Over Coming The Darkness, Advancing Community Based Health Care

The Family Doctor, The Nurse & Community
Overcoming The Darkness Covering

Movement Disorders and Mental Health
Disabilities- Reducing Reliance On Drug
Based Therapies & Hospitalization,
A Compilation
A Fletcher-Manaker Contribution To Community

Empowerment & Community Development
Not For Sale!
Compiled by:-
Basil Fletcher
Jamaica W.I.
1
Comment 1.................................................................................................................19
Dance as Therapy for Individuals with Parkinson Disease......................................24
Abstract.........................................................................................................................24
Introduction..................................................................................................................24
Dance as an Alternative Form of Exercise..............................................................25
Benefits of Dance for Individuals with PD...............................................................26
Are Benefits Obtained with Dance Clinically Meaningful for People with PD?. 28
Indications for Use of Dance as Therapy in PD.....................................................28
Intensity, Frequency, and Duration of Dance Intervention....................................28
Why Dance? Potential Mechanisms of Action........................................................29
Future Directions.........................................................................................................30
Summary......................................................................................................................31
Acknowledgments.......................................................................................................31
References...................................................................................................................31
[The effects of a Korean traditional dance movement program in elderly women].
...........................................................................................................................................36
Author information....................................................................................................36
Abstract......................................................................................................................36
PURPOSE:...........................................................................................................36
METHODS:..........................................................................................................36
RESULTS:............................................................................................................37
CONCLUSION:....................................................................................................37
Effect of Dance Exercise on Cognitive Function in Elderly Patients with Metabolic
Syndrome: A Pilot Study................................................................................................37
Abstract.........................................................................................................................37
Introduction..................................................................................................................37
Methods........................................................................................................................38
Participants................................................................................................................38
Figure 1.............................................................................................................................39
Assessment of cognitive function and depression.....................................................40
Metabolic syndrome (MS).........................................................................................41
Exercise intervention.................................................................................................41
Statistical analysis......................................................................................................42
Results..........................................................................................................................42
Table 1..............................................................................................................................42
Table 2..............................................................................................................................45
Discussion....................................................................................................................48
Conclusion....................................................................................................................51
Acknowledgements.....................................................................................................51
Disease: Improving Quality of Life...............................................................................51
Dance therapy for individuals with Parkinsons disease: improving quality of life......52
Abstract:.....................................................................................................................52
Introduction................................................................................................................53
Purpose and methods of this integrative review........................................................55
Do dance and exercise affect HRQOL?.................................................................56
What are dances effects upon HRQOL in individuals with PD?..........................57
2
What are dances effects on other populations at risk for loss of function?..........58
What are the mechanisms through which dance may improve HRQOL?.............59
Does enhanced motor function lead to increased participation?...........................59
Music.........................................................................................................................60
Physiology and psychopathology..............................................................................61
. Individuals with severe and persistent mental illness notably benetted in mood
from salsa dancing.................................................................................................61
Conclusion and recommendations for future research..............................................61
Dance Maybe Ideal For Individuals Suffering From PD.......................................62
Acknowledgments.................................................................................................63
Disclosure..............................................................................................................63
References..............................................................................................................63
Aerobic Exercise for Parkinson's Disease: A Systematic Review and Meta-
Analysis of Randomized Controlled Trials..................................................................69
Abstract.........................................................................................................................69
Background................................................................................................................69
Objective....................................................................................................................69
Methods.....................................................................................................................69
Results........................................................................................................................70
Conclusion.................................................................................................................70
Figures..........................................................................................................................70
Introduction..................................................................................................................72
Methods........................................................................................................................73
Search Strategy..........................................................................................................73
Study Selection..........................................................................................................73
Data Extraction..........................................................................................................73
Quality Assessment....................................................................................................74
Data Analysis.............................................................................................................74
Results..........................................................................................................................75
Study Selection..........................................................................................................75
Study Characteristics.................................................................................................76
Participants..........................................................................................................76
Interventions........................................................................................................76
Methodological Quality.............................................................................................76
Quantitative Data Synthesis.......................................................................................76
Unified Parkinson's disease rating scale (UPDRS).......................................76
Balance.................................................................................................................77
Gait........................................................................................................................78
Quality of life........................................................................................................80
Follow-up Effect........................................................................................................80
Adverse Events..........................................................................................................80
Discussion....................................................................................................................80
Conclusions..................................................................................................................82
Supporting Information...............................................................................................83
Author Contributions...................................................................................................83
3
References...................................................................................................................83
ORIGINAL RESEARCH ARTICLE...........................................................................91
Therapeutic Argentine tango dancing for people with mild Parkinsons disease: a
feasibility study...............................................................................................................91
Introduction.................................................................................................................92
Materials and Methods..............................................................................................94
Design.......................................................................................................................94
Participants..............................................................................................................94
Intervention.............................................................................................................95
Primary Outcomes.....................................................................................................96
Secondary Outcomes..............................................................................................97
Statistical Analysis.....................................................................................................97
Results..........................................................................................................................97
Participants..............................................................................................................97
Feasibility.................................................................................................................98
Recruitment..........................................................................................................98
Adherence............................................................................................................99
Attrition..................................................................................................................99
Personnel Requirements.................................................................................100
Safety..................................................................................................................100
Modifications to Dance Intervention...............................................................100
Health-Related Quality of Life and Depression......................................................100
Discussion..................................................................................................................101
Conclusion..................................................................................................................104
Author Contributions...............................................................................................104
Conflict of Interest Statement......................................................................................104
Acknowledgments.....................................................................................................104
References..................................................................................................................105
A dance movement therapy group for depressed adult patients in a psychiatric
outpatient clinic: effects of the treatment...................................................................112
Abstract.......................................................................................................................112
Introduction.................................................................................................................112
Methods......................................................................................................................114
Recruitment procedure.............................................................................................114
Participants...............................................................................................................116
Table 1.............................................................................................................................116
Table 2.............................................................................................................................119
Intervention procedure.............................................................................................121
Table 3............................................................................................................................122
Outcome measures...................................................................................................125
Statistical analysis....................................................................................................126
Results........................................................................................................................127
Symptom measurements..........................................................................................127
Table 4............................................................................................................................127
Differences between the groups on the basis of the use of antidepressants............130
4
Table 5............................................................................................................................130
Discussion..................................................................................................................132
Conflict of interest statement...................................................................................135
Footnotes....................................................................................................................135
References.................................................................................................................136
Dance movement therapy for depression........................................................................140
Author information..................................................................................................140
Abstract....................................................................................................................140
BACKGROUND:................................................................................................140
OBJECTIVES:.....................................................................................................140
SEARCH METHODS:........................................................................................140
SELECTION CRITERIA:...................................................................................140
DATA COLLECTION AND ANALYSIS:..........................................................141
MAIN RESULTS:................................................................................................141
AUTHORS' CONCLUSIONS:............................................................................141
Compilers Recommendation 1...............................................................................142
A Good Time to Dance? A Mixed-Methods Approach of the Effects of Dance
Movement Therapy for Breast Cancer Patients During and After Radiotherapy.
.........................................................................................................................................143
Abstract....................................................................................................................143
BACKGROUND:................................................................................................143
OBJECTIVE:......................................................................................................143
METHODS:.........................................................................................................144
RESULTS:..........................................................................................................144
CONCLUSIONS:...............................................................................................144
IMPLICATIONS FOR PRACTICE:.................................................................144
Overcoming Disembodiment: The Effect of Movement Therapy on Negative
Symptoms in Schizophrenia-A Multicenter Randomized Controlled Trial............144
Abstract....................................................................................................................145
OBJECTIVE:......................................................................................................145
METHOD:...........................................................................................................145
RESULTS:..........................................................................................................145
CONCLUSION:..................................................................................................145
Creative people ARE prone to suffering mental illness: Actors, dancers and musicians
'more likely to have the genes causing schizophrenia and bipolar disorder'...................147
Psychiatry and music....................................................................................................148
Abstract.......................................................................................................................148
INTRODUCTION.......................................................................................................148
HISTORY OF MUSIC AND MIND - A FOCUS ON INDIAN CLASSICAL
MUSIC........................................................................................................................148
MUSIC AND THE BRAIN.........................................................................................149
Perceptual processing..............................................................................................149
Emotional processing...............................................................................................150
5
Autonomic processing.............................................................................................151
Cognitive processing...............................................................................................151
Behavioral or motor processing...............................................................................152
Hemispheric heterogeneity......................................................................................152
Neurochemistry........................................................................................................153
PSYCHOANALYSIS AND MUSIC..........................................................................153
DEVELOPMENTAL PSYCHOLOGY AND MUSIC..............................................154
PSYCHOPATHOLOGY AND MUSIC.....................................................................154
Musical hallucinations.............................................................................................154
Musical obsessions..................................................................................................155
MUSIC THERAPY.....................................................................................................155
Definition and classification....................................................................................155
History of music therapy.........................................................................................156
Table 3............................................................................................................................157
Music therapy in India.............................................................................................157
Music within a psychiatric setting...........................................................................158
Music as therapy in psychiatry - emphasis on efficacy...........................................158
Depression and music therapy.......................................................................159
Indian studies...........................................................................................................160
Schizophrenia and music therapy..................................................................160
Summary of the non- or partially controlled studies...............................................161
Randomized control trials........................................................................................161
Other review cum meta-analyses.............................................................................162
Indian studies...........................................................................................................162
Dementia and music therapy..........................................................................163
Indian studies...........................................................................................................163
Substance use disorders and music therapy................................................163
Indian studies...........................................................................................................164
Pediatric psychiatric disorders and music therapy......................................164
Indian studies...........................................................................................................165
WHEN TO USE WHAT?..........................................................................................165
HOW DOES IT WORK?...........................................................................................165
Footnotes....................................................................................................................166
REFERENCES..........................................................................................................166
PsyMot: An instrument for psychomotor diagnosis and indications for
psychomotor therapy in child psychiatry..................................................................173
Ascott High School In Greater Portmore, St. Catherine Has Both Teachers and
Space , Ready To Work With Family Doctors and Local Pharmacists To Organize
and Carry Out Directed And Monitored Movement Therapy, Be It In The Form Of
Dance , Drama or Field Activities, The School Stands Ready................................179
PsyMot: An instrument for psychomotor diagnosis and indications for
psychomotor therapy in child psychiatry..................................................................179
The development of the PsyMot..............................................................................183
The ICF distinguishes four domains related to health and health behaviour..........183
The item list.............................................................................................................184
Table 1. The item list of the PsyMot........................................................................185
6
Domain: functions (126) Domain: activities and participation.............................185
Domain: environmental factors...............................................................................185
Domain: personal factors.........................................................................................185
Body awareness.......................................................................................................186
Clusters of treatment goals......................................................................................186
A. Body acceptance.................................................................................................186
B. Participation and enjoyment................................................................................187
C. Perceived physical and motor competence.........................................................187
D. Motor performance.............................................................................................187
E. Self-control..........................................................................................................187
F. Self-confidence and self-expression....................................................................187
G. Playing and interacting with peers......................................................................188
The assessment procedure.......................................................................................188
In the first session....................................................................................................188
The second session..................................................................................................189
The third session......................................................................................................189
Evaluation and scoring............................................................................................190
Future research and development............................................................................191
Notes on contributors...............................................................................................193
References................................................................................................................193
Dietary Intake of Patients with Schizophrenia................................................................195
Background..................................................................................................................195
Dietary Intake of Patients with Schizophrenia............................................................196
Synopsis.......................................................................................................................198
References....................................................................................................................200
The dietary pattern of patients with schizophrenia: a systematic review........................202
Abstract....................................................................................................................202
OBJECTIVE:.......................................................................................................202
METHODS:.........................................................................................................202
RESULTS:...........................................................................................................202
CONCLUSION:..................................................................................................202
Metabolic syndrome in bipolar disorder and schizophrenia: dietary and lifestyle factors
compared to the general population.................................................................................203
Abstract....................................................................................................................203
OBJECTIVE:.......................................................................................................203
METHODS:.........................................................................................................203
RESULTS:...........................................................................................................203
CONCLUSIONS:................................................................................................203
KEYWORDS:......................................................................................................204
Comment in.............................................................................................................204
Send to.................................................................................................................204
The dietary pattern of patients with schizophrenia: a systematic review........................204
Abstract....................................................................................................................204
7
OBJECTIVE:.......................................................................................................204
METHODS:.........................................................................................................204
RESULTS:...........................................................................................................204
CONCLUSION:..................................................................................................205
The traditional Korean dietary pattern is associated with decreased risk of metabolic
syndrome: findings from the Korean National Health and Nutrition Examination Survey,
1998-2009........................................................................................................................205
Abstract....................................................................................................................205
Custom made, purpose driven designed probotics On A Jamaican Table-These Are
Not Usually Made In Jamaica However The Average Jamaican Pharmacists or
Medical Doctor Can If Need Be Make Them With Great Ease...............................207
Grains, vegetables, and fish dietary pattern is inversely associated with the risk of
metabolic syndrome in South korean adults....................................................................207
Abstract....................................................................................................................208
BACKGROUND:................................................................................................208
OBJECTIVE:.......................................................................................................208
DESIGN:..............................................................................................................208
RESULTS:...........................................................................................................208
CONCLUSIONS:................................................................................................208
How to Use Diet As a Treatment for Schizophrenia........................................................208
Step 1...........................................................................................................................209
Step 2...........................................................................................................................209
Step 3...........................................................................................................................210
Step 4...........................................................................................................................210
Step 5...........................................................................................................................210
Things You'll Need.......................................................................................................210
About schizophrenia and psychosis.................................................................................211
WHAT IS SCHIZOPHRENIA?...........................................................................211
WHAT CAUSES SCHIZOPHRENIA?...............................................................212
DIET AND NUTRITION...WHAT WORKS......................................................212
Balance your blood sugar and avoid stimulants..................................................212
Increase essential fats..........................................................................................213
Up antioxidants....................................................................................................213
Consider niacin....................................................................................................214
Methylation, B12, folic acid and B6....................................................................215
Are you pyroluric? The zinc link.........................................................................216
Check for allergy.................................................................................................217
References............................................................................................................217
3 Ways Aerobic Exercise Improves Schizophrenia Symptoms...................................219
3 Ways Aerobic Exercise Improves Schizophrenia Symptoms by Firth et al.....220
Conclusion: Exercise Can Reduce Neurocognitive Deficits Associated with
Schizophrenia......................................................................................................220
Exercise for Mental Health..............................................................................................221
Footnotes......................................................................................................................222
8
References....................................................................................................................223
The influence of physical activity on mental well-being.................................................223
Abstract....................................................................................................................223
OBJECTIVE:.......................................................................................................223
DESIGN:..............................................................................................................224
CONCLUSIONS:................................................................................................224
Aerobic Exercise Improves Cognitive Functioning in People With Schizophrenia: A
Systematic Review and Meta-Analysis...........................................................................224
Abstract........................................................................................................................225
Introduction..................................................................................................................227
Methods.......................................................................................................................228
Search Strategy........................................................................................................228
Eligibility Criteria....................................................................................................229
Data Extraction........................................................................................................229
Statistical Analyses..................................................................................................231
Results..........................................................................................................................232
Search Results..........................................................................................................232
Included Studies and Participant Details.................................................................232
Meta-Analysis of the Neurocognitive Outcomes of Exercise.................................440
Factors Associated With Intervention Effectiveness...............................................443
Effects of Exercise on Individual Cognitive Domains............................................444
Discussion....................................................................................................................445
Supplementary Material...............................................................................................450
Funding........................................................................................................................450
Acknowledgments.......................................................................................................450
Please Use Link Provide Below For References.........................................................450
Metabolic issues in patients affected by schizophrenia: clinical characteristics
and medical management...........................................................................................450
Abstract.......................................................................................................................451
Introduction................................................................................................................451
The role of antipsychotic agents.............................................................................452
Table 1............................................................................................................................453
Metabolic syndrome and psychosis.......................................................................456
Prolactin levels..........................................................................................................456
QT- interval prolongation..........................................................................................457
Monitoring metabolic disorders among patients affected by chronic psychosis
.....................................................................................................................................458
Table 2............................................................................................................................458
Conclusions................................................................................................................461
Funding.......................................................................................................................461
Footnotes....................................................................................................................462
References.................................................................................................................462
The psychophysiological effects of Tai-chi and exercise in residential Schizophrenic
patients: a 3-arm randomized controlled trial..................................................................466
9
Abstract.....................................................................................................................467
Background...........................................................................................................467
Methods/design...................................................................................................467
Discussion.............................................................................................................467
Trial registration...................................................................................................467
Keywords...............................................................................................................468
Background.............................................................................................................468
Effectiveness of exercise interventions in psychiatric disorders..............468
Multiple benefits of Tai-chi as a physical and mental exercise.................468
Schizophrenic Symptoms and the HPA Axis..................................................469
Research objectives.............................................................................................469
Methods/design............................................................................................................470
Participant recruitment......................................................................................471
Intervention..........................................................................................................472
Setting....................................................................................................................473
Instruments...........................................................................................................473
Data analysis.........................................................................................................475
Effectiveness of the Tai-Chi intervention....................................................475
Analysis of salivary cortisol............................................................................476
Relationship between cortisol levels and physical and psychological
deficits................................................................................................................476
Discussion....................................................................................................................476
Declarations.................................................................................................................476
Acknowledgements..................................................................................................477
Authors' original submitted files for images............................................................477
Competing interests.................................................................................................477
Authors contributions........................................................................................477
References....................................................................................................................477
Pre-publication history.............................................................................................481
Copyright.....................................................................................................................481
Pets and Animal-Assisted Therapy.............................................................482
The Benefit of Pets and Animal-Assisted Therapy to the Health of
Older Individuals....................................................................................................483
Abstract.............................................................................................................483
1. Introduction................................................................................................484
2. Potential Benefits of Animals...............................................................484
3. Harms of Animals.....................................................................................491
4. Future Directions and Conclusions....................................................492
Conflict of Interests......................................................................................493
References.......................................................................................................493
Animal Assisted Therapy (AAT) Program As a Useful Adjunct to Conventional
Psychosocial Rehabilitation for Patients with Schizophrenia: Results of a Small-
scale Randomized Controlled Trial............................................................................499
10
Introduction...............................................................................................................501
Materials and Methods............................................................................................503
Study Design..........................................................................................................503
Sample....................................................................................................................504
Interventions.........................................................................................................507
Instruments...........................................................................................................509
Statistical Analysis................................................................................................511
Ethics......................................................................................................................512
Results........................................................................................................................512
Sample Characteristics.........................................................................................512
Schizophrenic Symptomatology (PANSS).........................................................513
Quality of Life (EQ-5D)........................................................................................514
Adherence to Treatment......................................................................................515
Salivary Cortisol and Alpha-Amylase.................................................................517
Discussion..................................................................................................................518
Conclusion..................................................................................................................524
Author Contributions...............................................................................................524
Funding......................................................................................................................524
Conflict of Interest Statement.................................................................................524
References..................................................................................................................525
Compilers Recommendation 2...............................................................................537
Animal-assisted interventions: making better use of the human-animal bond....538
Author affiliations.......................................................................................................538
Abstract.......................................................................................................................538
Statistics from Altmetric.com...................................................................................538
Emotional responses and development................................................................539
Underlying mechanisms...........................................................................................541
Cognitive development.............................................................................................542
Facilitating learning...................................................................................................544
Opportunities.............................................................................................................546
Developing One Health....................................................................................546
References.................................................................................................................546
Request permissions....................................................................................................558
The Effects of Animal-Assisted Therapy on Anxiety Ratings of
Hospitalized Psychiatric Patients.........................................................................559
Abstract.............................................................................................................559
OBJECTIVE........................................................................................................559
Methods...............................................................................................................561
Procedures............................................................................................................562
Analysis...............................................................................................................563
Results..................................................................................................................563
Patient characteristics..........................................................................................564
Comparison of therapy groups.............................................................................564
11
Discussion and conclusions.................................................................................564
Acknowledgments...............................................................................................566
Table 1. Mean pretreatment, posttreatment, and change scores on the State-Trait
Anxiety Inventory for hospitalized psychiatric patients with various diagnoses who
participated in an animal-assisted therapy session or therapeutic recreation..........567
References............................................................................................................567
Does Animal-Assisted Therapy Really Work?......................................................569
What clinical trials reveal about the effectiveness of four-legged therapists......569
First the Good News............................................................................................570
Animal-Assisted Intervention for trauma: a systematic literature review.............576
Abstract.......................................................................................................................576
Introduction................................................................................................................576
Methods......................................................................................................................578
Protocol....................................................................................................................578
Eligibility criteria.....................................................................................................578
Search procedure.....................................................................................................578
Data extraction and evaluation................................................................................579
Results........................................................................................................................579
Study selection.........................................................................................................579
Characteristics of AAI for trauma............................................................................580
Terminology........................................................................................................580
Animals and settings........................................................................................581
Interventionists and format..............................................................................581
Activities..............................................................................................................581
Duration..............................................................................................................582
Methodological evaluation......................................................................................583
Sample size and characteristics.....................................................................583
Diagnosis............................................................................................................584
Study design......................................................................................................584
Assessment type...............................................................................................584
Outcomes of AAI for PTSD....................................................................................585
Depression.........................................................................................................585
PTSD symptoms...............................................................................................586
Anxiety................................................................................................................586
Social outcomes................................................................................................586
Sleep...................................................................................................................587
Child functioning................................................................................................587
Quality of life......................................................................................................587
Discussion..................................................................................................................587
Characteristics of AAI for trauma............................................................................588
Assessing AAI for trauma........................................................................................589
Outcomes of AAI for trauma...................................................................................590
Risk of bias and future directions............................................................................591
Conclusion..................................................................................................................592
Author contributions..................................................................................................592
12
Notes...........................................................................................................................592
References.................................................................................................................592
The Benefit of Pets and Animal-Assisted Therapy to the Health of Older
Individuals......................................................................................................................596
Abstract.......................................................................................................................596
1. Introduction............................................................................................................596
2. Potential Benefits of Animals..............................................................................597
2.1. Effects on Mental Health..................................................................................597
2.2. Effects on Physical Health................................................................................601
3. Harms of Animals..................................................................................................604
4. Future Directions and Conclusions....................................................................604
Conflict of Interests...................................................................................................605
References.................................................................................................................606
Another Breed of Service Animals: STARS Study Findings about Pet Ownership
and Recovery from Serious Mental Illness...............................................................610
Abstract.......................................................................................................................610
Serious Mental Illness..............................................................................................611
Pets and Health............................................................................................................611
The Current Study........................................................................................................612
Methods......................................................................................................................613
Setting......................................................................................................................613
Study Design............................................................................................................613
Participant Identification, Inclusion and Exclusion Criteria, and Recruitment.......613
Participants..............................................................................................................614
Quantitative Data Collection and Analysis..............................................................614
Interview Procedures and Qualitative Data Analysis..............................................615
Results..........................................................................................................................615
Theme 1: Empathy and Therapy..............................................................................616
Theme 2: Connections.............................................................................................616
Theme 3: Pets as Family..........................................................................................617
Theme 4: Self-Efficacy/Self-Worth.........................................................................618
Discussion....................................................................................................................619
Implications.............................................................................................................620
Acknowledgement.......................................................................................................621
Footnotes......................................................................................................................621
References....................................................................................................................621
The Truth About Animal-Assisted Therapy.....................................................................623
Here are four more facts you might not know about animal-assisted therapy........624
1. They are not dependent on a specific theory........................................................624
Benefits of Animal-Assisted Therapy.........................................................625
Does Animal-Assisted Therapy Really Work?........................................................626
Gardening And Mental Health.....................................................................................627
.....................................................................................................................................628
What Is the Evidence to Support the Use of Therapeutic Gardens for the Elderly?
.........................................................................................................................................628
13
Abstract.......................................................................................................................629
INTRODUCTION.......................................................................................................629
HISTORY OF HORTICULTURE AS A THERAPEUTIC MODALITY.................630
CURRENT SCIENTIFIC UNDERSTANDINGS OF THE EFFECTIVENESS OF
HORTICULTURAL THERAPY FOR THE ELDERLY...........................................630
The therapeutic garden............................................................................................631
Reduction of pain.....................................................................................................632
Improvement in attention.........................................................................................632
The brain's physiological response to stress............................................................633
Damage to corticosterone receptors.........................................................................634
Reduction in stress...................................................................................................634
BENEFITS FOR RESIDENTS WITH DEMENTIA...............................................635
Wander garden studies concerning agitation...........................................................636
Reduction in falls and antipsychotic medications...................................................637
POSSIBLE LIMITATIONS OF GARDEN SETTINGS..........................................638
CONCLUSIONS........................................................................................................639
References.................................................................................................................639
Therapeutic landscapes and healing gardens: A review of Chinese literature in
relation to the studies in western countries...............................................................647
Abstract.......................................................................................................................647
Keywords.....................................................................................................................647
1. Introduction..............................................................................................................648
2. Theories and terminology of therapeutic landscapes and healing gardens in
the western countries...............................................................................................648
2.1. Medical geography...........................................................................................650
2.2. Environmental psychology...............................................................................650
2.2.1. Attention-Recreation Theory and the restorative environment.......650
2.2.2. Psycho-evolution theories and healing gardens...............................650
2.3. Salutogenic environments and the ecological approach...................................651
2.4. Horticultural therapy school.............................................................................652
3. Systematic literature review of therapeutic landscapes/healing gardens in
China...........................................................................................................................652
3.1. Keywords and search combinations.................................................................652
3.2. Analysis of 71 studies written by Chinese scholars..........................................653
3.3. Detailed analysis of the 19 studies....................................................................655
4. Comparison of research status between China and western countries......664
4.1. Terminology......................................................................................................664
4.2. Historical research............................................................................................665
4.3. Research focus and methods.............................................................................665
4.4. Theories............................................................................................................666
5. Conclusions...........................................................................................................666
Acknowledgement.....................................................................................................666
References.................................................................................................................667
Healing & Therapy....................................................................................................679
Fast Facts..................................................................................................................679
Nature in Hospitals...............................................................................................680
14
Nature in the Room..........................................................................................680
Healing Gardens and Therapeutic Horticulture.....................................681
Horticulture Therapy............................................................................................681
Mental Health, Function, and Therapy..........................................................682
Children and Attention Deficit......................................................................682
Depression...........................................................................................................682
Mental Stress and Cancer Patients.............................................................683
Psychiatric Patients...........................................................................................683
Dementia..............................................................................................................684
Elder Care............................................................................................................686
Physical Health & Therapy.................................................................................687
Obesity and Active Living...............................................................................687
Stress.....................................................................................................................687
Disabilities and Elder Care.............................................................................688
Recovery, Resilience, and Rehabilitation......................................................688
Crisis Recovery and Resilience.....................................................................688
Military Service and Stress Disorders.......................................................689
Prisons and Jails................................................................................................689
Nature & the Healthcare Industry..................................................................690
Prescriptions for Parks & Trails....................................................................690
Insurance.............................................................................................................690
References...............................................................................................................691
Research ArticleOpen Access...................................................................699
Comparison Of The Effects Of Individual And Group Horticulture
Interventions...............................................................................................................699
Abstract.............................................................................................................700
Keywords..........................................................................................................700
Introduction.....................................................................................................700
Materials and Methods................................................................................701
Results...............................................................................................................703
Discussion........................................................................................................705
Acknowledgements......................................................................................706
References............................................................................................................707
Closing Remarks..................................................................................................711
Forward;
This compilation of web based articles is primarily intended for nurses and family
doctors in the community as individuals of first reference and resort in the delivery of
health care and secondly to the Neurology, Geriatrics and Psychiatry Departments of the
regional hospitals, with the aim firstly of encouraging their search for more affordable,
15
quality, family and community friendly approaches to meeting the needs of the mentally
challenged, the elderly and individuals with movement disorders. While there are on the
surface a separation of disciplines, the average family doctor and experienced nurse, will
point out the internal points of convergence and connectiveness between these three areas
of specialization.
A second and equally important reason for the compilation of this set of articles, is to
facilitate the community based medical doctor and health care nurse in the process of
educating the afflicted and their relatives as to what they can do to deal with the given
health care challenge they face. Too many times the society ignores the fact that illnesses
have toll no only on the afflicted but also on the care given household, emotionally,
financial and in other areas. Thus given the very limited disposable incomes available to
these affected families and their afflicted members; this compilation seeks to empower
the community based health workers, doctors, pharmacist and nurses in the search for
affordable but medically proven effective methods of confronting the given health
problems.
Finally as a tool in the hands of the community doctor, health care nurse and pharmacist,
it further enhances their abilities to engage the various groups of community based stake
holders and potential partners, such as the Church, the Schools, the Police, the Citizen
Association in the creation of a social environment which facilitates the care and
recovery of the afflicted and to provide them with the necessary support and protection
they need as vulnerable individuals.
In ending the compilers would like to hope that those our good friends, outside of the
region who are faced with similar health care and financial challenges as we do in the
Americas will find this compilation useful and relevant to their specific environments.
Special thanks is also given to the authors and publishers of the various articles used and
hope that they will be of value to those health workers who work in the communities of
the poor and the middle classes, whose job it is to apply the various theories and
approaches presented to real world situations, at times very far from the ideal world of
the labs and the well equipped hospitals of the worlds capitals.
End,
Basil Fletcher,
April 2017,
Greater Portmore,
St. Catherine,
Jamaica W.I.
Comment 1
The cultivation of "Nobodiness and Inferiority Complex", a little boy on the roadside
watching vehicles and people walking pass as he awaits his mother.
16
Note the person standing behind the fence, establishing and defining importance and
status in terms of influence and power. This is but one way in which the Jamaican society
breeds and rear individuals with various complexes and lacking the mental attitude to
compete, trained to feel inferior.
Where do we ask our children to wait for their parents? Outside Mr. Chin's shop? Next
door to the Queenie pub and bar or at school, picking them up when ever other child who
has parents and a home is long gone?
Community Driven Mental Health Care, Facilitated and Encouraged By The Family
Doctor, The Family, and Community Based Institutions; Utilizing Those Resources
Which Are Affordable And Accessible To The Family And The Community Is Critical To
Prevent The Social Degrading and Marginalizing Of The Victims Of Health Diseases.
17
18
A Possible Way Of Organizing Health & Allied Services To Meet The Needs of Victims
of Mental Health Disorders and Their Families At The Community Level, A Similar
Structure Would Also Be Good For Individuals Suffering From Movement Disorders
19
Psychiatrists and
mental health
hospital
Family and patient,

