The Effect Of Art Therapy On Depressive Symptoms In The Elderly

Introduction

A diagnosis of depression involves a loss of interest in usual activities or feelings of sadness accompanied by an array of possible symptoms that must be present for at least two weeks (American Psychiatric Association, 2017). The Centers for Disease Control and Prevention (CDC) (2017) report that depression affects approximately 13. 5% of the elderly who require home healthcare and 11. 5% of elderly hospitalized patients. Depression is not considered a normal part of aging; however, as individuals age, there are certain factors that may increase the risk of developing depression.

According to the World Health Organization (WHO) (2017), there are certain stressors in life that are more common amongst the elderly population, such as a loss of independence, chronic health conditions, bereavement, elder abuse, and functional and mental decline. The WHO (2017) suggests that mental and physical health influence one another. In other words, if an individual has a physical disease, they are more likely to experience depression; and if an individual has untreated or undiagnosed depression with a physical disease it can lead to adverse consequences. Depression in the elderly often leads to poor functioning and can increase healthcare costs (WHO, 2017). With the increasing elderly population and the prevalence of depression, it is likely that the costs associated with it will grow as well (Snow & Abrams, 2016). With depression, there are direct and indirect costs to be considered such as the usage of medical resources and pharmaceuticals, as well as, caregiving, mortality and morbidity costs (Snow & Abrams, 2016). In about 70% of cases, depression continues to be ineffectively treated and underdiagnosed even though it has known medical implications (Bottino, Barcelos-Ferreira, & Ribeiz, 2012).

Although the use of antidepressants is typically considered first-line therapy and is often effective in the treatment of depression in the elderly, there are several factors that need to be considered when using these drugs. As individuals age, multiple biologic changes occur that effect the pharmacodynamics and pharmacokinetics of antidepressants which can result in an abundance of side effects, drug interactions, and inappropriate dosages (Alamo, Lopez-Munoz, Garcia-Garcia, & Garcia-Ramos, 2014). Taylor (2014) highlights that limited safety data exists for the use of antidepressants in the elderly. According to Alamo et al. (2014), recent research indicates that there is an increased mortality risk associated with antidepressants, specifically the use of SSRIs. Along with an increase in mortality, antidepressants may also increase the risk of accidental or intentional overdose in the elderly (Alamo et al. , 2014). Coupland et al. (2011) further support these findings by reporting that antidepressants may be associated with increased mortality, falls, fracture, stroke, suicide and self-harm, and seizures. Thus, alternative approaches to assist in decreasing depressive symptoms in older adults needs explored.

According to the American Art Therapy Association (2013), art therapy involves the use of art and creativity to “explore their feelings, reconcile emotional conflicts, foster self-awareness, manage behavior and addictions, develop social skills, improve reality orientation, reduce anxiety, and increase self-esteem” (p. 1). Noice, Noice, and Kramer (2014) reviewed and reported that recent research in the positive effects of art therapy in the elderly have revealed that it assists in reducing negative emotions, improves self-esteem and self-perceived mental and psychosocial health, and produces a sense of calm, enjoyment, relaxation, and satisfaction. Individuals often have a difficult time discussing their internal feelings or difficulties they may be experiencing; art therapy offers the opportunity to express oneself non-verbally (Blomdahl et al. , 2016). Art therapy not only allows individuals to express their physical symptoms, but also allows them to address their depressive thoughts and feelings (Blomdahl et al. , 2016). In a study conducted by Im and Lee (2014), they found that art therapy resulted in reduced scores in depression in the elderly. Unlike medication management, art therapy does not result in adverse side effects.

Therefore, art therapy has the potential to be a more safe and effective alternative therapy in the treatment of depression in the elderly.

Due to the widespread issue of depression in the elderly and the potential detrimental effects of using antidepressants as treatment, this art therapy research can be utilized in the clinical setting to address this issue more safely and effectively. The Koman and Kimmell Family Medicine practice currently sees patients at three separate nursing facilities. It is a common occurrence that several of these residents are diagnosed with depression and are currently being medically managed. The majority of these patients have several comorbidities they are also being medically managed for along with depression, such as hypertension, hyperlipidemia, and diabetes mellitus.

