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Uttley et al. BMC Psychiatry (2015) 15:151
DOI 10.1186/s12888-015-0528-4
RESEARCH ARTICLE Open Access
The clinical and cost effectiveness of group
art therapy for people with non-psychotic
mental health disorders: a systematic
review and cost-effectiveness analysis
*
Lesley Uttley , Matt Stevenson, Alison Scope, Andrew Rawdin and Anthea Sutton
Abstract
Background: The majority of mental health problems are non-psychotic (e.g., depression, anxiety, and phobias). For
some people, art therapy may be a more acceptable alternative form of psychological therapy than standard forms
of treatment, such as talking therapies. This study was part of a health technology assessment commissioned by
the National Institute for Health Research, UK and aimed to systematically appraise the clinical and cost-effective
evidence for art therapy for people with non-psychotic mental health disorders.
Methods: Comprehensive literature searches for studies examining art therapy in populations with non-psychotic
mental health disorders were performed in May 2013. A quantitative systematic review of clinical effectiveness and
a systematic review of studies evaluating the cost-effectiveness of group art therapy were conducted.
Results: Eleven randomised controlled trials were included (533 patients). Meta-analysis was not possible due to
clinical heterogeneity and insufficient comparable data on outcome measures across studies. The control groups
varied between studies but included: no treatment/wait-list, attention placebo controls and psychological therapy
comparators. Art therapy was associated with significant positive changes relative to the control group in mental
health symptoms in 7 of the 11 studies. A de novo model was constructed and populated with data identified from
the clinical review. Scenario analyses were conducted allowing comparisons of group art therapy with wait-list
control and group art therapy with group verbal therapy. Group art-therapy appeared cost-effective compared with
wait-list control with high certainty although generalisability to the target population was unclear; group verbal
therapy appeared more cost-effective than art therapy but there was considerable uncertainty and a sizeable
probability that art therapy was more cost effective.
Conclusions: From the limited available evidence art therapy was associated with positive effects compared with
control in a number of studies in patients with different clinical profiles. The included trials were generally of poor
quality and are therefore likely to be at high risk of bias. Art therapy appeared to be cost-effective versus wait-list
but further studies are needed to confirm this finding in the target population. There was insufficient evidence to
make an informed comparison of the cost-effectiveness of group art therapy with group verbal therapy.
Trial registration: HTA project no. 12/27/16; PROSPERO registration no. CRD42013003957.
Keywords: Art therapy, Mental health disorders, Psychological therapy, Systematic review, Health technology
assessment, Cost-effectiveness
* Correspondence: l.uttley@sheffield.ac.uk
School of Health and Related Research (ScHARR), University of Sheffield,
Regent Court, 30 Regent Street, Sheffield S1 4DA, UK
©2015 Uttley et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://
creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Uttley et al. BMC Psychiatry (2015) 15:151 Page 2 of 13
Background Methods
Mental ill health is recognised as the largest cause of Search methods
disability in the United Kingdom [1]. The UK Depart- Comprehensive literature searches were used to inform
ment of Health have prioritised making mental health the clinical and cost-effectiveness reviews. A search
services more effective and accessible in response to strategy was developed to identify reviews, randomised
evidence that such services are not meeting the needs controlled trials (RCTs), economic evaluations and all
of some groups of people [2, 3]. The majority of mental other study types relating to art therapy. Search terms
health problems are non-psychotic (e.g., depression, were restricted to “art therapy” or “art therap$”.Metho-
anxiety, and phobias). For some people with these con- dological search filters were applied where appropriate.
ditions, art therapy may be an acceptable alternative Noother search limitations were used and all databases
form of psychological therapy than more standard were searched from inception to present. Searches were
forms of treatment, such as talking therapies [4]. For conducted from May–July 2013.
example, for those who find it difficult to express them- Databases searched were: MEDLINE and MEDLINE
selves in verbal language alone as required by more in Process & Other Non-Indexed citations; EMBASE;
standard forms of treatment for mental health prob- Cochrane Library; Science Citation Index; Social Sciences
lems, arts therapies can provide an alternative means of Citation Index; CINAHL: Cumulative Index to Nursing
expression to help service users understand, make and Allied Health Literature; PsycINFO; AMED: Allied
sense of, and cope with their distress. There is some and Complementary Medicine; and ASSIA: Applied Social
published evidence to support the claim that art Sciences Index and Abstracts. All resources were searched
therapy is effective in treating a variety of symptoms from inception to present.