Pharmacy where the Community based
Community services of dance instructor organization or
doctor/family doctor and physical education community Church
teacher is paid for by health
card
or school
Recommends diet
and prescribes dance
Dance Instructor and
and physical training
physical Education
based on the
Teacher
recommendations of
the psychiatrist
20
Dance as Therapy for Individuals with Parkinson Disease
Gammon M. Earhart, PhD, PT1,2,3
Author information Copyright and License information
The publisher's final edited version of this article is available free at Eur J Phys Rehabil Med
See other articles in PMC that cite the published article.
Abstract
Introduction
Difficulties with gait and balance are common among individuals with Parkinson disease
(PD), contributing to an increased incidence of falls. Gait changes include slowness of
walking with short, shuffling steps and a flexed posture, and may also include festination
and/or freezing of gait.1 Aspects of walking that appear to be particularly impaired
include dual tasking, turning and walking backward.2 Balance difficulties also seem to be
particularly pronounced in the backward direction, with most falls occurring during tasks
that require backward movement or with perturbation in the backward direction.3,4 A
21
prospective, six-month study reported that more than 70% of individuals with PD fell in
this period of time, with 50% experiencing an additional fall in the subsequent six
months.5 Falls are a major concern in PD, as those with PD are 3.2 times more likely than
those without PD to sustain a hip fracture.6 The annual cost of hip fracture care for those
with PD in the United States is estimated to be $192 million.7 In addition to the obvious
financial costs associated with falls, reduced functional mobility can also contribute to
withdraw from activities, social isolation, osteoporosis, muscle weakness, and low self
esteem.8 In fact, axial impairment, which includes gait and balance problems, has been
identified as a major influence on health-related quality of life (QoL).9 Other major
contributors to QoL are psychological adjustment to PD, depression, and cognition.10-12
Medical treatments for PD, including medications and deep brain stimulation, do not
fully address gait and balance issues and, as such, other approaches are needed.13 One
approach to these problems is through the use of exercise. Traditional exercise
approaches to address gait and balance difficulties may include dynamic balance training,
treadmill training, or strength training. A recent review regarding the benefits of exercise
for those with PD concluded that there is sufficient evidence in the literature to support
the positive effects of exercise on gait speed, strength, balance, and quality of
life.14 Evidence also suggests that individuals with higher levels of habitual physical
activity are at lower risk for developing PD.15 Finally, animal models suggest that exercise
may decrease neuronal injury in a toxin-induced model of PD.16
Given the potential benefits of exercise for those with PD, recommendations have been
made regarding key components of an exercise program designed for those with PD.
Keus et al. 17 recommend four key areas: 1) cueing strategies to improve gait, 2) cognitive
movement strategies to improve transfers, 3) exercises to improve balance, and 4)
training of joint mobility and muscle power to improve physical capacity. Emerging
evidence also suggests that aerobic training, such as walking on a treadmill, may result in
improved quality of life, reduced disease severity as reflected by lowering of UPDRS-III
scores, and improved aerobic capacity.18-21
Despite mounting evidence regarding the importance of exercise for the general
population, and for those with PD, more than 50% of the general population does not
meet the recommended daily level of physical activity.22 This number is likely even
greater in individuals with PD, as their daily activity levels may be much lower than
those of individuals without PD.23 As such, development of exercise programs that
incorporate the key elements in a format that is enjoyable and engaging, thus potentially
promoting motivation to regularly participate in the activity, seems critical. Given these
specifications, dance may be a highly suitable intervention for individuals with PD.
Dance as an Alternative Form of Exercise

