Journal of Psychosocial Oncology

ISSN: 0734-7332 (Print) 1540-7586 (Online) Journal homepage: https://www.tandfonline.com/loi/wjpo20

Art therapy for anxiety, depression, and fatigue in

females with breast cancer: A systematic review

Yong Tang, Fang Fu, Hua Gao, Li Shen, Iris Chi & Zhenggang Bai

To cite this article: Yong Tang, Fang Fu, Hua Gao, Li Shen, Iris Chi & Zhenggang Bai (2019) Art
therapy for anxiety, depression, and fatigue in females with breast cancer: A systematic review,
Journal of Psychosocial Oncology, 37:1, 79-95, DOI: 10.1080/07347332.2018.1506855

To link to this article: https://doi.org/10.1080/07347332.2018.1506855

Published online: 13 Nov 2018.

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JOURNAL OF PSYCHOSOCIAL ONCOLOGY
2019, VOL. 37, NO. 1, 79–95
https://doi.org/10.1080/07347332.2018.1506855

ARTICLE

Art therapy for anxiety, depression, and fatigue in

females with breast cancer: A systematic review
Yong Tanga, Fang Fub, Hua Gaoc, Li Shend, Iris Chie, and Zhenggang Baif
a
School of Psychology and Sociology, Shenzhen University, Guangdong, 518060, China; bSchool
of Social Development and Public Policy, Fudan University, Shanghai, China; cSchool of Law and
Politics, Tianjin University of Technology, Tianjin, China; dDepartment of Sociology, Shanghai
Normal University, Shanghai, China; eSchool of Social Work, University of South California;
f
School of Public Affairs, Nanjing University of Science and Technology, Nanjing, China

ABSTRACT KEYWORDS
This systematic review employed a meta-analysis to examine Art therapy; meta-analysis;
the effectiveness of art therapy for treating anxiety, depression, anxiety; depression; fatigue;
and fatigue in female patients with breast cancer, the most breast cancer;
randomized trial
prevalent cancer and the most common cause of cancer-related
mortality among women worldwide. The review included nine
original studies and analyzed data from a total of 754 patients.
Data extraction and quality assessment were conducted by two
independent reviewers. In total, 1,466 articles were retrieved.
We excluded studies in which the participant, interventions, and
study design did not satisfy the inclusion criteria, leaving nine
articles for analysis, The Cochrane risk of bias assessment tools
were used for quality evaluation. The analysis revealed a signifi-
cant difference in treatment outcomes between patients who
received art therapy and those who did not (SMD ¼ –0.48,
95%CI [–0.75, –0.21, p ¼ 0.0005]). The review provides initial evi-
dence to suggest that art therapy benefits female breast cancer
patients with respect to the treatment of anxiety, depression,
and fatigue. However, additional and better-quality studies must
be conducted, particularly with larger sample sizes, greater
specificity of the design of trials and interventions, and a longer
follow-up duration.

Introduction
Description of the condition
Breast cancer is the most prevalent form of cancer and the most common
cause of cancer-related mortality among women worldwide.1,2 Breast cancer
is currently the most common cancer diagnosis and accounts for 9.6% of
all deaths from cancer worldwide.3,4 Approximately 10% of women will be
diagnosed with female breast cancer at some point during their lifetime.4
Studies have found that women with breast cancer report experiencing

CONTACT Fang Fu fufang812@163.com School of Social Development and Public Policy, Fudan
University, Room 926, 9th floor, Wenke Building, Handan Road, Shanghai 200433, China.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/wjpo.
ß 2018 Taylor & Francis Group, LLC
80 Y. TANG ET AL.

anxiety, depression, fatigue, and low self-esteem.5–7 These studies have also
reported that psychological therapy lessens the burden of breast cancer for
patients.8 Breast cancer diagnosis is a key turning point in a female patient’s
life. The diagnosis may cause her to experience severe and persistent emo-
tional, physical, and social suffering. Such a diagnosis also engenders anxiety
and depression associated with future prognosis and potential mortality.

Description of the interventions

Art therapy offers patients a way to communicate experiences, feelings, and
needs that are difficult to convey verbally.9 In this study, art therapy is an
umbrella term for therapies that may involve music, visual arts, dance,
movement, sculpture, poetry, and drama. Existing studies provide evidence
of the positive effects of art therapy. Evidence has shown that art therapy
interventions for problems, such as physical health and chronic disease, can
reduce accompanying symptoms of anxiety, depression, fatigue in cancer
patients and increase their self-esteem and cohesion.10,11 Art therapy is
therefore increasingly used in psycho-oncology with the goal of psycho-
social stabilization and providing support in coping with cancer.

