DOI: 10.7860/JCDR/2021/50465.

0000
Original Article

Effect of Art Therapy on Cognitive

Nursing Section

and Psychological Well-being

of Patients with Major Mental

coincide with the score given in [Table/Fig-6]. there it is given as 35.28

Note for the author: The baseline score of PGWBI given in the abstract doesn't
Disorders-An Experimental Study
S Sharmila1, Thereza Mathias2, J Shivakumara3, Jaison Jacob4

ABSTRACT purposive sampling technique. Data collection was done from

Introduction: Psychological and recreational activities have 1st December 2019 to 31st January 2020. Information was
been found to be useful in the field of psychiatry. ‘Art Therapy’ collected through Montreal Cognitive Assessment (MoCA)
uses therapeutic use of art within the professional role in the Scale and Psychological General Well-being Index (PGWBI)
personal development of the patient by creating art and finding Scale. The pretest was conducted on the first day. Art therapy
meaning through them. People can improve their awareness of sessions were conducted for four consecutive days. Post-test
self and cope with symptoms of stress, anxiety, and traumatic assessments were done on the seventh and fourteenth day.
experiences. They can also improve cognitive abilities and gain Results: The mean baseline MoCA score was 16.70±4.04
pleasure in making art. which improved to 19.10±4.07 on 7th day and 21.28±4.33 on
Aim: To evaluate the effectiveness of art therapy on cognitive 14th day. Similarly, baseline score of PGWBI was 35.48±13.94
functions and psychological well-being among mentally ill which improved to 53.58±13.88 on 7th day and further increased
patients admitted with major mental disorders. to 81.80±17.69.
Materials and Methods: An evaluative approach with a pre- Conclusion: Art therapy has a strong effect on the psychological
experimental, one group pre and post-test design was adopted wellbeing of the patients with mental illnesses and is effective in
to select 60 patients admitted with major mental disorders in improving cognitive functions and psychological wellbeing.
a selected psychiatric unit, Udupi, Karnataka, India through

Keywords: Adjunct therapy, Leisure activities, Mental health, Montreal cognitive assessmentment scale

INTRODUCTION 31st January 2020 at a selected psychiatric unit, Udupi, Karnataka,

Art therapy is one of the complementary therapies useful in a wide India. Ethical clearance was obtained from the Institutional Ethics
spectrum of disorders, disabilities, and diseases including mental Committee (A.J Institute of Medical Sciences and Research Centre),
illnesses. Art therapy influences body and mind interaction that can wide Ref no: AJEC/REV/17/2018, dated 26/3/2018. Consent was
affect physiological and psychological symptoms. By creating a obtained from participants before conducting the study.
work of art, an individual can ventilate his powerful emotions that are Sample size calculation: A purposive sampling technique was
internalised. It is essential for the promotion of well-being of people adopted to select mentally challanged patients admitted with major
with psychological disorders, since art therapy provides changes mental disorders with insight. Based on a pilot study, with the power
in the affective, interpersonal, and relational areas, improving the of the study as 80%, the sample size was calculated (using Open-
emotional balance at the end of each session. It provides patients epi software) and was found to be 60.
with the opportunity to address issues or express without the use
Inclusion criteria: Adults who had been diagnosed with specific
of spoken or written language. Art can not only be used to assess
conditions like schizophrenia, mania and depression and who had
patients but can help in the evaluation of emotional, cognitive, and
an insight into their illness.
developmental conditions of the clients. Few attempts have been
made to examine the effectiveness of art therapy as an adjunctive Exclusion criteria: Patients who were drowsy, violent and
treatment for people with schizophrenia [1-3]. uncooperative.
Results of previous studies have shown a statistically significant
relationship between art and the negative symptoms of schizophrenia Study Procedure
as well as in reducing social and life function problems [3-6]. Studies The instrument used for the study were MoCA Scale, and PGWBI
on the efficacy of art therapy have been conducted in other areas Scale. The following demographic data were also recorded: age,
as well, such as cancer, medical conditions, organic brain disorder, gender, marital status, residing place, education status, occupation,
long-term traumatic injuries, etc., [1,7-9]. However, Very few studies type of family, number of siblings, and history of mental illness.
have been done on mental health and mental illness [2,10]. Hence, MoCA scale was used to assess the cognitive functions among
this study was undertaken to assess the effectiveness of art therapy mentally ill patients. It has eight items. The tool consists of six areas
on the cognitive and psychological well-being of mentally ill patients with a maximum score of 30. Each correct answer has a score of
(viz., schizophrenia, depression, mania) with intact insight. one and the wrong interpretation is given a score of zero. Scores less
than 17 indicate severe impairment, 18 to 23 indicate mild impairment
MATERIALS AND METHODS and 24 to 30 indicate no cognitive impairment [11]. Permission was
An experimental one group pretest post-test research design was obtained for MoCA and was translated in Kannada, reliability was
adopted. The data collection was done from 1st December 2019 to checked using Cronbach’s alpha and found to be 0.98.
Journal of Clinical and Diagnostic Research, 2021. 1
 S Sharmila et al., Effect of Art Therapy on Cognitive Functions and Psychological Well-being www.jcdr.net

