of the participants. In four studies,72,73,76,78 all participants were female, while one study79 included 69 men and 88 women and a final study80 included four women and one man.

Study setting

Three studies80–82 were conducted in the UK. One of these studies82 provided data from patients and the other from GPs who referred patients to art therapy. 81 Four studies73,74,78,83 were conducted in the USA, with one of these studies73 also including participants from Canada. Three of these studies73,78,83 provided data from patients and the final study74 provided data from art therapists. The remaining five studies were conducted in European countries, Sweden,76 Germany,77 France,72 Italy79 and Switzerland,84 and provided data from patients.

In seven studies,72,74,76,77,79,82,84 the art therapy took place in secondary care; one study81 took place in primary care and one study78 took place in a state correctional facility (USA). In another study73 participants had taken part in art therapy in varied settings including secondary care and private sessions. The setting was not reported in two studies. 80,83

Intervention description

The reporting of the art therapy intervention was limited in a number of cases. One study81 did not report any details of the intervention, and two studies73,80 reported on perceptions of patients who had taken part in a variety of different interventions, although details of each were not reported. Of the remaining eight studies assessing patient views of art therapy, in four studies77,82,83,84 the art therapy had been conducted in a group, with group sizes ranging from four to nine participants, while three studies76,78,79 reported on individual sessions; in one study,72 the format was not reported. In six studies72,76,79,82–4 it was reported that the intervention had been delivered by an art therapist. This was reported to be a professional or qualified art therapist in three of these studies72,79,82 and an art therapy psychotherapist in a further study. 84 The service provider was not reported in the remaining two studies. 77,78 Sessions were 1 hour in length in three studies72,78,79 and 2 hours in length in two studies;82,84 duration was not reported in three studies. 76,77,83 The number of sessions delivered ranged from 1 to 22. Sessions were reported as occurring weekly in four studies; the frequency was not reported in three studies. One study82 reported perceptions of patients who had taken part in art therapy as part of a rolling programme. Table 19 shows the study characteristics of qualitative studies with data from patients.

Table 20 shows the study characteristics of qualitative studies with data from service providers.

Certainty of the review findings

As described in the Quality assessment strategy section, the CerQual approach to assess the certainty of the review findings was applied. The CASP quality assessment finding, together with the number of studies contributing to the finding, and an assessment of the consistency of study setting and population, was assessed. Each finding could potentially be graded as being of high, moderate or low certainty. For the evidence from patients, there were a total of 38 findings: 20 were assessed to be of moderate certainty and 18 were assessed to be of low certainty. For the evidence from service providers, as only two studies contributed to the evidence, there were a total of 25 findings: 19 were assessed to be of moderate certainty and six were assessed to be of low certainty. Owing to the limited number of studies contributing to each finding, together with the fact that the majority of the individual studies included in the review were of low to moderate quality, no findings were assessed as being of high certainty.

Benefits of art therapy

Acceptability and potential harms of art therapy

Although recipients in most of the studies indicated a high level of acceptability of art therapy, some studies also described less positive attitudes. 72,73,78,79,81 Some respondents made comments that indicated that, although they did not feel art therapy would be harmful, they did not feel it would be beneficial. In one study,79 a participant commented that art therapy was superficial; ‘I did not find anything particularly useful in it: afterwards I felt as before [she makes a gesture of opening her hands]. It is a little chat with a person who maybe can understand you, but in the end . . .’. Another patient felt it was childish. In another study,81 a participant felt it was self-indulgent, and, in a final study,78 a participant simply had a preference for other therapies. These findings were seen across only three studies of low to moderate quality.

More serious concerns included art therapy causing anxiety,72 increasing pain,72 and resulting in the activation of emotions that were not resolved. 73 In one study,73 a participant was also concerned that art therapy may be harmful if the art therapist was not skilled. A final concern was that it may be harmful if art therapy is suddenly terminated. 73 These findings were seen across only two studies, both in patients with cancer.

