IntroductionMajor experienced at least one depressive episode in

IntroductionMajor Depressive Disorder (MDD) is one of the most common psychological disorders in the world, with more than 300 million people having experienced at least one depressive episode in their lifetime (World Health Organisation). Conventionally we have seen the MDD can be treated with pharmacotherapy and several psychotherapies such as cognitive behavioural therapy (CBT) or interpersonal therapy (IPT). But it is also seen  that these conventional treatments could lack in terms of helping patients having difficulty communicating their inner thoughts or establishing a concrete rapport between the therapist and the patient. To tackle specificities as mentioned, creative expressive therapies such as Art therapy can be a effective way to counter specific weaknesses of other therapies. Art therapy is among the least researched psychotherapies but still has several promoters that consider it to be an effective treatment. However, research in the area of the effectiveness this is not conducted to considerable extent. This essay will attempt to answer the following research question, “To what extent is Art therapy an effective method to treat Major Depressive DIsorder?”.  Major Depressive DisorderMajor Depressive Disorder can be categorized as a mood disorder and is described as a depressed mood or loss of interest or pleasure in nearly all activities in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-IV. The etiology of the Major Depressive Disorder is a combination of biological factors, cognitive factors as well as sociocultural factors. The biological factors that can cause major depressive disorder include decrease in serotonergic nerve activity in the synaptic gap of the brain that leads to worsening of the mood and increase in emotional depressive symptoms; role of genetics where if a family member has previously suffered from MDD their predecessor is also likely to develop MDD. The cognitive factors that predispose an individual to develop MDD are depressogenic schemas, where the patient’s negative thoughts of him/herself develop during childhood due to bad experiences with parents or other authority figures, placing the patient in situation where they feel vulnerable. This position of vulnerability causes the patient to react to the external stressor by creating more negative thoughts of themselves and the situation around them as well as negative view of the future. The social factors that influence a person to develop depression are experiencing traumatic events such as abuse, death of a loved one or bullying. According to the DSM-IV-TR, the common symptoms of the major depressive disorder are categorized into physiological, cognitive, behavioural and emotional symptoms. The physiological symptoms of MDD include the feelings of fatigue and lack of energy, appetite loss, prominent weight gain or loss, migraines, body pain and loss of appetite. The cognitive symptoms include the patient having difficulty in concentrating, always feeling worthless and insignificant and has and negative and pessimistic attitudes and thoughts towards the world and the future. The behavioural symptoms include insomnia and irregular sleep patterns; self-destructive behaviour such as self-harm, suicidal thoughts; and also avoiding company of people. Lastly, the emotional symptoms include the patient having a lack of interest or presence in the environment around them and being in a state of sadness and distress. Art Therapy Art therapy is a type of expressive psychotherapy where the patient’s psychological health is improved through the art-making process. The process of art making helps the patient express their suppressed emotions in a constructive manner which aids in settling and resolving the psychological issues faced by them. There are different types of art therapies that can tackle different specific issues of the disorder. Individual art therapy focuses on tackling the person’s unconscious and repressed thoughts through the artwork they create. It is a beneficial way of forming a close bond between the therapist and patient and can accelerate the healing process. Group art therapy focuses on helping patients engage with other people, improving their social dynamics in the process. There is also the wide range of media which the patient chooses to express themselves in, ranging from the conventional media such as drawing and painting to alternative media such as sculpting, filmmaking and music. To evaluate the effectiveness of Art therapy to treat MDD, we have to analyse the strengths and weaknesses of the therapy. The main strength of art therapy relates to the fundamental of the therapy itself, with the ability for self expression. Art therapy has proven to be an effective way of treating MDD in its way of handling the obstacle of communicating with nonverbal, shy or resisting individuals. It is also seen the process of art making can lead to the active participation of all senses. Art therapy has seen to redirect and channel the patient’s attention towards the art-making process. In addition to promoting active participation, expressive therapies are sensory in nature. Many or all of the senses are utilized in one way or another when a person engages in art making.Kozhyna, Korostiy