PGWBI Scale is a standardised scale with 22 items, with values were more than two observations. Further post hoc test pairwise
ranging between zero and five which assess the psychological and comparison was done using Bonferroni. All the tests were two-
general well-being of respondents in six Health-related Quality of life tailed, and p<0.05 was regarded as statistically significant.
(HRQoL) sections developed in the United States [12]. Score zero
indicates the worst possible level of wellbeing and 110 indicates RESULTS
the maximum level of wellbeing. Scores between 73-110 indicate The sample characteristics revealed that out of 60 participants,
positive wellbeing, 61-72 indicate mild cognitive impairment and less 33.3% were in the age group of 39-48 years, the majority (56.7%)
than 60 indicate severe distress. Permission was obtained to use were females, and married (58.3%) [Table/Fig-2].
and translate the tools in the local language, Kannada. Cronbach’s
Variable Frequency(%)
alpha was used to check the reliability and found to be 0.88 for
Age (in years)
PGWBI scale [13].
20-28 12 (20%)
Pretesting of all the tools was done by administering to ten mentally
ill patients to determine the feasibility, clarity, and ambiguity of the 29-38 9 (15%)
tools and also the time required. 39-48 20 (33.3%)
49-58 12 (20%)
Data Collection Above 58 07 (11.7)
Out of 70, ten participants dropped out (two were non cooperative
Gender
and 8 got discharged before the completion of 14 days), and the
Male 26 (43.3%)
remaining 60 were considered for final analysis. The pre-test analysis
was done on day one. Female 34 (56.7%)

The art therapy sessions were administered by the investigator for Place of residence
45 minutes every day for four consecutive days. During the next 10 Urban 33 (55%)
days patients were allowed to practice art therapy during activities Rural 27 (45%)
by themselves under the observation of a staff. The first two days the Education
patients were shown to prepare paper bags from old newspapers
Primary education 12 (20%)
and the next two days envelop making from coloured papers and
brown sheets. The first post-test was conducted on the 7th day and Secondary education 10 (16.7%)

the second post-test on the 14th day. An atmosphere of safety and High school 20 (33.3%)
support was provided for all the patients [Table/Fig-1]. Pre University Course (PUC) 12 (20%)
Graduate 05 (8.3%)
Post-Graduate 01 (1.7%)
Occupation
Unemployed 15 (25%)
Daily wage worker 30 (50%)
Self-employed 9 (15%)
Government-employed 2 (3.3%)
Professional 4 (6.7%)
Marital Status
Single 23 (38.3%)
Married 35 (58.3%)
Widow/widower 02 (3.4%)
Divorcee -
Type of Family
Nuclear 22 (36.7%)
Joint 34 (56.7%)
Extended 04 (6.7%)
Number of siblings
None 28 (46.7%)
one 14 (23.3%)
two 13 (21.7%)
Three and more 05 (8.3%)
[Table/Fig-1]: The process of art therapy for mentally ill patients. History of admissions in a year
None 10 (16.7%)
STATISTICAL ANALYSIS Once 24 (40%)
Statistical analysis was done by Statistical Package for the Social
Twice 13 (21.7%)
Sciences (SPSS) 17 version. Descriptive statistics were used for
demographic details and categorical variables. The normalcy of Thrice 09 (15%)