Dance may address each of the key areas that have been identified as being important for
an exercise program designed for individuals with PD.17 First, dance is an activity
performed to music. The music may serve as an external cue to facilitate movement, thus
addressing the first recommended component which is the use of external cues. Dance
also involves the teaching of specific movement strategies, which is the second
recommended component of a PD-specific exercise program. For example, in Argentine
22
tango participants can be taught a very specific strategy for walking backward. They are
taught to keep the trunk over the supporting foot while reaching backward with the other
foot, keeping the toe of that rear foot in contact with the floor as it slides back and
shifting weight backward over the rear foot only after it is firmly planted. Dance also
addresses the third recommended component, balance exercises. Throughout dancing,
particularly with a partner, one must control balance dynamically and respond to
perturbations within the environment (e.g. being bumped by another couple). In fact,
people who have danced habitually over their lives are known to have better balance and
less variable gait than non-dancers.24,25 Additionally, dance-based balance training has
been shown to be successful in improving balance in elderly individuals.26 Dance also
could enhance strength and/or flexibility, although these may not be specific foci of the
instruction during a dance class. Finally, dance can result in improved cardiovascular
functioning, a testament to the fact that, if done with sufficient intensity, dance is an
excellent form of aerobic exercise.27 In addition to addressing each of the key
components, dance is an enjoyable and socially engaging activity. In fact, dance in a
social setting may enhance motivation.28 For these reasons, dance may be an excellent
form of exercise for those with PD. The section that follows reviews the available
research to date regarding the potential benefits of dance for people with PD.
Benefits of Dance for Individuals with PD

There are limited numbers of studies to date that examine the benefits of dance for
individuals with PD. One of the earliest such studies compared a 6-week period of
dance/movement therapy to a traditional exercise program. 29 The authors observed
improvements in movement initiation in the dance group but not in the exercise group.
Another early study examining the benefits of dance therapy for individuals with
neurological deficits (specifically traumatic brain injury and stroke) described
improvements in balance, gait, and cognitive performance with a twice weekly, 5-month
intervention.30 Within a few years of this study, the Mark Morris Dance Group and the
Brooklyn Parkinson Group collaborated to develop Dance for PD, a dance/movement
class. This class continues to be offered on a weekly basis and a recent study of this class
suggests that it positively impacts quality of life.31 While these studies have all focused on
dance/movement therapy using free-form movement and often dancing without a partner,
another line of research has examined the benefits of partnered dance, with a specific
emphasis on Argentine tango.
McKinley and colleagues were the first to report the benefits of Argentine tango for frail
elderly individuals who did not have PD.32,33 In comparison to a group who walked for
exercise, those who danced tango showed greater improvements in balance and walking
speed. They also noted improved strength in both groups, as assessed by a timed sit-to-
stand test. This work inspired our laboratory to pursue studies examining the effects of
tango on functional mobility in individuals with PD.
Individuals with PD demonstrated significant improvements in balance, as evidenced by
an average improvement of 4 points on the Berg Balance Scale, with a twice weekly, 10-
week tango program.34 In contrast, the traditional exercise group in this study did not
show significant improvements in balance. The tango group also showed an improvement
23
of 1s on the Timed Up & Go, while no improvement was noted in the traditional exercise
group. There was also an apparent difference in level of interest in continuing to
participate in tango vs. traditional exercise classes after the study ended, as nearly half of
the tango group continued to participate in ongoing classes but none of the exercise group
members continued.35 In fact, some of the traditional exercise group members joined the
tango classes upon completion of the study (Earhart lab, unpublished observation). These
were the first studies to demonstrate the potential benefits of Argentine tango for people
with PD. These studies were followed by additional investigations of the effects of
Argentine tango as compared to other interventions.
A comparison of tango, waltz/foxtrot, Tai Chi, and no intervention suggests that all three
interventions were superior to no exercise.36,37 With both forms of dance and Tai Chi there
were significant improvements on the Berg Balance Scale (Figure 1). Average
improvement in each dance group was 4 points with effect sizes >0.9 and in the Tai Chi
group was 3 points with an effect size of 0.8. All three interventions also resulted in
significant improvements of 40 meters or more in six minute walk distance (6MWD),
with effect sizes of 0.63, 0.50, and 0.36 for tango, waltz/foxtrot, and Tai Chi, respectively
(Figure 1). Backward walking velocity and backward stride length also improved
significantly in all 3 interventions, with effect sizes ranging from 0.3 to 0.6. Differences
between the interventions emerged for the Timed Up & Go and for forward walking.
Although no significant changes in these measures were noted with any of the
interventions, the largest improvements were noted in the tango group. The tango group
decreased TUG time by 2 seconds with an effect size of 0.45, while waltz/foxtrot showed
no change in TUG time and Tai Chi improved by only one second with an effect size of
0.23. The tango group also demonstrated an increase in forward walking velocity of 0.08
m/s, with an effect size of 0.36, while the other interventions showed changes of 0.02 m/s
or less.
Figure 1
Graph showing changes in performance on the Berg Balance Scale (A) and Six Minute
Walk (B) in individuals with PD who completed 20 twice weekly, one-hour sessions of
tango, waltz/foxtrot, Tai Chi, or no exercise (Control). Asterisks denote significant ...
In addition to these recent studies of dance for PD, there have been a few articles
published within the past year on the benefits of dance for elderly individuals without
PD. In elderly women, a once weekly 12-week jazz dance class was beneficial in
improving static balance as assessed by the Sensory Organization Test.38Another large
study of over 100 older women demonstrated improvements in 6MWD and Timed Up &
Go after a twice weekly, 12-week dance program.39 Finally, improvements in 6MWD,
24
balance, rising from a chair, and stair climbing were noted after an 8-week program of
folkloric dance.40
Are Benefits Obtained with Dance Clinically Meaningful for People

with PD?
Changes of 3-4 points on the Berg Balance score, as have been reported with several
dance interventions for those with PD, exceed the smallest detectable difference which
has been determined for individuals with PD to be 2.84.41 Changes in the Berg Balance
score with dance in a group of healthy elderly, however, were less than 2 points.40 The
reported changes in gait speed of 0.08-0.1 m/s for those with PD who participated in
dance are also above defined thresholds for a meaningful change. A change in gait speed
of 0.05 m/s has been deemed small but meaningful, and a 0.1 m/s change has been
deemed a substantial and clinically meaningful.42 A study of dance in healthy elderly
showed an increase of 0.05m/s in walking speed.42Finally, dance interventions for those
with PD have resulted in improvements of 40-60m in 6MWD which again are considered
meaningful. A change in 6MWD of 20m has been deemed small but meaningful, and a
50m change has been deemed a substantial and clinically meaningful change.42 It is
interesting to note that dance studies in the healthy elderly report similar gains of 40-60m
in 6MWD.39,40 In summary, the benefits of dance for those with PD appear to be of large
enough magnitude to be clinically meaningful. Those with PD may have similar benefits
as healthy elderly with respect to cardiovascular effects of dance, as reflected by 6MWD,
but may stand to gain more than healthy elderly with respect to balance and gait. Given
the very limited evidence, however, additional studies are needed to determine how those
with PD compare to the healthy elderly in terms of the benefits they may garner from
dancing.
Indications for Use of Dance as Therapy in PD

To date, published studies of dance for individuals with PD have included mainly
individuals in Hoehn & Yahr stages I-III. Some have suggested that early intervention
may be a key to improving and preserving function among those with PD, and as such
dance may be indicated even for those who have been diagnosed with PD but are not
experiencing falls or balance difficulties. Those with more advanced disease also may
benefit from dance, but inclusion criteria have often included a stipulation that the
individual must be able to walk 3m with or without an assistive device but without
physical assistance from another person.34,35,43Those whose disease has advance
sufficiently to warrant treatment with deep brain stimulation (DBS) are also likely
appropriate candidates for dance interventions. There is no reason to suspect that those
who have had DBS would respond very differently than those without DBS. In fact, our
most recent tango study has included individuals with DBS and we have noted no
differences in the responses of these individuals compared to those without DBS (Earhart
lab, unpublished data).
Intensity, Frequency, and Duration of Dance Intervention
25
Much remains to be studied about the ideal dosing of dance interventions for individuals
with PD. Most studies to date have involved twice weekly sessions of 60-90 minutes
duration that span a period of 6-12 weeks. One study, however, did examine the effects of
a two week intensive tango program for people with PD.43 In this study participants
danced five days per week for two weeks, with each session lasting 90 minutes. Results
showed a significant 3 point improvement on the Berg Balance Scale and improvements
of 0.1m/s in forward and backward walking velocity, as well as a 35m increase in
6MWD. Note that these improvements are not as large as those seen with a twice weekly,
10 week tango program, where average Berg improvement was 4 points and average
6MWD improvement was 60m.37 During this 10-week program, interim data were also
collected at 5 weeks (Earhart lab, unpublished data). These interim data suggested that
participants had made some gains at 5 weeks, but had not yet reached a plateau, as they
continued to improve from 5-10 weeks. Given current evidence, a program of 10 weeks
duration seems reasonable. As for frequency and duration of individual dance sessions,
data are limited to draw conclusions in this area. In our experience, sessions of 60
minutes duration appear to be challenging but manageable for participants, while sessions
of 90 minutes appear to induce some fatigue and some participants may need to rest more
often during the latter portion of a 90 minute session. Frequency of individual sessions
should likely be at least twice weekly, but three times a week may be superior and would
meet the CDC guidelines which suggest that effective exercise programs should include
at least 150 minutes of moderate-intensity activity per week.44
Why Dance? Potential Mechanisms of Action

As there are no studies to date investigating the neural mechanisms by which dance may
have beneficial effects in individuals with PD, one can only speculate about the ways that
dance may be exerting its influence. One possibility is that the practice of dance may
facilitate activation of areas that normally show reduced activation in PD. For example,
Brown et al. 45 showed that performance of tango movements to a metered and predicated
beat was associated with increased activation of the putamen. Sacco et al. 46 showed that
healthy controls who learned to dance tango showed a shift in cortical activation, with
increased activity in the premotor and supplementary motor areas during imagined
walking following a series of tango lessons. They propose that tango, which has walking
as its basic step, may serve as a means of focusing conscious attention on walking. This is
interesting in light of the fact that people with PD can clearly improve their walking
performance when they use attentional mechanisms and focus on walking quickly with
large steps.47,48 Perhaps tango serves as a means of focusing conscious attention on
walking and, with practice, the walking movements may become more automatic
resulting in enhanced performance that no longer requires conscious attention.
In addition to attentional cues, people with PD can utilize other forms of cueing to
improve movement performance. These cues may be auditory, visual, or
somatosensory.49 Such cues have been postulated to bypass the diseased basal ganglia and
utilize alternate pathways.50,51 Dance may have several sources of built-in cues, such as
those provided by the partner and the music. The music may serve as an auditory cue to
facilitate movement. Rhythmic auditory stimulation is known to enhance walking
performance in people with PD.52-55 Auditory cues may bypass the basal ganglia and
26
access the supplementary motor area via the thalamus 56 or they may access premotor
cortex via the cerebellum.57
Another important aspect of dance may be the specific movements incorporated in the
program. There is a vast body of evidence that supports the concept of task-specific
training, which states that in order to improve a particular task one should practice that
same task.58,59 Dance incorporates practice of many functional movements that people
with PD may struggle with, including backward walking and turning. Tango in particular
also includes pauses such that movement initiation is practiced repeatedly throughout the
dance. In addition, tango involves specific steps that resemble strategies to address
freezing of gait that are a common approach used in rehabilitation settings, such as
stepping over the foot of one's partner.60 The foot may serve as a visual cue to facilitate
the stepping movement. Another important feature of dance may be that it is, by nature,
an activity that requires multitasking. People with PD are known to have particularly
difficulty walking while performing a secondary task 61-65, but practice in multitasking
situations can improve performance.66,67 Dance provides a context for practice of
multitasking, as one must execute the steps while also navigating among others on the
dance floor, and attending to the music. In addition, the leader must be continually
planning ahead to execute the next step in the sequence, while the follower must wait for
and interpret signals from the leader regarding the next step.
Another aspect of dance that likely conveys benefit, particularly with respect to improved
endurance as reflected by increases in 6MWD, is the aerobic exercise dance can provide.
Waltz has been shown to provide cardiovascular benefits equal to those of treadmill
training.27 The cardiovascular effects of dancing tango have also been probed, and tango
elevates heart rate to approximately 70% of maximum which is in the appropriate range
for aerobic training.68
A final aspect of dance that should not be overlooked is its social nature. This may be
particularly important with respect to the effects of dance on quality of life. Dance may
enhance social support networks, thereby contributing to improved QoL. The social
nature of dance may also be important for promoting long-term participation in those
with PD, although this remains to be established. Dance is an enjoyable activity that
engages the elderly and is associated with enhanced motivation to pursue exercise-related
activities.28,69,70Dance not only expands older individuals' repertoire of physical activity,
but may also foster further community involvement, personal development, and self-
expression.71 Dance has been touted as a form of serious leisure that may support
successful aging.72
Future Directions
There is currently only a small body of literature regarding dance for PD and much
additional work is needed. All studies of dance for PD to date have used rather small
sample sizes and have only examined the short-term effects of dance programs. Future
work should include larger samples and assessment of the long-term effectiveness of
dance for PD, and optimal dosing of dance interventions with respect to frequency,
duration, and intensity. These studies should also include assessments of the effects of
dance on other factors, such as mood and cognition, that have yet to be explored.
27
Additional work is also needed to determine what mechanisms underlie the beneficial
effects of dance. This could be approached through the use of imaging techniques similar
to those that have been employed to study tango in healthy young individuals.46,47Another
avenue of exploration would be an economic analysis of dance as compared to other
methods of therapeutic interventions, as dance may be less expensive to deliver than
some other modalities. Dance may also decrease the need for utilization of other health
care services, as suggested by a relatively large study of Korean dance for elderly
women.73 Ultimately, these studies may help to determine more about the benefits that
dance may convey to those with PD and how best to structure a community-based dance
program for individuals with PD to maximize benefits and encourage long-term
participation.
Summary
Dance appears to meet many, if not all, of the recommended components for exercise
programs designed for individuals with PD. The benefits of dance include improved
balance and gait function as well as improved quality of life. Most studies of dance for
PD have included primarily individuals with mild to moderate PD. While benefits can be
obtained with a short, intensive dance intervention, longer interventions may prove to be
more effective. Much remains to be studied in several areas, including the mechanisms by
which dance conveys benefit to those with PD and the long-term effectiveness of dance
as therapy for this population.
Acknowledgments
Thanks to Madeleine Hackney for her assistance in assimilating data and relevant
literature for this review. This work was supported by NIH grant K01-HD048437-05.
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Source:- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780534/
[The effects of a Korean traditional dance movement

program in elderly women].
[Article in Korean]
Jeon MY1, Bark ES, Lee EG, Im JS, Jeong BS, Choe ES.
Author information
Abstract
PURPOSE:
This study was aimed to identify the effects of a 12 week Korean traditional dance movement
program on balance, depression, medical cost, medical institution's utilization and fall among
elderly women.
METHODS:
Using a quasi-experimental design, the experimental group was composed of 130 subjects
and the control group was composed of 123 subjects. The experimental group participated in
a 12 week Korean traditional dance movement program 3 times a week from December
2002 to February 2003. Data was analyzed with descriptive statistics, the chi-square test,
paired t-test and t-test.
33
RESULTS:
There was significant improvement in balance (right leg p=.000, left leg p=.004), depression
(p=.000), and the medical institution's utilization (p=.001) and fall (p=.002) in the
experimental group compared to the control group.
CONCLUSION:
A Korean traditional dance movement program improved balance, depression, and
decreased fall and medical cost in elderly women. Therefore, we recommend this program
be utilized as a health promoting program and falls preventing program for the elderly in the
community.
Source:- https://www.ncbi.nlm.nih.gov/pubmed/16418553
Effect of Dance Exercise on Cognitive Function in Elderly