Although numerous residents are being medically managed for depression, most of them are not offered an alternative to medical management and are not aware of the risks associated with these medications. If alternative treatments for depression such as art therapy were made readily available for the patients to participate in, it would potentially decrease the need for antidepressants and in turn decrease their risk of potential medication side effects, falls, drug interactions, and mortality. The purpose of this quality improvement project is to evaluate if the implementation of art therapy in older adults with depression leads to a decrease in depressive symptoms compared to medication management alone.

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The information described in this paper will investigate the effects of art therapy in older adults with depression. In patients over the age of 60 diagnosed with depression in a nursing home or assisted living facility, does the implementation of art therapy result in reduced post-test scores on the Geriatric Depression Scale compared to those of medication management alone within six months?

Literature Review

A literature review related to art therapy in the treatment for depression was performed using a comprehensive library with access to online peer reviewed journals from Ebsco Host, PubMed, Medline, and Cinahl with additional resources including the World Health Organization, the American Art Association, and the Centers for Disease Control. The terms depression, art therapy, medication management, antidepressants, elderly, and older adults were used in searching for this literature review.

The search was limited to articles between 2010 and 2019; twelve of which were chosen for this literature review.

The articles used in this research all agree that depression is a common condition in the elderly; however, Ciasca et al. (2018) elaborates that although depression is common in the elderly, it is not considered a normal aspect of aging and can have drastic consequences that effect not only their health, but also their quality of life mentally and physically. Antidepressants are often the mainstay of treatment and considered first-line therapy; however, Taylor (2014) and Coupland et al. (2011) agree that these medications are often associated with detrimental side effects in the elderly including an increased risk of falls. Taylor (2014) further explains that drug metabolism declines in the elderly which could account for the increased medication side effects. Alamo et al. (2014) support Taylor (2014) and Coupland et al. (2011) by elaborating on the dangers of using antidepressants in the elderly population, reporting that there are several risks involved when prescribing these medications including a risk of overdose, cardiovascular complications, bleeding, anticholinergic effects, sexual disfunction, fractures, and the most important of all, the increased risk of mortality.

The articles used in this research greatly support the benefits of art therapy for decreasing depressive symptoms in the elderly. Ciasca (2018), Stuckey and Nobel (2010), and Blomdahl et al. (2016) agree that art therapy enables therapeutic expression of thoughts and feelings personally or about a specific situation through non-verbal communication. In turn, this process helps individuals to cope with their situation or surroundings when unable to verbalize their thoughts or feelings. Expanding on the findings from Ciasca (2018), Stuckey and Nobel (2010), and Blomdahl et al. (2016); Gall, Jordan and Stern (2015) explore the concept that art therapy enables to elderly to escape a sense of apathy and hopelessness through self-expression. Art therapy may inspire the elderly to participate in more activities of daily living instead of withdrawing (Gall et al. , 2015). Im and Lee (2014) further support art therapy stating that art therapy allows the elderly to use their hands and creativity which stimulates the central nervous system and as a result, positively effects depression by boosting their ego and allowing the expression of buried feelings. Bitonte and De Santo (2014), also suggest that art therapy is a non-specific practice, meaning it can be tailored to each individual’s needs and be beneficial for several conditions. To elaborate on the benefits art therapy has in elderly individuals, Phinney, Moody, and Small (2014) identified six themes that older adults experienced after engaging in a community arts program.

In accordance with the other studies in support of art therapy, Phinney et al. (2014) found that art therapy facilitated coping, and they also discovered it can provide structure and discipline, promote social involvement, bring out the individual’s artistic side, encourage hard work and effort, and make the individual feel like they are making a contribution. In Blomdahl et al. (2016), the researchers discuss how art therapy can assist in mental illness recovery and improve a sense of self and the ability to deal with life’s daily challenges. This statement is in agreeance with Gall et al. (2015) who state that art therapy provides mental and social stimulation for the elderly, leading to a better quality of life.

Unlike previous studies mentioned, Belkofer, Hecke, and Konopka (2014) offer scientific evidence displaying the benefits of art therapy that are congruent with previous studies. Utilizing an electroencephalogram (EEG), their study evaluated pre and post recordings of participants in a drawing and non-drawing group. In the drawing group, results showed a statistically significant difference in the alpha frequency bands in the left posterior temporal, parietal, and occipital regions compared to the non-drawing groups (Belkofer et al. , 2014).