et al conducted a study to evaluate the effectiveness of art therapy in treatment in patients with melancholy in major depressive disorder on the quality of remission.Participants from the sample size of 135 patients were between the ages of 18 and 30 and had suffered from MDD. They were then divided into two groups where the experimental group were also given standard treatment and the experimental group were given standard care along with art therapy. The results showed that Art therapy was an effective way in treating the anxiety symptoms of MDD with 60% of the patients showing improvement in mood and quality of life while being in remission.In an alternate study conducted by the same researchers, where they studied the effectiveness of art therapy in the complex treatment of patients with major depressive disorder (DDR). The study revealed that reduced the level of anxiety; (75%) patients showed improvement in mood between sessions; 77% of patients improved self-esteem, 80% of patients had sustained remission; 68% – there was a positive outlook for the future; 65% reduced the level of anhedonia and 80% of patients with marked regression of depressive symptoms. Patients with DDR with the current episode mild effectiveness of AT was high. Patients with DDR with the current episode of moderate severity was average efficiency. In patients with recurrent episodes of DDR-severe AT efficiency was minimal. Patients with melancholic clinical variants AT had enough positive effect already from the 4th session; with a disturbing one – art therapeutic effect was observed after the first session, briefly, then resumed anxiety; with hypochondriacal option – AT had no effect and apathetic one effect was also absent due to reduced motivation of patients.The process of art making is also been linked to improving depressed mood and reducing stress in patients (Waller & Gilroy, 1992; Fryear 1992). Art therapy can help form a relationship between client and therapist (Dalley, 1984; Schaverien, 1995), provide the individual with a means of nonverbal communication of unconscious feelings (Carter, 1996), and allow the person to externalize and thereby resolve conflicting feelings (Bernstein, 1995; Kramer, 2000; Waller & Gilroy, 1992). It is also seen that art making diminish aggressive feelings because the individual replaces or sublimates these urges through art (Kramer, 2000; Levy, 1995). Levy also argued that the act of creating serene images could serve to alleviate anxiety. And Kramer argued that pleasure is gained from the very process of creating in art therapy. Therefore we can see through the various initial research conducted that art therapy does improve mood and reduce depressive symptoms. The prevalence of depression in adolescents has drastically increased just over the last decade. Disposition to depression in adolescents can be attributed to biological factors such as the physiological and psychological changes due to puberty, as well as social factors such as rejection from social groups or being subjected to abuse from parents. They also tend to react and cope with these emotions in a very violent and destructive manner, mostly through delinquent behaviours such as vandalism or self-destructive behaviours such as attempted suicide and self-harm. Depressive adolescents are also more reactive than depressive adults in terms of “acting-out”. As adults do not usually portray their distressed emotions and try to suppress them, adolescents would be more expressive and could exhibit them in different ways. The conventional therapies used to treat depression can be ineffective in many cases due to adolescents being rebellious in nature and unwilling to cooperate with the therapist. Conventional therapies require the patient to express their inner thoughts and problems verbally to the therapist which would most probably not work with adolescents who are usually less communicative. Art therapy as an alternative can aid in this process in terms of replacing the destructive behaviour with a constructive outlet in the form of an artwork through which the patient can project their emotions on. Producing an artwork gives the patient an opportunity to overcome the apprehensiveness to express their emotions. Rahmani et al. (2016) conducted a study to investigate the effect of art therapy and music therapy on adolescents suffering from depression. 24 participants were randomly divided into two groups, with the controlled group having no intervention and the experimental group being provided 7 two-hour simultaneous sessions of group art and music therapy. The results of the study showed that the group who received art and music therapy had a notable decline in depressive symptoms. This may be attributed to the inclusion of the group context where the participants were exposed to a more relatable environment, allowing the sense of mutuality to grow between them. This can be considered as one of the most important factors to reduce the level of depression, especially among adolescents who are shifting into their different role-playing state in society as more sociable members. However, the study shows the effect of two creative therapies on depression, so we cannot infer whether art therapy or music therapy contributed more to reducing the depressive