The provision of art therapy

Across several studies73,76,78,81 recommendations for art therapy were made. A participant in one study76 said that it was important that privacy be respected during art therapy. In addition, emotional support,73 a good relationship with the art therapist73,81 and that the art therapist should act as a guide73 were suggested to be important aspects of art therapy. Suggested improvements for art therapy were made in one study,78 including the need for further sessions of art therapy and for additional input from other therapies, such as individual counselling.

Barriers to participation

Barriers to participation in art therapy were reported in three studies. 72,79,80 Respondents commented that they thought they were too ill to take part in the therapy,72 and in a further study respondents reported that art therapy was restricted to people with certain medical conditions. 80 Other barriers included a fear of not being ‘good at art’80 and in two studies79,80 participants commented that a lack of understanding of art therapy could be a barrier to participation. Figure 8 shows the overall synthesis of patients’ views regarding the relative benefits, harm and acceptability of art therapy.

FIGURE 8.

Overall synthesis of patients’ views regarding the relative benefits, harms and acceptability of art therapy.

Benefits of art therapy

In many ways the data from the two studies examining service provider views of art therapy mirrored those of the patients. Service providers felt that art therapy was beneficial when patients have time invested in them. 81 One GP stated that ‘simply having the time to have somebody interested in them is therapeutic in itself’. 81 Service providers also felt that a good indicator of the benefit of art therapy was when the patients say they like it or they felt they benefited. 74,81 Art therapists felt that art therapy was most helpful when the therapist examines the effect of art-making process with clients. 74 Furthermore, it was seen as beneficial when clients can communicate through artwork,74 when art therapists help clients improve their ability to manage anger,74 when it increases pride and self-esteem,74 and when thoughts and feelings are expressed more effectively. 74 Finally, on a more practical level, art therapists felt that art therapy could be beneficial when it provides an opportunity for clients to do something better with their time. 74

Acceptability and potential harms of art therapy

Service providers made a number of observations about the acceptability and potential harms of art therapy. According to the study that examined the perspectives of GPs referring patients to art therapy81 GPs, while not believing that art therapy could be harmful, do not regard it as beneficial either. In that study, GPs referring patients to art therapy commented on a lack of understanding of art therapy, reporting, ‘I don’t think I understood what the art bit was about’. 81 They also suggested that the art part of the therapy was irrelevant, stating ‘[I] thought it was about offering people an opportunity to discuss things in therapy. If you or I went to a group we’d get something out of it’. 81 They felt it was unlikely to help everyone,81 and on a more practical note they felt that art therapy gave them with an opportunity to take time back: ‘leaves me free for more medical care’. 81 It should be noted that all of these neutral findings were generated from only one study of low quality, which looked at the opinions of GPs referring patients to art therapy and, therefore, cannot be generalised across other groups.

In terms of more serious detrimental effects of art therapy, Sharf74 reported findings from art therapists. These potential harms included when administrative decisions lead to poor treatment outcomes, for example when a client is not allowed to continue with art therapy; when the client lacks commitment or is non-compliant; and when the client is resistant to art therapy.

The provision of art therapy (service delivery)

Both types of service providers (GPs and art therapists), like patients, felt that a good relationship with the art therapist was important. 74,81 GPs also reported that they felt the one-to-one contact was an important aspect of the therapy. 81 Art therapists also felt that client commitment to recover, the client’s enjoyment of art therapy, providing a safe environment to express thoughts, feelings and experiences, matching techniques and materials to clients, displaying artwork, and creating art along with clients were important aspects of effective art therapy. 74

Barriers to the provision of art therapy

Art therapists felt that their profession was not respected by members of other professional groups,74 and that this created a barrier to patients being referred to art therapy. Art therapists went on to suggest that, in situations where art therapists and other professionals were able to work together, improvements to the service, patient outcomes and accessibility of art therapy were made. Figure 9 shows the overall synthesis of service providers’ views regarding the relative benefits, harms and acceptability of art theraphy.