The researchers go on to explain that alpha frequencies are associated with various positive outcomes such as self-regulation, creativity, intelligence, relaxation, memory, and visual processing which could begin to explain why art therapy is beneficial (Belkofer et al. , 2014).

Even though art therapy has proven to be beneficial, it continues to be underutilized in practice for unknown reasons (Bitonte & De Santo, 2014). Thus, if alternative treatments for depression such as art therapy were made readily available for the patients to participate in, it would potentially decrease the need for antidepressants. Art therapy would not only be beneficial in facilitating a decrease in depressive symptoms, but would also, decrease their risk of potential adverse side effects, falls, drug interactions, and mortality due to antidepressant use.

Implications for Clinical Practice

Depression continues to be a growing issue in the elderly population, and as Taylor (2014) explains, developing depression later in life is accompanied by more complications due to coexisting medical conditions and the risk of polypharmacy. However, if left untreated, depression can not only have its own detrimental effects on the individual, but it is also associated with poorer outcomes for other medical conditions (Taylor, 2014). As discussed, the utilization of medication management as treatment for depression in the elderly is often considered first-line; however, as reviewed, the risks and side effects of these medications may not outweigh the benefits for the elderly population. Therefore, alternative treatments such as art therapy provide a safe and effective strategy to combat depression and improve quality of life in the elderly. The literature review in this quality improvement project highlights several benefits of art therapy including utilizing individualized therapy, facilitating coping, allowing for the expression of feelings, improving self-worth and quality of life, providing mental and social stimulation, and encouraging creativity. As opposed to the use of medication, art therapy does not produce adverse side effects or increase mortality. The literature review has revealed that art therapy only yields positive effects; therefore, it should be considered as a safe and effective alternative in the treatment of depression in the elderly.

Project Design

This proposed project will be a randomized controlled trial utilizing the implementation of art therapy compared to medication management in depressed elderly patients in the nursing home setting. To receive approval for this project, the institutional review board will be presented with the current plan of study. Before the implementation of this quality improvement project, an educational session will take place for the providers, and the nurses and activities director at Sunrise Senior Living of McCandless to provide information regarding the purpose of the study, eligibility of participants, how to complete informed consent, and administer pre and post-tests using the Geriatric Depression Scale. This quality improvement project will involve two subject groups; one participating in art therapy sessions and the other receiving medical management alone. The subject group will be those who are participating in art therapy sessions; and the control group will be those receiving medication.

To participate in the study, the patients will sign an informed consent collected prior to treatment. Patients will be randomly selected by the provider to either be in the art therapy group or medication management group. Patients newly diagnosed with depression will be given a pre-test using the Geriatric Depression Scale (Appendix A) assessing their depressive symptoms. Patients assigned to the art therapy group will be scheduled to participate in art therapy sessions in the form of adult coloring books and free-hand drawing at least three days a week for six months. Patients in the medication management group will take the prescribed medication as recommended by the provider. The nurses of sunrise will be responsible for providing and collecting the Geriatric Depression Scale pre and post-tests to all designated participants, administering medications as prescribed to the medication management group, and ensuring that the art therapy group attend three art therapy sessions a week. The activity coordinator of Sunrise will provide an allotted time in the activities schedule three times a week for art therapy (coloring books, and free-hand drawing). The pre and post-tests will be evaluated and compared by the providing physician. The population for this project will be selected from Sunrise Senior Living of McCandless. Sunrise was chosen to be the implementation site as opposed to the two others due to the long-term residency population. The other two locations experience higher turn-over rates with shorter lengths of stay.