Patients with Metabolic Syndrome: A Pilot Study
Se-Hong Kim,1,* Minjeong Kim,2,* Yu-Bae Ahn,3,* Hyun-Kook Lim,4,* Sung-Goo Kang,1,* Jung-hyoun
Cho,1,* Seo-Jin Park,1,* and Sang-Wook Song1,*
Author information Article notes Copyright and License information
This article has been cited by other articles in PMC.
Abstract
Go to:
Introduction
The proportion of people aged 65 years and over in Korea is expected to increase from
7.3 % in 2000 to 15.1% in 2020 (The National Statistical Office, 2009). As the geriatric
population rapidly increases, the number of elderly people with dementia is also expected
to increase dramatically. In Korea, the incidence of dementia was 8.68 %, and the number
of patients with dementia was estimated to reach 430,000 in 2008. Dementia is one of the
most distressing and burdensome mental health problems affecting older adults. It is
characterized by the deterioration of cognitive function, behavior, and mental ability,
34
impairs occupational and social activity, and significantly decreases quality of life. Thus,
early intervention for individuals who are at increased risk of dementia is critical.
Metabolic syndrome (MS) is a cluster of cardiovascular risk factors, and like cognitive
impairment, the incidence of MS is rapidly increasing in people over 60 years of age
(Reynolds and He, 2005). MS is associated with an increased risk of cognitive
impairment (Komulainen et al., 2007; Solfrizzi et al., 2009; Yaffe et al., 2004). The
results of a prospective study conducted in adults over the age of 70 years showed that
cognitive function was significantly impaired in the patient group with MS (Yaffe et
al., 2004). The risk of progressing from mild cognitive impairment to dementia was
significantly increased in patients with MS (Solfrizzi et al., 2009). Furthermore, as the
number of cardiovascular risk factors such as hypertension, diabetes, hyperlipidemia, and
smoking increased, the risk of dementia increased (Whitmer et al., 2005).
Aerobic exercise improves cognitive function in elderly people and contributes to the
prevention of degenerative neurological disease and brain damage (Colcombe et
al., 2003; Kramer et al., 1999; Laurin et al., 2001; Stummer et al., 1994). Dance sport is a
form of aerobic exercise that does not require special equipment and can be performed
anywhere regardless of season or weather. Dancing is an ideal exercise to relieve tension
and pressure, and it is an enjoyable social activity that improves fitness levels. Dance has
been shown to reduce body fat and body mass index (BMI) and to improve blood
pressure and glycemic control (Gillett and Eisenman, 1987; Murrock and Gary, 2010;
Murrock et al., 2009; Shimamoto et al., 1998). Dance has also been successful in
promoting healthy activity in older adults and dementia patients (Hokkanen et al., 2008;
Jeon et al., 2005; Kim et al., 2003; Palo-Bengtsson and Ekman, 2002). It stimulates
multiple processes within the cognitive apparatus, including visual and auditory
perception and the capacity to follow instructions (Brown et al., 2006). Compared with
other aerobic exercises, dance sport has the additional benefits of stimulating the
emotions, promoting social interaction, and exposing subjects to acoustic stimulation and
music (Kattenstroth et al., 2010). Thus, dance might be a more effective modality to
improve cognitive function than other aerobic exercises.
Most studies employing dancing as an intervention in the elderly have focused on
improvement in cardiovascular parameters, muscle strength, posture and balance
(Adiputra et al., 1996; Crotts et al., 1996; Hui et al., 2009; Kreutz, 2008; Shigematsu et
al., 2002; Sofianidis et al., 2009), but few studies have examined the effect of dancing on
cognitive abilities. We therefore performed the present prospective pilot study to examine
the effects of dance exercise on the cognitive function of elderly patients with MS.
Go to:
Methods
Participants
Participants were drawn from a cohort of adults aged over 60 years who participated in
health promotion programs at a public health center located in Kyung Gi province
between March and August 2010. Of the 60 volunteers, 16 who failed to meet the
35
inclusion criteria were excluded (4 withdrew participation; 7 physical health exclusion
such as uncontrolled hypertension, arrhythmia, COPD, suspicious coronary heart disease
and symptomatic arthritis; 4 mental health exclusion such as cognitive impairment,
depressive symptoms; 1 could not be recontacted), and six people dropped out within 4
weeks of the study initiation due to exacerbation of pre-existing osteoarthritis, fall down
in the house, move to another area, palpitation and family problem. Thus, 26 Completed
6 months follow-up and the primary analysis was conducted on 38 older adults (26 in the
exercise group and 12 in the control group; Figure 1). Cognitive function was assessed in
all subjects, and height, weight, waist circumference (WC), and BP measurements were
taken. Blood samples were obtained after a 12-hour fast. Fasting plasma glucose, total
cholesterol, triglyceride (TG), and high density lipid (HDL) cholesterol levels were
measured using an auto-analyzer (Hitachi 747 auto-analyzer, Hitachi, Tokyo, Japan). The
exclusion criteria included (1) dementia or suspected dementia according to the DSM-IV
diagnostic criteria; (2) the deterioration of hearing or vision or presence of speech
disturbance; (3) neurological impairment that may have caused cognitive dysfunction; (4)
difficulty in performing daily routines; (5) a cardiac history of unstable angina, recent
myocardial infarction within the last 3 months, congestive heart failure, significant heart
valve dysfunction, or unstable hypertension; 6) taking medications that could negatively
affect cognitive function; and (7) psychological conditions that could affect cognitive
function. Additionally, in accordance with the recommendations of the American College
of Sports Medicine, an exercise stress test was performed on the high-risk group to detect
cardiovascular disease associated with fainting, chest pain, fatigue, arrhythmia or
tachycardia, dyspnea, edema in the lower limbs, and limping symptoms (ACSM., 1991).
Subjects showing abnormal exercise stress test results were excluded from the study.
Figure 1.
36
Flow chart of participant selection process.
The control group continued their daily activities and routines, while the exercise group
attended dance sport classes tailored to their physical condition twice a week for 6
months. The present study was approved by the Research Ethics Committee of the
Catholic University Hospital of Korea, and was conducted in accordance with the
Declaration of Helsinki.
Assessment of cognitive function and depression

Cognitive function was evaluated using the Korean version of the Consortium to
Establish a Registry for Alzheimers disease (CERAD-K) (Lee et al., 2002), and subjects
who had scores below the 5th percentile were excluded from the study on suspicion of
dementia. The CERAD-K neuropsychological assessment battery [CERAD-K(N)] is a
standardized evaluation tool for the early diagnosis of dementia. The test takes a short
time, approximately 30-40 min, and is relatively easy to perform, and thus, is very useful
for the evaluation of elderly patients with dementia. The CERAD-K neuropsychological
evaluation consists of nine neuropsychological subtests (Verbal Fluency Test, Modified
37
Boston Naming Test, Korean version of the Mini-Mental State Examination (MMSE),
Word List Memory, Construction Praxis, Word List Delayed Recall, Word List
Recognition, Construction Recall, and Trail-Making Tests A and B) and was administered
to all subjects by experienced clinical neuropsychologists or nurses prior to and after the
exercise program. The people who administered the neuropsychological and
physiological tests were thoroughly blinded. The total CERAD-K score was calculated by
adding the scores on six tests including the Verbal Fluency Test, Modified Boston
Naming Test, Word List Memory, Construction Praxis, Word List Delayed Recall, and
Word List Recognition. The maximum of total CERAD-K score was 100 points
(Chandler et al., 2005; Seo et al., 2010).
Because depression is closely related to the lowering of cognitive function (Cipolli et
al., 1996), we evaluated depression symptoms using the Korean version of the Short
Geriatric Depression Scale (SGDS-K). The SGDS-K consists of 15 questions and has
been shown to be a reliable and valid screening test for geriatric depression (Bae and
Cho, 2004). The optimal SGDS-K cutoff point for depression was defined as 8 points.
Metabolic syndrome (MS)

MS was defined according to the revised National Cholesterol Education Program Adult
Treatment Panel III (NCEP-ATP III) criteria using KOSSOs cutoff point for abdominal
obesity ( 90 cm for men and 85 cm for women) (Grundy et al., 2005; Lee et
al., 2007). The diagnosis of MS was based on the presence of three or more of the
following clinical criteria: (1) WC 90 cm for men or 85 cm for women; (2) TG levels
150 mgdL-1; (3) HDL levels <40 mgdL-1 for men or <50 mgdL-1 for women; (4)
systolic blood pressure (SBP) 130 mmHg or diastolic (DBP) 85 mmHg, or the use of
antihypertensive medication; and (5) Fasting plasma glucose (FBS) 100 mgdL -1, or the
use of anti-diabetic medication or insulin.
Exercise intervention
The Latin dance, the Cha-Cha, was selected as the exercise intervention. An experienced
dance instructor supervised the dance class twice a week for 6 months. Each 60-min
dance class included a 5-min warm-up, 45 min of dance, and a 10-min cool down period.
The main structure of Cha-Cha is three fast steps and two slow steps with forward-
backward and backward-forward weight transfer. The first three steps require coordinated
movement of one-leg take-off, two-leg knee-bends and light one-leg push. The
synchronized forward-backward weight transfer that follows is accompanied by a free
hand motion. The Cha-Cha has been reported to expend 74.67 kcal/10 min, and as an
exercise, its effect is comparable to jogging (Seo, et al., 2004). Because all participants
had never experienced Cha-Cha before, the initial exercise intensity was similar to that of
the subjects daily routine and gradually increased to a target heart rate. The Karvonen
formula was used to calculate a target heart rate of 50-80% of the level of heart rate
reserve (HRR) (Karvonen et al., 1957). The Karvonen formula is as follows:
where THR is target heart rate and HRrest is resting heart rate.
38
Statistical analysis
The data were analyzed using the Statistical Package for the Social Sciences version 13
(SPSS Inc., Chicago, IL, USA), and the results are expressed as the mean SD. The
Students t-test was used to test baseline comparisons between the exercise and control
groups. A repeated- measures analysis of covariance (ANCOVA) adjusted for baseline
age and education was used to assess the effect of dance exercise on cognitive function
and cardiometabolic risk factors. A general linear model for repeated measures ANCOVA
in SPSS was used and a two sided p-value <0.05 was considered statistically significant.
Results
Table 1 summarizes the baseline characteristics of the study participants. No significant
differences were found between the groups; however, the mean level of education was
higher in the exercise group than in the control group (6.23 1.45 years vs. 4.66 3.02
years, respectively). Age, gender, and the SGDS-K score were not significantly different
between groups. We found no significant between- group difference in BMI (kgm-2),
WC, TG, FPG, or BP. However, HDL cholesterol was significantly higher in the exercise
group compared with the control group (53.38 14.20 vs. 44.08 7.57 mgdL-1,
respectively; p = 0.041). The total CERAD-K score and CERAD-K subtest scores were
not significantly different between group
Table 1
General baseline characteristics of the study participants (n = 38). Data are means (SD).
Exercise (n=26) Control (n=12) P-value *
Age (years) 68.19 (3.66) 68.16 (5.14) .986
Sex (n) Male 7 (26.9%) 2 (16.7%)
Female 19 (73.1%) 10 (83.3%)
Education (years) 6.23 (1.45) 4.66 (3.02) .112
39
BMI (kgm-2) 25.71 (2.87) 25.90 (2.38) .845
WC(cm) 94.43 (6.22) 92.95 (5.05) .481
Triglyceride (mgdl-1) 126.76 (54.41) 134.90 (50.0) .155
Glucose (mgdl-1) 102.00 (10.86) 96.55 (6.71) .504
HDL cholesterol (mgdl-1) 53.38 (14.20) 44.08 (7.57) .041
SBP (mmHg) 131.92 (11.73) 133.41 (7.68) .690
DBP (mmHg) 80.11 (6.95) 80.91 (5.83) .731
CERAD-K Verbal Fluency 13.46 (3.56) 11.66 (3.98) .173
Boston naming test 11.61 (2.15) 10.25 (2.95) .116
MMSE-KC 26.42 (2.10) 25.66 (2.77) .358
40
Word list learning 18.50 (4.10) 15.50 (5.10) .060
Constructional praxis 9.38 (1.57) 9.75 (1.05) .471
Word list recall 6.26 (1.90) 5.08 (1.78) .358
Word list recognition 9.19 (1.13) 8.41 (1.62) .096
Constructional recall 6.73 (2.79) 5.08 (2.19) .080
Trail making A 144.34 (125.08) 120.40 (80.38) .549
Trail making B 239.54 (87.63) 266.16 (65.71) .356
Total score 68.42 (9.75) 60.66 (13.25) .088
SGDS-K 3.88 (3.53) 5.16 (4.04) .327
* Statistical significance was tested using independent t-tests. or 2 test.

BMI: body mass index; WC: waist circumference; TG: triglycerides; SBP: systolic blood pressure; DBP:
diastolic blood pressure; CERAD-K: Consortium to
41
The changes in cognitive function and metabolic risk factors following the intervention
are shown in Table 2. The repeated-measures ANCOVA adjusted for age and education
revealed significant improvement after exercise in verbal fluency (F = 4.21, p = 0.048,
2 = 0.11), word list delayed recall (F = 4.64, p = 0.038, 2 = 0.12), word list recognition
(F = 8.35, p = 0.007, 2 = 0.197), and the total CERAD-K score (F = 4.71, p = 0.037, 2 =
0.122) compared with the control group. In the exercise group, verbal fluency was 13.46
3.56 prior to exercise and improved to 14.96 3.50 after exercise, reflecting an
increase of 1.50 3.55 (changes in control group: 0.00 2.41). Word list delayed recall
improved from 6.26 1.90 at baseline to 7.76 1.83 after 6 months dance exercise,
increasing by 1.50 1.52 (control group: 0.50 1.24). Word list recognition increased
from 9.19 1.13 at baseline to 9.62 0.75 after exercise, increasing by 0.42 0.95
(control group: 0.17 1. 90). The total score of CERAD-K increased by 6.82 5.54 after
exercise (control group: 3.24 0. 93; p = 0.037). No significant between-group
difference was found in scores on the Modified Boston Naming Test, Korean version of
the MMSE, Word List Memory Test, Construction Praxis, Construction Recall, and the
Trail-making Tests A or B after exercise. The mean time of the Trail- making Tests A and
B increased by 72.73 117.57 and 21.52 49.40 seconds, respectively, after exercise;
however, these values were not significantly different from the control group. No
between- group difference was found in the cardiometabolic risk factors of blood
pressure, BMI, WC, FBS, TG, and HDL cholesterol before or after the intervention.
Table 2
Changes in cognitive function and metabolic risk factors. (age and education adjusted).
Data are means (SD).
Exercise (n=26) Control (n=12)
P-value*
Baseline Post Baseline Post
CERAD-K Verbal Fluency 13.46 (3.56) 14.96 (3.50) 11.66 (3.98) 11.67 (3.39) .048
Boston naming test 11.61 (2.15) 12.27 (2.29) 10.25 (2.95) 10.75 (3.25) .262
42
P-value*
MMSE-KC 26.42 (2.10) 27.62 (1.75) 25.66 (2.77) 26.00 (2.83) .214
Word list learning 18.50 (4.10) 20.25 (4.69) 15.50 (5.10) 17.00 (4.61) .095
Constructional 9.38 (1.57) 10.38 (.94) 9.75 (1.05) 10.08 (1.24) .414
praxis
Word list recall 6.26 (1.90) 7.76 (1.83) 5.08 (1.78) 5.58 (2.57) .038
Word list 9.19 (1.13) 9.62 (.75) 8.41 (1.62) 8.58 (1.88) .007
recognition
Constructional 6.73 (2.79) 7.50 (3.26) 5.08 (2.19) 5.33 (2.53) .189
recall
Trail making A 144.34 71.61 120.40 94.51 .798

(125.08) (30.84) (80.38) (68.35)
43
P-value*
Trail making B 239.54 218.03 266.16 252.67 .372

(87.63) (82.24) (65.71) (74.86)
Total score 68.42 (9.75) 75.25 (9.23) 60.66 (13.25) 63.66 .037
(12.58)
BMI (kgm-2) 25.71 (2.87) 25.55 (2.95) 25.90 (2.38) 25.15 (2.19) .156
WC (cm) 94.43 (6.22) 90.27 (6.13) 92.95 (5.05) 88.28 (2.01) .703
Triglyceride 126.76 120.21 134.90 (50.0) 124.78 .564

(mgdl-1) (54.41) (45.68) (40.54)
Glucose (mgdl-1) 102.00 110.17 96.55 (6.71) 107.00 .530

(10.86) (13.89) (6.00)
HDL cholesterol 53.38 (14.20) 53.29 44.08 (7.57) 46.11 (7.74) .458
(mgdl-1) (14.19)
44
P-value*
SBP (mmHg) 131.92 123.41 133.41 (7.68) 130.71 .559

(11.73) (10.83) (8.61)
DBP (mmHg) 80.11 (6.95) 74.00 (8.04) 80.91 (5.83) 80.15 (6.93) .794
SGDS-K 3.88 (3.53) 3.39 (3.05) 5.16 (4.04) 5.00 (2.00) .341
Statistical significance was tested using repeated measures analysis of covariance.