FIGURE 9.

Overall synthesis of service providers’ views regarding the relative benefits, harms and acceptability of art therapy.

Experience/qualification of the art therapist

The review of the quantitative evidence demonstrated that there was considerable variability in the reporting of the accreditation of the therapist, although most studies were conducted by a person who was seen be qualified as an art therapist. The findings of the qualitative review demonstrated that a good relationship with the art therapist was reported as an important for art therapy to be helpful. Therefore, it appears that the experience and skill of the art therapist may be an important mechanism of art therapy.

Individual versus group art therapy

The quantitative review reported that the majority of RCTs are of group art therapy, with only four of the 15 RCTs examining individual art therapy. 49,55,56,62 Of the studies of individual art therapy, two49,62 did not demonstrate an improvement on quantitative measures compared with the control group. Given that the qualitative findings also pointed to the importance of relationships with other group members as a particularly beneficial aspect of art therapy, with this finding seen in across several studies, an important mechanism in art therapy may be the group setting.

Pre-existing physical condition

The quantitative review highlighted that in nine studies patients had pre-existing physical conditions. 50,51,54–58,61,62 The remaining six studies were in people who were depressed,47,59 people with PTSD,48,49 or older people. 52,53 Neither the qualitative review nor the quantitative review found evidence that the effectiveness or helpfulness of art therapy differed across patients with or without pre-existing physical conditions. However, the qualitative review showed that a small number of themes appeared to apply mainly to people with pre-existing physical conditions. These themes included the facilitation of an improved relationship with family, friends and caregivers; facilitation of an understanding of the illness in two studies,72,84 one of obesity and one of palliative care impatients; distraction from pain; distraction from the illness/escapism; and providing the opportunity for legacy. These findings may have implications for how art therapy is delivered to different populations to maximise beneficial effects.

Although age and gender were identified as potential treatment modifiers in the quantitative review, neither review was able to demonstrate any evidence that these variables had an effect on quantitative outcomes or patients’ perspectives and attitudes towards art therapy.

Discussion of the qualitative review

The aim of the qualitative systematic review was to provide a detailed user perspective on the acceptability and relative benefits and potential harms of art therapy. Overall, art therapy was viewed as an acceptable treatment across the populations of participants studied.

A number of beneficial aspects of art therapy emerged, together with a relatively smaller number of harmful aspects of art therapy, with relative harms being reported in only two studies. 72,73 An important theme emerging from the data was the relationship with the art therapist. This was raised as a positive and beneficial aspect of art therapy but also as potentially harmful, and further as a recommendation for service provision. A good relationship between the patient and art therapist was viewed as essential for successful, effective art therapy. However, harm could be caused in situations in which a positive relationship was not achieved, the therapist was viewed as unskilled, when emotions activated through therapy could not be resolved or the therapist was suddenly unavailable through sudden termination of the service. This finding was seen in evidence reported by patients and by service providers,74,81 who also stressed the importance of a good therapeutic relationship.

Some themes, such as the importance of expression, the relationship with the art therapist and with other group members and the facilitation of an increased understanding of self, were consistent across populations, while a small number of themes appeared to apply to populations in which a diagnosis of a pre-existing physical condition was present. These themes included the facilitation of an improved relationship with family, friends and caregivers, identified in one study of a cancer population,72 facilitation of an understanding of the illness in two studies (one of obesity84 and one of cancer73), distraction from pain in one study of cancer,72 distraction from the illness/escapism in two studies of cancer populations72,73 and one of an obesity population84 and providing the opportunity for legacy in a study of a cancer population. 72

Understanding and personal achievement were other important themes emerging from the evidence. In addition, some barriers to participation were reported. A small number of participants also reported that they did not want to take part in art therapy, which reiterates the importance of considering patient preference in choice of treatment. 14,15

The combination of the findings from the quantitative and qualitative reviews examined how outcomes from the quantitative review mapped on to themes emerging from the qualitative review. This demonstrated that a number of themes from the qualitative review appear to map on to the quantitative coping outcome. This included both helpful and unhelpful qualitative themes. Self-esteem also mapped on to qualitative findings. Furthermore, the combining of the two reviews identified a number of mechanisms within art therapy that may modify the effectiveness and acceptability of the treatment and should be considered in further research and in the implementation of art therapy.

