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Home / Group Art Therapy as an Adjunctive Treatment for People With Schizophrenia

Group Art Therapy as an Adjunctive Treatment for People With Schizophrenia

  1. Enquiry
  2. Group fine art therapy as...
  3. Grouping art therapy as an adjunctive treatment for people with schizophrenia: multicentre businesslike randomised trial

Research

Group art therapy equally an adjunctive treatment for people with schizophrenia: multicentre pragmatic randomised trial

BMJ 2012; 344 doi: https://doi.org/ten.1136/bmj.e846 (Published 28 February 2012) Cite this as: BMJ 2012;344:e846

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  1. Mike J Crawford , professor in mental health researchone,
  2. Helen Killaspy , reader in rehabilitation psychiatry2,
  3. Thomas R E Barnes , professor of clinical psychiatryi,
  4. Barbara Barrett , lecturer in health economics3,
  5. Sarah Byford , reader in health economicsiii,
  6. Katie Clayton , caput of arts therapiesiv,
  7. John Dinsmore , enquiry associate5,
  8. Siobhan Floyd , research associatevi,
  9. Angela Hoadley , research associatetwo,
  10. Tony Johnson , senior statistician7,
  11. Eleftheria Kalaitzaki , medical statistician8,
  12. Michael Rex , professor of primary care psychiatrytwo,
  13. Baptiste Leurent , medical statistician8,
  14. Anna Maratos , head of arts therapiesnine,
  15. Francis A O'Neill , senior clinical lecturer5,
  16. David P Osborn , senior clinical lecturer2,
  17. Sue Patterson , research associate1,
  18. Tony Soteriou , director of research and development6,
  19. Peter Tyrer , professor of customs psychiatryi,
  20. Diane Waller , honorary professor of art psychotherapyane
  21. on behalf of the MATISSE projection team
  1. iCentre for Mental Health, Department of Medicine, Imperial Higher London, Claybrook Centre, London W6 8LN, UK
  2. twoUnit of Mental Wellness Sciences, Faculty of Encephalon Sciences, Academy College London, London, Britain
  3. 3Centre for the Economics of Mental Health, Wellness Service and Population Inquiry Department, King's College London, London UK
  4. 4Camden and Islington NHS Foundation Trust, London, UK
  5. 5Centre for Public Wellness, Queen'southward University, Belfast, Uk
  6. 6Avon and Wiltshire Mental Health Partnership NHS Trust, Chippenham, UK
  7. viiMRC Biostatistics Unit of measurement, Cambridge, UK, and MRC Clinical Trials Unit of measurement London, Britain
  8. 8MRC General Exercise Enquiry Framework, London, UK
  9. 9Primal and North Westward London NHS Foundation Trust, London, UK
  1. Correspondence to: M J Crawford m.crawford{at}purple.ac.uk
  • Accepted 7 December 2011

Abstract

Objectives To evaluate the clinical effectiveness of grouping art therapy for people with schizophrenia and to exam whether whatever benefits exceed those of an active control treatment.

Pattern Three arm, rater blinded, businesslike, randomised controlled trial.

Setting Secondary intendance services beyond 15 sites in the United kingdom of great britain and northern ireland.

Participants 417 people anile 18 or over, who had a diagnosis of schizophrenia and provided written informed consent to have office in the report.

Interventions Participants, stratified by site, were randomised to 12 months of weekly grouping art therapy plus standard care, 12 months of weekly activity groups plus standard care, or standard care lonely. Art therapy and action groups had upwardly to eight members and lasted for 90 minutes. In art therapy, members were given admission to a range of fine art materials and encouraged to utilize these to express themselves freely. Members of activity groups were offered various activities that did not involve use of art or craft materials and were encouraged to collectively select those they wanted to pursue.

