CD003728

Cochrane
Library
Cochrane Database of Systematic Reviews
Art therapy for schizophrenia or schizophrenia-like illnesses

(Review)
Ruddy R, Milnes D
Ruddy R, Milnes D.
Art therapy for schizophrenia or schizophrenia-like illnesses.
Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD003728.
DOI: 10.1002/14651858.CD003728.pub2.
www.cochranelibrary.com
Art therapy for schizophrenia or schizophrenia-like illnesses (Review)

Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.
Library Better health. Cochrane Database of Systematic Reviews
TABLE OF CONTENTS
HEADER......................................................................................................................................................................................................... 1
ABSTRACT..................................................................................................................................................................................................... 1
PLAIN LANGUAGE SUMMARY....................................................................................................................................................................... 2
BACKGROUND.............................................................................................................................................................................................. 3
OBJECTIVES.................................................................................................................................................................................................. 3
METHODS..................................................................................................................................................................................................... 3
RESULTS........................................................................................................................................................................................................ 7
DISCUSSION.................................................................................................................................................................................................. 10
AUTHORS' CONCLUSIONS........................................................................................................................................................................... 11
ACKNOWLEDGEMENTS................................................................................................................................................................................ 11
REFERENCES................................................................................................................................................................................................ 12
CHARACTERISTICS OF STUDIES.................................................................................................................................................................. 14
DATA AND ANALYSES.................................................................................................................................................................................... 17
Analysis 1.1. Comparison 1 ART THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 1 Leaving the study early - short 18
term........................................................................................................................................................................................................
Analysis 1.2. Comparison 1 ART THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 2 Leaving the study early - 19
medium term.........................................................................................................................................................................................
Analysis 1.3. Comparison 1 ART THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 3 Leaving the study early - long 19
term........................................................................................................................................................................................................
Analysis 1.4. Comparison 1 ART THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 4 Mental state: 1a. Average score 20
- short term (endpoint data, SANS, high = poor)................................................................................................................................
Analysis 1.5. Comparison 1 ART THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 5 Mental state: 1b. Average score 20
- short term (endpoint skewed data, various scales, high = poor)....................................................................................................
Analysis 1.6. Comparison 1 ART THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 6 Social functioning: 1a. Average 20
score - short term (endpoint data, SFS, high = poor).........................................................................................................................
Analysis 1.7. Comparison 1 ART THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 7 Social functioning: 1b. Average 21
score - short term (endpoint skewed data, IIP, high = good).............................................................................................................
Analysis 1.8. Comparison 1 ART THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 8 Quality of life: Average score 21
- short term (endpoint data, PercQoL, high = good)..........................................................................................................................
WHAT'S NEW................................................................................................................................................................................................. 21
HISTORY........................................................................................................................................................................................................ 21
CONTRIBUTIONS OF AUTHORS................................................................................................................................................................... 21
DECLARATIONS OF INTEREST..................................................................................................................................................................... 22
SOURCES OF SUPPORT............................................................................................................................................................................... 22
INDEX TERMS............................................................................................................................................................................................... 22
Art therapy for schizophrenia or schizophrenia-like illnesses (Review) i

Informed decisions.
[Intervention Review]
Rachel Ruddy1, David Milnes2
1Academic Unit of Psychiatry & Behavioural Sciences, University of Leeds, Leeds, UK. 2Acomb Medical Centre, York, UK
Contact address: Rachel Ruddy, Academic Unit of Psychiatry & Behavioural Sciences, University of Leeds, 15 Hyde Terrace, Leeds, LS2
9LT, UK. R.A.Ruddy@leeds.ac.uk.
Editorial group: Cochrane Schizophrenia Group.

Publication status and date: Edited (no change to conclusions), published in Issue 1, 2010.
Citation: Ruddy R, Milnes D. Art therapy for schizophrenia or schizophrenia-like illnesses. Cochrane Database of Systematic Reviews
2005, Issue 4. Art. No.: CD003728. DOI: 10.1002/14651858.CD003728.pub2.
ABSTRACT
Background
Many people with schizophrenia or schizophrenia-like illnesses continue to experience symptoms in spite of medication. In addition to
medication, creative therapies, such as art therapy, may be helpful. Art therapy allows exploration of the patient's inner world in a non-
threatening way through a therapeutic relationship and the use of art materials. It was mainly developed in adult psychiatric inpatient
units and was designed for use with people for whom verbal psychotherapy would be impossible.
Objectives
To review the effects of art therapy as an adjunctive treatment for schizophrenia compared with standard care and other psychosocial
interventions.
Search methods
We updated the search of the Cochrane Schizophrenia Group's Register (February 2005), hand searched reference lists and 'Inscape' (the
Journal of the British Association of Art Therapists), and contacted relevant authors.
Selection criteria
We included all randomised controlled trials that compared art therapy with standard care or other psychosocial interventions for
schizophrenia.
Data collection and analysis

We reliably selected, quality assessed and extracted data from the studies. We excluded data where more than 50% of participants in any
group were lost to follow up. For continuous outcomes we calculated a weighted mean difference and its 95% confidence interval. For
binary outcomes we calculated a fixed effects risk ratio (RR), its 95% confidence interval (CI) and a number needed to treat (NNT).
Main results
The search identified 61 reports but only two studies (total n=137) met the inclusion criteria. Both compared art therapy plus standard
care with standard care alone. More people completed the therapy if allocated to the art therapy group compared with standard care in
the short (n=90, 1 RCT, RR 0.97 CI 0.41 to 2.29), medium (n=47, 1 RCT, RR 0.34 CI 0.15 to 0.80) and long term (n=47, 1 RCT, RR 0.96 CI 0.57 to
1.60). Data from one mental state measure (SANS) showed a small but significant difference favouring the art-therapy group (n=73, 1 RCT,
WMD -2.3 CI -4.10 to -0.5). In the short term, a measure of social functioning (SFS) showed no clear difference between groups in endpoint
scores (n=70, 1 RCT, WMD 7.20 CI -2.53 to 16.93) and quality of life, as measured by the PerQoL, did not indicate effects of art therapy (n=74,
1 RCT, WMD 0.1 CI -2.7 to 0.47).
Art therapy for schizophrenia or schizophrenia-like illnesses (Review) 1

Informed decisions.
Authors' conclusions
Randomised studies are possible in this field. Further evaluation of the use of art therapy for serious mental illnesses is needed as its
benefits or harms remain unclear.
PLAIN LANGUAGE SUMMARY
Most people with schizophrenia or schizophrenia-like illnesses will be treated with medication, although on average, 5-15% will continue
to experience symptoms in spite of this. This review explores whether art therapy, one of a number of creative therapies, could be beneficial
when used in addition to medication. The British Association of Art Therapists definition of Art Therapy is "the use of art materials for
self-expression and reflection in the presence of a trained art therapist. Clients who are referred to art therapy need not have previous
experience or skill in art, the art therapist is not primarily concerned with making an aesthetic or diagnostic assessment of the client's
image. The overall aim of its practitioners is to enable a client to effect change and growth on a personal level through the use of art
materials in a safe and facilitating environment." It has proved to be difficult to estimate how widely this intervention is available. However,
there are descriptions of its use with people with schizophrenia, individually and in groups, in inpatient and outpatient settings as well
as in the private sector.
Unfortunately we only found two randomised controlled trials that studied the use of art therapy for people with schizophrenia. Both
studies did not include enough participants to make the results meaningful and we were unable to draw clear conclusions regarding the
benefits or harms of art therapy from these studies. More research is needed to determine the value of art therapy in this population.