Limitations

Overall the evidence base was small (n = 12), with only two studies examining service provider views74,81 and, furthermore, only one of these74 examined art therapists’ views. The majority of the included studies were of low or moderate quality. Limitations on word limits imposed by journals may have contributed to this, as theses and grey literature provided better-quality evidence. Lack of rich data was the main limiting factor relating to the qualitative evidence base.

Other significant limitations in the evidence base include the fact that the vast majority of studies reported only positive findings. This may have been because of researcher bias, in that most of the authors of the reports were art therapists,85 and the method of investigation in a number of studies appears to be biased towards the reporting of positive findings.

There was a lack of evidence comparing art therapy with other treatment options; therefore, we are unable to make comparisons regarding the acceptability of art therapy compared with other potential treatments participants might be offered.

Combining the qualitative and quantitative data proved difficult because of the paucity of the evidence base as a whole and the fact that meta-analysis was not possible. However, coping emerged as an important factor across both reviews, and this is an outcome domain that is likely to be pertinent to people with long-term health conditions. The small evidence base means it is not currently possible to make any generalisations around age, gender or setting.

Form of evaluation

The evaluation to be undertaken is that of a cost–utility analysis in order that the results presented can be compared with interventions in other disease areas and be framed within the cost-effectiveness thresholds [of £20,000–30,000 per quality-adjusted life-year (QALY)] reported by NICE. 86 Ideally, RCTs would report utility measures directly, but where this was not the case mappings from outcome measures reported to a preference-based utility [such as the European Quality of Life-5-dimensions (EQ-5D) health instrument] would be considered, as would using intermediate metrics to arrive at a utility value, such as mapping from outcome A to outcome B, which could be mapped into a preference-based utility.

Comparators

The comparators are limited to those that have been included in a RCT and compared directly with art therapy. This represents a limited selection of possible comparators, as any potential comparators that have been trialled only against a control strategy would not be included. This decision has been taken for three principal reasons: (1) the clinical profile of patients considered for art therapy is heterogeneous and thus any estimated comparisons of effectiveness made indirectly through a common intervention could be highly uncertain; (2) the position of art therapy may vary within packages of care which may affect the observed efficacy; and, most importantly, (3) there are myriad treatments that could be considered which would have resulted in a very large number of records identified in a literature search. The approach taken was supported by the project steering group and resulted in the following potential set of comparators: treatment as usual, wait-list control, CBT, verbal therapy, educational support, guided garden walking, art and craft activities, regular programme activities, simple calculations and video tape on use of art therapy.

Search methods

The comprehensive searches from the quantitative and qualitative reviews of art therapy were designed to capture relevant economic studies. Within these searches, synonyms relating to the condition were combined with a search filter aimed at restricting results to economic and cost-related studies (used in the searches of MEDLINE, CINAHL, EMBASE, and PsycINFO, with an amended version used for Web of Science; see Appendix 2).

Screening and eligibility

All citations generated from the comprehensive searches (see Chapter 2) were reviewed by at least one reviewer (LU or AS) and any studies reporting on costs or economics were flagged as potentially relevant to the project health economic modellers. UK-specific citations were identified and the abstracts of these were sifted to identify any potentially relevant economic evaluations for inclusion in the review. One health economic modeller (AR) independently screened the relevant titles and abstracts. When there was uncertainty in the decision, a second health economic modeller (MS) was consulted and a consensus was obtained through discussion. Owing to the small number of papers identified from the title/abstract sift, a conservative strategy was employed that included papers for appraisal at full text if there were even a small possibility that relevant data could be reported. Full papers of potentially relevant studies were obtained and assessed by one modeller (AR), with discussion with a second modeller (MS) where appropriate. In addition, the studies included in the review of clinical effectiveness were also appraised to identify any potentially relevant economic information. A modified preferred reporting items for systematic reviews and meta-analyses (PRISMA) diagram for the selection process is provided in Figure 10.