Principal event measures The primary outcomes were global functioning, measured using the global assessment of functioning calibration, and mental wellness symptoms, measured using the positive and negative syndrome calibration, 24 months later randomisation. Principal secondary outcomes were levels of group attendance, social functioning, and satisfaction with intendance at 12 and 24 months.

Results 417 participants were assigned to either fine art therapy (n=140), action groups (northward=140), or standard care alone (north=137). Chief outcomes between the three report artillery did not differ. The adjusted mean difference betwixt art therapy and standard intendance at 24 months on the global assessment of functioning scale was −0.nine (95% confidence interval −three.eight to 2.i), and on the positive and negative syndrome scale was 0.seven (−3.i to 4.half dozen). Secondary outcomes did not differ betwixt those referred to art therapy or those referred to standard intendance at 12 or 24 months.

Conclusions Referring people with established schizophrenia to group fine art therapy as delivered in this trial did non improve global performance, mental health, or other health related outcomes.

Trial registration Current Controlled Trials ISRCTN46150447.

Introduction

Schizophrenia is a severe mental disorder that affects equally many as 1 in 100 people at some point in their lives. In addition to "positive" symptoms such equally hallucinations and delusions, many people too experience varying degrees of loss of free energy and motivation, impaired attention, and other so called negative symptoms.1 Although treatment with antipsychotic drugs reduces the positive symptoms of schizophrenia and decreases the likelihood of relapse, it has little bear upon on negative symptoms.two 3 Psychological and social interventions are widely used in combination with drugs in an effort to farther improve the wellness and social outcomes of people with schizophrenia, and several interventions take been shown to be effective.4

The possibility that involvement in creative activities tin can amend health has frequently been discussed but rarely examined.five Information technology has been argued that for people with severe mental disorders such equally schizophrenia, art therapy has advantages over other treatments considering the utilize of art materials tin can help people to understand themselves improve while containing powerful feelings that might otherwise overwhelm them.6 Few attempts have been made to examine the effectiveness of group fine art therapy as an adjunctive handling for people with schizophrenia,7 merely the results of a pilot trial suggested that information technology may help bring nigh clinically important reductions in negative symptoms of schizophrenia.8 Findings of this study, together with those of trials of other creative therapies, take resulted in the inclusion of arts therapies in national treatment guidelines, which recommend that clinicians consider referring all people with schizophrenia for arts therapies, specially for the alleviation of negative symptoms of the disorder.three

We examined the impact of adding group art therapy to the treatment of people with schizophrenia compared with both agile control treatment and standard care lonely on global operation and symptoms of schizophrenia.

Methods

The MATISSE (Multicenter study of Art Therapy In Schizophrenia: Systematic Evaluation) written report was a rater blinded, parallel group, randomised controlled trial of either group art therapy plus standard care, activity groups plus standard care, or standard care alone.9 We carried out a parallel economic evaluation (reported elsewhere) and a process evaluation, which examined the organisation and delivery of treatment in the study and the relation between handling process and treatment outcomes.

Participants

Study participants were recruited from community based mental health and social care services in four centres in England and Northern Ireland. We also considered inpatients, only eligible participants were non randomised until later on discharge from inpatient care. Participants were aged eighteen years or over and had a clinical diagnosis of schizophrenia, confirmed by an examination of instance notes using operationalised criteria.10 To take role in the written report, potential participants had to exist willing to take role in group therapy and to provide written informed consent. We excluded those with astringent cerebral impairment, those who were unable to speak sufficient English to complete the baseline assessment, and those already receiving art or some other creative therapy. Health and social care professionals working on inpatient units or in customs teams, twenty-four hours centres, and rehabilitation and residential units identified potential participants. Researchers and clinical studies officers of the UK Mental Health Inquiry Network met those who had given verbal consent to be approached about the study, assessed eligibility, provided written and verbal information, and obtained written informed consent.