Informed decisions.
BACKGROUND the maker' (Sarra 1998). This can help to affirm a sense of self,
which may be unclear in schizophrenia and which can be further
Schizophrenia is a mental illness and is described as a disorder with threatened within an institutional setting (Sarra 1998).
fundamental, characteristic distortions of thinking and perception,
and inappropriate or blunted affect in clear consciousness (WHO It has proved difficult to estimate how widely available this
1992). The characteristic distortions of thinking and perception intervention is. However there are descriptions of its use in people
fundamentally relate to a sense of invasion of self. A person with schizophrenia, individually and in groups, in inpatient and
with schizophrenia may experience difficulties in distinguishing outpatient settings and in the private sector. A current issue for
between self and non-self; this is called a loss of ego boundaries. art therapists is how to translate the work that used to be done
One of the other distortions of thinking is called 'concrete thinking' with acutely psychotic patients in the supportive environment of a
and refers to literalness of expression and understanding. Another hospital with studio art spaces, to an outpatient setting with often
way of describing this is the absence of symbol formation (Sims less ideal art space, in line with the move away from hospital based
1995). treatment to care in the community (Wood 1997).
Medication is the mainstay of treatment for schizophrenia. There has been a number of promising single case reports of using
However, 5-15% of people continue to experience symptoms in art therapy with schizophrenia (Waller 1992) but this review aims to
spite of medication and may also develop undesirable adverse look for higher quality evidence of its effects.
effects (Johnstone 1998). Art therapy is one of the creative therapies
that can be used in addition to medication for helping people with Technical background
schizophrenia. Art therapy in Britain developed primarily within There is ongoing discussion about whether the healing aspect of art
adult inpatient psychiatric units, it is therefore one of the only forms therapy is the process of making art, the relationship that develops
of therapy designed to cater for the needs of more disturbed people between the therapist and the patient, or most likely, a complex
in the inpatient setting. Art therapy is also unique in the way that intervention of the two (Edwards 2004). One of the rationales for the
art materials are utilised to make a link with and engage severely use of art therapy in schizophrenia is that it addresses the problems
disturbed people in psychodynamic therapy (Deco 1998). with ego boundaries and symbol formation (described above).
Killick identified three 'fields of communication' within the art
Lyddiatt describes the use of art as a means of forging a link therapy relationship that are important when working with people
with the self that we know little about being "an age old means with schizophrenia (Killick 1995). These are the 'intrapersonal',
that is natural to man" (Thomson 1989). In the 1940s and 1950s, the 'intermediary' and the 'interpersonal' communications. These
one theory of art therapy was that the art itself was a healing fields of communication exist in relation to one another and
process or an occupation, and patients made images in large studio exert continuous influence on one another. The 'intrapersonal'
environments (Gilroy 1995). Another view originated from the work field is the potential for image making and is maintained for the
of Freud and viewed art as a method of accessing the unconscious, patient by the therapist. Within this the patient develops a unique
similar to dream interpretation. An important strand of thinking interaction with the art materials that can result in healing symbol
that has also influenced the theory and practice of art therapy is formation (Killick 1995). Kandinsky describes symbol formation
that embodied in the Withymead Centre, a therapeutic community aptly in relation to colour in his book 'Concerning the Spiritual in
founded in 1942 in the UK. This centre ran on Jungian principles. Art'; 'light blue is like a flute, a darker blue a cello, and the darkest
Art making formed the core of the treatment with the art therapist blue of all: an organ' (Kandinsky 1955). The 'intermediary' field
acting like a midwife, allowing the art 'to be born' (Edwards relates to 'transitional' phenomena described by Winnicott. This
2004). The current practice of art therapy uses theory from a intermediary field creates scope for play where the patient can
variety of psychoanalytic schools. There are a number of different experiment with objects in symbolic activity and learn that they do
definitions of art therapy from different national organisations not have concrete effects on themselves or the therapist. Finally,
but the underlying fundamental principle is the same for all of the 'interpersonal' field is the relationship between patient and
them, basically that the process of art making should take place therapist which includes the images. The folder, which contains the
within a patient therapist relationship. The British Association images or the absence of images, is important in keeping a link
of Art Therapists definition is "art therapy is the use of art between patient and therapist (Killick 1995).
materials for self-expression and reflection in the presence of a
trained art therapist. Clients who are referred to art therapy need OBJECTIVES
not have previous experience or skill in art, the art therapist is
To review the clinical effects of art therapy on people with
not primarily concerned with making an aesthetic or diagnostic
schizophrenia or schizophrenia-like illnesses who are concurrently
assessment of the client's image. The overall aim of its practitioners
receiving standard care compared with no additional intervention
is to enable a client to effect change and growth on a personal
to standard care or other additional psychosocial interventions to
level through the use of art materials in a safe and facilitating
standard care.
environment." (Edwards 2004). Wood gives a detailed description
of the history of the use of art therapy for schizophrenia in the
METHODS
book 'Art, Psychotherapy and Psychosis' (Wood 1997). Art therapy
is considered to be more suitable for people with schizophrenia Criteria for considering studies for this review
than some other forms of exploratory psychotherapy because the
art work offers a buffer to reduce the intensity in the relationship Types of studies
between the therapist and patient. Through an image an individual
We included all relevant randomised controlled trials. Where a
can communicate 'both the rational and the irrational and find an
trial was described as 'double-blind' but it was implied that the
acceptance interpersonally that need not threaten the integrity of
study was randomised we included these trials in a sensitivity
Informed decisions.
analysis. If there was no substantive difference within primary Secondary outcomes

outcomes (see types of outcome measures) when we added these
1. Death - suicide and natural causes
'implied randomisation' studies, then we included them in the
final analysis. If there was a substantive difference we only used 2. Global state
clearly randomised trials and described the results of the sensitivity 2.1 Time to relapse
analysis in the text. We excluded quasi-randomised studies, such as 2.2 No clinically important change in global state
those allocating by alternate days of the week. We included group 2.3 Average endpoint global state score
randomised studies. 2.4 Average change in global state scores
Types of participants 3. Service outcomes
We included trials where it was implied that the majority of people 3.1 Hospitalisation
had a severe mental illness which was likely to be schizophrenia or 3.2 Time to hospitalisation
a schizophrenia-like illness using any criteria. We did not exclude
4. Mental state
trials due to age, nationality or gender of participants. We included
4.1 Average endpoint general mental state score
trials with participants with any length of illness who were being
4.2 Average change in general mental state scores
treated in any treatment setting.
4.3 No clinically important change in specific symptoms
Types of interventions 4.4 Average endpoint specific symptom score
4.5 Average change in specific symptom scores
1. Art therapy (in groups or individually), for any length of time,
as an adjunctive treatment for schizophrenia or schizophrenia - 5. Leaving the study early
like illnesses, regardless of the other interventions being used 5.1 For specific reasons
(eg medication, hospitalisation, problem solving therapy, psycho- 5.2 For general reasons
education, social skills training, cognitive-behavioural therapy,
family therapy or psychodynamic psychotherapy). We used The 6. General functioning
British Association of Art Therapists definition of art therapy as 6.1 No clinically important change in general functioning
a gold standard for inclusion. Their definition is as follows: "Art 6.2 Average endpoint general functioning score
Therapy is the use of art materials for self-expression and reflection 6.3 Average change in general functioning scores
in the presence of a trained art therapist. Clients who are referred 6.4 No clinically important change in specific aspects of
to art therapy need not have previous experience or skill in art, the functioning, such as social or life skills
art therapist is not primarily concerned with making an aesthetic 6.5 Average endpoint specific aspects of functioning, such as social
or diagnostic assessment of the client's image. The overall aim of or life skills
its practitioners is to enable a client to effect change and growth 6.6 Average change in specific aspects of functioning, such as social
on a personal level through the use of art materials in a safe or life skills
and facilitating environment." (Edwards 2004). We excluded art
produced by none art therapists with patients for recreational, 7. Behaviour
diagnostic or therapeutic purposes because it did not have the key 7.1 No clinically important change in general behaviour
factors needed to define it as art therapy according to the above 7.2 Average endpoint general behaviour score
definition. 7.3 Average change in general behaviour scores
7.4 No clinically important change in specific aspects of behaviour
2. Standard care 7.5 Average endpoint specific aspects of behaviour
This is the care that a person would normally receive had they not 7.6 Average change in specific aspects of behaviour
been included in the research trial. This includes interventions such
as medication, hospitalisation, community psychiatric nursing 8. Adverse effects
input and day hospital. 8.1 No clinically important general adverse effects
8.2 Average endpoint general adverse effect score
3. Other treatments 8.3 Average change in general adverse effect scores
This includes any other treatment (biological, psychological or 8.4 No clinically important change in specific adverse effects
social) such as medication, problem solving therapy, psycho- 8.5 Average endpoint specific adverse effects
education, social skills training, cognitive-behavioural therapy, 8.6 Average change in specific adverse effects
family therapy or psychodynamic psychotherapy.
9. Engagement with services
Types of outcome measures 9.1 No clinically important engagement
9.2 Average endpoint engagement score
All outcomes were reported for the short term (up to 12 weeks), 9.3 Average change in engagement scores
medium term (13 to 26 weeks), and long term (more than 26 weeks).
10. Satisfaction with treatment
Primary outcomes 10.1 Recipient of care not satisfied with treatment
1. Global state 10.2 Recipient of care average satisfaction score
1.1 Relapse 10.3 Recipient of care average change in satisfaction scores
10.4 Carer not satisfied with treatment
2. Mental state 10.5 Carer average satisfaction score
2.1 No clinically important change in general mental state 10.6 Carer average change in satisfaction scores