symptoms. The small sample size of the experiment also signifies the inability to generalize the findings to all adolescents. Since the therapy sessions were conducted only for seven weeks and no follow up study was conducted, we could not be sure if they were high relapse rates causing the participants to re-acquire depressive symptoms. There have been several approaches to art therapy that have been influenced by the various paradigms throughout the history of psychology as a discipline. The psychoanalytic approach to art therapy was the basis from which all the fundamentals of art therapy emerged. The Psychoanalytic theory suggested by Sigmund Freud considered the significance that past experiences and events that could unconsciously influence a person’s current behaviour. These unconscious thoughts could also be transferred onto the canvas as the patient draws them in the process of art therapy, which is called ‘Transference’. As in the psychoanalytic theory and its conception of unconsciousness, Freud elaborates on the fact that the unconscious thoughts are usually expressed through in the form of symbols representations which can be considered as evidence for the psychotic symptoms of a disorder. In terms of art therapy, these “symbolic representations” refer to the artwork that the patient creates. A psychoanalytic approach to art therapy can particularly beneficial in treating MDD because it specifically addresses the sociocultural etiology of depression by analysing the interpersonal relationships of the patient through their artwork.A research study conducted by Thyme et al (2007) investigates the application of the psychoanalytic principles by comparing the outcome of two types of therapies, short-term psychodynamic art therapy and short-term psychodynamic verbal therapy on women suffering from depression. The sample size consisted of 39 women with depression, of which 18 participants  psychodynamic art therapy and 21 received psychodynamic verbal therapy. Researchers collected the data with self rating scales and observer-based scales at different intervals, before the therapy, after the therapy and after a 3 month interval. The average participant in both groups had few depressive symptoms and stress?related symptoms. The conclusion was that short?term psychodynamic art therapy could be a valuable treatment for depressed women.Another key fundamental of art therapy was influenced by the analytical approach of Carl Jung. In the analytical approach, the gap between the unconscious and the conscious thoughts is connected through the process of active imagination. This process is implemented in several manners, even through art-making. The drawings created in a spontaneous manner depict images that signify the person’s unconscious thoughts. The case example of Jenna, a patient suffering from depression (Malchiodi, 2002), that illustrates the concept of how active imagination can improve depressogenic schemas. Jenna had developed depression because she of her relationship problems. She was treated with art therapy and was explained the process of active imagination to develop images of her unconscious thoughts by the therapist. The first image she produced through active imagination depicted a dark tunnel with a small opening at the end where a star appeared. While describing the image she created through active imagination she recounts her experience isolation and coldness in the tunnel and her helpless effort to attempt to reach the star at the end of tunnel. These unconscious thoughts could be influenced through her depressogenic schemas about her future. The star in her active imagination drawings was a recurring symbol and as the therapy sessions progressed, the star was depicted out of the dark tunnel and independent into the sky. The evolution of the star as a symbol can denote the transition from her depressogenic schemas to more a perspective optimistic and about herself and her future. The images she created through active imagination helped Jenna make connections between her conscious and unconscious depressive thoughts. This process of self expression through a Along with the psychoanalytic and analytical approaches to art therapy which focus on  the influence of past experiences and unconscious thoughts on person’s psyche, an alternative approach is the cognitive-behavioural approach to art therapy. This approach combines aspects of cognitive behavioural therapy (CBT) into art therapy.  It is also seen that Art therapy can be effective in resolving specific cognitive and sociocultural etiologies of MDD in elderly adults. McCaffrey et al. (2011) investigated the effect of art therapy and garden walking on aged depressed adults. The participants were over 65 years old, suffering from depression and divided into two groups, one being treated garden walking as a therapy and the other being treated with art therapy. The Geriatric Depression Scale (GDS) was used to measure the depression in the participants. Researchers found that there was a significant change from the depression scores of the patient before and after the therapies provided. All the participants had a lower percentage of negative-emotion word use and a higher percentage of positive-emotion word as time progressed.

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