*P values correspond to between-group comparisons for the change over time for each variable.
BMI: body mass index; WC: waist circumference; TG: triglycerides; SBP: systolic blood pressure; DBP:
diastolic blood pressure; CERAD-K: Consortium to Establish a Registry for Alzheimers disease- Korean
version; MMSE-KC: Mini-Mental State Examination-Korean version; SGDS-K: Short Geriatric
Depression Scale-Korean version.
Discussion
To our knowledge, the present study is the first to demonstrate the effect of dance
exercise on cognitive function in older adults with MS. We found that dance exercise
performed for 6 months improved cognitive function in this population. After dance
exercise, the total CERAD-K score increased by an average of 6.8 points. In particular,
positive effects were observed in verbal fluency, delayed recall, and recognition memory
function.
Our results are consistent with previous studies showing that exercise improved delayed
recall, but not immediate recall. Shin et al. (2009) reported that a 16- week exercise
program for cognitively intact older adults improved frontal lobe cognitive functions such
as attention, delayed memory, and verbal fluency, but not immediate recall. A systematic
review found that physical activity improved cognitive function, delayed recall in
particular, in healthy older adults (Angevaren et al., 2008). Other studies also reported
45
that aerobic exercise improved the delayed recall function in elderly individuals (Lam et
al., 2009; Lautenschlager et al., 2008).
In the present study, we found that dance exercise improved verbal fluency. The music
itself may have played a role in this improvement. Previous studies have also reported
that verbal fluency was improved after aerobic exercise (Baker et al., 2010), and that the
effect was larger when the older adults were exposed to music and exercise
simultaneously (Emery et al., 1998; 2003).
We observed no improvement in executive function (Trail-making Test B) in the exercise
group. The subjects in our study were within the normal range of cognitive function at the
start of the exercise program, which may explain the small, non-significant changes in
executive function after the exercise intervention. Alternatively, the absence of significant
improvement in executive function may have been the result of the small number of
subjects in our study and the short observation period. Previous research has shown that
the effect of exercise on executive function is inconsistent and depends on the
characteristics of the subjects, exercise types, and exercise duration (Angevaren et
al., 2008; Baker et al., 2010; Quaney et al., 2009). However, our results are consistent
with those of a study on 311 older adults with subjective memory impairment that
showed that 24-week home-based physical activity improved word list delayed recall but
not word list immediate recall and executive function (Lautenschlager et al., 2008).
In a recent meta-analysis, aerobic exercise was shown to improve cognitive function in
elderly people (Colcombe and Kramer, 2003). Aerobic exercise may decrease brain
amyloid load (Adlard et al., 2005). Dance, as a type of aerobic exercise, requires the
repetitive movement of large and small skeletal muscle groups in the legs, trunk, and
arms. Besides this aspect of physical exercise, the emotional and social aspects of
dancing might contributed to further beneficial effects on cognitive function. The
movement of Cha-Cha is complex sensorimotor activities, and provides an opportunity
for emotional experience and social interaction such as eye contact, touch, talking and
music. Study using positron emission tomography has been shown that dancing elicits
multisite brain activations implicating the involvement of widespread interacting brain
networks (Brown et al., 2006). Another possible effect of Cha-Cha on cognitive function
is that the learning effect during dance class (e.g. remembering dance steps, partner
names and time of the classes). Given that cognitive function improved irrespective of
cardiovascular risk factors in our study, learning dance motion might contribute to further
beneficial effects on cognitive function. The learning therapy was reported as an effective
cognitive rehabilitation for the dementia patients by improving prefrontal function
(Sekiguchi and Kawashima, 2007), and Cross et al., 2009 demonstrated that learning to
dance by effective observation appeared to be closely related to learning by physical
practice, both in the level of achievement and also the neural substrates that support the
organization of complex actions. Moreover, dancing can be performed at any level of
expertise, which encourages regular and continued participation, and because it appeals
to most people, compliance is high and the dropout rate is low. Thus, dance has several
advantages that make it a more practical and useful way to improve cognitive function
than other aerobic exercises. Previous studies have reported that dance sport is more
effective in preventing dementia than several other physical activities (Kattenstroth et
al., 2010; Verghese et al., 2003). On the other hand, Alpert et al., 2009 concluded that a
46
16-week jazz dance program did not improve cognitive function measured by the MMSE.
This finding, however, may be explained by the lack of sensitivity of the MMSE and the
relatively short duration of the exercise intervention.
Cardiovascular risk factors such as hypertension, diabetes, hyperlipidemia, and
abdominal obesity often cluster into a metabolic syndrome that may increase the risk of
dementia (Kalmijn et al., 2000; Yaffe, 2007). In the present study, we did not observe
significant changes in the cardiovascular risk factors after exercise. The mean values of
WC, TG, and BP were decreased in the exercise group; however, the values were not
significantly different from those of the control group. This may be owing to the
relatively low intensity of dance exercise in our study. Because all participants were not
familiar with the dance movements and they spent much time to learn, the exercise
intensity might not be sufficient to improve the metabolic syndrome risk factors. An
alternative explanation is that a substantial number of study subjects were taking
medication to control hypertension and dyslipidemia. Of the 26 subjects in the exercise
group, 13 (50%) and 10 (38.5%) were taking antihypertensive drugs and lipid-lowering
agents. Of the 12 subjects in the control group, 5 (41.7%) and 3 (25%) were taking anti-
hypertensive drugs and lipid-lowering agents, respectively. Only half of subjects
remained after excluding those who took medication, and might be too small to show a
statistical significance. Furthermore, we did not take into account food intake and
physical activity. The cardiovascular risk factors are affected not only by exercise, but
also by other factors including food intake and physical activity. While all participants
were asked not to change their life style, no measure of nutritional intake and physical
activity was performed in this study. Nevertheless, our data show that dance exercise
improved cognitive function irrespective of cardiovascular risk factors, and this finding
suggest the additional beneficial effects of dancing on cognitive function compared to
aerobic exercise.
The present study has some limitations. First, we could not perform a brain imaging
study; thus, we cannot identify the potential physiological mechanisms mediating the
relationship between physical activity and cognitive function. Second, our subjects were
neither randomized nor blinded, and it is possible that those who agreed to participate in
the study may have been more motivated. Participant expectancy and experimenter bias
may have played a role in the observed improvements. Moreover, given the small sample
size in this preliminary study, generalizability of our findings to the larger population of
older persons should be approached with caution.
Despite these limitations, the results of our study support evidence showing a positive
effect of dance exercise on cognitive function in elderly people with MS, a recognized
risk factor for the progression to dementia. Further studies to evaluate the effect of
various types of dance exercise as well as exercise intensity, frequency, and duration on
cognitive function are needed to verify the improvements observed in the present study.
Such studies would provide important information on methods to prevent degenerative
neurological diseases among elderly people with MS.
Conclusion
47
In the present study, dance exercise for a 6-month period improved cognitive function in
older adults with MS. In particular, positive effects were observed in verbal fluency, word
list delayed recall, word list recognition, and the total CERAD-K score. Thus, dance
exercise may reduce the risk for cognitive disorders in elderly people with MS. In light of
the growing number of older adults suffering from dementia, our data suggest that the
implementation of dance exercise programs may be an effective means of prevention and
treatment of cognitive disorders.
Acknowledgements
This research was supported by the Basic Science Research Program of the Catholic
University of Korea through a research grant from Daewoong (VC10EISI0011).
Publication of the study results was not contingent upon sponsors approval. We thank
Sang-young Han from the public health center of Dongtan, Korea for providing space and
support.
Disease: Improving Quality of Life
Abstract
Parkinson's disease (PD) affects mobility and health-related quality of life (HRQOL),
through a neurodegenerative disease process. Drugs and pharmacology do not fully
address motor, cognitive, and psychosocial symptoms; therefore, adjunctive therapies
have been researched for their efficacy at addressing these issues. One form of exercise,
dance, has received attention because recent studies have demonstrated dance's ability to
improve mobility and HRQOL in people with PD. The purpose of this integrative review
was to present evidence supporting or refuting improved HRQOL in individuals with PD
after participation in a dance-or music-based movement intervention. Potential
mechanisms of HRQOL improvement are offered. Search terms including "Parkinson's
disease", "dance", "quality of life", "exercise", "dance/movement therapy", and "music"
were entered in groupings into PubMed, CINAHL , EMBASE, PsycINFO , Web
of Science, and the Cochrane Library databases. Papers were included if they were
randomized controlled trials, pilot studies, or case reports that were related to HRQOL
and dance/movement and/or specifically related to determining the mechanisms
potentially underlying dance effects. To date, the available research has been inconclusive
in demonstrating that dance has a positive impact on HRQOL; however, further research
is required. This review suggests that, at the very least, dance has the potential to impact
the HRQOL and possibly the health behaviors of individuals with PD. Interventions for
those with PD must be targeted and efficient. Going forward, research should explore
48
mechanisms of dance's effects for those with neurodegenerative conditions in order to
inform novel mobility rehabilitation that benefits HRQOL.
Publication (PDF): Dance Therapy for Individuals with Parkinson's Disease: Improving
Quality of Life. Available from:
https://www.researchgate.net/publication/260597165_Dance_Therapy_for_Individuals_w
ith_Parkinson's_Disease_Improving_Quality_of_Life [accessed Apr 10, 2017].
2014 Hackney and Bennett. This work is published by Dove Medical Press Limited,
and licensed under Creative Commons Attribution Non Commercial (unported, v3.0)
License. The full terms of the License are available at
http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are
permitted without any further permission from Dove Medical Press Limited, provided the
work is properly attributed. Permissions beyond the scope of the License are
administered by Dove Medical Press Limited. Information on how to request permission
may be found at: http://www.dovepress.com/permissions.php
Journal of Parkinsonism and Restless Legs Syndrome 2014:4 1725
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Dance therapy for individuals with Parkinsons disease: improving

quality of life
Madeleine E Hackney13
Crystal G Bennett4,5
1Veterans Affairs Rehabilitation R&D Center of Excellence, Atlanta,
GA, USA; 2Birmingham-Atlanta VA
Geriatric Research, Education and Clinical Center, Decatur, GA, USA;
3Division of General Medicine and Geriatrics, Department of Medicine,
Emory University School of Medicine, Atlanta, GA, USA; 4Department of
Nursing, University of West Florida, Pensacola, FL, USA; 5Department of
Adult and Elderly Nursing, College of Nursing, University of Florida,
Gainesville, FL, USA Correspondence: Madeleine E Hackney PhD
Research Health Scientist, Atlanta VA Medical Center, 1670 Clairmont Rd,
Decatur, GA 30033, USA
Tel +1 404 321 6111, ext 5006
Cell +1 314 412 4852
Email mehackn@emory.edu; madeleine.
hackney@gmail.com
Abstract:
Parkinsons disease (PD) affects mobility and health-related quality of life (HRQOL),
49
through a neurodegenerative disease process. Drugs and pharmacology do not fully
address motor, cognitive, and psychosocial symptoms; therefore, adjunctive therapies
have been researched for their efcacy at addressing these issues. One form of exercise,
dance, has received attention because recent studies have demonstrated dances ability to
improve mobility and HRQOL in people with PD. The purpose of this integrative review
was to present evidence supporting or refuting improved HRQOL in individuals with PD
after participation in a dance- or music-based movement intervention. Potential
mechanisms of HRQOL improvement are offered.
Search terms including Parkinsons disease, dance, quality of life, exercise,

dance/movement therapy, and music were entered in groupings into PubMed,
CINAHL, EMBASE, PsycINFO, Web of Science, and the Cochrane Library
databases. Papers were included if they were randomized controlled trials, pilot studies,
or case reports that were related to HRQOL and dance/movement and/or specically
related to determining the mechanisms potentially underlying dance effects.
To date, the available research has been inconclusive in demonstrating that dance has a
positive impact on HRQOL; however, further research is required. This review suggests
that, at the very least, dance has the potential to impact the HRQOL and possibly the
health behaviors of individuals with PD. Interventions for those with PD must be
targeted and efcient. Going forward, research should explore mechanisms of dances
effects for those with neurodegenerative conditions in order to inform novel mobility
rehabilitation that benets HRQOL.
Keywords: exercise, music, QOL, mobility rehabilitation, intervention,

neurodegenerative
Introduction
Parkinsons disease (PD) is a common neurodegenerative disorder affecting close to one
million adults in the United States. By 2030, the number of people living with PD is
expected to double because of the increasing aging population.
1 Due to the progressive worsening of PD-related symptoms, management and treatment

of this disease can be costly. Common symptoms of PD include tremor, bradykinesia,
postural instability, and gait impairments, which often lead to lost independence. PD can
also severely impact psychological and cognitive aspects of well-being.
2 Non-motor manifestations of PD, specically declining emotional health and health-

related quality of life (HRQOL), may in fact precede the diagnosis of PD by several
years.
3 HRQOL is the perception and evaluation by patients of the impact that the illness
and its consequences have caused in their life.
4 Self-assessed health status has been demonstrated to be more powerful at predicting

mortality and morbidity than many objective measures of health.
50
5,6 HRQOL measures, which are generally self-reported and related to physical or mental
health, make it possible to demonstrate scientically the impact of health on quality of
life (Center for Disease Control, http:// www.cdc.gov/hrqol/concept.htm). Several valid,
reliable and standardized measures have been used to assess HRQOL and related
concepts, eg, the Medical Outcomes Study Short Forms 12 and 367,8 (SF-12 and SF-36).
The Parkinsons Disease Questionnaire (PDQ)-399 is a PD-specic measure of HRQOL

and is used widely. The self-reported information gathered concerning HRQOL in
individuals with PD is gaining importance as an outcome measure for long-term
trials.
10 HRQOL is affected early in PD by multiple non-motor symptoms. 11 As the disease

progresses, a collage of motor, affective, and behavioral symptoms often leads to
considerably reduced HRQOL for many with PD.12
Mood disorders, impaired cognition, and sleep patterns worsen, which contribute to
increased stress and social isolation over time.13,14 HRQOL is particularly affected by
depression, which is comorbid with PD in nearly half of those affected by the disease.
Although PD is classically thought to be a movement disorder, motor symptom
treatment cannot be the sole concern in care. HRQOL in PD must be addressed with
appropriate therapies. Does increased social engagement and better motor function
improve HRQOL in individuals with PD?
Addressing issues of well-being for those with PD is important because psychological

adjustment to the effects of PD can have greater impact on HRQOL than disease
severity.13 Increased depression, anxiety, and stress levels are signicantly associated
with increased problems in self-reported social support.15 Life goal disturbance as a
result of neurological disease may impact HRQOL, mood, and independence.14
Relationship goals with partner and family are often of utmost importance to those with
PD.14 Axial impairment adversely impacts HRQOL in those with PD16,17 as well.
Therefore, therapeutic interventions that foster achievable life goals and improve social
network size and quality, while concurrently targeting motor impairments, are necessary
for enhancing mood function and HRQOL of individuals with PD.14 Exercise therapy
may reduce axial impairment, alleviate depression, and by proxy, enhance HRQOL.18
Higher levels of physical activity are associated with signicantly less apathy and
depression, while promoting greater positive affect in individuals with PD.19 Recently, a
series of studies has examined a form of exercise, dance, for its effects on mobility, and
postural control in people with PD.
An adapted form of Argentine tango,20,21 Irish set dancing,22 contact improvisation,23