Informed decisions.
11. Quality of life excluded. We recorded all rejected papers and documented
11.1 No clinically important change in quality of life reasons for exclusion.
11.2 Average endpoint quality of life score
11.3 Average change in quality of life scores We retrieved the full papers of all remaining titles and abstracts
11.4 No clinically important change in specific aspects of quality of deemed relevant. In addition, we reviewed all other potentially
life relevant articles identified by the various search strategies
11.5 Average endpoint specific aspects of quality of life (reference checking, personal communications etc). All papers
11.6 Average change in specific aspects of quality of life in languages other than English were translated/reviewed by
someone who spoke the language (as far as possible). We
12. Economic outcomes independently reviewed all the articles and completed a form for
12.1 Direct costs each study and scored the quality of the research as defined below.
12.2 Indirect costs We documented the reasons for exclusion. Where the same study
had more than one article detailing the outcomes, we treated all the
Search methods for identification of studies articles as one study and presented the results only once.
Electronic searches 2. Data extraction
1. Electronic searches We extracted all data from the selected trials, again, working
We searched the Cochrane Schizophrenia Group's Trials Register independently of each other, and resolved any disputes by
(February 2005) using the phrase: discussion. We placed trials on a list of those awaiting assessment.
When it was not possible to extract data, or if further information
[(* art * or *painting* or *milieu* or *drawing* or *creative* or was needed, we attempted to contact the relevant authors.
*projective* or *craft*in title, abstract, index terms of REFERENCE)
or (art * or craft* in interventions of STUDY)] 3. Assessment of quality
We assessed the quality of a particular trial in accordance
This register is compiled by systematic searches of major with guidelines in the Cochrane Handbook (Jadad 1996). To
databases, hand searches and conference proceedings (see Group prevent selection bias, someone not responsible for recruiting the
Module). participants, such as a central trial office or a person not involved
in the trial conducted the randomisation. We noted the method of
Searching other resources randomisation on the data extraction form. Allocation concealment
1. Reference searching was assessed as described in the Cochrane Reviewers Handbook
We inspected references of all identified studies, included or (Alderson 2004):
excluded, for more studies.
(A) Adequate description of the allocation procedure
2. Hand searching (B) Unclear description of the allocation procedure
We manually searched 'Inscape', the journal of the British (C) Inadequate description of the allocation procedure
Association of Art Therapists, from 1996 -2001 for relevant trials. (D) Allocation concealment was not used.
Conference proceedings for The Association of Art Therapists
We accepted trials that were of category A and B and commented
conference 2002 and Vth Music Therapy Congress 2001 were also
on any problems with allocation concealment in the text. In cases
hand searched.
of disagreement, we sought clarification from the authors of the
3. Personal contact trial and added these to the list of those awaiting assessment. In
We contacted authors of relevant reviews or studies to enquire addition, we were blinded to the authors' names, institutions and
about other sources of relevant information. journal title to prevent any bias.
Data collection and analysis 4. Data analysis

4.1 Managing loss to follow up
1. Selection of trials The paper should give an adequate description of the loss of its
We (RR and DM) independently selected suitable studies for participants in terms of the number of withdrawals, dropouts, and
inclusion in the review as detailed below. In cases of disagreement protocol deviations. We excluded data from studies where more
we obtained the article and independently assessed each article than 50% of participants in any group were lost to follow up. In
for relevance to the review and consulted a third reviewer where studies with less than 50% dropout rate, we considered people
necessary. We resolved any arising disagreements by discussion leaving early to have had the negative outcome, except for the
and where there was still doubt, we added the study to those event of death. We analysed the impact of including studies with
awaiting assessment and contacted the study authors for further high attrition rates (25-50%) in a sensitivity analysis. If inclusion of
clarification. data from this latter group did result in a substantive change in the
estimate of effect we did not add the data to trials with less attrition,
We assessed the titles and abstracts of identified studies to but presented it separately.
determine whether they met the inclusion criteria. In order to
minimise bias, we printed a list of all titles and abstracts excluding We assessed outcomes using continuous (for example, changes on
the authors' names, institutions, and journal title. In cases where physical function scales), categorical (for example, one of three
the title and abstract contained sufficient information to determine categories on a quality of life scale, such as 'better', 'worse' or
that the article did not meet the inclusion criteria, these were 'no change'), or dichotomous (for example, either returned to
employment or did not return to employment) measures.

Informed decisions.
4.2 Dichotomous data Where clustering was not accounted for in primary studies, we
For dichotomous outcomes, we estimated a relative risk ratio with presented the data in a table, with a (*) symbol to indicate
its associated 95% confidence intervals (CI). As a summary measure the presence of a probable unit of analysis error. In subsequent
of effectiveness, where possible, we calculated the number needed versions of this review we will seek to contact first authors of studies
to treat statistic (NNT). to obtain intra-class correlation co-efficients of their clustered data
and to adjust for this using accepted methods (Gulliford 1999).
4.3 Continuous data Where clustering has been incorporated into the analysis of primary
Many rating scales are available to measure outcomes in studies, we will also present these data as if from a non-cluster
psychosocial trials. These scales vary in the quality of their randomised study, but adjusted for the clustering effect.
validation and reliability. Therefore, if a rating scale's validation has
not been published in a peer-reviewed journal, we excluded the We have sought statistical advice and have been advised that the
data (Marshall 2000). In addition, it is preferable for the rating scale binary data as presented in a report should be divided by a 'design
to be either a self-report or completed by an independent observer effect'. This is calculated using the mean number of participants per
or relative and where this was not the case this was noted in the cluster (m) and the intra-class correlation coefficient (ICC) design
discussion. Where possible we used trials that had used the same effect = 1+(m-1)*ICC (Donner 2002). If the ICC was not reported it
instrument to measure specific outcomes in direct comparisons. was assumed to be 0.1 (Ukoumunne 1999).
Where continuous data were presented from different scales rating
the same effect, we presented both sets of data and inspected the If cluster studies had been appropriately analysed taking into
general direction of effect. We reported the mean and standard account intra-class correlation coefficients and relevant data
deviation. Where standard deviations were not reported in the documented in the report, synthesis with other studies would have
paper we attempted to obtain these from the authors or to calculate been possible using the generic inverse variance technique.
them using others measures of variation such as the confidence
5. Sensitivity analyses
intervals. For continuous data we calculated the weighted mean
Where data permitted, we were to have undertaken a sensitivity
difference.
analysis in order to see if sub-grouping the data resulted in
4.3.1 Skewed data: Often, continuous data on clinical and social important changes in the results. The results of the subgroup
outcomes do not follow a normal distribution. To avoid the pitfall analysis was to have been compared with the overall result to
of applying parametric tests to non-parametric data, the following see if there was any important difference and the differences then
standards were applied to all data before inclusion: (a) standard discussed in the results section. We pre-specified five such sub-
deviations and means were either reported in the paper or were groupings, recognising that data may be too sparse to undertake all
obtained from the authors; (b) when a scale started from the finite of them.
number zero, the standard deviation, when multiplied by two,
* group vs individual therapy
was less than the mean (otherwise the mean was unlikely to be
* differences between studies that give self-reported or observer-
an appropriate measure of the centre of the distribution, (Altman
rated outcomes
1996)); (c) if a scale started from a positive value (such as PANSS
* differences between studies with more than 50% attrition rate
which can have values from 30 to 210) the calculation described
and those with less than 50% attrition rate
above in (b) was modified to take the scale starting point into
* differences between studies using intention to treat analyses and
account. In these cases skew is present if 2SD>(S-Smin), where S is
those not using intention to treat analyses
the mean score and Smin is the minimum score. Endpoint scores
* differences between cluster randomised trials and non cluster
on scales often have a finite start and endpoint and these rules
randomised trials
can be applied to them. When continuous data are presented on
a scale which includes a possibility of negative values (such as 6. Testing for heterogeneity
change on a scale), there is no way of telling whether data are non- Firstly, we considered all the included studies within any
normally distributed (skewed) or not. It is thus preferable to use comparison to estimate clinical heterogeneity. Then we undertook
scale endpoint data, which typically cannot have negative values. If visual inspection of the graphs to investigate the possibility
endpoint data were not available, the reviewers used change data, of statistical heterogeneity. This was supplemented employing,
but they were not subject to a meta-analysis, and were reported in primarily, the I-squared statistic. This provides an estimate of
the 'Additional data' tables. the percentage of inconsistency thought to be due to chance.
Where the I-squared estimate was greater than or equal to 75%,
4.3 Endpoint versus change data
this was interpreted as indicating the presence of high levels of
Where possible we presented endpoint data and if both endpoint
heterogeneity (Higgins 2003). If inconsistency was high, we did
and change data were available for the same outcomes then we
not summate data, but presented it separately and investigated
only reported the former.
reasons for heterogeneity. We then re-analysed data using a
4.4 Cluster trials random effects model to see if this made a substantial difference.
Studies increasingly employ 'cluster randomisation' (such as If it did, and results became more consistent, falling below 75%
randomisation by clinician or practice) but analysis and pooling of in the estimate, we added the studies to the main body of trials.
clustered data poses problems. Firstly, authors often fail to account If using the random effects model did not make a difference
for intra-class correlation in clustered studies, leading to a 'unit and inconsistency remained high, we did not summate data, but
of analysis' error (Divine 1992) whereby p values are spuriously presented it separately and investigated reasons for heterogeneity
low, confidence intervals unduly narrow and statistical significance
7. Addressing publication bias
overestimated. This causes type I errors (Bland 1997, Gulliford
1999).
Informed decisions.
We entered data from all included studies into a funnel graph (trial therapy as an adjunctive treatment in severe mental illness". The
effect against trial size) in an attempt to investigate the likelihood aim of Richardson 2002 was to "conduct a controlled evaluation
of overt publication bias (Davey Smith 1997). of the effects of art therapy on the quality and clinical outcome of
mental health service users with severe mental illness".
8. General
Where possible, we entered data in such a way that the area to the 4.2 Methods
left of the line of no effect indicated a favourable outcome for the Green 1987 simply stated that the study was randomised.
psychosocial intervention. Richardson 2002, however, stated that the study participants
were randomly allocated by a computer programme using the
RESULTS minimisation method, with groups balanced for Care Programme
Approach level (this is broadly a measure of risk, severity of
Description of studies mental illness and service involvement received, with standard
This review is a rewrite and update of the version published in 2003 level being the lowest), length of illness, gender and ethnicity.
(Ruddy 2003). However, we did not find any new studies but did Both studies were single blind with the assessors not knowing
manage to obtain all the results from Richardson 2002 which are whether the participants were receiving art therapy or treatment as
rewritten below. usual. Richardson 2002 commented that the participants may have
informed the assessors which treatment group they were in, so
Please see Excluded and Included Trials table. the assessors may not have been truly blind. Richardson 2002 also
specified that the study was designed to conform to the CONSORT2
1. Excluded studies standards for the conduct of randomised controlled trials (Moher
We excluded 17 studies. One did not have a control group 2001).
(Korlin 2000), one was not randomised (Diaz Martinez 1996) and in
three, allocation was unclear (Matthews 1979, Paul 1977, Grodner 4.3 Length
1982). In Odell-Miller 2001, allocation to treatment group and Green 1987 involved 20 weeks of interventions with follow up
control group was randomised. However, the treatment group was at nine months. Participants in Richardson 2002 had 12 weeks of
then assessed and allocated, not randomly, to an individualised intervention with follow up at six months.
package of care (some of which contained art therapy). Only the
minority of participants (7/45) in Grodner 1982 had schizophrenia 4.4 Setting
or schizophrenia-like illnesses and results were not presented by Green 1987 was conducted at Central Psychiatric Clinic, a
diagnosis. Most studies were excluded because art therapy was not community based aftercare service clinic for people with long term
the intervention under investigation (DeCarlo 1985, Dincin 1982, mental illnesses in Cincinnati, Ohio, USA between April and October
Dobson 1995, Durell 1968, Karon 1972, Kremer 1984, Matthews 1980. Richardson 2002 was conducted within the Lewisham and
1979, Munjiza 1999, Paul 1977, Yu 2002). Some of the trials involved Guys Mental Health NHS Trust, London, UK, between June 1997 and
a package of care; one element of which was art therapy. These May 1999. This could have led to differences between the studies
three trials had to be excluded because it was impossible to because within the profession, the nature of art therapy practice
determine the effect of the art therapy alone (Gauthier 1972, on either side of the Atlantic is significantly different due to the
Liberman 1981, Lukoff 1986). different contexts of practice, training, education and the primary
disciplines of art therapists (Edwards 2004).
2. Awaiting assessment
Krajewski 1993 compared art therapy with cognitive behavioural 4.5 Participants
therapy and a combination of art therapy and cognitive behavioural Half the 47 participants in Green 1987 had a diagnosis of
therapy in people with schizophrenia. We were only able to obtain schizophrenia, 21% had a major affective disorder or psychotic
the abstract for this study and this did not contain any usable data, disorder and 18% had a neurotic disorder and may have had an
so we classified this trial as still awaiting assessment. Bowman 2000 associated personality disorder (30 women, 17 men). These people
is a poster describing a conference presentation on art therapy for were on average about 40 years old. They had been involved with
psychosis. We do not know whether this is a report of a trial and the service for several years and had on average been admitted
to date have been unsuccessful in ascertaining further information to hospital three times. Most were single, 29% were divorced
about this, so we have classified it as still awaiting assessment. or separated, 11% married and 7% widowed. Of the 452 people
who were identified to take part in Richardson 2002, 101(22%)
3. Ongoing studies failed to attend two appointments to discuss the trial and 206
We know of no ongoing studies. (46%) refused to participate. The 90 people who did enter the
study were mental health service users who were currently in
4. Included trials active contact with Community Mental Health Teams (CMHTs)
Two studies met the inclusion criteria (Green 1987, Richardson in South East London. All CMHTs were invited to refer patients
2002). with a diagnosis of chronic schizophrenia for at least two years
duration. Exclusion criteria were organic illness, referral to art
4.1 Objectives therapy services in the previous two years, currently receiving
Green 1987 looked at "Group art therapy as an adjunct to treatment another formal psychological treatment or current admission to
for chronic outpatients". The aim of this study was to show that a inpatient care. Of the 90 participants 59 were male and 31 were
"time-limited experience with art therapy in a group setting could female.
help patients enhance their self -esteem and promote positive
interaction with others". Richardson 2002 also investigated group The participants were broadly similar in the two studies. Both
art therapy and conducted "a randomised trial of group based art studies involved people of similar age and most participants had
Informed decisions.
been in contact with services for a fairly long time (mean 13 years had access to a variety of day treatment facilities according to their
in Richardson 2002 and average three admissions in Green 1987). location. The amount of input therefore differed across people. The
The difference was that in Green 1987 participants had a range of treatment as usual interventions in both groups were sufficiently
diagnoses, whereas in Richardson 2002 people only had psychosis. similar. Both studies used groups for administering the art therapy
We felt it was reasonable to combine the results of these two studies but in neither study did the control intervention involve group
as the people involved are likely to reflect those seen in most art work. It is possible that any beneficial effect of the art therapy may
therapy groups. be due to group factors rather than the treatment itself.
4.6 Interventions 4.7 Outcomes

