Integrating effect of art- and music-therapy on depression in adolescents
Mansooreh Rahmani1, Bahram Bakhtiari Saeed1*, Mojtaba Aghili2
1
2
Department of Psychology, Gorgan Branch, Islamic Azad University, Gorgan, Iran
Department of Psychology, Gorgan Payame Noor University, Gorgan, Iran
*
Corresponding author: [email protected]
Abstract:
The present paper reports an investigation on integrating effect of art and music therapy in order
to ameliorate depression in adolescents. Due to potential side effects of variety of anti-depressant
medications on clients, especially children and adolescent, a great deal of attention has been paid
to positive effects of non-pharmaceutical interventions to reduce symptoms of depression. A
controlled clinical trial was performed with a sample of 24 depressed adolescents. The Beck
Depression Inventory (BDI) and the Children’s Depression Inventory (CDI) were adopted for
selection and assessment purposes. The adolescents were randomly assigned to two groups, i.e.
control (n = 12) who received no intervention in the course of the study and music and art
therapy (n = 12) who received seven 2-h sessions of art and music therapy. Art-therapy was
performed by using painting tasks. Music therapy sessions were performed simultaneously with
art therapy. The subjects were exposed to three music themes, i.e. exhilarating, sad, and
strengthening. The results revealed that integrating art and music therapy could significantly
decrease depression in the adolescents.
Keywords: Adolescents, Art therapy, Depression, Music therapy.
Introduction
Adolescence is an important shifting stage from puberty to adulthood. Adolescents are prone to
variety of physical and mental risks. One of the most important risks in adolescence is depression
which might severely affect adolescents and hinder them from any potential achievement
(Monteiro et al., 2015). Depression is considered a common, debilitating, burdensome, and
chronic mental health problem. Furthermore, it is regarded as a developmental phenomenon
(Hankin, 2015). Adolescent development is accompanied by the appearance of a populationwide rise in susceptibility to depression that is continued in adulthood (Davey et al., 2008).
Depression in adolescence has been widely examined in several investigations (e.g. McPhie &
Rawana, 2015; Hankin, 2015; Monteiro et al., 2015; Dierker et al., 2015; Hamilton et al., 2014;
Monshouwer et al., 2012; Verbeek et al., 2012).
Depression might have variety of consequences such as unhappy temper, reduced concentration
or desire in most actions, being too thin or overweight, insomnia or hypersomnia, anxiety,
exhaustion, feelings of worthlessness, and even thoughts of death or suicide (Dere-Meyer et al.,
2011). Such consequences might be more severe in adolescents who are passing through one of
their most important and sensitive stages of their lives.
Art therapy has been claimed to be effective to cure depression (Preskorn et al., 2004). For one
thing, it may provide a basis for a depressed person to express his/her depression safely (Branch,
1992). Art therapy is considered a soft way by which a depressed person can release his/her
aggression without having to engage in any verbal communication (Harnden et al. 2004). Art
therapy is also beneficial to strengthen the relationship between the client and treatment team
(Dere-Meyer et al., 2011).
Music therapy can be defined as the intended use of music to attain therapeutic results. Music
therapy is frequently presented via group and individual programs after a process of referral and
assessment (Castillo-Pérez et al., 2010). Music therapy arouses cognitive functions, acts on
anxiety, depressive phases and aggressiveness and therefore, considerably improves attitude,
communication and independence (Guétin et al., 2009). Maratos et al. (2008) claimed that music
therapy is accepted by people suffering from depression and it can improve mood in them.
Raglio et al. (2012) believe that a music therapy intervention should occur in a therapeutic
setting and be directed by trained music-therapists. Effect of music therapy on depression and
several depression-related disorders have been evaluated (Shirani Bidabadi & Mehryar, 2015;
Zhou et al., 2015; Schwantes et al., 2014; Esfandiari & Mansouri, 2014; Verrusio et al., 2014; Lu
et al., 2013; Romito et al., 2013; Castillo-Pérez et al., 2010).
To the best of our knowledge, no research has been performed yet on integrating effect of music
therapy and art therapy on depression of adolescents. Therefore, the present study was
formulated in order to assess such effect on adolescents.