Art therapy with females breast cancer patients

Studies have revealed that anxiety and depression are emotional stressors
that are negative factors closely related to cancer.12,13 Some meta-analyses
have explored anxiety and depression among different cancer patients,14
but few studies have assessed the effects of art therapy on the psychological
and physical conditions of female breast cancer patients.8,15 Furthermore,
no review that has assessed the available data on all forms of art therapy
used with these patients.
We found three new issues through our literature review. First, as men-
tioned previously, art therapy is a broad category encompassing all forms
of art, including musical, dance, and visual arts. Although some studies
show that music therapy has beneficial effects on pain, anxiety, depression,
and the quality of life among patients with cancer,16,17 these studies did
not examine other types of art therapy interventions.
Second, studies have established anxiety and depression as two types of
emotional distresses that most commonly accompany cancer,18 although
few empirical trials have assessed the effects of art therapy on female breast
cancer patients’ coping with fatigue.5,19 Cancer patients characterize fatigue
as a feeling of overwhelming exhaustion and lack of energy and enthusi-
asm. Most breast cancer patients and survivors experience high levels of
fatigue during and following treatment. According to Thompson,17 women
 JOURNAL OF PSYCHOSOCIAL ONCOLOGY 81

diagnosed with Stage II breast cancer experienced high levels of fatigue

after receiving chemotherapy. Patients may experience fatigue for months
to years following the completion of their treatment. Based on this evi-
dence, we include fatigue as a new outcome in this study.
Third, although multiple studies using art-related interventions with cancer
patients have reported positive outcomes, the treatment effect may be small
and unconvincing to caregivers, patients, and their families.20,21 For example,
studies have provided initial evidence that art interventions benefit adult
cancer patients by reducing symptoms of anxiety and depression. However,
higher quality research is required, particularly for drama and dance move-
ment therapies.21 Differences in study designs, interventions, types, durations,
intervention intensity, and art therapists may also produce varying results.
An increasing demand for art therapy among patients has highlighted the
need for research on this form of intervention.22 No review has assessed the
available data on art therapy specifically in female breast cancer patients, par-
ticularly in the Chinese context. The present review aims to evaluate existing
evidence and examine the effects of art therapy on reducing the levels of
anxiety, depression, and fatigue in female breast cancer patients including
Chinese patients using the vigorous systematic review method detailed in the
Cochrane Handbook of Systematic Reviews of Interventions.23

Methods
Search strategy
We searched electronic databases, including MEDLINE/PubMed,
ScienceDirect, Springer, ProQuest, SSCI, SAGE, EBSCO, Campbell Library,
and the Cochrane Central Register of Controlled Trials (CENTRAL), for
eligible studies published since January 2006. We searched Google Scholar
for gray literature and attempted to identify additional studies from the
references of studies cited therein. We also performed a search in Chinese
in the following databases: China National Knowledge Infrastructure
(CKNI), Chinese Biomedical Medicine Database, Chinese Scientific
Journals Full-Text Database and Wan Fang Data.
The search terms used with CENTRAL were as follows: (breast OR
mamma) AND (cancer OR tumor) AND (art therapy OR art therapy OR
music therapy OR dance therapy OR movement therapy OR poetry therapy
OR sculpture therapy OR drawing therapy OR painting therapy) AND
(anxiety) AND (depression) AND (fatigue) AND (clinical trial OR explana-
tory trial OR pragmatic trial OR randomized controlled trial OR RCT).
The search terms used in different databases were slightly different.
Since some breast cancer studies were published in Chinese, we included
relevant publications from both Chinese and English-language databases
82 Y. TANG ET AL.

(our team consisted of four researchers from China and one researcher
from the United States). All of them were unfamiliar with some languages
from other Asian countries, such as, Japanese and Korean. Two reviewers
independently searched and screened the titles and abstracts of the English-
language studies identified by the search against the eligibility criteria, and
two reviewers independently searched and screened the Chinese-language
studies. Selected articles were then retrieved in their entirety and assessed
as to whether they fulfilled the inclusion criteria. The reference lists of all
articles were also reviewed to identify other relevant studies that may have
been overlooked when using the search strategy. Articles written in both
English and Chinese were included in the search criteria.