4.6.1 Art therapy The only usable data for Green 1987 was for the outcome of
In Green 1987, this was conducted in two groups of 12 patients leaving the study early by 20 weeks and by nine months (which
over ten sessions. The sessions lasted 90 minutes and were was available in another publication (Borchers 1985)). We have not
held fortnightly. The same art therapist led both groups and been successful in our attempts to contact the author for further
the sessions were divided into several sections. They began clarification. The data for leaving the study early by the end of
with a "short introduction and socialisation period". This was therapy and by six month follow up were available for Richardson
followed by a directed relaxation lesson where participants were 2002. For some reason different numbers of participants completed
encouraged by "carefully sequenced imagery to visualise scenes the assessments at the end of therapy and the average number
and activities in their mind's eye". Following this they were given of participants completing all assessments has been used as the
art materials to work on the session project. In the final part number remaining in the study at this stage.
of the session, participants discussed their art work as a group
"if their psychological states permitted". Selected art works from Green 1987 used outcome-rating scales, but unfortunately no
each patient were subsequently displayed in the art therapy room. means or standard deviations were reported. ANOVA calculations
The sessions aimed to develop self-expression, promote group and significance levels for the statistically significant results were
cohesion, increase tolerance of disclosing emotionally significant also too inaccurate to use. The satisfaction questionnaire that
material and encourage group interaction, support and positive was used in the study was not a standardised tool and was
feedback. All participants also received treatment as usual, but it only administered to people receiving art therapy, therefore these
should be noted that the art therapy group received an intervention results are impossible to use.
that involved them in services for an extra 15 hours compared with
the control group. Richardson 2002 used seven rating scales (Brief Psychiatric
Rating Scale, Brief Symptom Inventory, Health of the Nation
In Richardson 2002 the art therapy was conducted in groups of Outcome Scale, Inventory of Interpersonal Problems 32, Lancashire
four or five participants. Groups continued to function as long as Quality of Life Profile, Social Functioning Scale and the Scale for
three members remained but if they became smaller than three Assessment of Negative Symptoms). We could not include data
the members were transferred to other parallel groups. The therapy from one of these scales. The Health of the Nation Outcome Scale
involved 12 weekly sessions lasting 90 minutes. The authors state is not considered suitable for use in clinical trials (Wing 1994). Data
that it was conducted according to published guidelines (Waller from the BPRS (Overall 1962), BSI (Derogatis 1983) and the IIP32
1993). The theory behind these guidelines is that through using (Barkham 1996) were skewed and are only presented in other data
art materials and associated imagery the therapist promotes an tables. The author kindly provided unpublished data for all the
environment which allows the service user to "learn about and scales that has allowed us to use the results in this review. Although
understand the patterns of behaviour that are causing distress". both long term and short term data were presented, only short
The participants receiving art therapy also received standard care term data from these scales were usable in this review because over
from the CMHT and therefore had 18 hours more intervention than 50% of the participants withdrew before their six month follow up.
the control group during the study. The art therapy interventions Such high attrition data were considered to be too prone to bias to
in the two studies were probably different. This is partly because present (see Methods 4.1).
of the already acknowledged difference in art therapy practice
between the UK and the USA and partly because Green 1987 had an 4.7.1 Outcome rating scales included in this review
additional introduction to the session that included relaxation (that 4.7.1.1 Scale for the Assessment of Negative Symptoms (SANS,
may have been the active component of the treatment). Richardson Andreason 1989)
2002 also had smaller groups and two more sessions than Green SANS is a six-point scale that gives a global rating of the following
1987. Both studies, however, used an art therapy intervention that negative symptoms: alogia, affective blunting, avolition-apathy,
fits within the definition we used for this review so we have decided anhedonia-asociality, and attentional impairment. Higher scores
to combine the study results where possible. indicate more symptoms.
4.6.2 Standard care (treatment as usual) 4.7.1.2 Social Functioning Scale (SFS, Birchwood 1990)
Green 1987 stated that treatment as usual consisted of individual The SFS is assesses areas of functions that are crucial for
verbal therapy from a member of the community team every two the community maintenance of individuals with schizophrenia.
to four weeks for about 20 minutes, a team psychiatrist review The seven areas are social engagement/withdrawal, interpersonal
for 10-15 minutes once a month and psychotropic medication. behaviour, pro-social activities, recreation, independence-
Richardson 2002's treatment as usual group received standard competence, independence-performance and employment/
psychiatric care that involved regular contact with the CMHT occupation. A low score is poor.
(frequency determined by care program approach (CPA) level),
4.7.1.3 Lancashire Quality of Life Profile (Perc QoL, Oliver 1996)
regular medication review and CPA review meetings. Patients also