Subjects and methods
Subjects (n= 24) selected for the present study were all 15 year-old girls belonging to high
schools in Gorgan, a city located in the north of Iran. Approval for study was achieved from
Gorgan Education Office. The questionnaires used in the study were also approved by Research
Department of Education Head Office of Golestan Province, Iran. The Beck Depression
Inventory (BDI) and Children’s Depression Inventory (CDI) were used to find depressed
students in 10 high schools and finally, 24 depressed students were found. Permission were taken
from the students’ parents and they were asked to sign consent forms for their children to
participate in the study. The students were randomly assigned to two groups (n= 12), i.e. control
and experimental. It was assured that all the subjects were not suffering from any other
neurological problem and they were not taking any other psychological treatment since any other
treatment might cause disturbance in the process of the study. The tools adopted in the study
were all anonymous and any information regarding the identity of the subjects was kept
confidential.
The experimental group received music therapy and art therapy simultaneously while the control
group didn’t receive any treatment in order to check the potential influence of the therapies used
in the study. Depression levels of the respondents in both groups were evaluated by using the
Beck Depression Inventory (BDI) and the Children’s Depression Inventory (CDI) before and
after the treatment.
The questionnaires
The Beck Depression Inventory (BDI) is a 21-question multiple-choice self-report inventory, one
of the most widely used instruments for measuring the severity of depression. The questionnaire
consists of items which are related to symptoms of depression including hopelessness and
irritability, cognitions like guilt or feelings of being punished, in addition to physical symptoms
like fatigue, weight loss, and lack of interest in sex (Beck, 1972).
The Children’s Depression Inventory (CDI) is a psychological test which evaluates the extents of
symptoms associated with depression in children and adolescents. The CDI is a self-rated and
symptom-oriented 27-item scale which is grouped into five major factor areas. Clients rate
themselves according to their feelings and thoughts and each statement is rated from 0-2
(Kovacs, 1992).
Art therapy
Art-therapy was performed by using painting tasks. Painting was considered because it provides
a basis for the subjects to express their feelings without worrying about any sudden reaction by
audiences. The tools provided for the subjects for painting consisted of crayons, colored pencils,
water color, and papers. The subjects in experimental group were painting 2 hours in seven
sessions. While painting, they were also listening to music.
Music therapy
Music therapy sessions were performed simultaneously with art-therapy. While the music tracks
were playing, the therapist made sure there was no noise or stressor. There were seven 2-h
sessions altogether. The subjects were exposed to three music themes, i.e. exhilarating, sad, and
strengthening. Exhilarating theme consisted of rhythmic music with rather fast beat in order to
induce happiness without too much excitement. Sad theme was tragic and magnificent inducing
sympathy and relief. Strengthening theme included heavy and hard beats stimulating positive and
pleasant feelings and a sense of arousal and excitement. The music tracks were selected by a
counselor with over 10 year experience of working with depressed adolescents.
Data analysis
A Cronbach’s Alpha test was run in order to determine reliability of the questionnaires. In order
to find out whether parametric or nonparametric tests should be used to evaluate the data,
normality of the data was evaluated by using Kolmogorov-Smirnov Test. To understand whether
there were statistically significant (p<0.05) differences within the groups before and after the
intervention, independent t-test was adopted. All operations were performed in SPSS Software
(version 22).
Results
The results obtained from the Cronbach’s Alpha Test indicated that both the questionnaires were
reliable since the alpha for BDI and CDI were found to be 0.787 and 0.712, respectively.
Validity of the tools had also been approved by asking the ideas of experienced experts in the
area of children and adolescents psychology. All the samples had normal distributions and
therefore, we used independent t-test as a parametric test.
Table 1 shows that there is no major change in depression of the adolescents as reported through
BDI from pretest to posttest in control group. However, in the experimental group, the scores
from pretest to posttest decrease considerably. Furthermore, according to Table 2, there is not
any significant difference between the CDI scores of pretest and posttest in control group
(p>0.05); however, a significant decrease was observed from pretest to posttest in art and music
therapy group (p<0.05). These findings illustrate that incorporated use of art and music therapy
helped lessen depression among the participants of the experimental group.
Table 1
Scores on adolescent report of depression (BDI).