FIGURE 10.

Modified PRISMA flow diagram for the systematic review of cost-effectiveness.

Inclusion and exclusion criteria

Studies were selected for inclusion according to predetermined eligibility criteria. Studies were included if they reported the cost-effectiveness of art therapy using the definitions outlined in Chapter 1 of this report. Owing to the dearth of evidence surrounding the cost-effectiveness of art therapy, studies were also included if they investigated the costs incurred and health-related benefits accrued by the use of the art therapy to treat patients with a diagnosed non-psychotic mental health illness and delivered by the NHS.

Studies that evaluated the cost-effectiveness of art therapy combined with any other therapy were excluded, as were studies not published in the English language.

Included studies: economic evaluation

Of the 10,270 total records, 192 records were identified by a systematic reviewer as potentially relevant to the review of cost-effectiveness. Following a further title/abstract sift and subsequent full paper sift by health economic modellers, only one study was considered as relevant that had not been included in the clinical evidence base because it was not a RCT. A table of studies excluded at full text level is provided in Appendix 5 along with the reason for exclusion. Although the identified study is not an economic appraisal, it does investigate the costs incurred and health-related benefits accrued by the use of the art therapy. 87

Applying an economic checklist, such as that by Drummond et al. ,88 was deemed inappropriate. A considerable limitation of this case study is that it reports costs and outcomes over a 6-year period for only a single patient, who had been receiving ‘other forms of psychological treatment for many years’. Six years would be considered an extreme time period for receiving art therapy and it is unlikely that patients in the NHS would receive treatment for this length of time. In addition, although 357 patients were recruited to the full research study, the results for only one participant were reported, with no discussion of the impact of selection bias on the results presented.

In total, the patient received 233 sessions of art therapy, each lasting 1.25 hours, over the 6-year period. It was commented that the patient was receiving additional psychological therapy together with pharmacological treatments at the time she started art therapy, but after 2 years of art therapy these treatments were discontinued. Effectiveness was measured through two metrics, the Clinical Outcomes in Routine Evaluation Outcome Measure89 and the BDI,90 both of which improved throughout the art therapy and were maintained at 3 years’ follow-up.

The total cost of providing art therapy to this patient over the 6-year period was £7915 including salary and trust overheads (assumed to be 2004 figures), which equates to approximately £34 per session or £27 per hour. At the time of the study the authors state that the adult mental health cost per day was £300 for an inpatient and thus the total cost of art therapy was equivalent to approximately 26 days’ hospital admission, although hospital admission data were not reported. In addition, the patient was discharged from psychiatric outpatient therapy and stopped taking antidepressant medication, reducing costs to the health service.

Costs associated with the Monti et al.,61 Thyme et al.47 and Thyme et al.62 randomised controlled trials

Only the costs of art therapy have been included in the analyses. Any effect on other costs, for example that of prescription medication hospitalisations or specialist care, has been excluded, owing to the lack of robust data.

The costs presented are estimated on the assumption that those receiving group art therapy remain in the group until the end of the sessions, even were there to be regular non-attendance. It was assumed that those receiving individual treatment who did not attend still incurred the cost of attendance, as the art therapist would be required to be present. If these assumptions were relaxed, it is anticipated that the cost per patient could decrease, although the impact on effectiveness in group therapy because of a higher ratio of participants to therapists would be unknown.