Informed decisions.
Perc QoL is a scale that measures quality of life in each of nine up as they are likely to be significantly affected by this large attrition
domains (work, leisure, religion, finance, living situation, legal and rate and therefore unreliable.
safety, family relations, social relations, health) and also contains
three general sub-scales for global well-being, affect balance and 4. Overall impression
self-concept. A higher score indicates a better quality of life. Currently reports of both studies do not provide reassurance
that allocation was fully concealed, therefore both studies are
4.7.1.4 Brief Psychiatric Rating Scale (BPRS, Overall 1962) categorised as 'B'. Green 1987 is single blind, but this is likely
This scale consists of 24 psychiatric symptom constructs. Each to have been compromised and the reasons for people leaving
one is rated on a seven point scale of severity ranging from 'not early are not reported. Richardson 2002 is also single blind, but
present' (1) to 'extremely severe' (7). A higher score therefore as the authors have pointed out, this is likely to be compromised
indicates more psychiatric symptoms. by the interview assessments. Richardson 2002 included a power
calculation that estimated that it was necessary to have 64 people
4.7.1.5 Brief Symptom Inventory (BSI, Derogatis 1983) in each group to show significant differences between groups on
This is a 53-item symptom checklist developed as a shortened the main outcome variables but unfortunately they did not achieve
form of the SCL-90-R (Derogatis, 1983). Scoring is on a 5- this figure. Richardson 2002 has not yet been fully published and we
point scale leading to nine independent symptomatic profiles: are grateful to the authors for the information that we have been
somatisation, obsessive-compulsive, interpersonal sensitivity, able to include.
depression, anxiety, hostility, phobic anxiety, paranoid ideation
and psychoticism. In addition, it yields two general measures of Effects of interventions
symptomatic distress: the Global Severity Index (GSI) and the
Positive Symptom Total (PST). The higher the score, the greater the 1. Search
number of symptoms. The search identified 62 references, 41 of which were clearly
not relevant to this review. Of the remaining 21 reports, we were
4.7.1.6 Inventory of Interpersonal Problems 32 (IIP 32, Barkham able to include two trials but more information is needed before
1996) we can use all of the results (Green 1987, Richardson 2002) and
The IIP 32 has eight subscales that measure interpersonal one abstract reported no usable data (Krajewski 1993) and awaits
problems (hard to be supportive, hard to be assertive, hard to be assessment. Attempts are still being made to obtain data from
involved, hard to be sociable, too dependent, too aggressive, too these studies. This review contains data from only Green 1987 and
caring, and too open). Each subscale has four items and they are Richardson 2002 (total n=137).
rated 0-4 according to the severity of the problem with a higher
score indicating more problems. 2. COMPARISON: ART THERAPY + STANDARD CARE versus
STANDARD CARE
Risk of bias in included studies
2.1 Leaving the study early
1. Randomisation 2.1.1. Leaving the study early - short term
Green 1987 stated that people were randomised to the two Richardson 2002 provided short-term data. More people
interventions, but did not make it explicit how this was undertaken. completed the therapy if allocated to the art therapy group than
Readers of this report are not reassured that allocation was truly standard care but this was not a significant difference. (n=90, 1 RCT,
concealed. In Richardson 2002 the randomisation was achieved RR 0.97 CI 0.41 to 2.29)
using a computer programme employing the minimisation
method. The groups were balanced for various factors as described 2.1.2. Leaving the study early - medium term
above. Again, however, it is not clear if allocation was concealed. Both studies presented medium-term data. Nineteen of the 47
participants (40%) left Green 1987 before the completion of 20
2. Blindness weeks of therapy and in this study significantly more people in the
Green 1987 stated that the members of the community team rating standard care group left the study early (n=47, 1 RCT, RR 0.34 CI 0.15
outcomes were blind to the study aims and the group to which to 0.80, NNT 3 CI 2-9). Richardson 2002 again had different numbers
people had been allocated. The authors pointed out, however, of people completing the scales at six months. In this study more
that participants may have told assessors which therapy they were people dropped out of the art therapy group (25 of 43) than those
receiving. Richardson 2002 felt that since the research assistant had in the standard care group (25 out of 47) but this difference was
to interview the participants to complete the assessments, they not significant (n=90, 1 RCT, RR 1.09 CI 0.76 to 1.58). Combining was
were unlikely to remain blind to group allocation. not undertaken as this resulted in the introduction of significant
heterogeneity (I-square 85%).
3. Descriptions of people who withdrew before completion
Green 1987 states that there was no difference between those 2.1.3. Leaving the study early - long term
leaving the study on initial levels of functioning and demographic The nine month follow up data for Green 1987 is reported in
characteristics and those completing the trial, but exactly why Borchers 1985. No significant difference in loss was found between
people left remains unclear. For Richardson 2002 the number groups (n=47, 1 RCT, RR 0.96 CI 0.57 to 1.60).
of people leaving after randomisation is reported at the end of
the study and at the six month follow up, however there is no 2.2 Mental state
description of why they left the study early. Unfortunately because Only one study (Richardson 2002) reported data for mental state.
more than 50% of the participants withdrew before the follow up at The study used three different assessment scales but data from two
six months, we have had to exclude the results for six month follow of these (BPRS and BSI) were skewed and can only be used in 'other
data tables'. Data from the SANS scale, however, were normally
distributed and showed a significant difference favouring the art-
Informed decisions.
therapy group although the average mean scores seemed to be very 2002 found that with a 12 week art therapy intervention there
low for this scale (n=73, WMD -2.3 CI -4.10 to -0.5). was no significant difference between groups for leaving the study
early. Overall, the differences between groups were not significant.
2.3 Social functioning There were no reasons given as to why people left the study early.
Richardson 2002 used the SFS scale to measure social functioning. However, Green 1987, with a 20 week art therapy intervention,
Short-term data showed no significant difference between groups suggests that it was three times more likely that people in the
in endpoint scores for social functioning (n=70, WMD 7.20 CI -2.53 control group would leave the study before the end of therapy
to 16.93). Richardson 2002 also used the IIP but data from this scale than those allocated art therapy. Everyone received treatment as
are skewed and included in 'other data tables'. usual, but people in the art therapy group clearly received an
intervention which involved group work and an extra 15 hours of
2.4 Quality of life
therapy. Any difference in results may be due to extra contact, or
Again Richardson 2002 was the only study to present usable data.
group cohesiveness, rather than the art therapy per se. We also do
Short-term data from the Perc QoL found no significant differences
not know why people left early. It could be that people stay in a
in endpoint scores (n=74, WMD 0.1 CI -2.7 to 0.47).
study because they feel satisfied with care and that their hope and
self-esteem is improved. Alternatively those who leave early may
DISCUSSION
have recovered and might be eager to leave behind the role which
1. Strengths and weakness of the review their illness defines for them. It is difficult to know why there is such
This review represents an all too rare attempt at quantifying the a difference between the two studies. We have described above
effects of a treatment approach for people with schizophrenia how Green 1987 included a component of relaxation into their art
that is advocated by art therapists (Killick 1995, Gilroy 1995, therapy sessions that Richardson 2002 did not, so any difference
Wood 1997). Great efforts have been made to identify randomised may reflect differing interventions. It is also possible that a 20 week
studies in order to measure the value of this specialised treatment intervention may be more effective at keeping people engaged than
as objectively as possible. Green 1987, Richardson 2002, and a 12 week intervention. At present the results are inconclusive and
perhaps Krajewski 1993 recognise the need for this and prove that it is impossible to say with certainty what effect art therapy has on
randomisation is possible; this review brings their work to the fore keeping people involved with services during the therapy.
and highlights important lessons for future trialists.
Both studies found that engagement with the study after the
Only two of these studies could be included in the review and therapy had finished was poor. Sixty six percent left Richardson
poor reporting of data led to further loss of information. Both 2002 before six month follow up, thus rendering the six month
studies are small and likely to be too underpowered to find a follow up data for other outcomes unusable by this review and
clinically meaningful effect. Understandably, scales have been used that 65% had left Green 1987 before nine month follow up. Both
in these hypothesis-generating trials. Significant shifts in scales studies found no significant difference between groups in terms of
could suggest clinical meaning that could be tested in a fully dropouts after therapy had ended.
powered study.
3.2 Mental state
2. Applicability One study, Richardson 2002 (n=90), presented data from three
Only Richardson 2002 provided data on the number of people mental state scales (BPRS, BSI and SANS) but only one of these, the
originally identified as eligible for the study and the number SANS, had normally distributed data. Results suggested a beneficial
actually entering the trial. It appears that up to 68% of potential effect on mental state in the short-term for those receiving art
participants refused the possibility of art therapy. This may suggest therapy (n=73, WMD -2.3 CI -4.10 to -0.5) However, this result should
that the idea of art therapy as a treatment is not appealing to be treated with caution for several reasons. Firstly it is based on
people with schizophrenia or schizophrenia-like illnesses, although one small study. Secondly the data is not intention-to-treat (n=73)
it is not clear whether the 22% of the total who failed to attend and the clinical significance of the difference between the groups
appointments were aware that they were being considered for an is debatable. This is because there is a similar significant difference
art therapy study. Only 49 people were excluded by the trialists for between the groups at baseline, so it is unclear if the difference
not meeting the inclusion criteria which means that the remainder is purely due to the therapy. Finally it should be noted that the
made their own decisions not to be involved. It is possible that results are only presented for the short-term as more than 50% of
those participants who did become involved in the study are participants dropped out before the six month follow up, and as
not representative of people with schizophrenia who are seen in such, the longer term effects of art therapy on mental state are not
everyday practice. presented. Skewed data from the BPRS and BSI showed no clear
differences in mental state between groups.
3. COMPARISON: ART THERAPY + STANDARD CARE versus
STANDARD CARE 3.3 Social functioning
Again only Richardson 2002 presented usable data for social
3.1 Leaving the study early functioning. Data from the SFS suggests there is no significant
Green 1987 and Richardson 2002 have differing results. Forty difference in social functioning in the short term. As above, this
percent left Green 1987 before the end of therapy compared result is not robust, it is based on one small study and data is
with 19% in Richardson 2002. Green 1987 included people with not intention-to-treat (n=70). Long-term effects of art therapy on
several other diagnoses other than schizophrenia (50% major social functioning were also lost due to high attrition with over
affective disorder, neurotic disorder, personality disorder) whereas 50% of participants leaving before the six month follow up. IIP data
Richardson 2002 included only people with chronic schizophrenia. also suggested no difference between groups in short-term social
This alone could well account for the heterogeneity. Richardson functioning but data from this scale were skewed.