The participants and target population are residents over the age of 60 newly diagnosed with depression. Based on the inclusion criteria of patients over the age of 60 newly diagnosed with depression, the nurses will distribute the Geriatric Depression Scale pre-test. If the patients score severely (20-30) on the Geriatric Depression Scale, they will be excluded from this study due to potential danger of undertreatment. This study will be conducted for six months allowing the treatments for depression to take full effect. If the patients enrolled in the art therapy group display a worsening of depressive symptoms, they will be withdrawn from the study to explore other treatment options to ensure their safety. After implementation for six months, patients will again be evaluated using the Geriatric Depression Scale. The pre and post-test data of the Geriatric Depression Scale will be collected and will be entered into an Excel spread sheet in order to compare results and assess for improvement, as well as, to determine which treatment is more effective. Quality improvement will be reflected if the patients in the art therapy group display a greater decrease in their depressive symptoms compared to the medication management group. If art therapy is successful in significantly decreasing depressive symptoms, this could further assist in raising awareness for alternative treatments for depression in the elderly and promote future research.

Stakeholders

Through the research reviewed, it is clear that providing an alternative option in the form of art therapy for the treatment of depression will involve a multidisciplinary approach. The stakeholders for this project involve the providers, nurses, and activities coordinator; all of which will assist in different aspects of implementing this project. This project will potentially have an impact on how they coordinate future care. Another important stakeholder to consider are the patients who will be actively participating in this quality improvement change and their willingness to adapt and accept alternative treatment. On a greater scale, potential stakeholders would include the health insurance companies that have the potential to save money utilizing art therapy which will promote physical and mental health, as well as, have no adverse side effects, potential complications from polypharmacy, or increased mortality risk all of which could increase heath care costs. Vasiliadis, Latimer, Dionne, and Preville (2013) discuss how depression is associated with increased cost due to an increase in use of healthcare. Results showed that antidepressant use did not result in cost savings overall and that those using antidepressants accrued more costs as opposed to those not using antidepressants (Vasiliadis et al. , 2013). Depressed patients are more likely to utilize health care inappropriately with twenty-five percent of cost of care attributable to depression due to longer hospital stays (Zivin, Wharton, & Rostant, 2013). These findings further support the utilization of alternative methods from a financial aspect as well. As discussed by Bitonte and De Santo (2014), art therapy continues to be underutilized in practice for unknown reasons. This study could increase awareness in the general public and allow for better utilization and more available options in the treatment of depression.

Barriers

There are several potential barriers that could impact this quality improvement project that can be attributed to both the staff and the patients. One potential barrier that could present in this study is the inclusion criteria. Many residents are already diagnosed and are being treated for depression limiting the sample size. The small sample size of older adults used from one location site may limit the generalization of results to a larger population. Also, most of the residents have different comorbidities effecting their quality of life that can not be controlled for in this proposed study. The residents may also be resistant or reluctant to accept an alternative therapy other than medication; or given their comorbidities, they may not always be able to participate in the scheduled art therapy sessions. A major staff-driven barrier in this study is the burden of work that this study entails and the general concern over short-staffing issues and time constraints. When considering provider-based barriers in this study, they may feel pressure either by the residents or their power of attorneys to prescribe medications in the treatment of depression due to a lack of knowledge of alternative therapies. In order to maintain patient satisfaction, the providers may feel the need to comply.

Summary and Conclusion

The findings in the current research discourage the use of or at least recommend using caution when utilizing antidepressants in the treatment of depression in the elderly due to the adverse side effects and risks associated with them. This information can be used in the clinical practice setting to re-evaluate current treatment options available for the treatment of depression in the elderly and offer more safe and effective alternative methods such as art therapy. Dr Kimmell of Koman and Kimmell Family medicine was very supportive and accepting of this quality improvement project and its implementation at Sunrise Senior Living of McCandless. He agrees that the treatment of depression in the elderly with antidepressants can involve great risks and believes this alternative therapy is worth trialing.

Through composing this quality improvement project, I have grown significantly not only personally, but professionally as well. I have learned how to utilize my academic knowledge and education I have gained throughout this program and apply it to all aspects of this quality improvement project. This project has allowed me to explore a topic of interest and become passionate about it through the process. I have learned that I have the diligence and the patience to research and develop a proposed clinical practice change based on a clinical problem I identified.

Most of all, I have learned that I am capable of using my voice to influence others and make a difference in something I believe in. Through hard work and dedication, I can positively affect the lives of others through this project. As healthcare providers, it is our duty to advocate for the best care for our patients based on current evidence-based research. Through this quality improvement project, it is my hope to help provide patients with an effective alternative treatment to depression in order to reduce adverse effects and improve their depressive symptoms.

References

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