Inclusion and exclusion criteria

According to the theme and abstract of the present study, two researchers
made a tentative selection of research papers that conformed to the speci-
fied standards. Using the study title and abstract, the two researchers
decided whether to include an article based on the specified inclusion crite-
ria. Excluded studies either were clearly not relevant or clearly did not
meet at least one inclusion criterion. When the value of a study was uncer-
tain, a third researcher was assigned to read the abstract and make a final
decision. In the case of a difference of opinion among the authors, the
opinion of the third researcher was crucial to determine whether to include
the study in this report.
The inclusion criteria for articles in this study were as follows: females
with breast cancer were the subjects of the study; intervention measures
aimed at addressing the psychosocial problems of females with breast can-
cer; a standard and credible research purpose; reported conclusions and
data on the efficacy of the psychosocial intervention; psychosocial health
indicators including anxiety, depression, or fatigue; use of the RCT method;
study written in English or Chinese; and a publication date between the
study’s inception and July 2017.
The exclusion criteria for articles in this study were as follows: females
with breast cancer who reported no psychosocial changes resulting from art
therapy and their cancer diagnoses were in Stage III or IV. The stage of a
cancer is based on the size of the tumor and whether the tumor has spread
to other parts of the body. Cancer patients’ treatment preference and the
surgical options most appropriate for the stage and type of breast cancer
should be considered. Most women with breast cancer will undergo some
form of surgery to remove the tumor in the early stage of cancer. Studies
involving late-stage diagnoses were excluded because cancer in these cases
has spread beyond the breast, and the treatments varied among patients.
 JOURNAL OF PSYCHOSOCIAL ONCOLOGY 83

Data extraction
Two reviewers conducted the literature search independently based on the
inclusion criteria. Two other reviewers reviewed all the searched articles to
evaluate their suitability for inclusion. Uncertainty was resolved through
discussion with the corresponding reviewers. After the selection of studies,
the reviewer extracted the following data from the chosen articles: author,
publication year, country of origin, study design, participants, outcome
measures, art therapy intervention, control intervention, main results, and
adverse events. Discrepancies were resolved through discussion with a third
reviewer. Important missing data regarding the study design and statistical
analysis were obtained by contacting the original authors by email
and telephone.

Outcome assessment
The primary outcome of interest was a reduction in anxiety (measured by
the State-Trait Anxiety Inventory [STAI], State Anxiety Inventory [SAI],
Self-Rating Anxiety Scale [SAS], Hospital Anxiety and Depression Scale
[HADS], and Emotion Thermometers Tools [ETT]); depression (measured
by the Self-Rating Depression Scale [SDS] and Zung Self-Rating Depression
Scale [ZSDS]); and fatigue (measured by the Revised Piper Fatigue Scale-
Chinese version [RPFS-C] and Brief Fatigue Inventory [BFI]). The reduc-
tions were determined based on the rating scale scores, which are expressed
as the standard mean difference (SMD) with a 95% confidence interval
(CI). Outcome measures were determined by the measure that served as
the major outcome in the published articles. Studies were excluded if they
did not use the identified assessments methods.

Assessment of risk of bias

In considering the heterogeneity of interventions and data, this review
adopted the Cochrane risk of bias (RoB) assessment tool to evaluate the
overall quality of the research. The assessment includes six perspectives:
selection bias (selected by random sequence or allocation concealment),
performance bias (blinding of participants and personnel), detection bias
(blinding of outcome assessment), attrition bias (incomplete outcome data),
reporting bias (comprehensive reporting), and other bias.

Statistical analysis
Review Manager 5 meta-analysis software was utilized to generate pooled
estimates of effect size for change in the outcome using the random effects
84 Y. TANG ET AL.

Database: 99 reports
MEDLINE: 28
EMBASE: 24
PsycINFO: 6

Other Sources: 1,466 reports CNKI:15

ProQuest: 46 WANFANG:26
Excluded: 1,439 reports
Google Scholar:1420 Not RCT: 489
Not arts therapy: 368
No depressive, anxiety, or
fatigue symptoms: 42
Others:540

Abstracts: 126

Full Text: 38 reports
Database sources: 22
Other sources:16
Excluded: 88 reports
Not RCT: 35
Not arts therapy: 20
Not depressive, anxiety, or
fatigue symptoms:22

Excluded: 28 reports
Review: 5
Not arts therapy: 5
Not depressive, anxiety, or fatigue symptoms: 11
Data not available:7

Included studies: 9

Figure 1. Literature flow diagram.

model. Heterogeneity was assessed with the Q-test and further validated
with the I2 formula for variability. I2 percentages of 25%, 50%, and 75%
reflect low, moderate, and high heterogeneity, respectively. The authors
described dichotomous variables using odds ratios (ORs), relative risks
(RRs), and risk differences (RDs) and described continuous variables using
mean differences (MDs) and SMDs.