and modern dance,24 among other forms of dance, have been demonstrated to have
benecially affected mobility in those with PD. Because social dance often involves
meeting regularly to work in pairs or groups for honing skill and/or to enjoy the activity,
dance may encourage teamwork, which can allow the cultivation of friendships and
51
may foster larger community involvement and social support.
Dancing also necessitates the practice of dynamic balance and adjustment to nvironment,
which are key features for rehabilitating balance impairments.25 Many individuals nd
dance enjoyable and engaging, which could promote adherence and enhance motivation
for rehabilitative purposes.26,27
Because of these qualities, when used as an intervention for individuals with motor
impairments, dance may contribute to improved HRQOL for individuals with PD.28,29
Dances effects upon HRQOL have been studied in other populations. A randomized
controlled trial (RCT) of 162 adult participants who suffered from stress, demonstrated
that dance/movement therapy was effective at improving short- and long-term HRQOL,
as measured by the World Health Organization QOL questionnaire, compared with
usual care.30 A similar large-scale trial examining dances effects on HRQOL in PD is
not currently available; however, a handful of smaller trials have explicitly examined
this construct.
Two former reviews have examined the effects of dance for people with PD. An early
review by Earhart included studies from 1989 to 2009, only one of which had examined
HRQOL.31 Evidence, compiled in a rigorous meta-analysis by de Dreu et al32 on music-
based movement therapies for those with PD, suggested only a trend towards improved
HRQOL, as measured by a happiness scale. However, de Dreu et al32 ultimately
included only six studies in their rigorous systematic meta-analysis.
The present review, in contrast, provides a broader perspective about the state of
research into HRQOL and dance, ie, rhythmic multimodal movement and movement set
to music, for PD and will present several mechanisms by which dance might benecially
inuence HRQOL.
Purpose and methods of this integrative review
The main aim of this review was to critically evaluate the evidence for the use of dance
and movement therapies that employ music to improve HRQOL for individuals with PD
as well as for other populations at risk for loss of physical function and decreased
HRQOL.
This was accomplished in the integrative format by synthesizing the ndings of selected
studies. This review also postulates mechanisms by which dance could impact HRQOL in
individuals with PD.
The following methods were used for this integrative review. Search terms were entered
into databases, and entries were reviewed for appropriateness and inclusion in the paper.
Systematic reviews, meta-analyses, RCTs, case studies, and smaller pilot trials that
included individuals with PD or other neurological disorders, other comorbidities (ie,
breast cancer), or older adults and were related to improved HRQOL or to determining
52
the mechanisms of dance effects upon HRQOL were included. Perspective pieces, purely
qualitative reviews, and trials involving non-dance- or music-related interventions were
excluded.
Papers about non-PD populations were included because relatively little research has
been specically conducted on dances effects on HRQOL. Conference proceedings were
not included, nor were non-English language papers. Both authors and a research
assistant began with a PubMed search using the following groups of terms consecutively:
Parkinsons, dance, and quality of life (13 entries), then Parkinsons, exercise,
and quality of life (125 entries), Parkinsons and dance (45 entries), and
Parkinsons music, quality of life and health related quality of life (10 entries).
The journals American Journal of Dance Therapy and Music and Medicine were also
reviewed for appropriate titles and abstracts. Next, the rst author and a research assistant
reviewed the following databases: PsycINFO (23 entries), Web of Science (5
entries), CINAHL (6 entries), Cochrane Library databases (3 entries), and EMBASE
(97 entries), for a total of 152 additional entries. Eighty-four of these were inappropriate
upon review.
Fifty-four entries were redundant with the previous PubMed search, leaving 14 additional
papers that were, at the onset, appropriate for inclusion. Three of these were not obtain-
able, and of the remaining eleven papers, six were deemed inappropriate upon review.
Five more papers were included from the secondary search.
Do dance and exercise affect HRQOL?
What are dance and exercises effects in community-dwelling older adults?

Understanding how dance affects HRQOL in community-dwelling older adults will
provide perspective in comprehending dances effects, if any, upon HRQOL in those
with PD. Research on dances effects has been conducted upon not only motor, but also
cognitive and psychosocial function of the healthy older adult population.
In an RCT with healthy older participants, improvements in general and mental health
aspects of HRQOL were found following 8 weeks of folklore dance, while the control
group experienced declines.33 Another study which included 111 older adults who
participated in 23 sessions of dance over 12 weeks improved in mobility and general
health (measured by the SF-36) and believed their health status was improved by the
intervention.34
In a study of Korean dance for older adults,35 improvements were found in social
interaction components of HRQOL. Likewise, in a qualitative study conducted in Brazil,
60 participants in a ballroom dancing intervention that met for 1 hour, twice weekly for 1
year, reported dancing gave them opportunity to socialize and increase their connection to
their own culture.36
53
In a pilot study examining adapted tango for oldest-old adults with low vision, along
with improvements in postural stability, there was a signicant positive change
on vision-related quality of life in 12 participants.37
What are dances effects upon HRQOL in individuals with PD?
Dance research conducted in older adults has led to the examination of dances effects for
individuals with PD. Studies examining the effects of dance forms in varying regimens
on HRQOL in those with PD have revealed: 1) dance can be safe and enjoyable and can
improve HRQOL;21,38,39 2) dance may have an early effect on HRQOL, as
improvements have been found after as few as 2 weeks;23 and 3) dance may improve
HRQOL in those with a severe and/or end-stage neurological disorder.40,41
However, RCTs examining HRQOL with PD participants assigned to a dance

intervention have been very limited. Thirteen studies are examined here that involved
a movement intervention for people with PD. There were seven RCTs, ve single-arm
(no-control) trials, and one case report (Table 1). {The compiler of these set of documents
was unable to upload the table in Microsoft Word format, please use web page address to
go to original article where the table is included)
Volpe et al22 did not determine any signicant difference in effects upon HRQOL
between Irish dancing and physiotherapy, although both groups experienced non-
signicant improvements on the PDQ-39. In contrast, a study investigating effects of
tango dance found improvements in activity participation following 12 months of the
intervention.39
Additionally, in an RCT of 32 participants with PD, music therapy involving strongly

rhythmic body movement demonstrably improved scores on the PD Quality of Life
questionnaire.42
In 12 participants with PD who engaged in the Ronnie Gardiner Rhythm and Music
Method twice weekly over 6 weeks, improved HRQOL scores were noted.43
A theatrical movement therapy examined in 20 patients with PD over 3 years resulted in
improved HRQOL44 as measured by the standard, valid, and reliable PDQ-39, which
measures subjective health status.
A recent study that primarily examined the effects of adapted tango on spatial cognition
in individuals with PD also explicitly examined HRQOL with the PDQ-399 and the SF-
12,7 which have satisfactory clinimetrics. However, no changes were noted on either
scale, in comparison with an education control group.45
In studies of individuals with PD without a control group, improvements in HRQOL were

noted in eleven individuals with PD after participation in contemporary dance.46 Also,
those with PD who participated in contact improvisation (n=11) self-reported enjoyment
and interest in dance classes.23
54
Furthermore, improvements in HRQOL were found in a case study of a severely
mobility-impaired participant with Stage V PD.40 In a mixed-methods study examining
the effects of a ballet class that included participants with PD,47 the participants reported
being highly motivated and valued dance as being important.
When evaluated, modern dance in the guise of the very popular Dance for PD class
format showed a trend towards positive inuence on HRQOL in those with PD in an
uncontrolled study.48 A movement class with strong musical cueing was benecial for
trunk rotation in seven individuals with PD, and there was a trend toward positive
changes on several dimensions of the PDQ-39.49
That several of the studies investigating dance and free movement in PD have not been
controlled and may have been subject to bias decreases the rigor of the body of work.
Plus, many of the sample sizes were small. The results of these studies are therefore
compromised because of study limitations, which weaken any evidence that supports
improved HRQOL.
More research that observes rigorous scientic methods needs to be performed to make
conclusive inferences about dances effects upon HRQOL in individuals with PD.
What are dances effects on other populations at risk for loss of function?
Recent research has shown that other populations may have benetted from participation
in dance interventions of various types, through improved HRQOL. Improvements were
found with an impaired individual with chronic stroke41 who self-reported that dance
improved his HRQOL and that he enjoyed the dance classes. Improvements in HRQOL
were found in a 13-week RCT of dance/movement therapy with participants with breast
cancer.50 In a pilot study with individuals with serious mental illness who participated in
salsa dance, participants reported improved mood, enjoyment of classes, and the desire to
continue to dance.20
Further, compared with meditation and usual care, individuals with self-reported
depression who participated in tango reported reduced stress.51 However, in a group of
individuals with Huntingtons disease who participated in the video game Dance Dance
Revolution, gait improved, and participants were motivated to continue, but there were
no signicant improvements on measures of HRQOL.52
Further, a systematic review showed that dance/movement therapy was not found to be
effective at improving self-constructs in breast cancer survivors.53 Thus, it is interesting
and hopeful that some evidence indicates the efcacy of dance in improving HRQOL
amongst multiple populations.
However, the evidence is weak overall, because few studies have directly examined this
construct in conjunction with dance- or music-based interventions, and there is a
55
dearth of properly conducted RCTs.54
What are the mechanisms through which dance may improve HRQOL?
A number of mechanisms, including increased participation through enhanced motor

function, mental imagery and engagement, music, and physiology, may mediate dances
effects upon HRQOL in those with PD, as well as other comorbid conditions.
Does enhanced motor function lead to increased participation?
A suggested hypothesis for why partnered dance would improve HRQOL is that in
addition to improving balance impairment, dance involvement may reduce social isola-
tion for those with PD. The World Health Organizations International Classication of
Functioning, Disability and Health (ICF) takes into account social aspects of disability.
In the ICF model, an individuals functioning in activities is an interaction between health

condition, environmental, and personal contextual factors. People with PD experience
physical and cognitive performance problems because of environmental factors
interacting with their health condition and impairment.
Loss of mobility leads to reduced ability to interact with a complex world. Physical and
cognitive changes faced by those with PD may also preclude interacting in the hectic life
environment that is reality for many. Participation, dened as involvement in a life
situation, is especially related to mobility-related HRQOL and the ability to do functional
tasks like rising from a chair.55
Potentially, some individuals with PD have benetted in HRQOL through dance by the
removal of barriers to participation (eg, availability of dance programs and motor
challenges of the steps).
Participation in a yearlong program of tango led to participants recovering lost activities,

beginning new ones, and gaining the ability to engage in more complex activities.39
Exercise programs for individuals with PD that are self-guided may not be as helpful for
HRQOL as programs that involve a supportive therapist or instructor.56
In a culturally specic dance study in which middle-aged and older African

American women (ages 3582 years) participated, social support was found to mediate
the effects of the dance on lifestyle physical activity.57
Social support is undoubtedly important for improving HRQOL; however, the delivery
of this support is relevant. A cohort with PD and their caregivers who did not participate
in exercise but did receive educational information designed to increase social support
and relieve stress and caregiver burden did not signicantly improve on the PDQ-39, nor
on the EuroQOL 5D, a questionnaire for caregivers.58
56
Therefore, the motor symptom improvement that can be gained from physical
interventions like dance is especially important for enhancing HRQOL. Gait and bal-
ance are increasingly recognized as especially important for determinants of HRQOL as
well as mortality.59 Dance may improve the axial impairment38 that greatly affects
participation and also HRQOL in those with PD.60
Mental imagery and engagement in motor practice Mental activity performed in a task-
specic manner, as in dance, may be an important factor contributing to overall
improved well-being. Mental practice and motor imagery can impact gait and tasks that
require coordinated movements of lower extremities in those with PD and other
populations.61
A mindful movement program aimed at improving HRQOL and mindfulness in older

breast cancer survivors was moderately effective, and the effects were retained 6 weeks
after the intervention.62
Healthy middle-aged adults who underwent tango training for 1 week and incorporated
mental imagery of gait patterns demonstrated expanded bilateral motor activation.63 This
nding shows that there is a strong link between activity, mental engagement, and neural
pathways.
Dancing, whether it be tango, contemporary, or folk dance, involves complex, unfamiliar

tasks like walking backward, problem solving, and movement improvisation, which pos-
sibly target mobility issues in individuals with PD through increased mental engagement
and strategy development.
The creativity involved in a dance form might tap into mechanisms of neural plasticity
for novices just beginning classes for therapy. The exposure to novel steps and choreo-
graphic patterns could, through the mechanisms of neural plasticity, expand neural areas
and improve connections on neural pathways that facilitate HRQOL.
Music
Music, which has been found to activate specic neural pathways associated with
emotion, might reduce stress and enhance social relationships.29
Music-therapy programs that include any consistent rhythmic auditory stimulation to

facilitate motor movements are recommended for those with PD as a way to improve
HRQOL.49 However, gross motor action coordinated to music may be essential for
improving HRQOL, because choral singing alone did not result in improved HRQOL in
15 individuals with PD.64
57
The role that music may play in any signicant improvements noted in HRQOL and
possibly obtained through dance is not yet understood. More research is certainly needed
to better characterize musics impact on dance used as therapy.
Physiology and psychopathology
Psychopathology in some individuals with PD, which often leads to reduced HRQOL,
results from the underlying physiology of the disease.65 Neurotransmitter systems that
are typically degraded in PD (eg, dopamine and serotonin) also contribute to
depression.66 Decreased availability of the dopamine transporter in the anterior
putamen correlates with depressive symptoms and anxiety.67
However, in a positron emission tomography study, rhythmic tango steps have been
shown to selectively activate the putamen,68 an area of the brain particularly affected
by the loss of dopamine in PD. Perhaps through this pathway, dance affects depressive
symptoms. In an RCT of tango over 2 weeks (meeting 1.5 hours four times per week)
with middle-aged adults with self-referred symptoms of anxiety, stress, and depression,
signicant improvements in anxiety, stress, and depression were noted at post-test, which
were maintained at a 1-month follow-up.69 Moreover, those in the tango group had
signicantly greater satisfaction with life at 2 weeks.
Likewise, similar improvements in stress, anxiety, and depression were noted in the
same population after 8 weeks of tango dance.70 The neuroprotection and
neurorestoration that may be derived from consistent, task-specic, and frequent aerobic
exercise, which could be provided by dance, may extend into improved mood and
capability to accomplish activities of daily living and thereby impact HRQOL
. Individuals with severe and persistent mental illness notably benetted in mood
from salsa dancing, which is highly aerobic.71 After 36 sessions of aerobic and strength
conditioning, individuals with PD demonstrated improvements in social interactions,
emotional reactions, and physical ability on the Nottingham Health Prole,72 which is a
patient-reported, subjective outcome measure of health and life areas affected by
illness.73 Improvement gained potentially through plasticity-related changes in
synaptogenesis, angiogenesis, and neurogenesis may have allowed older adults to benet
after regular aerobic activity.74
Conclusion and recommendations for future research
The denitive benecial ingredients of dance for improved HRQOL require elucidation,
but dance programs may have multidimensional effects on self-assessment. The departure
from the daily routine in everyday lives of patients with PD may alone provide an effect
that appears in improved HRQOL measure scores. Possibly, therapies involving the
arts and self-expression, both emotional and physical, are especially helpful for managing
symptoms leading to reduced HRQOL.
58
Therapies that 1) allow the patient to regain and exert control on their body and 2)
involve extensive social interaction have been shown to be effective at improving
quality of life.44 Future research should evaluate the role of a regained locus of control
and consider depression and cognitive impairment as they relate to interventional success
on HRQOL as a primary outcome of interest.
Furthermore, future research should include retention measures and delineate ideal
frequency, duration, and intensity of dance sessions to obtain and retain gains in HRQOL.
Dance, which may benet HRQOL, may also prove economic because group classes are
comparatively inexpensive to administer.75,76 However, engaging in exercise habitually
remains overwhelmingly poor in the general older adult population. An epidemiologic
study reported only one in eight older adults engage in strength or balance-challenging
activities.77
Individuals with PD are less active than their age-matched peers without PD.78
Rehabilitation to restore and/or improve HRQOL in people with PD must be efcient as
well as effective, because adherence to an exercise regimen is critical. Thus, identifying
aspects of dance, which are most responsible for benets to HRQOL or mediating
symptoms, ie, axial impairment, will be important for adherence to exercise.
Understanding these crucial aspects will also help determine foundational principles of
motor training and emotional therapy. Creating sustained behavioral change
through targeted programs may be most effective at addressing HRQOL issues.79
This review has considered the available evidence that examines whether dance and
music-based movement therapies impact HRQOL and potentially other characteristics,
eg, health behaviors, of individuals with PD, as well as those with related comorbid and
neurological conditions.
These early studies may provide fodder for future, more rigorous research into the effects
of dance for various populations facing aging-related diseases.
Dance Maybe Ideal For Individuals Suffering From PD
For the frequently overlooked issue of improving HRQOL for those with PD, dance
interventions may be ideal because:
1) dance targets axial impairment and gait decits that are major contributors to
reduced HRQOL;
2) dance is a social activity that could enhance strong supportive relationships between
those with PD, their caregivers, and other loved ones; and
3) dance is enjoyable and motivating, possibly promoting long-term, consistent
involvement. Going forward, uncovering mechanisms may be the most important area of
discovery for the investigation of non-pharmacologic interventions that address HRQOL
issues.
59
The knowledge and principles gained could impact not only dance disciplines but also
physical, occupational, and emotional therapy for older adults with PD and related
neurological disorders. With improved and/or maintained independence via enhanced
mobility and an expanded social network, the overall goal of improving HRQOL in those
with PD can be reached.
Acknowledgments
We would like to acknowledge our helpful staff, in particular, Aaron Bozzorg, for
assisting us in the preparation of this manuscript as well as our prior and present
colleagues who provided inspiration.
Disclosure
The authors report no conicts of interest in this work. The authors alone are responsible
for the content and writing of the paper. Department of Veterans Affairs (VA) Career
Development Awards (E7108M and N0870W) supported Dr ME Hackney.
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Publication (PDF): Dance Therapy for Individuals with Parkinson's Disease: Improving
Quality of Life. Available from:
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ith_Parkinson's_Disease_Improving_Quality_of_Life [accessed Apr 10, 2017].
Aerobic Exercise for Parkinson's Disease: A