and disorders in patients of different ages [5, 6]. How-
ever, to date a full systematic review of the clinical Clinical effectiveness review methods
and cost-effectiveness of art therapy for non-psychotic Screening of records, study selection, and data extrac-
mental disorders had not been undertaken. This pro- tion were performed by one assessor and checked by a
ject aimed to systematically review the current clinical second assessor. All studies identified for inclusion
and cost-effectiveness evidence for art therapy for at abstract stage were obtained in full text for more
people with non-psychotic mental disorders. In ad- detailed appraisal. Non-English studies were translated
dition, a de novo cost-effectiveness analysis would be and included if relevant. Quality assessment of included
undertaken if the systematic review did not identify studies was performed independently by two reviewers
suitable studies. using quality assessment criteria adapted from the
Art therapy is a specific branch of treatment under Cochrane risk of bias, CRD guidance, and CASP check-
the umbrella term “arts therapies” used by the Health lists to develop a modified tool to allow comprehensive
Care Professions Council (HCPC) which includes drama and relevant quality assessment for the included trials.
therapy and music therapy. For the purpose of this The inclusion and exclusion criteria for the clinical ef-
review these other forms of arts therapies, which do fectiveness review are documented in Table 1.
not centre on the creation of a sustainable, physical
piece of visual art, are excluded. Despite art therapy Mathematical modelling methods
being an established and practised form of psycho- A de novo mathematical model was constructed. Due to
logical therapy for decades, only more recently have the nature of the study question it was deemed that a
researchers in the field of art therapy addressed the need complex model was not required, and that a simple
to integrate art therapy into a model of evidence-based model which could more clearly demonstrate the impact
practise. Therefore, an abundance of literature exists of key drivers of the cost effectiveness ratio would be
consisting of single case studies or theoretical concepts sufficient. As such, an area under the curve model was
in art therapy [7]. This study was part of a health technol- developed to estimate the gain in utility with the follow-
ogy assessment commissioned by the National Institute ing assumptions in the base case.
for Health Research, UK and aimed to systematically
assess: 1. That the maximum treatment effect would be
associated with the time at which treatment ended.
a)Whatistheevidencethatarttherapyis 2. That there would be a linear increase in treatment
clinically effective in people with non-psychotic effect, from zero at baseline to the maximum at the
mental health disorders? time at which treatment ended.
b)Whatistheevidencethatarttherapyis 3. That there would be a residual effect of treatment
cost-effective in people with non-psychotic with a linear decline in benefit until there was zero
mental health disorders? benefit at 52 weeks.
Uttley et al. BMC Psychiatry (2015) 15:151 Page 3 of 13
Table 1 Inclusion and exclusion criteria for the systematic review and Cognitive Behavioural Group Training provided lar-
Included Excluded ger decreases in an outcome measure (the Spielberger
Population Non-psychotic clinical People with psychosis Test Anxiety Inventory) [12] the effect had not entirely
samples Healthy samples waned at twelve month follow-up. This may be generalis-
a able to other forms of successful psychological therapy,
Intervention Group art therapy as might Other “arts therapies” and conservatively we elected to assume that all benefit
be delivered in the NHS including drama; music;
and dance had dissipated at 52 weeks post treatment, although a lon-
Play therapy ger period of 104 weeks was used in sensitivity analyses.