Mean Scores
Control group (n = 12)
Pretest
Posttest
41
40
41
38
39
44
35
34
37
44
35
36
43
49
41
41
43
41
41
54
44
45
38
32
39.83
41.50
Art and music therapy group (n = 12)
Pretest
35
37
41
37
46
47
38
45
47
43
45
39
41.67
Posttest
22
21
26
24
14
22
30
24
21
29
22
24
23.25
Table 2
Independent samples t-test on the Beck Depression Inventory (BDI)
Measures
Control
Pretest-posttest
Art and music therapy
Pretest-posttest
Mean difference
Std. error
t
Df
Sig. (1-tailed)
-1.667
2.005
-0.831
22
0.415
18.417
1.734
10.621
22
0.000
As shown by the results in Table 3, the same trend with BDI results can be detected in the case
of CDI. Again, the scores from pretest to posttest in control group had no major change while in
the art and music therapy group, the participants’ scores decreased. Moreover, there was no
significant difference between the scores of participants in control groups from pretest to posttest
(p>0.05) while a significant difference was found in the scores of the participants in art and
music therapy group from pretest to posttest (p<0.05) (Table 4). It again shed light on the
considerable effect of incorporation of art and music therapy in order to reduce depression levels
in adolescents.
Table 3
Scores on adolescent report of depression (CDI).
Mean Scores
Control group (n = 12)
Pretest
Posttest
27
29
32
26
24
28
31
32
27
29
27
40
34
22
29
35
33
34
26
39
30
37
33
28
39.83
41.50
Art and music therapy group (n = 12)
Pretest
29
33
27
29
33
22
43
29
29
27
27
34
41.67
Posttest
26
27
27
28
24
28
31
15
28
22
22
26
23.25
Table 4
Independent samples t-test on the Children’s Depression Inventory (CDI)
Measures
Control
Pretest-posttest
Art and music therapy
Pretest-posttest
Mean difference
Std. error
t
Df
Sig. (1-tailed)
-2.167
1.846
-1.174
22
0.253
4.833
1.923
2.513
22
0.020
Fig. 1 depicts seven paintings representing each single session. The first painting is a crying face
of a woman and a burning candle with falling melted wax as if they are tears of the candle. There
is a great sorrow in the eyes of the woman and the form of the lips is in a way that it reflects a
great sense of indifference which can be a consequence of a big grief.
The second painting shows a girl with long black hair dressed in a red gown through which her
body is also recognizable. It shows a land with seemingly yellow grass and either a blue sky or
blue sea with a beautiful sun in the middle. The red grass might point to a degree of depression in
which the adolescent has considered herself in but there is also a sign of hope for her to reach the
blue sky or sea and the beautiful sun.
In the third painting, there is no person but a view of sea and the beach with some rocks. It seems
like there is no major sign of depression in this picture but it still induces a feeling of
indifference and the fact that there are not enough reasons to be happy.
The fourth painting depicts the face of a girl. Unlike the first painting, there are no tears on the
face of the girl and there is no burning candles. The girl looks confident and she is looking at
somewhere very assertively. There is barely a sign of boredom or irritation. The way she is
looking induces a feeling of hope and purposefulness. Her hair is tidy and she seems to pay a lot
of attention to her appearance. Unless from a very pessimistic point of view, the girl’s face
indicates positive emotions.
In the fifth painting, two trees can be seen, one very upright and fresh and another with falling
leaves. The beautiful sun and blue clouds give a happy sensation to the audience as does the
fresh tree. However, there is a sign of disappointment as the leaves are falling off another tree.
The sixth painting is a plant stand with beautiful green leaves and visible roots. The roots can
indicate the firmness of the plant and green leaves induce a feeling of dignity and prosperity. The
small buds at the tip of some branches also indicate hope of growth and revitalization. It seems
like the painter had a good feeling while painting this plant stand.
The culmination of happiness and livelihood can be seen in the seventh painting. There are
beautiful green tress and birds flying in the beautiful sky with marvelous sun and glorious
clouds. The green lawn is so inspiring and the overall scene can be a spot of choice for everyone
who wants joy and bliss. Needless to say, there is no sign of depression, anxiety, or boredom in
this painting.
Session 1
Session 2
Session 3
Session 4
Session 6
Session 5
Session 7
Fig. 1. Paintings of seven art and music therapy sessions.