Randomisation and masking

Post-obit completion of baseline assessments, participants were randomised through an independent and remote phone randomisation service provided by the Aberdeen Clinical Trials Unit. We used permuted blocks, stratified past site. Cake size was randomly assigned between three and six. Participants and clinical staff were aware of the trial arm to which the study participants were allocated only all interviews were done by researchers blinded to resource allotment status. Researchers were asked to guess what arm participants had been randomised to after the concluding follow-up interview had been completed.

Interventions

Those randomised to group art therapy were offered weekly sessions of 90 minutes' elapsing for an boilerplate of 12 months. Art therapy was carried out in keeping with recommendations of the British Association of Art Therapists11 and aimed to enhance self expression, improve emotional wellness, and help people develop better interpersonal functioning. Patients were given access to a range of art materials and encouraged to apply these to express themselves freely. Fine art therapists generally adopted a supportive approach, offering empathy and encouragement. They rarely provided psychotherapeutic interpretations of interpersonal process or images. They did, however, often discuss these processes in supervision. Within this framework, therapists employed specific therapeutic interventions considered appropriate to private needs and circumstances. This approach is in keeping with recommendations for the pragmatic evaluation of complex interventions in which individual therapists are encouraged to employ treatment principles flexibly to fit with the needs of participants.12

Activity groups likewise took identify on a weekly basis and were made available to participants for an average of 12 months. Facilitators of these groups encouraged participants to agree activities collectively; these included playing board games, watching and discussing DVDs, and visiting local cafes. The use of fine art materials was prohibited. Group facilitators were asked to refrain from exploring the thoughts and feelings of study participants or offering psychotherapeutic interventions.

All art therapy and activity groups were cofacilitated past a fellow member of staff or volunteer who received training in the trial and intervention. During the handling stage of the trial, art therapists and activeness group facilitators received monthly group supervision from a senior practitioner with relevant expertise. Recordings of each supervision session were reviewed by a senior member of the written report squad who provided feedback to supervisors well-nigh adherence to agreed guidelines for the delivery of respective interventions. Standard care involved follow-upward from secondary care mental health services, intendance coordination, pharmacotherapy, and the option of referral to other services equally clinically indicated, except other creative therapies, which participants agreed non to undertake until completion of follow-up.

Result measures

The primary outcomes for the study were global functioning (measured using the global cess of operation scale)13 and symptoms of schizophrenia (measured using the positive and negative syndrome scale) assessed at 24 months.xiv Secondary outcomes were global operation and mental wellness symptoms measured at 12 months as well as levels of grouping attendance, social functioning (measured using the social function questionnaire),15 adherence with prescribed drugs (measured using the Morisky scale),16 satisfaction with care (measured using the customer satisfaction questionnaire),17 mental wellbeing (measured using the full general wellbeing scale),xviii and health related quality of life (measured using the five item EQ-5D)19 assessed at 12 and 24 months afterwards randomisation.xx

Statistical assay

The sample size was based on detecting a minimal clinically significant departure of half dozen (SD ten) points on the global assessment of performance scale at 24 months, between those randomised to art therapy and those randomised to active control or standard care solitary. Taking into account an inflation cistron for therapist clustering of 2.22 (based on eight participants or therapists and an intraclass correlation coefficient of 0.175) and a 20% loss to follow-upward, nosotros aimed to recruit 376 participants. All chief statistical analyses were done using the intention to treat principle. We imputed missing baseline data using regression or mean imputation. Follow-upwards information were not imputed. Differences in mean score betwixt those randomised to each of the three trial arms were examined using analysis of covariance adjusting for baseline value of the outcome, site, sexual activity, and age. All secondary outcomes (positive and negative syndrome calibration and global assessment of functioning score at 12 months, and positive and negative syndrome scale; negative, positive, and general symptoms subscales; social function; wellbeing; drugs; and satisfaction with services at 12 and 24 months) were analysed in a similar mode. Nosotros written report whatever significant findings. To take into business relationship the clustered structure of the data we fitted dissimilar mixed effects models equally sensitivity analyses, including a two level heteroscedastic model allowing the within site variance to differ beyond arms, and a 3 level model, with study eye equally level 3 and site as level 2.21