Results
As shown in Figure 1, 1,466 reports, including research articles and studies,
were identified through a comprehensive literature search by the lead
reviewer. From this set, 1,439 reports were excluded because they did fail
to not satisfy the inclusion criteria. Specifically, 489 reports were not RCTs;
368 reports did not examine the impact of art therapy on depressive, anx-
iety, and fatigue symptoms; 42 reports did not address depression, anxiety,
Table 1. Participant characteristics and study methods of included trials.
Free of
Participants’ Main outcomes; tools; Allocation Incomplete selective
Author (date) Country age (N) Intervention Comparison measure time Design concealment Blinding data addressed reporting
Xie (2006) China Age: 32–68 Music, move- Control group Anxiety (SAS); at 2 and RCT Yes Yes Yes Yes
years (70) ment therapy 4 weeks
Gil Bar-sela USA Age: 25–72 Art therapies Control group Anxiety (HADS); Fatigue RCT Yes No Yes Yes
et al. (2007) years (60) (painting with (BFI); at 4 weeks
water-
based paints)
Wu et al. (2010) China Age: 26–63 Music therapy Control group Fatigue (BFI); at 2 days RCT Yes Yes Yes Yes
years (80) and 2 and 4 weeks
Lu and Hu (2010) China Age: 18 Dance, Control group Anxiety (SAI); Rotterdam RCT Yes No Yes Yes
years (110) music therapy, Symptom Checklist; at 3
and 6 weeks
Zhou and China Age: 25–65 Music therapy Control group Anxiety (STAI); at 6 and RCT Yes No Yes Yes
Li (2011) years (105) 9 weeks
Chen, Zheng and China Age: 65 Music therapy Control group Fatigue (RPFS-C); at RCT Yes No Yes Yes
Gao (2011) years (80) 3 weeks
Zhou, Li, Yan, China Age: 25–65 Music therapy Control group Depression (ZSDS); at RCT Yes Yes Yes Yes
Dang, and years (120) 14, 21, and 28 days
Wang (2011)
Huang (2012) China Age: 21–55 Music therapy Control group Depression (SDS); at 3 RCT Yes No Yes Yes
years (60) and 9 weeks
Romito USA Age: 20–75 Music therapy, Control group Anxiety and Depression RCT Yes No Yes Yes
et al. (2013) years (62) emotional (ETT); at 1 month
expression
Control group indicates no other intervention except ordinary therapy.
BFI, Brief Fatigue Inventory; ETT: Emotion Thermometers Tools; FACT-B: Functional Assessment of Cancer Therapy-Breast; HADS: Hospital Anxiety and Depression Scale; ROM: Range of
Motion; RPFS-C: Revised Piper Fatigue Scale-Chinese version; SAI: State Anxiety Inventory; Rotterdam Symptom Checklist; SAS: Self-Rating Anxiety Scale; SDS: Self-Rating Depression
Scale; STAI: State-Trait Anxiety Inventory; ZSDS: Zung Self-Rating Depression Scale.
JOURNAL OF PSYCHOSOCIAL ONCOLOGY
85
86 Y. TANG ET AL.

Figure 2. Assessment of bias risk in the eligible studies.

and fatigue; and 540 reports were excluded for other reasons, including
identification of duplication. Two reviewers independently screened 126
abstracts and excluded 88 of them (20 studies did not focus on art therapy;
22 studies did not investigate the outcome of depressive, anxiety, or fatigue
symptoms; 35 studies were not RCTs; and the remaining 11 studies were
excluded for other reasons, including qualitative synthesis). Of the remain-
ing 38 trials, five were excluded because they were reviews; 11 were
excluded for using depression, anxiety, and fatigue as demographic descrip-
tions rather than outcomes; 5 were excluded for combining art therapy
with co-interventions for depression, anxiety, and fatigue; and 7 were
excluded because data could not be extracted for all elements required by
the 2008 Cochrane Handbook. When ascertaining the eligibility of included
studies, the selection of the two reviewers yielded a kappa coefficient of 0.8,
showing high consistency in the literature search. Table 1 summarizes the
main characteristics of the eligible studies, revealing some variability in
baseline anxiety, fatigue, and depressive symptoms and main outcome
assessment tools. The nine trials were similar in terms of participant age
and basic health condition.