Systematic Review and Meta-Analysis of
Randomized Controlled Trials
Hai-Feng Shu, Tao Yang, Si-Xun Yu, Hai-Dong Huang, Ling-Li Jiang, Jian-Wen Gu,
Yong-Qin Kuang
Published: July 1, 2014

http://dx.doi.org/10.1371/journal.pone.0100503
Abstract
Background
Although some trials assessed the effectiveness of aerobic exercise for Parkinson's
disease (PD), the role of aerobic exercise in the management of PD remained
controversial.
Objective
The purpose of this systematic review is to evaluate the evidence about whether aerobic
exercise is effective for PD.
Methods
Seven electronic databases, up to December 2013, were searched to identify relevant

studies. Two reviewers independently extracted data and assessed methodological quality
based on PEDro scale. Standardised mean difference (SMD) and 95% confidence
intervals (CI) of random-effects model were calculated. And heterogeneity was assessed
based on the I2statistic.
66
Results
18 randomized controlled trials (RCTs) with 901 patients were eligible. The aggregated
results suggested that aerobic exercise should show superior effects in improving motor
actions (SMD, 0.57; 95% CI 0.94 to 0.19; p=0.003),
balance (SMD, 2.02; 95% CI
0.45 to 3.59; p=0.01),
and gait (SMD, 0.33; 95% CI 0.17 to 0.49; p<0.0001) in patients
with PD, but not in quality of life (SMD, 0.11; 95% CI 0.23 to 0.46; p=0.52).
And there
was no valid evidence on follow-up effects of aerobic exercise for PD.
Conclusion
Aerobic exercise showed immediate beneficial effects in improving motor action,

balance, and gait in patients with PD. However, given no evidence on follow-up effects,
large-scale RCTs with long follow-up are warrant to confirm the current findings.
Figures
67
68
Citation: Shu H-F, Yang T, Yu S-X, Huang H-D, Jiang L-L, Gu J-W, et al. (2014)
Aerobic Exercise for Parkinson's Disease: A Systematic Review and Meta-Analysis of
Randomized Controlled Trials. PLoS ONE 9(7): e100503.
doi:10.1371/journal.pone.0100503
Editor: Alfonso Fasano, University of Toronto, Italy
Received: January 27, 2014; Accepted: May 23, 2014; Published: July 1, 2014
Copyright: 2014 Shu et al. This is an open-access article distributed under the terms
of the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original author and source are
credited.
Funding: This work was supported by National Natural Science Foundation of China
(No. 81100975, 81371430), China Postdoctoral Science Foundation (No. 2012T50850),
Research Foundation of General Hospital of Chengdu Military Region (No. 424121H3),
and Science Foundation of Health Office of Sichuan Province (No. 42412D16). The
funders had no role in study design, data collection and analysis, decision to publish, or
preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Parkinson's disease (PD) is a relatively progressive and neurodegenerative movement
disorder that is characterized by many motor and non-motor symptoms such as resting
tremor, bradykinesis, balance decrements, gait disruption, and reduced quality of life [1].
It is estimated that PD affects approximately 340,000 adults in the United States and this
number would be probably doubled by the year of 2030 [2]. Although the causes of PD
are still under investigation, its incidence obviously increases among people aged more
than 50 years old [3]. In China, for example, PD prevalence is 1.70% in people aged
more than 65 years old [4].
In recent years, aerobic exercise is widely used in assisting pharmacological treatments of

PD. It may promote brain health by reducing inflammation, suppressing oxidative stress,
and stabilizing calcium homeostasis [5]. Studies in healthy older rodents have shown that
regular aerobic exercise triggered plasticity-related changes in the central nervous
system, including synaptogenesis, enhanced glucose utilization, angiogenesis, and
neurogenesis [6]. Other studies have shown that aerobic exercise, such as treadmill
training, dancing, etc, may be beneficial in improving balance, gait, physical function,
and quality of life in individuals with PD [7][9].
Some systematic reviews and meta-analyses supported that exercise therapies were
effective in improving both motor and non-motor impairments of patients with
PD [10], [11], but no review has addressed the specific effectiveness of aerobic exercise
for PD. In the previous reviews, it is difficult to extract accurate information regarding
the contribution of aerobic exercises in patients with PD because multiple exercise
therapies were often involved.
69
Therefore, this systematic review aims to evaluate the evidence about whether aerobic
exercise is effective for patients with PD. And we conducted meta-analyses of
randomized controlled trials (RCTs) focusing specifically on balance, gait, and quality of
life in patients with PD.
Methods
Search Strategy
The following electronic databases were searched from their inception to December
2013: PubMed, EMBASE, OVID-MEDLINE, Cochrane Library, CNKI (China
Knowledge Resource Integrated Database), Weipu Database for Chinese Technical
Periodicals, and Wan Fang Data. The following keywords were used in combinations:
Parkinson, Parkinson's disease, Parkinsonism, exercise, physical activity, and physical
therapy. Literature was also identified by citation tracking using reference lists from
papers and internet searching. In order to include unpublished studies in our review,
dissertations and trial registrations were also searched, and we contacted experts in this
field. Two authors (HFS and TY) undertook the initial literature search and identified
eligible studies. If it was unclear as to whether the study met the inclusion criteria, advice
was sought from a third author and any disagreement was settled down by a consensus
after discussion.
Study Selection
The studies that met the following criteria were included: (1) RCTs of aerobic exercise
for PD; (2) the target population was aged 2085 years and confirmed diagnosis of PD;
(3) the main intervention should be aerobic exercise and the exercise should be
specifically suitable for the challenges and difficulties presented by PD; (4) the effect of
aerobic exercise intervention was compared with any comparator, including other forms
of exercise or physical activity; (5) the outcomes included at least one of the following:
balance, gait, or health-related quality of life; (6) RCTs should contain available data for
the meta-analysis; (7) the paper was available in either English or Chinese.
A study was excluded if: (1) the effect of a non-aerobic exercise intervention was
evaluated (such as resistance training, behavioral interventions, music therapy, cueing
strategies.); (2) the paper did not report outcomes for the first assessment period (cross-
over studies only) so as to prevent any bias of carry over or order effects.
Data Extraction
Two reviewers (HFS and SXY) independently extracted data onto

predefined criteria in Table 1. We contacted primary authors when
relevant information was not reported. Differences were settled by
discussion with reference to the original article. For crossover studies,
we considered the risk for carryover effects to be prohibitive, so we
selected only the first phase of the study. First author, country, and
70
year of the study were extracted as general study information.
Population data, outcome assessments, interventions, and length of
follow-up were taken to analyze the study characteristics.
Quality Assessment
The methodological quality of RCTs was assessed independently by two reviewers (SXY
and HDH) with PEDro scale, which is based on the Delphi list and has been reported to
have a fair-to-good reliability for RCTs of the physiotherapy in systematic
reviews [12], [13]. The PEDro score ranged from 0 to 10 points. A cut point of 6 on the
PEDro scale was used to indicate high-quality studies as this had been reported to be
sufficient to determine high quality versus low quality in previous studies [12].
Disagreements were resolved by discussion between the reviewers, with the information
of the primary author being sought if necessary. The PEDro scores were all settled down
by consensus.
Data Analysis
Meta-analysis was conducted with Cochrane Collaboration software (Review Manager

Version 5.1). For continuous data, standardized mean difference (SMD) and 95%
confidence intervals (CI) of random-effects model were calculated for all eligible trials.
Heterogeneity across studies was tested based on the I2 statistic, a quantitative measure of
inconsistency across studies, and studies with I2<40% was considered to have low
heterogeneity, I2 of 40% to 75% was considered moderate heterogeneity, and I2>75% was
71
considered high heterogeneity. Trials, including 2 similar intervention or control groups,
had the groups combined with computational formula provided by the Cochrane
handbook to create a single pair-wise comparison. Detailed subgroup analyses were
conducted based on different outcomes and outcome measures.
Results
Study Selection
Searching identified 310 records, of which 35 documents were retrieved from the
screening of titles and abstracts. At last, 18 trials published between 1996 and 2013 were
included in our meta-analysis [7][9], [14][28]. 17 literatures were eliminated for the
reasons that 2 of them failed to randomize [29], [30], 8 without available data for the
meta-analyses [31][38], and 7 violated the inclusion criteria [39][45]. Detailed
selection process was showed in Figure 1. In course of document screening, no divergent
views were found between the reviewers.
72
Study Characteristics
Participants.
There were 901 patients in the 18 eligible RCTs. Mean and standard deviation (SD) of
age for all participants was 673.3 years, and the PD duration was 6.42.7 years. Most
trials recruited participants with mild-to-moderate PD, including 14 with Hoehn and Yahr
stage I to III [7], [8], [15][22], [24], [26][28] and 2 with Hoehn and Yahr stage I to
IV [9], [25].
Interventions.
All the eligible literatures reported aerobic exercise interventions including treadmill
training, Tai Chi, walking, dancing, etc. The interventions in control group were various,
such as no intervention, usual care, stretching, resistance exercises, physical therapy, and
other exercise. The intervention time spanned from 3 weeks to 16 months. Detailed
characteristics of the included trials were summarized in Table 1.
Methodological Quality
The quality of the included studies was summarized in Table 2. The total scores for the
methodological quality ranged from 4 to 8 points. No studies reported subjects-blinding
and therapists-blinding, which were the common failing for the non-pharmacological
clinical trials. However, most of them (78%) performed assessors-blinding [7][9], [17]
[21], [23][28]. Although all trials adopted random assignment of patients, only 4 used
adequate method of allocation concealment [8], [18], [20], [26]. The expulsion of 7
studies was definitely higher than 15% [7], [16], [18], [19], [21], [26], [27]. As for the
intention-to-treat analysis, 9 trials were failed for cancelling the dropout data in the last
results [7], [16], [18], [19], [21], [23], [25][27]. For the remaining items on PEDro scale,
the eligible studies showed a high methodological quality.
Quantitative Data Synthesis
Unified Parkinson's disease rating scale (UPDRS).
UPDRS, as the most common marker in the clinical study of PD, was employed in most
eligible RCTs. The aggregated result showed a statistically significant benefit in favor of
aerobic exercise for PD in UPDRS III (SMD, 0.57; 95% CI 0.94 to 0.19; p=
0.003; Figure 2) [7][9], [15], [16], [20][23], [25], [26], [28]. But it was not associated
with significant improvements in UPDRS I (SMD, 0.33; 95% CI 0.87 to 0.22; p=
0.24; Figure 2) [15], [16], [20], UPDRS II (SMD, 0.31; 95% CI 0.97 to 0.35; p=
0.36; Figure 2) [15], [16], [20], [26], UPDRS IV (SMD, 0.56; 95% CI 1.26 to 0.13; p=
0.11; Figure 2) [15], [16], nor UPDRS tot (SMD, 0.28; 95% CI 0.73 to 0.18; p=
0.23; Figure 2) [15], [16], [20], [26]. This suggested that aerobic exercise could positively
improve motor actions in patients with PD.
73
Balance.
5 studies assessed equilibrium function of patients with PD. Nearly half of trials showed
favorable effects of aerobic exercise in improving balance in patients with PD, and the
aggregated result also supported it (SMD, 2.02; 95% CI 0.45 to 3.59; p=0.01;
Figure
3) [7], [19], [21], [25], [26].
74
Gait.
Aerobic exercise showed superior effects in improving gait in patients with PD (SMD,
0.33; 95% CI 0.17 to 0.49; p<0.0001; Figure 4). 6-minute walking test, stride/step length,
gait velocity, cadence, and time up and go were analyzed in eligible studies. The
aggregated results suggested that aerobic exercise should show significant effects
compared with control therapies in 6-minute walking test (SMD, 0.72; 95% CI 0.08 to
1.36; p=0.03;
Figure 4) [7], [8], [21], [22], [27], stride/step length (SMD, 0.31; 95% CI
0.08 to 0.53; p=0.008;
Figure 4) [7][9], [17], [21][23], [28], gait velocity (SMD, 0.35;
95% CI 0.10 to 0.60; p=0.005;
Figure 4) [7][9], [14], [15], [17], [20][24], [28], and
time up and go (SMD, 0.42; 95% CI 0.08 to 0.76; p=0.02; Figure
4) [7], [9], [21], [23], [25]. However, none of the trials indicated the evidence in favor of
aerobic exercise for PD in the assessment of the cadence (SMD, 0.18; 95% CI 0.52 to
0.15; p=0.28;
Figure 4) [14], [17], [20], [23], [28].
75
Quality of life.
Four trials reported beneficial effects of aerobic exercise for PD in the quality of life, but
there was no difference between aerobic exercise and control
76
therapies [8], [18], [24], [26]. And the synthetical effect size did not either show superior
effects of aerobic exercise (SMD, 0.11; 95% CI 0.23 to 0.46; p=0.52;
Figure
5) [8], [26].
Follow-up Effect
3 trials reported the follow-up effects of aerobic exercise for PD. The follow-up duration
ranged from 4 weeks to 24 weeks. 1 study showed persistency effects of aerobic exercise
in the number of steps for the 10-m walk [16], 1 in quality of life [8], and 1 in balance,
gait, and motor action [25].
Adverse Events
Only two studies reported non-serious adverse events during the aerobic exercise training
period. Two patients experienced hypotension in hot weather, four fell due to obstacles,
five twisted ankles during cross-country walking, and one complained of pain in Reuter's
study [24]. The other study reported one non-injurious fall and two complaints of
soreness or pain during aerobic exercise intervention [26].
Discussion
This is the first systematic review to evaluate the effectiveness of aerobic exercise for PD.
Our meta-analyses suggested that aerobic exercise significantly improve motor action,
balance, and gait including gait velocity, stride/step length, and walking ability in patients
with PD. Currently, there was no sufficient evidence to support or refute the value of
aerobic exercise in improving quality of life in patients with PD compared with other
therapies. And there was no valid evidence on follow-up effects of aerobic exercise for
PD.
In our systematic review, most eligible trials showed moderate methodological quality
based on PEDro score, which suggested that our findings were believable. We analyzed
the 18 RCTs of aerobic exercise, including treadmill training, dancing, walking, and Tai
Chi for PD conditions. Our aggregated results supported that aerobic exercise showed
superior effects in improving motor action, balance, and gait in patients with PD. It was
similar to related systematic reviews. Herman's systematic review suggested that
treadmill training should play an important role in improving gait and mobility in patients
with PD [46]. But it was only a qualitative review, and any strictly qualitative approach
may be problematic since it can be more subjective than meta-analyses. Mehrholz's
review also concluded that treadmill training was likely to improve gait hypokinesia and
77
showed better safety [47]. Comparing with these reviews, larger new eligible RCTs (the
last searching December 2013), more electronic databases (especially including 3
Chinese databases), and detailed subgroup meta-analyses (motor action, balance, gait and
quality of life) strengthened our confidence in our systematic review.
In our review, two parts of analyses (UPDRS II and quality of life) came to the same
conclusion that there was no sufficient evidence to support or refute the value of aerobic
exercise in improving quality of life in patients with PD compared with other therapies.
Some related systematic reviews drew a different conclusion that the evidence supported
exercise as being beneficial with regards to health-related quality of life for patients with
PD [48], [49], but the evidence was gained through the utilization of various exercise
therapies. The reviews, focusing on aerobic exercise for PD, only suggested that treadmill
training potentially improve quality of life in patients with PD [46], [47]. Modestly, our
review included meta-analyses with larger data, but more trials were warranted to prove
it.
PD is a complex disease that can compromise physical performance. Depending on the