Evaluation of the robustness of results reported in Monti et al.,61 Thyme et al.47 and Thyme et al.62

An assessment of the clinical methodology used within each of the three RCTs that provide an estimate of utility differences has been undertaken in order to evaluate the robustness of the reported results. All of the three studies had limitations, but the Thyme et al. 47,62 RCTs were shown to have the most potential confounding and uncertainty in the true effect size.

The report by Monti et al. 61 does not offer a discursive description of the working art therapy definition used for the trial, but it contains a table showing the linking of the mindfulness aspects with the art therapy which provides a clear indication of what was being tested.

The comparison between verbal therapies and art therapy reported in Thyme et al. 47 may be problematic. The verbal psychotherapy treatment follows the long-established ideas of Mann104 on brief structured psychotherapy. Mann is clear about structure and about significant aspects of brief therapy. In contrast, the range of art therapy literature cited (Cane,105 Waller and Gilroy,106 Betensky107 and Schaverien108) represent very different approaches to art therapy. One chapter in one of these four books contains some speculative ideas about brief work,106 but brief work is not mentioned in the rest. The differences between the art therapy approaches cited are evident in the apparently unconnected, somewhat prescriptive, tasks the women in the group are asked to undertake. This is in contrast to the relative coherence of Mann’s ideas for brief work,104 which are sometimes used, incidentally, by art therapists. In addition, the results may be confounded by the imbalances between the trial arms in the numbers of patients with borderline personality organisation (BPO), receiving adjunct antidepressants and receiving adjunct body awareness treatment. It was seen that four (22%) participants receiving art therapy had BPO compared with three (14%) receiving verbal therapy. A smaller proportion of participants were using antidepressants in the art therapy group [11% (n = 2)] than in the verbal therapy group [14% (n = 3)]. Potentially of more importance was the fact that 10% (n = 2) of participants in the verbal therapy group also received body awareness treatment, compared with no participants in the art therapy group. These factors raise concerns regarding whether or not the results are confounded, particularly as the sample size in the study is small. However, the authors do state that ‘the results indicated that the variables did not distort the main results of the study. Neither did the interviews that were performed after the psychotherapy and at 3-month follow-up disclose any major changes in the participants’ life that could explain our results.’104

The art therapy intervention in the Thyme et al. 62 RCT appeared more clearly structured and described than the Thyme et al. 47 RCT. It is believed that the structure of the treatment programme (individual and for only five sessions) was because of logistical reasons; however, this may present limitations in the generalisability of the results. It was observed, in contrast to Monti et al. 61 and Thyme et al. ,47 that benefits increased after cessation of treatment. It is unclear whether or not this benefit is related to the shorter duration of treatment. While the Thyme et al. 47 RCT does provide data that can be used in the cost-effectiveness analyses, it is believed that conclusions produced from these should be interpreted with caution.

Primary results

The deterministic results from Monti et al. 61 are shown in Table 36. It is seen that in all cases art therapy had a cost per QALY gained of less than £6000, providing an indication that art therapy is highly cost-effective compared with wait-list control using thresholds of either £20,000 or £30,000 per QALY gained.

Probabilistic results are provided in Table 37. These are very similar to the deterministic results, with the discrepancy caused by Monte Carlo sampling error. The jackknifed mean costs per QALY values had small CIs, indicating that 1000 PSA samples were sufficient. The CEAC for the scenario least favourable to art therapy is provided in Figure 12, with a histogram of the utility gain in this scenario provided in Figure 13.

FIGURE 12.

The cost-effectiveness acceptability curve for the Monti et al. 61 RCT, mapping from Ara and Brazier97 and assuming 52 weeks’ residual benefit and costs per patient from Curtis. 103

FIGURE 13.

A histogram of the utility gain of art therapy compared with wait-list estimated from the Monti et al. 61 RCT, mapping from Ara and Brazier97 and assuming 52 weeks’ residual benefit and costs per patient from Curtis. 103

It is seen that even with the scenario least favourable to art therapy there is a high probability of art therapy being optimal assuming a cost per QALY threshold of £10,000.