Informed decisions.
3.4 Quality of life 4. For funders

Richardson 2002 (n=90) found no significant difference in quality Funders with an interest in the projective therapies should support
of life for the short-term when measured by Perc QoL. Again it further adequately powered and designed studies of art therapy for
is difficult to draw any firm conclusions from such data as the schizophrenia.
numbers involved are small and data is not intention-to-treat
(n=74). The results also seem to be very static over time and it is Implications for research
unclear whether the authors have again reduced the rating scale
1. General
score to a different scale. Again in this study, long-term effects were
If the CONSORT recommendations (Moher 2001) were followed in
not available due to more than 50% of participants leaving the
reporting future studies, we would be more aware of the effects of
study early.
art therapy. Much important data from one of the included studies
was lost due to poor reporting.
AUTHORS' CONCLUSIONS
2. Specific
Implications for practice As art therapy is used for people with schizophrenia, large simple,
1. For people with schizophrenia well-designed and reported trials comparing it to standard care
If offered art therapy, a person with schizophrenia should made without art therapy are justified to establish whether it has a role in
aware that its use is under evaluation and its benefits or harms are, the treatment of schizophrenia or schizophrenia-like illnesses.
as yet, unclear. The person offered this intervention could suggest
that they would comply only in the context of inclusion in real Researchers may wish to involve more comparable interventions.
world, evaluative research. Some way of compensating for the additional time spent with
people and the group cohesiveness generated by allocation to art
2. For clinicians therapy may be seen as desirable. A variety of clinically meaningful
If art therapy is available for people with schizophrenia its use can outcomes are important in future art therapy studies. For example,
only be viewed as experimental as it is currently not known whether clinically significant changes in global functioning, mental state
this approach helps or harms. Although the previous version of and behaviour, relapse, admission to hospital, engagement with
this review suggested that there was some evidence to support services, quality of life, leaving the study early, satisfaction
that art therapy may be of more value than standard care for with care, adverse effects, death and economic outcomes (cost-
keeping people engaged with services, this seems dubious now effectiveness and cost-benefit).
the results of Richardson 2002 have been added. It is unclear
whether art therapy may improve mental state, social functioning, ACKNOWLEDGEMENTS
interpersonal relationships or quality of life and there are no data
The reviewers would like to thank Clive Adams for advice during
available for outcomes such as satisfaction with care.
the production of this review, Mark Fenton and Judith Wright for
running the searches, Evandro da Silva Freire Coutinho and Jun Xia
3. For policy makers
for translation and Andrea Gilroy for her help with peer review
There is no evidence to support the use of art therapy as part of
policy.

Informed decisions.
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Library. Chichester, UK: John Wiley & Sons, Ltd, 2004. [In: The Gilroy 1995
Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley &
Sons, Ltd] Gilroy A, Lee C. Art and music therapy and research. London &
New York: Routledge, 1995.
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Gulliford 1999
Altman DG, Bland JM. Detecting skewness from summary
information. BMJ 1996;313(7066):1200. Gulliford MC. Components of variance and intraclass
correlations for the design of community-based surveys and
intervention studies: data from the Health Survey for England
1994. American Journal of Epidemiology 1999;149:876-83.

Informed decisions.
Higgins 2003 Sims 1995

Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring Sims A. Symptoms in the mind: An introduction to descriptive
inconsistency in meta-analyses. BMJ 2003;327:557-560. psychopathology. 2nd Edition. London: WB Saunders, 1995.
Jadad 1996 Thomson 1989

Jadad A. Assessing the quality of reports of randomized Thomson M. On art and therapy. London & New York: Free
clinical trials: Is blinding necessary?. Controlled Clinical Trials Association Books, 1989.
1996;17:1-12.
Ukoumunne 1999
Johnstone 1998 Ukoumunne OC, Gulliford MC, Chinn S, Sterne JAC, Burney PGJ.
Johnstone E, Freeman C, Zealley A. Companion to psychiatric Methods for evaluating area-wide and organisation-based
studies. 6th Edition. Edinburgh: Churchill Livingstone, 1998. interventions in health and health care: a systematic review.
Health Technology Assessment 1999;3(5):1-75. [MEDLINE:
Kandinsky 1955 10982317]
Kandinsky W. Concerning the spiritual in art, and painting in
particular. New York: Wittenborn, 1955. Waller 1992
Waller D, Gilroy A. Art therapy: A handbook.. London: Routledge,
Killick 1995 1992.
Killick K, Greenwood H. Research in art therapy with people
who have psychotic illnesses. In: Gilroy A, Lee C editor(s). Waller 1993
Art and music therapy and research. London & New York: Waller D. Group Interactive Art Therapy. London: Routledge,
Routledge, 1995. 1993.
Marshall 2000 WHO 1992

Marshall M. Unpublished rating scales: a major source of bias in World Health Organisation. The ICD 10 Classification of Mental
randomised controlled trials of treatments for schizophrenia. and Behavioural Disorders: clinical descriptions and diagnostic
British Journal of Psychiatry 2000;176:249-52. guidelines. Geneva: World Health Organisation, 1992.
Moher 2001 Wing 1994

Moher D, Schulz KF, Altman D. The CONSORT statement: revised Wing J. Measuring Mental Health Outcomes: a perspective from
recommendations for improving the quality of reports of the Royal College of Psychiatrists. Outcomes in Clinical Practice.
parallel-group randomized trials. JAMA 2001;285(15):1987-91. London: BMJ Publishing, 1994.
Oliver 1996 Wood 1997

Oliver J, Huxley P, Bridges K, Hadi M. Quality of Life and Mental Wood C. The history of art therapy and psychosis (1938-95).
Health Services. Florence, KY, USA: Taylor and Francis, 1996. In: Killick K, Schaverien J editor(s). Art psychotherapy and
psychosis. London & New York: Routledge, 1997.
Overall 1962
Overall J, Gorham D. The Brief Psychiatric Rating Scale.
Psychological Reports 1962;10:799-812. References to other published versions of this review
Ruddy 2003
Sarra 1998
Ruddy R, Milnes D. Art therapy for schizophrenia or
Sarra N. Connection and disconnection in the art therapy group.
schizophrenia-like illnesses. Cochrane Database of Systematic
Working with forensic patients on the locked ward. In: Skaife S,
Reviews 2003, Issue 2. [DOI: 10.1002/14651858.CD003728.pub2]
Huet V editor(s). Art psychotherapy groups. Between pictures
and words. London & New York: Routledge, 1998:74.
* Indicates the major publication for the study
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Green 1987
Methods Allocation: randomised.
Blindness: raters blind to treatment group, unaware of study hypothesis.
Duration: 20 weeks (end of therapy).
Participants Diagnosis: schizophrenia (50%), major affective disorder or psychotic disorder (21%), neurotic disorder
+/- personality disorder (18%).

