The report is a product of the VA/HSR&D Evidence Synthesis Program.
Art Therapy: A Map of the Evidence
Many Veterans desire complementary and integrative health or alternative medicine modalities, and art therapy is one such option. The National Organization for Arts in Health identifies six “distinct regulated health professions” within the Creative Arts Therapies, which have “a definition of the profession, a legally defensible scope of practice, educational competencies, standards of practice, code of ethics, and evidence-based research.” These include art therapy, dance/movement therapy, drama therapy, music therapy, poetry therapy, and psychodrama therapy. The focus for this report is art therapy.
Given VA’s desire to promote evidence-based practice, this evidence mapping project aims to help provide guidance to VA leadership about the distribution of evidence on art therapy to inform policy and future directions for it within the VA healthcare system. The report also will provide a visual overview—or evidence map—of the distribution of evidence for art therapy. Evidence maps serve to identify current knowledge and future research needs.
Investigators with VA’s Evidence Synthesis Program in West Los Angeles, CA conducted broad searches from database inception through May 5, 2018 using terms related to art therapy in two databases: PubMed and PsycINFO. They conducted two searches specifically for randomized controlled trials (RCTs) and systematic reviews, as well as a third, more general search that did not specify a study design. From the 1,330 references identified by searches, 94 were used in the evidence map: 19 systematic reviews, 31 RCTs, and 44 impact evaluations that were not RCTs.
Summary of Review
The evidence map displays each of the 94 included references, sorted by health condition and type of study. Systematic reviews are grouped in green, red, or orange bubbles, and impact evaluations, including RCTs and other quantitative evaluations, are grouped in gray bubbles.
This map is running on the 3ie evidence gap map platform (http://egmopenaccess.3ieimpact.org/evidence-maps/art-therapy) developed by the International Initiative for Impact Evaluation, 3ie. Each bubble has been assigned a color and a coordinate in the evidence map for ease of identification. This coordinate is assigned a number, based on the corresponding health condition, and a letter, based on the treatment modality (“A” for art therapy or “B” for mixture/combination). In cases where there is more than 1 bubble in that map segment, the gray impact evaluation bubbles have a “1” appended to the end of this coordinate, the green systematic reviews bubbles (rated high confidence) have a “3” appended to the end of the coordinate, the orange systematic reviews bubbles (rated medium confidence) have a “4” appended to the end of the coordinate, and the red systematic reviews bubbles (rated low confidence) have a “2” appended to the end of this coordinate.
This evidence map also can be explored in an interactive way online at http://egmopenaccess.3ieimpact.org/evidence-maps/art-therapy . The online version allows users to view citations by different categorizations or to view citations attributed to specific bubbles.
Of the 19 systematic reviews included in this map, only 2 were appraised as having high confidence in their conclusions (one on pain and quality of life for patients with cancer, and another on art therapy for patients with schizophrenia), while 6 reviews were appraised as having medium confidence, and 11 were appraised as low confidence. Moreover, many of the systematic reviews included in the evidence map focused on a specific health condition but looked broadly across art therapy modalities, with 16 of the 19 reviews falling into a combination of Creative Arts Therapies. The evidence within reviews was often described as having low methodological quality, lacking details about the therapy itself, as well as the evaluation methods and measures.
Despite these issues, preliminary positive effects were described in a majority of the systematic reviews for a range of health conditions.
Relevance to VA Priority Topics
Certain high-priority areas within VA were represented within the literature included in this evidence map. For example, investigators identified two impact evaluations and one medium-confidence systematic review relevant to PTSD, which is included as a stand-alone category within the evidence map, while one study of PTSD and traumatic brain injury (TBI) addressed both priority areas. The category of cancer/palliation included studies and systematic reviews about cancer-related pain, which address the VA priority area of pain. However, aside from one systematic review for patients with cancer-related pain, none of the systematic reviews for VA priorities were appraised as high confidence.
When multiple systematic reviews within the evidence map overlap in coverage, cross-checking these reviews may be necessary to determine if the same primary studies are being described, the extent of the overlap, and applicability of some or all findings in a review for a particular research or policy question. A future synthesis would be needed to determine which studies were included in all reviews, and which were in some but not others to determine a new finding inclusive of all potential evidence. For future primary research studies, larger studies with rigorous designs that report their therapy approach and methodological details also would be beneficial. In addition, high-quality systematic reviews related to various VA high-priority topic areas (i.e., PTSD, pain, TBI) would help describe what is known about the effectiveness of art therapy as a treatment.
Miake-Lye IM, Apaydin EA, Mak SS, Begashaw MM, Beroes-Severin JM, Shekelle PG. Evidence Map of Art Therapy. Washington, DC: Evidence Synthesis Program, Health Services Research and Development Service, Office of Research and Development, Department of Veterans Affairs. VA ESP Project #05-226; 2019. Available at: https://www.hsrd.research.va.gov/publications/esp/art-therapy.cfm
ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.
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