It is seen that, in the vast majority of cases, art therapy resulted in a QALY increase, although in one sample (0.1% of all samples) it was estimated that art therapy could have a detrimental effect. This is shown on the far left of the graph and is coloured black. Typically the gain in QALYs was between 0.035 and 0.050.

Exploratory results

Thyme et al.47

The deterministic results from Thyme et al. 47 are shown in Table 39. It is seen that in all cases verbal therapy was estimated to dominate art therapy, in that it is cheaper and more efficacious. However, as will be detailed, there is considerable uncertainty in these results.

TABLE 39 - Deterministic results from Thyme et al.:47 verbal therapy versus art therapy

Dominated means both more expensive and less efficacious.

Duration of residual benefit	Costing source	Using the Ara and Brazier97 mapping			Using the Rowen et al.98 mapping
		Incremental costs (£)	Incremental QALY	Cost per QALY (£)	Incremental costs (£)	Incremental QALY	Cost per QALY (£)
52 weeks	BAAT	–16	0.0666	Dominated	–16	0.0744	Dominated
52 weeks	Curtis	–22	0.0666	Dominated	–22	0.0744	Dominated
104 weeks	BAAT	–16	0.1224	Dominated	–16	0.1367	Dominated
104 weeks	Curtis	–22	0.1224	Dominated	–22	0.1367	Dominated

Probabilistic results are provided in Table 40. These are very similar to the deterministic results. The jackknifed mean costs per QALY values had small CIs indicating 1000 PSA samples were sufficient. Although the mean cost per QALY value looks considerably favourable to verbal therapy in all scenarios the 95% CIs indicate that art therapy may have a cost per QALY gained compared with verbal therapy of less than £300.

TABLE 40 - Probabilistic results from Thyme et al.:47 verbal therapy versus art therapy

Dominated means both more expensive and less efficacious.

These values represent cost per QALY lost and as such these upper bound values indicate art therapy is more cost-effective than verbal therapy.

Duration of residual benefit	Costing source	Using the Ara and Brazier97 mapping			Using the Rowen et al.98 mapping
		Incremental costs (£)	Incremental QALY	Cost per QALY (£)	Incremental costs (£)	Incremental QALY	Cost per QALY (£)
52 weeks	BAAT	–16	0.0675	Dominating (dominating – 183a)	–16	0.0757	Dominating (Dominating – 99a)
52 weeks	Curtis	–22	0.0675	Dominating (dominating – 251a)	–22	0.0757	Dominating (Dominating – 136a)
104 weeks	BAAT	–16	0.1241	Dominating (dominating – 168a)	–16	0.1391	Dominating (Dominating – 91a)
104 weeks	Curtis	–22	0.1241	Dominating (dominating – 230a)	–22	0.1391	Dominating (Dominating – 125a)

The CEAC for the scenario least favourable to verbal therapy is provided in Figure 14, with a histogram of the utility gain in this scenario provided in Figure 15.

FIGURE 14.

The cost-effectiveness acceptability curve for the Thyme et al. 47 RCT, mapping from Ara and Brazier97 and assuming 52 weeks’ residual benefit and costs per patient from Curtis. 103

FIGURE 15.

A histogram of the utility gain of verbal therapy compared with art therapy estimated from the Thyme et al. 47 RCT, mapping from Ara and Brazier97 and assuming 52 weeks’ residual benefit and costs per patient from Curtis. 103

It is seen that there is considerable uncertainty in the optimal decision, with art therapy being optimal in 20% of the PSA evaluations. As there is little difference in the cost of these interventions, this uncertainty is caused solely by uncertainty in which treatment is the most efficacious, as shown in Figure 14. In addition, limitations within the Thyme et al. 62 RCT would increase the uncertainty of the results.

