Efficacy of Collage Therapy on Anxiety and Depression of Cancer Patients under Chemotherapy

The present study aimed to investigate efficacy of collage therapy on anxiety and depression or spirituality of advanced cancer patients under chemotherapy. Eight patients with variety kinds of cancer participated in this study. An art therapist conducted collage therapy to patients during chemotherapy two times. A participant made arts on tables beside a reclining chair or a bed about one hour. They completed the Hospital Anxiety and Depression Scale (HADS) consisted of anxiety and depression, and the FACIT-Sp scale to measure spirituality about meaning of life pre and post the intervention. The Wilcoxon sign rank test was conducted on mean scores of scales. The score of Anxiety significantly decreased from 5.13 to 1.75 (p<.05) and the score of Depression significantly decreased from 6.00 to 3.38 (p<.05). And the total HADS score significantly decreased from 11.13 to 5.13 (p<.05). There was not significance in score of the FACIT-Sp because of ceiling effects. These results showed that collage therapy has potential to alleviate psychological distress like anxiety and depression of advanced cancer patients under chemotherapy.

Distress related to cancer diagnosis and treatment is explicitly tied to a number of common practical, physical, and psychological problems [1]. Depression and anxiety are common among patients receiving palliative care and contribute to a greatly diminished quality of life [2]. Particularly in cases of chemotherapy, patients confronted with fear of ambiguity or recurrence of disease, they often experience anxiety or depression. Jiang [3] showed that art therapy in care decreased anxiety, symptoms, depression, and improved the quality of life of cancer patients from systematic review. Lin, et al. [4] showed effects of art-making intervention on anxiety, depression, psychological well-being and physical well-being of adults with cancer. However, art-making included various types such as visual art, performing art, and integrated both forms of art, and it was no wonder which art therapy was effective. Bozcuket [5] focused on painting, and painting art therapy program (PATP) increased patients’ QOL and decreased depression, but not anxiety measured by the Hospital Anxiety and Depression Scale (HADS) under chemotherapy. And Elimimian [6] showed that Art therapy including painting, drawing, clay work, and collage improved emotional distress, depression, anxiety and pain among cancer patients immediately after the session. Although art therapy was useful to improve psychological distress, since art therapy methods was various and it is hard to confirm which art therapy method was useful. In our previous study, we conducted an art therapy including painting, drawing, or collage for cancer patients under chemotherapy treatment by Ando, et al. [7]. And collage therapy was easy for them to participate it, then we investigated the effects of collage therapy for those kinds of patients. The materials to construct a collage are readily available. Ordinary Collage therapy can be made from magazines, newspaper clippings, or photographs, and a participant cut these papers as elements freely and paste them on a paper. However, we used a collage box method in which a therapist already cut them into elements because of chemotherapy.

The participants were eight cancer patients. The inclusion criteria were cancer in advanced stage ? or IV under chemotherapy, ability to communicate, and age >20 years. The exclusion criteria were severe pain or physical symptoms diagnosed by the primary physician, and cognitive impairment such as dementia or serious mental illness. Performance status (PS) was measured by the Eastern Cooperative Oncology Group Performance Status Rating (ECOG-PSR), which is a single item rating of five activity levels from 0 (fully active) to 4 (completely disabled) [8].

After getting informed consent, the clinical psychologist with art therapist certification conduced collage therapy. A patient selected elements and pasted them on the white B4 paper. Then the therapist and the patient talked about his art. Two weeks later, in the second session, the patient made arts like the first session and talked with the therapist about the art. The patient completed questionnaires before the first session and after the second session. 

1. Hospital Anxiety and Depression Scale (HADS) [9]: The Japanese version of the HADS was used to measure levels of anxiety and depression. The HADS score included 14 items measured from 0 to 3, and range from 0 to 42. The high score shows high anxiety or depression.
2. FACIT-Sp [10]: We used the Japanese version of the FASIT-Sp to measure meaning of life or meaning of existence or well-being of mind. The FACIT- Sp consists of two domains, meaning of life and religious issues, but only the meaning of life domain was used because collage therapy might not be effective on religious issue in short term. The meaning of life domain includes eight items and is scored on a 5-point scale (range 0-4). The total range of the FACIT-Sp is 0-32, and high scores indicates high sense of meaning.
   

The ethical review board at Nisikyusyu University, Saga, Japan approved the study. The special nurse certified for oncology nursing recruited patients with various types of advanced cancer and obtained initial informed consent. Then the psychologist explained the study in detail and got agreement. After getting informed consent, we began to the study.

We conducted the Wilcoxon sign rank test on mean score of each participant. 

Background of participants and completion rate

A special nurse of oncology recruited 10 participants and eight completed the study. Two could not completed the study. One could not receive chemotherapy, another one did not want to make a collage. The completion rate was 80% (Table 1).

Table 1: Background of participants.

Mean score of questionnaires

The mean score of questionnaires are followings. The score of Anxiety significantly decreased from 5.13 to 1.75 (p<.05) and the score of Depression significantly decreased from 6.00 to 3.38 (p<.05). And the total HADS score significantly decreased from 11.13 to 5.13 (p<.05). However, there was not significance in score of FACIT-Sp. (Table 2).

Table 2: Mean score of each questionnaire at pre and post Collage Therapy (n=8).

As for completion rate, 8 completed of 10 patients, then completion rate was 80%. It suggests possibility of collage therapy for advanced cancer patients under chemotherapy. Patients has uncertainty for future between recovery from cancer or stop of chemotherapy, suggesting other medical treatment or palliative care. Particularly, when chemotherapy was last medical treatment and stopped it, patients experience much confusion. Then mental or psychological support is much required. Collage therapy decreased anxiety and depression significantly.

There are some reasons of these effects:

1. A patient could express his emotion, mood in safety environment holding by a therapist. That is, collage therapy has catharsis effects.
2. A patient selects element in photos or magazines and assembled them in a paper. This action reflects unconscious part of mind. It might develop a new cognition for anxiousness. These process supports McClement [11]. She showed that collage therapy involves assembling different material, such as images, text, and objects, to create a visual composition representing individuals to tap into their subconscious and express their innermost anxieties in a non-verbal and symbolic way. Through the act of creation, collage therapy provides a channel for exploring and externalizing complex emotions, offering individuals a sense of control and empowerment over their anxieties. Like this, the patient could confront anxiety through unconscious journey.
3. A patient can focus attention on making an art during making a collage art with a clinical psychologist, preventing from confounding anxiety or depression. It might relate with mindfulness therapy.
   

As for benefit of collage therapy, collage is easy to conduct even during chemotherapy in a small space. Since collage therapy do not require special art talent, and patients’ psychological varia was lower than drawings. In this point, collage was applicable for cancer patients under chemotherapy. Stallings [12] said that collage can be used as an assessment tool and as a therapeutic art directive, and collage provides a less threatening starting point for art therapy. Related with this, the reason why painting was not effective on anxiety reported by Bozcuket [5] and collage in the present study decreased anxiety might be easiness to participation. As for FACIT-Sp score, the range of this scale was from 0 to 32 and the mean score of the FACIT-Sp in the present study was 31. Then ceiling effects influenced on no significance of this aspect. And the duration of this therapy in this study was about 2 weeks. Making or finding meaning of life might require much more time and duration. In future, we need to approve this explanation. 

Collage therapy decrease anxiety and depression of advanced cancer patients under chemotherapy. This therapy may be useful for their psychological distress. We need confirm this evidence including many participants.

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