In some other secondary analysis we examined the bear upon of the uptake of the interventions on our principal outcomes using two phase least squares estimates.22 This assay is based on instrumental variable methods and avoids the selection bias of per protocol or as treated analysis. The arroyo assumes that the event of allocation to treatment has no effect on the outcome if the patient does not receive the treatment. As at that place are no information to suggest that there is a minimum number of sessions of art therapy that someone needs to attend to derive do good from this intervention, we used this approach to estimate the benefit per session, assuming it is proportional to the number of sessions attended, when adjusted for site, sex activity, and historic period. All P values were two sided and considered significant when less than 0.05.

Results

In total, 649 people were assessed for the written report over a 19 month period between Feb 2007 and August 2008. Of these, 417 (64%) were randomised, 361 (87%) were followed upwardly at 12 months, and 355 (85%) were followed upward at 24 months. The figure⇓ presents the reasons for not-participation and attrition. Table 1⇓ shows the baseline characteristics of the participants. Study participants had a mean age of 41 and a mean duration of illness of 17 years. All but 15 (iv%) were being prescribed antipsychotic drugs, and 134 (32%) had had a period of inpatient psychiatric handling in the 12 months earlier randomisation. The attrition rate was similar across artillery, and reasons for attrition did not differ (decease, withdrawal, lost to follow-up). Of the seven deaths, four were from suicide or likely suicide. Three additional serious agin events were reported, 1 a nigh fatal episode of deliberate self harm and ii involving harm to others. None seemed to exist related to the interventions beingness examined in the study.

Table 1

 Personal characteristics of participants at baseline. Values are numbers (percentages) unless stated otherwise

Participants who completed follow-upwardly had baseline characteristics like to those who did non, but attrition rates varied by report eye. When researchers attempted to guess allocation status afterward the terminal follow-up interview, about half of the guesses were correct (north=119, 48%).

Those allocated to art therapy attended between 0 and 51 groups, and those allocated to control groups attended betwixt 0 and 45 groups. Eighty six (61%) of those randomised to art therapy and 73 (52%) randomised to activity control groups attended at to the lowest degree i group. Among those who attended one or more groups, median levels of attendance were higher amid those randomised to group art therapy (xi for fine art therapy versus five for activity groups, P=0.04). The median delay between randomisation and someone attending his or her first group was 61 days for both fine art therapy and activity groups. The content of audio recordings showed that supervision sessions of both art therapy and activity groups were delivered in a consistent style across study centres.

Table 2⇓ presents the baseline and follow-up issue scores by trial arm. During the 2 yr follow-up menses, the number of full symptoms of schizophrenia decreased. No differences in primary outcomes were found betwixt trial arms. The adjusted mean difference between those randomised to art therapy and those randomised to standard intendance alone on the global assessment of functioning calibration was −0.nine (95% confidence interval −3.eight to 2.i, P=0.57) and on the positive and negative syndrome calibration was 0.7 (−3.i to 4.vi, P=0.71). The adjusted mean difference betwixt those randomised to fine art therapy and those randomised to activity groups on the global assessment of functioning scale was −1.1 (−4.0 to 1.eight, P=0.47) and on the positive and negative syndrome calibration was three.1 (−0.7 to 6.9, P=0.11). Global cess of performance scores at 24 months showed little clustering across study sites (intraclass correlation coefficient 0.06), simply variance between sites in scores on the positive and negative syndrome scale was important (intraclass correlation coefficient 0.47). None of the mixed models that were fitted to take into business relationship the amassed construction of the data showed significant differences in the primary outcome between groups.