It is evident that the participants in the art and music therapy group showed signs of hope and
recovery from depression as the painting they presented in the last sessions were happier and less
depressed that those painted in the first few sessions.
Discussion
The results obtained from the present study revealed that depression among adolescents can be
alleviated by incorporation of art and music therapies. The results from the control group also
implied that depression might exacerbate with time as some participants suffered from higher
level of depression in the posttest.
Brillantes-Evangelista (2013) believes that although visual arts can lead a person to release
his/her life in the form of, say, a painting, gain higher level of awareness cognition about
him/herself, and get to know what kinds of conflicts he/she is suffering from, subjective
therapeutic changes cannot be achieved solely through visual arts. However, in the present study,
consolidation of art therapy with music therapy could significantly lessen depression level
among the adolescents.
One of the most important features of the art therapy adopted in the present study is that it was
performed in a group context where the participants felt containment and they could also
communicate with their mates. This definitely brings them a sense of mutuality and can be
considered as one of the most important factors to reduce the level of depression (Gatta et al.,
2014), especially among adolescents who are shifting into their different role-playing state in
society as more sociable members.
Another very important implication of the present study is that non-pharmaceutical interventions
can also be applied in order to alleviate adverse effects of depression. Of course, the present
study did not compare the effect of art and music therapy and pharmaceutical interventions on
the depression level. However, in a study by Castillo-Pérez et al. (2010), it was revealed that the
subjects in the music-therapy group had less depressive symptoms than those in the
psychotherapy group. Nevertheless, the authors suggested that non-pharmaceutical interventions
would best suit for those suffering from low and medium levels of depression.
One of the distinguishing properties of the present study is incorporated use of art and music
therapy to cure depression in adolescents. However, other combinations are also possible. For
instance, Kim et al. (2014) evaluated the effects of group art therapy along with breath
meditation on the subjective amelioration of depression and anxiety symptoms in adolescents.
They found that group art therapy has a better effect on improving the well-being of the
adolescents when combined with breath meditation. This study had opened an avenue toward the
higher effects of combinations of different psychotherapy methods. However, it seems more
rational to combine interventions which are more popular and easier to teach to potential
therapists. As music is almost always popular among adolescents, it would be easier to make use
of music therapy, instead of breath meditation, combined with art therapy for depressed
adolescents.
Art therapy is a wide concept per se and may include variety of artistic activities from painting to
sculpture. In some studies, variety of artistic activities were used in a single intervention as art
therapy. However, it seems the most popular type of art therapy in literature was painting (Gantt
and Tabone, 1998; Diaz, 2009 as cited in Dere-Meyer et al., 2011; Brillantes-Evangelista, 2013;
Kim et al., 2014; Gatta et al., 2014; Petruta-Maria, 2015, among others). However, it seems that
different types of art therapy, and even different types of, say, painting, might have various
psychological and mental influence. Therefore, we preferred to make use of only one of type of
art therapy (i.e. painting). Nonetheless, it seems very interesting area of research to investigate
effects of different kinds of art therapy in isolation and combination.
There were some limitations concerning the present study. The first limitation is related to
limited number of participants; however, as it seems cumbersome to work this type of subjects,
the results obtained here may be considered valuable. Another limitation, which can be somehow
attributed to the limited number of participants, is the lack of separate art therapy and music
therapy groups in order to compare the effect of each single therapy with each other and with the
ones obtained from incorporating both therapies.
Future research is directed toward investigating the combined effect of art and music therapy on
greater number of participants as there might be some inter- and intrapersonal differences in a
group art and music therapy intervention. Future research can also consider the differences
between art and music therapy in isolation and combination and also goes so far as to analyze
differential influence of variety of arts and different types of music on different age groups.
The findings of the present study support the effectiveness of art and music therapy in
combination on amelioration of depression among 15-year old adolescents. On account of
significant improvement of those adolescents who were subjected to art and music therapy, the
present study implies that adoption of non-pharmaceutical interventions should be first
considered in order to treat adolescents with the symptoms of depression.
Compliance with Ethical Standards:
Authors declare that the present study is in a perfect compliance with ethical standards. All
procedures performed in studies involving human participants were in accordance with the
ethical standards of the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical standards.
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