It is seen that there is considerable uncertainty in the results regarding whether art therapy or verbal therapy is more efficacious. The bars coloured black and white indicate where art therapy is estimated to be more efficacious, with those in green indicating where verbal therapy is estimated to be more efficacious. The analyses of uncertainty indicate that further research is required before a definitive statement could be made, and it is commented that the data presented may be confounded (see Chapter 2).

Discussion of the economic evaluation

The primary analyses indicate that art therapy as delivered in the Monti et al. 61 RCT may be highly cost-effective compared with wait-list but the generalisability of this study to patients in England and Wales is unknown, as the population consisted of women with breast cancer and the percentage with a non-psychotic mental health disorder was unknown. Confirmatory studies would be required to establish this definitively. An analysis of the effectiveness, in terms of utility gain that would need to be produced for art therapy as used in England and Wales, to be cost-effective was undertaken. This indicated that the values reported in the 8-week Monti et al. 61 RCT would be associated as a cost-effective intervention even with the costs associated with a year of treatment.

Exploratory analyses using data from Thyme et al. 47 indicate that, when using midpoint values, verbal therapy appears more efficacious than art therapy. However, there is considerable uncertainty in this estimation and a possibility that the results are confounded by concomitant treatments. Further research is required before definitive conclusions can be made on the cost-effectiveness of art therapy against verbal therapy.

The results produced using the data from Thyme et al. 62 change markedly based on the assumptions used. Given this and the potential for the results to be confounded by concomitant treatment, further research is required before any definitive conclusion can be made on the cost-effectiveness of individual art therapy against control.

Limitations

The analyses undertaken have been simplistic, a decision necessitated by the dearth of RCT evidence available; as such any conclusions reached should be treated with a degree of caution. The key RCT on which our conclusions are based recruited women with breast cancer and the generalisability of data from this group to those with non-psychotic mental health disorders is unclear. In addition, results generated from Thyme et al. 47 and Thyme et al. 62 may be confounded. The Thyme et al. RCTs47,62 also required mapping from GSI data from the SCL-90-R to the SF-36, and then from these data to the EQ-5D, compared with a mapping of SF-36 to EQ-5D for Monti et al. 61 The simplistic model did, however, allow key variables that affect the cost-effectiveness ratio to be determined, and it is seen that the assumed length of residual benefit, on which very few data are available, significantly impacts on the estimated QALYs gained.

Search strategy

1. SU.EXACT(‘Art therapy’) OR (ti(art therap* OR art psychotherap*) OR ab(art therap* OR art psychotherap*))

2. ti((meta-anal* OR metaanal* OR quantitativ* review* OR quantitativ* overview OR systematic* review* OR systematic* overview* OR methodologic* review* OR methodologic* overview* OR integrative research review* OR research integration* OR quantitativ* synthes*)) OR ab((meta-anal* OR metaanal* OR quantitativ* review* OR quantitativ* overview OR systematic* review* OR systematic* overview* OR methodologic* review* OR methodologic* overview* OR integrative research review* OR research integration* OR quantitativ* synthes*))

3. 1 AND 2 [to identify reviews]

4. ti(random* OR placebo* OR single blind* OR double blind* OR triple blind* OR randomized OR randomly OR clin* trial*) OR ab(random* OR placebo* OR single blind* OR double blind* OR triple blind* OR randomized OR randomly OR clin* trial*)

5. 1 AND 4 [to identify clinical trials]

6. ti(economic* OR cost* OR fiscal OR funding OR financial OR finance OR pharmacoeconomic* OR price* OR pricing) OR ab(economic* OR cost* OR fiscal OR funding OR financial OR finance OR pharmacoeconomic* OR price* OR pricing)

7. 1 AND 6 [to identify economic evaluations]

8. ti(findings OR interview OR qualitative) OR ab(findings OR interview OR qualitative)

9. 1 AND 8 [to identify qualitative research]

10. 3 OR 5 OR 7 OR 9

11. 1 NOT 10 [to identify other study types]