Table 2

 Main and secondary outcomes at baseline and 12 and 24 months. Values are means (SDs)

Wellbeing, satisfaction with intendance, or other secondary outcomes at 12 and 24 months did not differ significantly, except that those referred to an activeness group had fewer positive symptoms of schizophrenia at 12 and 24 months compared with those randomised to group art therapy (adapted mean difference one.four, 95% confidence interval 0.1 to 2.6, P=0.03).

Analysis of instrumental variables indicated that omnipresence at fine art therapy groups was non associated with improvements in global functioning or in symptoms of schizophrenia (table 3⇓).

Tabular array 3

 Instrumental variables analysis at 24 calendar month follow-up, adjusted for site, sex, and age

Discussion

In this randomised trial the mental health and global functioning of people with schizophrenia was non improved by offering a place in a weekly art therapy group in addition to their standard care. Those randomised to weekly group art therapy had similar levels of global functioning and mental health as those randomised to an action control group over a 2 twelvemonth period, except that the activity control grouping had a greater reduction in positive symptoms of schizophrenia at 24 months. People offered a place in an fine art therapy group were more likely to nourish sessions than those offered a place in an activity group, just levels of omnipresence at both types of group were low.

Strengths and weaknesses of the report

The master strengths of the study are that it was adequately powered, used a rigorous approach to minimising bias, and used broad inclusion criteria to appraise whether the intervention could help nigh people with schizophrenia. Data from a national survey of art therapists working throughout England and carried out in parallel with this trial suggested that the approach used to deliver art therapy in the study is the same as that used more widely across the country.23 The study was not, nevertheless, without its limitations, chief among these existence the level of engagement with the intervention. We deliberately set up out to test the effectiveness of grouping art therapy among almost people with schizophrenia who expressed a willingness to use this form of handling. Almost 40% of participants randomised to grouping art therapy did not nourish whatever sessions. Among those who did, few attended regularly. Possible explanations for the low level of attendance are that the interventions may not have been acceptable to participants or that participants lacked the motivation and organisational skills to attend.24 However, the average effect of attendance at art therapy among the compliant population was estimated in a two stage to the lowest degree squares interpretation, which suggested that even in those willing to participate in fine art therapy, attendance was not related to study outcomes.

Many groups had only i or two regular attendees, with an average of two or three people attending art therapy groups. Although this meant that therapists may have been able to pay greater attention to each participant than would have been possible in a larger group, opportunities for group members to collaborate with each other were more express.25

We did not collect consequence data during the intervention stage of the study, potentially precluding observation of brusk term benefits. However, the absence of statistically or clinically significant differences in outcomes between participants in the three intervention artillery at 12 months suggests that even if short term benefits did occur, these prodigal within a yr. Previous accounts of the potential benefits of group fine art therapy suggest that it may aid people in ways that are hard to quantify.25 We do not know whether fine art therapy resulted in other outcomes that are valued by service users but were not measured in this trial. Nevertheless, our study did not corroborate the findings of other small smaller scale trials of creative therapies that take shown improvements in symptoms of schizophrenia.26

Comparison with other studies

Levels of omnipresence at group art therapy were also low in the two previous community based randomised trials of group art therapy. In the outset ever clinical trial of art therapy, the researchers studied 47 people with chronic mental disease of whom half had a diagnosis of schizophrenia.27 Detailed information about levels of attendance were not provided just the authors state that amidst nineteen people who were followed upwardly, eight (42%) attended fewer than three sessions of art therapy. The authors compared outcomes between patients who completed 10 groups with those who did not and plant that the completers had higher levels of self esteem.

In a subsequent trial, the researchers examined the furnishings of adding upwardly to 12 sessions of weekly grouping art therapy to the standard intendance of people with schizophrenia.viii Among those offered a place in an art therapy group, mean attendance was 3.5 sessions, and 37% attended no sessions at all. Fewer than one-half of all participants were followed upwardly at six months, just among those who were followed up a statistically significant reduction in negative symptoms was found. It is unclear whether the researchers who carried out follow-up assessments in these trials were masked to the allocation status of participants.