each observation of both outcome variables (cognitive functioning More than thrice 04 (6.7%)
and psychological wellbeing) was tested using the ‘Kolmogorov- [Table/Fig-2]: Frequecy and percentage distribution of particpants.
Smirnov’ test and found to have a p>0.05. The p-value justifies
that the data is normally distributed, therefore, parametric tests like Level of Cognitive Functions among Mentally Ill Patients
Repeated Measures Analysis of Variance (RMANOVA), were used Data in [Table/Fig-3] depicts that 95%(57) of patients had cognitive
to find the significant difference between the observation as there function impairment at baseline which reduced to 88.4% (53) on
2 Journal of Clinical and Diagnostic Research, 2021.
 www.jcdr.net S Sharmila et al., Effect of Art Therapy on Cognitive Functions and Psychological Well-being
Note to the author: For pretest and post-test 1 and 2, the sum of all bar graphs should equal 100% but they
are exceeding the value. Kindly check. Also, post-test 1 bar results are not matching with the results in the

the 7th day (post-test 1) after introducing art therapy and further visuospatial, naming, attention, language, abstraction, delayed
reduced to 63.3% (38) by the 14th day (post-test 1). It also shows recall, and orientation [Table/Fig-8].
that severe impairment of cognition was reduced from 58.3% (35)
text. We also suggest mentioning the percentages instead of [Cellrange][value] on each Paragraph.

to 15% (9) and on the contrary, participants having no impairment Psychological Mean difference
Mean (SD) p-value
wellbeing with baseline
improved from 5% (3) to 36.7% (22) in 14 days.
Pre-test 35.28 (13.94)
Post-test 1 53.58 (13.88) -30.68 <0.001
Post-test 2 81.80 (17.69) -57.90 <0.001
[Table/Fig-6]: Effectiveness of art therapy on Psychological General Wellbeing
Index (PGWBI).
F (1.26, 74.37) =292.41, p <0.001)

Time (Mean) df
MoCA at- Post Post F value
Pre-Test Time Error

in [Table/Fig-7], kindly explain.

Note to the author: What is the unit of time (Mean)
tributes Test 1 Test 2
Visuospatial 2.48 3.36 3.9 1.39 82.07 74.63*#
Naming 2.33 2.45 2.71 2 118 29.01*#
Attention 2.36 2.63 3.03 1.61 94.97 22.67*#
Language 1.05 1.33 1.61 1.67 98.59 29.86*#
[Table/Fig-3]: Level of cognitive functioning among the study respondents.
Abstraction 0.75 0.81 0.83 1.11 65.51 129.04*#
The data in [Table/Fig-4] reveals that in the pre-test and positive Delayed Recall 2.76 3.11 3.48 1.17 104.87 50.73*#
wellbeing was not present but after the art therapy intervention Orientation 4.35 4.66 5 1.65 97.83 30.33*#
the positive wellbeing rose to 8.3% (5) on the 7th day and further [Table/Fig-7]: Repeated measures ANOVA on MoCA attributes.
increased to 56.7% (34) on the 14th day. On the contrary, the *p<0.001, df= degrees of freedom,  Sphericity accepted,
distress which was severe in 100%(60) in pre-test was reduced to # Bonferroni pairwise comparison was significant

91.7%(55) on the 7th day and declined to 43.3%(26) by the 14th

day. This data supports that art therapy can influence the positive
well-being of mentally ill patients to a good extent.
Note to the author: the percentage values of the bars do

[Table/Fig-8]: Effect of art therapy on MoCA attributes.