Comparator Any including: interventions None The conceptual model used to calculate the utility gain
including an RCT containing across time is shown in graphical form in Fig. 1. In this
art therapy; treatment as figure it is assumed that there is a gain in utility of
usual; waiting list; attention 0.0780 at week 8. The area under the curve was then
placebo; or other translated in quality adjusted life years (QALYs) assum-
psychological therapy
Outcomes Primary: treatment Outcomes focussed on ing 52.18 weeks per year. The QALY considers both
effectiveness; response as interpretation of the art duration and quality of life: a person living 10 years at a
determined by changes in work itself, not the utility of 0.5 would accrue 5.0 undiscounted QALYs
mental health rating scales; participant whilst a person living 8 years with a utility of 0.8 would
Secondary: Related clinical accrue 6.4 undiscounted QALYs.
or quality of life outcomes
Studies Randomised controlled trials Non-randomised
controlled studies Results and discussion
a
Whilst the full health technology assessment (Uttley et al., in press) included The total number of published articles yielded from elec-
studies of both individual and group art therapy, only studies of group art tronic database searches after duplicates were removed
therapy are included in this paper was 10,073. An additional 197 records were identified
4. That given the short assumed duration of benefit, from supplementary searches, resulting in a total of
discounting of future costs and benefits was not 10,270 records for screening. Of these, 10,221 records
necessary. were excluded at title/abstract screening. Figure 2 shows
the flow of studies identified and included in the review.
The rationale for choosing 52 weeks as the base case
duration of residual benefit was based on a number of Clinical effectiveness results and discussion
relevant references. Discussing data in Nicholson and Eleven RCTs of group art therapy were included in the
Berman [8] and in Lambert and Ogles [9], Cooper wrote clinical effectiveness review. Eight of the studies were
that ‘findings from the empirical research are fairly clear: conducted in adults and three were conducted in chil-
clients, on average, do not tend to improve once their dren. All trials had small final sample sizes with the
therapy is over...., but equally they do not tend to deterior- number of participants reported to be included in each
ate rapidly’ [10]. More recent data provided in Sportel et study ranging between 18 and 111. The total number of
al. [11], indicate that where Cognitive Bias Modification patients in the included studies is 533.
0.090
0.080
0.070
0.060
n
y gai0.050
t
i
l
i0.040
Ut
0.030
0.020
0.010
0.000
0 50 100 150 200 250 300
Time from start of treatment (weeks)
Fig. 1 An illustration of the conceptual model of utility
Uttley et al. BMC Psychiatry (2015) 15:151 Page 4 of 13
Fig. 2 A modified PRISMA flow diagram of the studies identified and included in the clinical effectiveness review
As can be seen from Table 2 eight studies compared effects depending on what art therapy is compared
art therapy with an active control group. The compara- against. Additionally, despite common mental health
tor groups from the included studies can be seen in symptoms being investigated across the included RCTs,
Fig. 3. Two of the studies were versus a psychological the majority of studies were using different measure-
therapy (Broome [13] & Thyme [14]) whereas six studies ment scales to assess these outcomes (see Table 3).
were attention placebo control groups which mimic the Therefore as there is insufficient comparable data on
amount of time and attention the intervention group outcome measure across studies it is not possible to per-
receives. Three studies compared art therapy with a form a formal pooled analysis.
wait-list control or treatment as usual. The majority of Potential treatment effect modifiers include the experi-
studies were conducted in a community/outpatient set- ence/qualification of the art therapist, characteristics
ting, but the precise setting location for conducting the that were not consistently reported. Also, the age of the
intervention was not reported in four studies (Broome included patients could be a potential effect modifier as
[13]; Kim [15]; Monti [16]; Monti [17]) and one study eight studies are of adults and three are of children. Pre-
was reported to be conducted in an outpatient setting existing physical conditions were present in seven of the
(Lyshak-Stelzer et al. [18]). included studies which could also represent a potential
The symptoms or ‘outcome domains’ under investiga- treatment effect modifier.
tion and associated outcome measures are reported in The direction of statistically significant results from
Table 3. the 15 included RCTs are summarised in Table 4.
The study populations were heterogeneous in their As can be seen in Table 4, in 10 of the 11 included
clinical profiles highlighting the wide application of art studies there were improvements from baseline in some
therapy but also demonstrating the difficulty in obtain- outcomes in the art therapy groups. However, both the
ing a pooled estimate of treatment effect. The control intervention and the control groups improved from
groups across the included studies are heterogeneous baseline in three studies with no significant difference
therefore there may be different estimates of treatment between the groups (Broome [13]; McCaffrey [19] and
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