Informed decisions.
Green 1987 (Continued)

N=47.
Age: mean ˜ 40 years.
Sex: 17M, 30F.
History: 23 single, 14 divorced or separated, 5 married, 3 widowed, attended psychiatric clinic for sev-
eral years, seen > once a month, mean 3 admissions.
Setting: Cincinnati, USA.
Interventions 1. Art therapy + standard care: therapy for 1.5 every 2 weeks for 10 sessions, 2 groups of 12 people,
same art therapist for both groups. N=24.
2. Standard care: individual verbal therapy from MDT member every 2-4 weeks for ˜20 mins, psychia-
trist review for 10-15 mins monthly, psychotropic medication. N=23.
Outcomes Leaving the study early .
Unable to use -
Psychosocial functioning: Progress Evaluation Scales (no means, SDs, or Ns by group).
Self esteem: Rosenberg's Self Esteem Scale (no mean, SD, or N by group).
Patient satisfaction: (no control group data).
Leaving the study early - at 9 months (data not presented by group).
Notes
Risk of bias
Bias Authors' judgement Support for judgement
Allocation concealment? Unclear risk B - Unclear
Richardson 2002
Methods Allocation: randomised using computer programme, stratified for severity, gender, chronicity and eth-
nicity.
Blindness: rater blind.
Duration: 6 months.
Participants Diagnosis: chronic schizophrenia of more than 2 years duration.

N=90.
Age: range 23 - 69 years, mean ˜ 41 years.
Sex: 59M, 31F.
Race: 43 white European, 42 black Afro-Caribbean, African, British, 5 unknown.
History: duration ill range 1-37 years, mean ˜13 (SD 9), CPA level 13=1, 44=2, 8=3.
Setting: Inner city London.
Interventions 1. Art therapy + standard care: therapy for 1.5hrs every week for 12 weeks, 4 people per group. N=43.
2. Standard care by CMHT. N=47.
Outcomes Leaving the study early.

Mental state: BPRS, BSI, SANS.
Social functioning: IIP32, SFS.
Quality of life: Perc QoL
Unable to use -
Health and social functioning: HoNOS (not validated for use in trials).
Notes
Risk of bias

Informed decisions.
Richardson 2002 (Continued)
Bias Authors' judgement Support for judgement
Allocation concealment? Unclear risk B - Unclear
BPRS = Brief Psychiatric Rating Scale

BSI = Brief Symptom Inventory
CMHT = community mental health team.
HoNOS - On this scale an increase in score represents a worsening of health and social functioning.
IIP32 = Inventory of Interpersonal Problems 32
MDT = multidisciplinary team.
Perc QoL = Lancashire Quality of Life Profile
SANS = Scale for the Assessment of Negative Symptoms
SFS = Birchwood Social Functioning Scale
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
DeCarlo 1985 Allocation: randomised.

Participants: included people with schizophrenia.
Interventions: activity therapy (finding magazine pictures to represent themselves, designing coat
of arms with sections aimed at self disclosure, listening tasks, eye contact game, role plays) versus
verbal therapy versus normal day treatment, no intervention consistent with defintion of art thera-
py.
Diaz Martinez 1996 Allocation: not randomised.
Dincin 1982 Allocation: randomised.

Participants: mostly people with schizophrenia.
Interventions: comprehensive treatment (individual casework, vocational rehabilitation, social re-
habilitation, residential facilities, academic programme, prevention of rehospitalisation) versus
supportive treatment, no intervention consistent with defintion of art therapy.
Dobson 1995 Allocation: randomised.

Participants: people with schizophrenia.
Interventions: social skills group versus social milieu group (choice of structured activities for the
same time period as the active treatment group), no intervention consistent with defintion of art
therapy.
Durell 1968 Allocation: randomised.

Interventions: therapeutic community (no individual psychotherapy, no occupational or recre-
ational therapy, encouraged to seek employment and appropriate social and homelife) versus con-
trol group, no intervention consistent with defintion of art therapy.
Gauthier 1972 Allocation: randomised.

Interventions: 8 combinations of milieu A1 (traditional ward with dormitory), milieu A2 (small
modern clinical section in research department), group psychotherapy, occupational therapy pro-
gram (5 activities - one being "1 hour of pictorial expression either on an assigned theme or follow-
ing personal inspiration"), art therapy just one part of occupational therapy, so imposssible to de-
termine the effect of this intervention.
Grodner 1982 Allocation: unclear.

Participants: minority of people (7/45) had schizophrenia.
Karon 1972 Allocation: randomised.

Informed decisions.
Study Reason for exclusion

Interventions: psychoanalytic psychotherapy of an active variety without medication versus psy-
choanalytic psychotherapy of an "ego-analytic" variety with medication versus "treatment as good
practice recommends", no intervention consistent with defintion of art therapy.
Korlin 2000 Allocation: not randomised, no control group.
Kremer 1984 Allocation: randomised.

Participants: chronic psychiatric patients.
Interventions: three different activity groups: cooking, craft, or sensory awareness, no intervention
consistent with definition of art therapy.
Liberman 1981 Allocation: randomised.

Interventions: social skills training versus intensive holistic health therapy (jogging, meditation,
yoga and art therapy) + insight orientated family therapy, art therapy just one of holistic therapies,
imposssible to determine the effect of art therapy alone.
Lukoff 1986 Allocation: randomised.

Interventions: social skills training versus holistic treatments(exercise, yoga, meditation, stress ed-
ucation sessions, art therapy activity, positive reframing of patients psychotic ideas), art therapy
just one of holistic therapies, imposssible to determine the effect of art therapy alone.
Matthews 1979 Allocation: unclear.

Interventions: intensive interpersonal treatment program in community facility versus neuroleptic
medication + standard inpatient care, no intervention consistent with defintion of art therapy.
Munjiza 1999 Allocation: randomised

Interventions: group therapy and pharmacotherapy versus psychopharmacotherapy in milieu
therapy, no intervention consistent with defintion of art therapy.
Odell-Miller 2001 Allocation: randomised to treatment and control, thereafter assessment determined which type of
therapy people received - not truly randomised.
Participants: people with continuing mental health problems (9/25 had schizophrenia).
Interventions: individualised packages of arts therapies some including art therapy but not stan-
dard package to compare with controls.
Paul 1977 Allocation: unclear.

Participants: chronically institutionalised psychotic people.
Interventions: milieu therapy versus social -learning therapy, no intervention consistent with
defintion of art therapy.
Yu 2002 Allocation: randomised.

Interventions: Literature-art-therapy (consisted of practicing calligraphy and painting, reciting po-
etry, writing stories, having parties and being given prizes for their achievements) versus routine in-
patient care. No interventions consistent with definition of art therapy.
DATA AND ANALYSES

Informed decisions.
Comparison 1. ART THERAPY + STANDARD CARE versus STANDARD CARE
Outcome or subgroup title No. of No. of Statistical method Effect size

studies partici-
pants
1 Leaving the study early - short term 1 90 Risk Ratio (M-H, Fixed, 95% CI) 0.97 [0.41, 2.29]
1.1 before the end of therapy 1 90 Risk Ratio (M-H, Fixed, 95% CI) 0.97 [0.41, 2.29]
2 Leaving the study early - medium term 2 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
2.1 before the end of therapy 1 47 Risk Ratio (M-H, Fixed, 95% CI) 0.34 [0.15, 0.80]
2.2 before 6 month follow up 1 90 Risk Ratio (M-H, Fixed, 95% CI) 1.09 [0.76, 1.58]
3 Leaving the study early - long term 1 47 Risk Ratio (M-H, Fixed, 95% CI) 0.96 [0.57, 1.60]
3.1 before 9 month follow up 1 47 Risk Ratio (M-H, Fixed, 95% CI) 0.96 [0.57, 1.60]
4 Mental state: 1a. Average score - short 1 73 Mean Difference (IV, Fixed, 95% CI) -2.30 [-4.10, -0.50]
term (endpoint data, SANS, high = poor)
4.1 at the end of therapy 1 73 Mean Difference (IV, Fixed, 95% CI) -2.30 [-4.10, -0.50]
5 Mental state: 1b. Average score - short Other data No numeric data
term (endpoint skewed data, various scales,
high = poor)
5.1 BPRS Other data No numeric data
5.2 BSI Other data No numeric data
6 Social functioning: 1a. Average score - 1 70 Mean Difference (IV, Fixed, 95% CI) 7.20 [-2.53, 16.93]
short term (endpoint data, SFS, high = poor)
6.1 at end of therapy 1 70 Mean Difference (IV, Fixed, 95% CI) 7.20 [-2.53, 16.93]
7 Social functioning: 1b. Average score - Other data No numeric data

short term (endpoint skewed data, IIP, high
= good)
8 Quality of life: Average score - short term 1 74 Mean Difference (IV, Fixed, 95% CI) 0.10 [-0.27, 0.47]
(endpoint data, PercQoL, high = good)
8.1 at end of therapy 1 74 Mean Difference (IV, Fixed, 95% CI) 0.10 [-0.27, 0.47]
Analysis 1.1. Comparison 1 ART THERAPY + STANDARD CARE versus