not coincide with values given in text. kindly check

DISCUSSION
[Table/Fig-4]: Level of psychological wellbeing among mentally ill patients. Art therapy has been used as a therapeutic method in various
populations like dementia, alzheimers, schizophrenia, depression,
Cognitive Func- Mean Difference cancer patients, inmates, elderlies. Few studies in mental illness
Mean (SD) p-value
tion with Baseline have revealed art therapy effectively reducing psychiatric symptoms
Pre-test 16.70 (4.04) and improving wellbeing or quality of life [1,4,6]. Thus, researchers
Post-test 1 19.10 (4.07) -2.40 <0.001 wanted to assess how effective art therapy works on cognition
and psychological wellbeing among patients with major psychiatric
Post-test 2 21.28 (4.33) -4.58 <0.001
illnesses like schizophrenia and depression. The result revelaed that
[Table/Fig-5]: Effectiveness of art therapy on Montreal Cognitive Assessment
(MoCA).
art therapy on daily basis is effective for improving cognition and
F (1.32, 78.28) = 177.20, p<0.001) psychological wellbeing.
The current study was focused on major illnesses like schizophrenia,
As there were multiple observations (more than two observations) mania, and depression whereas, others were more specific- on
RMANOVA was used to find the significant difference between depressive symptoms [6] Schizophrenic patients [2,4,14-16],
related population means. The Normalcy was tested using the and dementia [17]. Present study was conducted for two weeks
‘Kolmogorov-Smirnov’ test and found to be normally distributed continuous session and whereas, other researchers like Richardson
(p>0.05). Mauchly’s test of Sphericity indicated that the assumption P et al., Crawford MJ et al., and Leurent B et al., conducted 12-week
of Sphericity was violated, χ2=51.21, p<0.0001, hence, Greenhouse session involving 1.5 hours and Chandraiah S et al., conducted for
Geisser correction was used to test the hypothesis. Data in [Table/ eight weeks, weekly session for 45 to 60 minutes [3,4,6,18]. The
Fig-5] reveals that there was a significant effect of art therapy on current study was most similar to the study conducted by Isaac S
cognitive function (F(1.32,78.28)=177.20, p<0.001) and positive et al., which was conducted on a daily basis for 30 days [10]. The
wellbeing {F(1.26,74.37)=292.41, p<0.001} [Table/Fig-6]. Pairwise above studies suggest that daily sessions of a duration of 45-60
comparison was done using Bonferroni which revealed that the minutes are better than weekly sessions for improving cognitive and
means was significantly different over the period [Table/Fig-7]. psychological wellbeing. Further studies with three month follow-
Repeated measures ANOVA of MoCA variables revealed that there ups are recommended to find the effectiveness of art therapy in
was a significant effect of art therapy on cognitive variables viz., medium term.
Journal of Clinical and Diagnostic Research, 2021. 3
 S Sharmila et al., Effect of Art Therapy on Cognitive Functions and Psychological Well-being www.jcdr.net

The current study findings revealed that art therapy has a good permitting us to use both the standardised tools for the study and
[Table/Fig-8] instead of [Table/Fig-2]. Kindly acknowledge.

influence on cognitive functioning among the mentally ill [Table/ administrative permission to conduct the study permission.
Note to the author: we have changed the table cited to

Fig-8] which was similar to findings of a study conducted in India

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Acknowledgement
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The authors would like to thank all the patients for their cooperation plosone/article?id=10.1371/journal.pone.0112348
during the study. Gratefulness is accorded to the authors for

4 Journal of Clinical and Diagnostic Research, 2021.

www.jcdr.net S Sharmila et al., Effect of Art Therapy on Cognitive Functions and Psychological Well-being

PARTICULARS OF CONTRIBUTORS:
1. Lecturer, Department of Mental Health Nursing, Father Muller College of Nursing, Mangalore, Karnataka, India.
2. Professor and Head, Department of Mental Health Nursing, Laxmi Memorial College of Nursing, Mangalore, Karnataka, India.
3. Professor, Department of Mental Health Nursing, Laxmi Memorial College of Nursing, Mangalore, Karnataka, India.
4. Tutor/Clinical, Department of Instructor Mental Health Nursing, All India Institute of Medical Sciences, Bhubhaneswar, Odisha, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: PLAGIARISM CHECKING METHODS: [Jain H et al.] Etymology: Author Origin
Dr. Thereza Mathias, • Plagiarism X-checker: 000 00, 0000
A.J. Towers, Balmatta, Mangalore, Karnataka, India. • Manual Googling: 000 00, 0000
E-mail: [email protected] • iThenticate Software: 000 00, 0000 (00%)

Author declaration:
• Financial or Other Competing Interests: None Date of Submission: May 21, 2021
• Was Ethics Committee Approval obtained for this study? Yes Date of Peer Review: Jul 09, 2021
• Was informed consent obtained from the subjects involved in the study? Yes Date of Acceptance: Aug 07, 2021
• For any images presented appropriate consent has been obtained from the subjects. NA Date of Publishing: 000 00, 0000

Journal of Clinical and Diagnostic Research, 2021. 5