Conclusions and futurity research

These findings challenge current national treatment guidelines that clinicians should consider referring all people with schizophrenia for arts therapies.3 Although we cannot dominion out the possibility that group art therapy benefits people with schizophrenia who are motivated to employ this treatment, our findings suggest that it does not lead to improved patient outcomes when offered to virtually people with this disorder.

Levels of attendance at art therapy may be higher when people are receiving inpatient treatment,28 and the impact of art therapy delivered in this setting should be studied.

Results of randomised trials of other creative therapies for people with schizophrenia, such as music therapy and body movement therapy, are more promising.29 xxx These interventions combine creativity with other approaches specifically aimed at providing an enjoyable experience, stimulating physical movement, and increasing interactions with others. Although information technology has been argued that interest in artistic activities is inherently skillful for mental health, it may be that for people with severe mental illnesses such equally schizophrenia it is only when such activities are used in combination with other interventions that benefits are seen.

What is already known on this topic

  • Although drugs can reduce the symptoms of schizophrenia, many people still experience poor mental health and social operation

  • Group art therapy has been used as adjunctive handling for people with schizophrenia, just few studies have examined its clinical effects

What this report adds

  • Group art therapy, as delivered in this trial, did not improve global functioning or health outcomes of people with schizophrenia

  • Levels of omnipresence at both art therapy and activity groups were low

  • Although grouping fine art therapy may do good a few highly motivated people, evidence of improved patient outcomes for nearly people with schizophrenia was lacking

Notes

Cite this as: BMJ 2012;344:e846

Footnotes

  • We thank Sakina Hossany, Aimee Ayton, and Martin Keats for helping to coordinate the report and enter and manage report data; the Mental Health Inquiry Network for supporting the recruitment and follow-up of participants; and patients and staff who took part in the study. A more detailed account of the report methods and findings will exist published in total in Health Technology Assessment in 2012.

  • Contributors: MJC, HK, and DW are coprincipal investigators of the MATISSE trial, had full admission to all of the data in the study, and take responsibility for the integrity of the data and the accuracy of the data analysis. EK designed the statistical assay plan with guidance provided by TJ. Consequence data were analysed by BL with guidance from TJ. DW, KC, and AM provided clinical expertise on arts therapies. DPO led the training of activity grouping facilitators. The principal investigators at each centre were MJC, HK, TS, and FAO'Due north. SP, AH, SF, and JD recruited and followed up participants. MK, BB, SB, TREB, and PT provided expertise in trial methods, including input to the planning of the study and the information assay program. All report authors contributed to the grooming of this report. MJC is the guarantor.

  • Funding: The project was funded by the National Institute for Health Enquiry Health Technology Assessment program (projection No 04/39/04) and received financial support from Avon and Wiltshire Mental Health Partnership NHS Trust, Belfast Health and Social Care Trust, Camden and Islington NHS Foundation Trust, and Central and North West London NHS Foundation Trust. The sponsors of the written report played no part in the preparation of this paper. The views and opinions expressed therein are those of the authors and do non necessarily reflect those of the Health Applied science Cess programme, the National Institute for Health Research, or the Department of Wellness.

  • Competing interests: All authors have completed the ICMJE compatible disclosure course at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with whatsoever organisations that might accept an interest in the submitted work in the previous three years; DW, AM, and MJC are executive members of a non-profit system (the International Eye for Research in Arts Therapies) that aims to promote enquiry and evolution of arts therapies in wellness and social care.

  • Upstanding approval: This study was approved by the Huntingdon research ideals committee (06/Q0104/82).

  • Data sharing: No boosted data available.

This is an open up-access commodity distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits utilize, distribution, and reproduction in whatsoever medium, provided the original piece of work is properly cited, the use is non commercial and is otherwise in compliance with the license. Encounter: http://creativecommons.org/licenses/by-nc/two.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

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Source: https://www.bmj.com/content/344/bmj.e846