Study design and interventions

All included studies were RCTs published in peer-reviewed journals. Partial
data from the included studies were deemed appropriate for use in the
meta-analysis. These data were obtained either from statistical imputation
or directly from the original authors. Each of these studies compared art
therapy to different interventions and controls. A detailed description of
the characteristics of the studies is reported in Table 1. Each of the nine
included studies compared art therapy to different interventions and con-
trols, as follows: Xie examined music therapy and movement therapy24;
Bar-Sela et al. examined art therapy (i.e. painting with water-based paints)
 JOURNAL OF PSYCHOSOCIAL ONCOLOGY 87

Figure 3. Summary of the RoB assessment in included studies.

and a control group;9 Lu and Hu examined dance therapy, music therapy

and a control group25; Wu et al., Chen, Zheng, & Gao, Zhou, Li, Yan, Dan,
& Wang, Zhou & Li examined music therapy with a control
group19,20,26–28; and Romito et al. examined music therapy and emotional
expression with a control group.29

Types of participants
The characteristics of the included studies are summarized in Table 1.
These studies were conducted in three different countries and regions,
namely, the USA (n ¼ 1),29 Israel (n ¼ 1),9 and mainland China
(n ¼ 7).19,20,24–28 The sample sizes range from 60 to 120. Three studies used
music therapy alongside standard therapies (i.e. movement therapy, dance
therapy, and emotional expression) to compare outcomes with a control
group.24,25,29 Two studies involved diagnoses of varying degrees of
88 Y. TANG ET AL.

Figure 4. Effect size of arts therapy versus control in decreasing anxiety rating scores. Note:
CI ¼ confidence interval.

fatigue,19,26 five studies involved diagnoses of anxiety,9,24,25,28,29 and two

studies involved diagnoses of depression.28,29

Outcome measures
Zhou and Li measured anxiety symptoms using the STAI.27 Lu and Hu
measured anxiety symptoms using the SAI.25 Huang measured depressive
symptoms using the SDS measure (the SDS score range was 0.50–0.69).20
Chen et al. measured fatigue symptoms using the RPFS-C and the BFI.19
Xie measured anxiety symptoms using the SAS.24 Zhou et al. measured
depressive symptoms using the ZSDS.27 Bar-Sela et al. measured anxiety
and fatigue symptoms using the HADS and BFI.9 Romito et al. measured
anxiety and depressive symptoms using the ETT.29

Quality of study methods

Figures 2 and 3 show the assessment of bias risk in the eligible studies.
Bar-Sela et al. included blinding of the outcome assessor and an intention-
to-treat (ITT) analysis.9 Long-term follow-up data, which were collected at
the conclusion of the interventions, were described in three studies. Zhou
& Li and Huang reported follow-up for nine weeks.20,28 Wu et al, Bar-Sela
et al., and Romito et al. assessed follow-up outcomes for four weeks.9,26,29
All the studies reported the outcomes planned in the research protocol.
Wu et al., and Zhou, Li, Yan, Dan, and Wang reported follow-up data at
three-time points (2 days, 2 and 4 weeks; 14, 21, and 28 days).26,27 Lu &
Hu, Zhou & Li, and Huang reported follow-up at two-time points (three
and six weeks; six and nine weeks; three and nine weeks).20,25,28 Bar-Sela
et al., Chen, Zheng & Gao and Romito et al. reported only one follow-up
assessment (three weeks; four weeks).9,19,29 Xie used a very small sample,
creating the risk of overestimated intervention outcomes.24

Effect of art therapy on anxiety, depression, and fatigue

Figure 4 presents the meta-analysis results of the effect of art therapy based
on the rating scores for anxiety symptoms. The pooled SMD calculated
 JOURNAL OF PSYCHOSOCIAL ONCOLOGY 89

Figure 5. Effect size of arts therapy versus control in decreasing depression rating scores. Note:
CI ¼ confidence interval.

Figure 6. Effect size of arts therapy versus control in decreasing fatigue rating scores. Note:
CI ¼ confidence interval.