STANDARD CARE, Outcome 1 Leaving the study early - short term.
Study or subgroup Art therapy Standard care Risk Ratio Weight Risk Ratio
n/N n/N M-H, Fixed, 95% CI M-H, Fixed, 95% CI
1.1.1 before the end of therapy
Richardson 2002 8/43 9/47 100% 0.97[0.41,2.29]
Favours art therapy 0.1 0.2 0.5 1 2 5 10 Favours control

Informed decisions.
Subtotal (95% CI) 43 47 100% 0.97[0.41,2.29]
Total events: 8 (Art therapy), 9 (Standard care)
Heterogeneity: Tau2=0; Chi2=0, df=0(P<0.0001); I2=100%
Test for overall effect: Z=0.07(P=0.95)
Total (95% CI) 43 47 100% 0.97[0.41,2.29]

Heterogeneity: Tau2=0; Chi2=0, df=0(P<0.0001); I2=100%
Favours art therapy 0.1 0.2 0.5 1 2 5 10 Favours control

STANDARD CARE, Outcome 2 Leaving the study early - medium term.
1.2.1 before the end of therapy
Green 1987 5/24 14/23 100% 0.34[0.15,0.8]
Subtotal (95% CI) 24 23 100% 0.34[0.15,0.8]
Heterogeneity: Not applicable
1.2.2 before 6 month follow up

Richardson 2002 25/43 25/47 100% 1.09[0.76,1.58]
Subtotal (95% CI) 43 47 100% 1.09[0.76,1.58]
Favours treatment 0.1 0.2 0.5 1 2 5 10 Favours control

STANDARD CARE, Outcome 3 Leaving the study early - long term.
1.3.1 before 9 month follow up
Green 1987 13/24 13/23 100% 0.96[0.57,1.6]
Subtotal (95% CI) 24 23 100% 0.96[0.57,1.6]
Total (95% CI) 24 23 100% 0.96[0.57,1.6]

Favours treatment 0.1 0.2 0.5 1 2 5 10 Favours control

Informed decisions.
Analysis 1.4. Comparison 1 ART THERAPY + STANDARD CARE versus STANDARD CARE,
Outcome 4 Mental state: 1a. Average score - short term (endpoint data, SANS, high = poor).
Study or subgroup Art therapy Standard care Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) Fixed, 95% CI Fixed, 95% CI
1.4.1 at the end of therapy
Richardson 2002 35 7.6 (3.4) 38 9.9 (4.4) 100% -2.3[-4.1,-0.5]
Subtotal *** 35 38 100% -2.3[-4.1,-0.5]
Total *** 35 38 100% -2.3[-4.1,-0.5]

Favours treatment -10 -5 0 5 10 Favours control
Analysis 1.5. Comparison 1 ART THERAPY + STANDARD CARE versus STANDARD CARE, Outcome 5
Mental state: 1b. Average score - short term (endpoint skewed data, various scales, high = poor).
Mental state: 1b. Average score - short term (endpoint skewed data, various scales, high = poor)
Study Intervention Mean SD N Notes
BPRS
Richardson 2002 Art therapy 13.5 6.5 35
Richardson 2002 Standard care 16.5 8.6 38
BSI
Richardson 2002 Art therapy 0.80 0.50 35 This seems to be a very
small score for this rating
scale and the change be-
tween this and the base-
line data is only -0.1 for
standard care and -0.2
for art therapy.
Outcome 6 Social functioning: 1a. Average score - short term (endpoint data, SFS, high = poor).
1.6.1 at end of therapy
Richardson 2002 33 117.9 (21.2) 37 110.7 (20.2) 100% 7.2[-2.53,16.93]
Subtotal *** 33 37 100% 7.2[-2.53,16.93]
Total *** 33 37 100% 7.2[-2.53,16.93]


Informed decisions.
Analysis 1.7. Comparison 1 ART THERAPY + STANDARD CARE versus STANDARD CARE, Outcome
7 Social functioning: 1b. Average score - short term (endpoint skewed data, IIP, high = good).
Social functioning: 1b. Average score - short term (endpoint skewed data, IIP, high = good)
Study Intervention Mean SD N Notes
Richardson 2002 Art therapy 0.90 0.60 35
Outcome 8 Quality of life: Average score - short term (endpoint data, PercQoL, high = good).
1.8.1 at end of therapy
Richardson 2002 35 4.6 (0.7) 39 4.5 (0.9) 100% 0.1[-0.27,0.47]
Subtotal *** 35 39 100% 0.1[-0.27,0.47]
Total *** 35 39 100% 0.1[-0.27,0.47]

WHAT'S NEW
Date Event Description
21 October 2008 Amended Converted to new review format.
HISTORY
Protocol first published: Issue 3, 2002
Review first published: Issue 4, 2002
Date Event Description
26 July 2005 New citation required and conclusions Substantive amendment

have changed
CONTRIBUTIONS OF AUTHORS
Rachel Ruddy - initiated review, protocol production, study searching and selection, data extraction, assimilation, report writing, review
maintanence.
David Milnes - helped with protocol and data extraction.

Informed decisions.
DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT
Internal sources
• Leeds Community Mental Health Trust, UK.
• University of Leeds, UK.
• York Primary Care Trust, UK.
External sources
• No sources of support supplied
INDEX TERMS
Medical Subject Headings (MeSH)

Art Therapy [*methods]; Randomized Controlled Trials as Topic; Schizophrenia [*therapy]
MeSH check words

Humans


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Cochrane

Art therapy for schizophrenia or schizophrenia-like illnesses

Art therapy for schizophrenia or schizophrenia-like illnesses (Review)

Art therapy for schizophrenia or schizophrenia-like illnesses (Review) i

Art therapy for schizophrenia or schizophrenia-like illnesses

Rachel Ruddy1, David Milnes2

Editorial group: Cochrane Schizophrenia Group.

Data collection and analysis

Art therapy for schizophrenia or schizophrenia-like illnesses (Review) 1

PLAIN LANGUAGE SUMMARY

Art therapy for schizophrenia or schizophrenia-like illnesses

Art therapy for schizophrenia or schizophrenia-like illnesses (Review) 2

analysis. If there was no substantive difference within primary Secondary outcomes

Art therapy for schizophrenia or schizophrenia-like illnesses (Review) 4

Data collection and analysis 4. Data analysis

Art therapy for schizophrenia or schizophrenia-like illnesses (Review) 5

4.6 Interventions 4.7 Outcomes

Art therapy for schizophrenia or schizophrenia-like illnesses (Review) 8

Art therapy for schizophrenia or schizophrenia-like illnesses (Review) 10

3.4 Quality of life 4. For funders

Art therapy for schizophrenia or schizophrenia-like illnesses (Review) 11

Art therapy for schizophrenia or schizophrenia-like illnesses (Review) 12

Hamburg, Germany. Vol. 2, Conifer, Excerpta Medica Medical Andreason 1989

Art therapy for schizophrenia or schizophrenia-like illnesses (Review) 13

Higgins 2003 Sims 1995

Jadad 1996 Thomson 1989

Marshall 2000 WHO 1992

Moher 2001 Wing 1994

Oliver 1996 Wood 1997

Characteristics of included studies [ordered by study ID]

Art therapy for schizophrenia or schizophrenia-like illnesses (Review) 14

Green 1987 (Continued)

Outcomes Leaving the study early .

Bias Authors' judgement Support for judgement

Allocation concealment? Unclear risk B - Unclear

Participants Diagnosis: chronic schizophrenia of more than 2 years duration.

Outcomes Leaving the study early.

Art therapy for schizophrenia or schizophrenia-like illnesses (Review) 15

Richardson 2002 (Continued)

Bias Authors' judgement Support for judgement

Allocation concealment? Unclear risk B - Unclear

BPRS = Brief Psychiatric Rating Scale

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

DeCarlo 1985 Allocation: randomised.

Diaz Martinez 1996 Allocation: not randomised.

Dincin 1982 Allocation: randomised.

Dobson 1995 Allocation: randomised.

Durell 1968 Allocation: randomised.

Gauthier 1972 Allocation: randomised.

Grodner 1982 Allocation: unclear.

Karon 1972 Allocation: randomised.

Art therapy for schizophrenia or schizophrenia-like illnesses (Review) 16

Study Reason for exclusion

Korlin 2000 Allocation: not randomised, no control group.

Kremer 1984 Allocation: randomised.

Liberman 1981 Allocation: randomised.

Lukoff 1986 Allocation: randomised.

Matthews 1979 Allocation: unclear.

Munjiza 1999 Allocation: randomised