Figure 7. Effect size of arts therapy versus control in decreasing anxiety rating scores. Note:
CI ¼ confidence interval.

Figure 8. Effect size of arts therapy versus control in decreasing depression rating scores.

using the random effects model was –0.48 (95% CI –0.75 to –0.21,
p ¼ 0.0005), showing a significant difference between art therapy and the
control conditions. Figure 5 presents the meta-analysis results of the effect
of art therapy on the rating scores for depressive symptoms. The pooled
SMD calculated using the random effects model was –6.59 (95% CI –7.70
to –5.47, p < 0.00001), showing a significant difference between art therapy
90 Y. TANG ET AL.

Figure 9. Sensitivity analyses: Effect size of arts therapy versus control in decreasing anxiety on
rating scores.

and the control conditions. Figure 6 presents the meta-analysis results of

the effect of art therapy on the rating scores corresponding to fatigue. The
pooled SMD calculated using the random effects model was –1.90 (95% CI
–2.93 to –0.87, p ¼ 0.0003), indicating a significant difference between art
therapy and the control conditions.
Lu & Hu and Zhou & Li compared art therapy with a control condition
for a period of less than four weeks (Figure 7).25,28 The SMD was –7.07
(95% CI –11.21 to –2.93, p ¼ 0.63), suggesting a small effect on self-
reported depression favoring art therapy. However, the result was not stat-
istically significant (p ¼ 0.000), and no significant heterogeneity
between studies.
Zhou, Li, Yan, Dang, & Wang compared art therapy with a control con-
dition in terms of decreasing depressive symptoms over a period less than
four weeks (Figure 8).27 The SMD was –6.48 (95% CI –7.68 to –5.28) and
favored art therapy but the difference was not statistically significant at
four weeks (p < 0.00001). Huang20 compared art therapy with a control
condition in terms of decreasing depressive symptoms for a period longer
than four weeks (Figure 8). The SMD was –7.27 (95% CI –10.30 to –4.24),
thus favoring art therapy but reaching a statistically insignificant level at
four weeks (p < 0.00001). There was no significant heterogeneity
between studies.

Sensitivity analyses
Sensitivity analyses, or assessments of the individual effects of pooled vari-
ables, were conducted by excluding studies assumed to have large effects
on meta-analysis results because of the participants’ baseline health. After
excluding the Lu & Hu study from the analysis,25 the SMD was –0.46
(95% CI –0.73 to –0.18), suggesting a small effect on depressive symptoms
favoring art therapy at a statistically significant level (p ¼ 0.001). No sig-
nificant heterogeneity between studies was observed, showing that the
effect size of art therapy compared with that of a control group was larger
in terms of decreasing depressive symptoms in female cancer patients
(Figure 9).
 JOURNAL OF PSYCHOSOCIAL ONCOLOGY 91

Discussion
Nine randomized control trials with female breast cancer patients (total
number ¼747) were examined to assess the impact of art-related interven-
tions on reducing symptoms of anxiety, depressive, and fatigue. Our review
confidently supports art therapy as a highly effective intervention for anx-
iety, depression, and fatigue. The reviews combined different comparison
interventions and induced greater heterogeneity than tolerated in this ana-
lysis. We also found art interventions effective. Wide variations were
observed in participants’ demographics, the quality of the methodology,
designated outcomes, the duration of the intervention, time spent practic-
ing art therapy, and the sample size. However, all nine studies reported on
anxiety, depression, or fatigue, which made them suitable for analyses.
Heterogeneity in comparison interventions and participant health condi-
tions was resolved through subgroup analyses and sensitivity analyses. The
main meta-analysis revealed a significant difference in terms of decreasing
depression, anxiety, and fatigue scale scores when comparing art therapy
with the absence of therapy. Subgroup analyses were used to investigate the
effect of participant health condition on the effectiveness of art therapy for
decreasing depressive symptoms. In this respect, art therapy was found to
be more effective at decreasing depressive symptoms among female cancer
patients who received art therapy for four weeks than among control par-
ticipants. In terms of the sensitivity analysis, the results changed when the
Lu and Hu’ study25 was deleted from the pooled analysis to explore the sta-
bility of the final results. This change implies that art therapy has a greater
effect than no art therapy in terms of decreasing the depressive symptoms
of female cancer patients.
Of the nine analyzed studies, four studies9,27–29 were considered high in
quality because each fulfilled more than two quality assessment criteria.
The remaining studies were rated as moderate in quality because they satis-
fied fewer than two quality assessment criteria for internal validity. Some
quality problems included insufficient power, detection bias induced by
self-reporting, no ITT analysis and no reported treatment fidelity.
Among these studies, some collected only baseline data on psychological
variables and did not measure depressive, anxiety, and fatigue symptoms as
outcomes. These studies were therefore excluded from the present review.
When comparing art therapy with a control condition in assessing
decreases in anxiety, depression, and fatigue symptoms among participants,
the results favored art therapy but did not show a significant difference
between the two conditions (SMD ¼ –0.25; 95% CI –0.55 to 0.05; p ¼ 0.10).
This finding underscores the necessity for additional research on the effects
of art therapy on depressive, anxiety, and fatigue symptoms.
92 Y. TANG ET AL.

Implications of the findings

Incorporating art therapy within the hospital or clinical environment where
cancer patients are being treated can be very beneficial. Many clinics and
hospitals conduct chemotherapy and radiation regularly, and breast cancer
patients spend many hours waiting for and receiving treatments. This time
would offer ideal opportunities for patients and even family members to
participate in art therapy programs. Such programs could be designed for
individuals, families, or even groups. Cancer is an overwhelming experience
for not only the patient as well as anyone who supports them, including
friends or family. Having an on-staff art therapist available for patients and
supporters would be helpful. Even after the treatment is completed, the
patient and survivors would benefit from assistance from a community-
centered group in helping them cope with their new reality. Cancer support
groups centered on an activity tend to help patients and survivors engage
in new activities and distract them from negativity. Participation in an
open studio art group would be an excellent opportunity for patients
and survivors.
Other ways to combat depression and fatigue, including the use of mind-
fulness practices, positive psychotherapy, expressive arts therapies and art
therapy, have been examined by studies. These practices and therapies are
also helpful in improving patients’ quality of life.

Conclusion
The strengths of the present systematic review include the use of a system-
atic and transparent literature search and standardized inclusion and study
evaluation criteria. To our knowledge, the present study is the first system-
atic review to examine the effectiveness of art therapy in terms of reducing
depressive, anxiety, and fatigue symptoms among female breast cancer
patients. This study is also the first to include fatigue as an outcome.
Based on the results, we can conclude that art therapy is effective in
decreasing depressive, anxiety, and fatigue symptoms. The results from the
subgroup analysis further suggest that art therapy is slightly more effective
than control conditions in decreasing these symptoms among female breast
cancer patients, although the difference is not statically significant.
Given the unique characteristics of art therapy, it might be a preferable
form of therapy for female breast cancer patients because it features min-
imal risk. However, we could not confirm these benefits in the present
study. The findings should be interpreted with caution given the limited set
of studies included in the present meta-analysis. Future trials should strive
to improve quality and reporting. The use of concealed allocation and
blinded assessors is important to reduce bias. Attention should also be
 JOURNAL OF PSYCHOSOCIAL ONCOLOGY 93

given to the timing of assessment, the duration of the intervention to maxi-

mize benefits, and the styles of art therapy examined. Care providers
should determine whether art therapy is an appropriate intervention based
on the resources, abilities and needs of their clients. Due to differences in
both culture and policy across patients and care providers, further confirm-
ation of the present study’s findings is required to ascertain whether or
how the conclusions can be extended.

Limitations
We are cognizant of the limitations of our search results. First, we have
relied heavily on published studies, particularly those that could be accessed
electronically. Although reviews comparing art therapy with other interven-
tions for depression, anxiety, and fatigue were identified during the search
process, none of the reviews used the rigorous meta-analysis methodology
of the Cochrane Handbook to examine the effect size of art therapy for
reducing depression, anxiety, and fatigue in female breast cancer patients.
Second, the present review is limited in terms of its applicability and general-
izability due to the small number of participants. Generalizability refers to
both implications for specific practice and indications for further research.
Because of the small sample size, this study review has a low effect size in
terms of its generalizability for practice, but its results are preferable to no
evidence in guiding future research and practice. Third, the results suggest
that more research is required to examine the true effects of art therapy
on anxiety, depression, and fatigue. Fourth, the current study was not
actually a worldwide study because it included only journal papers published
in English and Chinese. It would be helpful to go beyond just a Chinese
population and focus on the benefits of art therapy overall.

Disclosure statement
No potential conflict of interest was reported by the authors.

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