symptom severity, PD can present many obstacles to traditional exercise programming.
Tough movement can be difficult for PD patients to perform. Recently, more studies have
reported that intensive exercise achieved optimal results in the rehabilitation of patients
with PD [50]. In these studies, intensity of exercise interventions depends on frequency
and duration of exercises, number of repetitions, and complexity of exercises. A treatment
is generally considered intensive when involving 2 to 4 hours of exercises per week, for 6
to 14 weeks. And larger studies reported the effect of intensive exercise in improving cell
proliferation and neuronal differentiation [50][52]. In our review, almost 80% of aerobic
exercises are intensive exercise. And the intensive aerobic exercise showed superior
effects in improving motor action, balance, and gait of patients with PD.
Based on maximal heart rate or metabolic equivalents, the recent studies have showed
that lower-intensity treadmill training yields more improvements in gait velocity than
higher-intensity treadmill training for PD patients [27]. But Fisher's study led to different
conclusion in gait of early PD undergoing high-intensity body weight-supported treadmill
training [20]. The different conclusions may be rooted in the variation in types of
treadmill training, duration and amount of exercises, patient characteristics, and main
outcome measures. However, the physical activity guidelines reported by the U.S.
Department of Health and Human Services suggested that moderate intensity physical
activity could generate multiple health benefits [53]. Considering the disease
characteristics and safety of exercise interventions, moderate or light intensity exercises
should be considered beneficial and adoptive for individuals with PD [54][56]. In our
review, the Hohen and Yahr stage of participants mainly arranged from I to III. So the
exploration of these RCTs suggested that low to moderate intensity aerobic exercise, such
as treadmill training, Tai Chi, dancing, etc, would benefit mild to moderate staged PD
patients. However, the evidence is not conclusive. Future research should further
investigate intensity level of aerobic exercise to check and monitor its effectiveness based
on maximal heart rate or metabolic equivalents.
78
There were some limitations in our review. The large span of the durations (from 3 weeks
to 64 weeks) in aerobic exercise interventions could influence our analysis. So it is
difficult to conduct subgroup analyses on the different durations of aerobic exercise and
determine the optimal size of aerobic exercise for PD. And there was insufficient data for
the follow-up effect of aerobic exercise for PD, which is important for final decision of
the clinicians. In addition, we could not get rid of the publication bias due to retrieval of
documents in English and Chinese databases only.
Conclusions
This systematic review shows the positive evidence that aerobic exercise has immediate
beneficial effects in improving motor action, balance, and gait in patients with PD.
However, this is not sufficient to reach any definitive conclusion because there are very
few studies with a follow-up evaluation. Large-scale RCTs with long follow-up are
warrant to confirm the current findings of aerobic exercise for PD.
Supporting Information
79
Author Contributions
Conceived and designed the experiments: HFS JWG YQK. Performed the experiments:
HFS TY SXY HDH. Analyzed the data: HFS SXY LLJ. Contributed
reagents/materials/analysis tools: HFS TY SXY HDH. Wrote the paper: HFS YQK.
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Source:- http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0100503
ORIGINAL RESEARCH ARTICLE

Front. Neurol., 27 May 2015 | https://doi.org/10.3389/fneur.2015.00122
Therapeutic Argentine tango dancing for people

with mild Parkinsons disease: a feasibility study
Laura M. Blandy, Winifred A. Beevers, Kerry

Fitzmaurice and Meg E. Morris*
College of Science, Health and Engineering, School of Allied Health, La Trobe
University, Bundoora, VIC, Australia
Background: Individuals living with Parkinsons disease (PD) can experience a

range of movement disorders that affect mobility and balance and increase the risk of
falls. Low health-related quality of life, depression, and anxiety are more common in
people with PD than age-matched comparisons. Therapeutic dance is a form of physical
activity believed to facilitate movement and therapy uptake. As well as being enjoyable,
dancing is thought to improve mobility, balance, and well-being in some people living
with PD. The primary objective of this study was to evaluate the feasibility and safety of
a 4-week Argentine tango dance program for people with PD.
Methods: Six community dwelling individuals with mild to moderate

PD were recruited from Parkinsons support groups, movement
disorder clinics, and the PD association in Australia. To minimize falls
risk, participants were required to be <75 years of age and physically
independent (Hoehn and Yahr stages IIII). They were also required to
speak English. Participants attended a 1-hour dance class at a dance
studio twice per week for 4 weeks. A professional dance instructor led
and choreographed the Argentine tango dance classes. Physiotherapists
were present to assist participants during the class and served as dance
partners as necessary. The primary outcome was feasibility, which was
determined by measures of recruitment, adherence, attrition, safety
(falls, near misses and adverse events), and resource requirements.
Secondary measures included the Beck Depression Inventory and the
88
Euroqol-5D, administered at baseline and post intervention. Therapy
outcomes pre- and post-intervention were analyzed descriptively as
medians and interquartile ranges and using Wilcoxon matched pair
signed-rank tests.
Results: The Argentine tango dance intervention was shown to be safe,
with no adverse events. Adherence to the dance program was 89%.
Depression scores improved after intervention (p = 0.04). Some
challenges were associated with the need to quickly recruit participants
and physiotherapists to act as dance partners during classes and to
monitor participants.
Conclusion: The 4-week, twice weekly Argentine tango dancing
program was shown to be feasible and safe for people with mild-to-
moderately severe PD.
Introduction
Idiopathic Parkinsons disease (PD) is a progressive neurological disorder
associated with reduced mobility, falls, and reduced quality of life (QOL) (1).
International guidelines endorse exercise therapy to retrain balance and
preserve physical capacity for individuals living with PD (2). Meta-analyses
have also shown exercise therapy to have positive effects with regards to
physical functioning, balance, and health-related QOL (3, 4). Despite the
potential benefits of movement rehabilitation, long-term adherence to
traditional exercise programs can be problematic (5). A systematic review
evaluating exercise adherence in PD reported that reduced motivation was a
common reason for reduced participation (6). This demonstrates a need for
community-based physical activity programs that facilitate uptake and
enjoyment (7).
Emerging evidence suggests that therapeutic dance may be an appropriate and

enjoyable form of physical activity for some individuals with PD (8). Dance
may address some of the physical impairments in PD through teaching
movement strategies, challenging balance, and improving physical fitness
(9, 10). The musical rhythm could become an auditory cue to engage cortical
89
control of movement, which in turn might potentially enhance motor learning
(11). Preliminary trials suggest dance can facilitate improvements in gait,
balance, and motor impairment in comparison to exercise (12), physiotherapy
(13), and control conditions (8, 1416). It has been proposed that therapeutic
dance may also facilitate QOL and well-being through enabling movement
expression and building social connections (17).
The Argentine Tango dance genre is arguably one of the most suitable dance
forms for people with PD (8, 14, 15). It has been proposed to target the
movement impairments of PD with strong musical rhythms that trigger
movement and enable greater amounts of physical activity. Compared to other
dance genres, the choreography can be designed to train specific movement
strategies such as walking backwards and turning (18). Furthermore, as a
partnered form of dance, tango may facilitate interpersonal connections that
positively affect QOL and mood (18).
While a growing number of pilot studies have explored the effects of dance on
movement disorders in PD, there is a paucity of feasibility data and
recommendations that allow researchers to design future protocols (19).
Comprehensive exploration of the safety of specific dance genres is still
required given that individuals with PD have a propensity to fall (20). This
research also focused on QOL and depression outcomes, as there is little
published literature on the effects of therapeutic dance on perceived QOL and
mood for adults with PD.
The primary purpose of the current study was to evaluate the feasibility and
safety of an Argentine tango dance intervention and to provide
recommendations for future research. The specific aims were to: (i) determine
if 4 weeks of twice weekly Argentine tango dance classes were feasible and
safe for people with PD, allowing the development of recommendations for a
future research protocol and (ii) measure the within-group change for
90
depressive symptoms and health-related quality of life (HRQOL) following
participation in the dance classes.
Materials and Methods

Design
This feasibility study adopted a single-group, pre-/post-test design and received ethical
approval by the La Trobe University Faculty of Health Sciences Human Ethics
Committee (ref. FHEC13/026). The trial was registered with ANZCTR, number
ACTRN12613001058763.
We recruited participants with idiopathic PD from the metropolitan Melbourne region in

Australia. As the current body of literature does not provide an arbitrary method for
determining sample sizes in pilot research (21), there were various considerations
involved in determining sample size. Primarily, it was anticipated that a dance class with
six to eight participants could be adequately monitored (18).
Participants
The eligibility criteria tested what was planned for a future clinical trial. Criteria were
also established to maximize safety and reduce risk of falls during the interventions.
Eligibility criteria therefore included: (i) a diagnosis of idiopathic PD confirmed by a
neurologist; (ii) mild-to-moderate disease severity (Hoehn and Yahr stages IIII) (22);
(iii) community dwelling; (iv) aged 1875 years; and (v) medically safe to participate.
Volunteers were excluded if they were unable to provide informed consent (Mini Mental
State Examination, MMSE, score <24) (23) and did not have sufficient English to be able
to follow instructions. Volunteers were recruited through local Parkinsons support
groups, movement disorder clinics, and the website and newsletter of Parkinsons
Victoria, Australia.
At intake, participants signed informed consent and were screened for eligibility. The
Unified Parkinsons Disease Rating Scale motor subsection (MDS-UPDRS-III) (24) and
a health status screening form to identify any comorbidities that could require extra
monitoring during intervention were also administered. They were then asked to provide
written consent to contact their medical practitioner for written medical clearance.
91
Intervention
Participants were invited to participate in 1-hour dance classes that ran twice
weekly over 4 weeks at a dance studio in metropolitan Melbourne. They were
required to make their own way to classes, and were provided with taxi vouchers
if required. Classes of Argentine tango choreography were designed and led by a
professional dance instructor, with experienced physiotherapists present to spot
participants at risk of falls and serve as dance partners. People who were partners
were all able-bodied participants. Classes included regular rest breaks, typically
at 20-min intervals, to minimize fatigue (18). Modifications were made to the
intervention by physiotherapists to reduce falls risk as needed. The participants
essentially had the same class, although as is customary with tango dancing,
there were some gender differences in the dance routines. Women are usually the
followers in tango, and were required to frequently do steps backwards, in
contrast to men. All of the participants were using PD medications and they were
in the on phase of the medication cycle during the dancing classes. An outline
of class structure and content is detailed in Table 1.
92
Primary Outcomes
(i) Feasibility of Argentine tango dance was determined by quantifying recruitment
rates, adherence, attrition, safety, and resource requirements. Feasibility outcomes
were monitored throughout the recruitment phase and over the 4-week intervention
phase, and data were entered into customized forms.
(ii) Recruitment: researchers collected data regarding the time taken to recruit, the
number of respondents to advertisements, and proportions considered eligible or
ineligible to participate.
(iii) Adherence and attrition: participants were required to sign an attendance form at
each of the dance sessions. Reasons for non-attendance were recorded as (i) medical
(specified as related or unrelated to the dance intervention), (ii) disinterest, (iii)
personal, or (iv) difficulty accessing venue. The number who withdrew and reason
for withdrawal were also recorded.
(iv) Safety: adverse events (fall, injury, or medical emergency), near misses (slips or
trips) and complaints of pain, stiffness, or fatigue were documented. It was also
noted if participants required hands on assistance for balance and if on the spot
modifications were made to the intervention for safety purposes.
(v) Resource requirements: to document whether attaining the personnel required was
feasible (19), the attendance of supervising physiotherapists was recorded.
To objectively establish if the proposed research protocol was successful, the following a
priori criteria for feasibility success were developed (19): (i) recruitment strategy and
screening process enable recruitment of eight participants within 1 month; (ii) adherence
70%, which has been deemed as high in older adults with a physical impairment (25);
(iii) attrition 15%, an arbitrary figure for acceptable attrition established by the PEDro
scale (26); and (iv) safety: the dance intervention was considered safe if there were no
falls or injuries during the intervention and no hands on assistance was required for
prolonged periods.
93
Secondary Outcomes
The effects of the intervention on HRQOL were measured with the Euroqol-5D (27, 28),
a validated measure of HRQOL in PD, using the rating questionnaire and the visual
analog scale (VAS). The summary index was computed for the descriptive system using
normative data sets from the United Kingdom, with a possible value between 0.59 and
1, where 1 represents full health. The VAS scale is a self-perceived rating of health
status scored from 0 to 100, with 100 indicating best imaginable health state. The Beck
Depression Inventory (BDI) (29) was used to measure depression. This questionnaire has
established validity and reliability for assessment of depressive symptoms in the PD
population (30). The BDI scores are tallied to obtain a score out of 63, with a higher score
indicating greater severity of symptoms. Both questionnaires were administered at
baseline and at the end of the 4-week intervention phase.
Statistical Analysis
Therapy outcomes at pre- and post-intervention were analyzed descriptively as medians
and interquartile ranges (IQR) to better describe the small data set and control for
extremes in scores (31). Where participant data were missing at post-test, baseline data
were carried over to complete the analysis. To establish statistical significance of within-
group change between the two time points, a Wilcoxon matched pair signed-rank test was
performed with p-value set at <0.05. A non-parametric technique was necessary given
data were collected from a small sample and was not normally distributed (31). Statistical
analysis of therapy outcomes was performed using SPSS statistics (IBM, Armonk, NY,
USA).
Results
Participants
Participant demographic data are detailed in Table 2. Participants had mild PD
as indicated by low mean scores on the UPDRS part III, motor examination,
and with all participants scoring 2 on the modified Hoehn and Yahr scale.
94
TABLE 2
Feasibility
Recruitment
The proposed recruitment strategy did not meet a priori criteria. Six individuals
were recruited over 2 months. Figure 1 indicates the flow of participants in the
recruitment and intervention phases.
95
Adherence
Attendance to the dance classes was 89%, exceeding the a priori criterion of 70%. One
participant was unable to attend one class due to an unrelated medical matter, and another
participant was unable to attend two classes secondary to a scheduled vacation.
Attrition
One participant dropped out for the final week of the dance intervention (including the
post-intervention assessment) citing a combination of medical and personal reasons.
96
Attrition rate was thus 17% for the 4-week dance intervention, failing to meet the
feasibility criteria of 15%.
Personnel Requirements
Attendance of the supervising physiotherapists throughout the program was 86%, lower
than the required 100% to provide dance partners for participants.
Safety
There were no falls, injuries, or medical emergencies throughout the intervention period.
Three participants withdrew from the class on separate occasions due to (i) one episode
of transient vertigo following rehearsal of fast-paced turning; (ii) pain at an arthritic hip
joint; and (iii) medication-related motor complications. There was one documented near
miss without injury where a participant destabilized secondary to a dyskinetic tick.
Incidents of mild pain at the back (n = 1), shoulder (n = 1), foot/ankle (n = 1), and hip
(n = 1) were also documented. In health status screening forms, these participants cited
arthritis at these joints. Hands on assistance was required in only one instance and
distant (1 m) supervision was provided to all participants at all other times.
Modifications to Dance Intervention
The intervention was modified on four occasions to ensure participant safety; no walking
backwards in the first session, steps requiring single leg stance to be performed while
seated, practice of turns to be performed over an arc rather than on the spot, cessation of
dance to music with fast tempo. The tango hold position was also modified for one
participant due to shoulder pain.
Health-Related Quality of Life and Depression

The EuroQol median score increased from a baseline score of 0.796 (IQR: 0.731.00) to
a post intervention score of 0.890 (IQR: 0.801.00), indicating improvement; however,
this did not reach statistical significance (p = 0.317). There was a small but not
97
significant improvement in the VAS score from a median score of 80 (IQR: 77.591.25)
at baseline to 82.5 (IQR: 77.591.25) post intervention (p = 0.854).
Beck Depression Inventory scores at both time frames were distributed around the lower
end of the scale, suggesting that overall depressive symptoms were low (32). The BDI
scores decreased, indicating an improvement in depression, from a median score at
baseline of 5.5 (IQR: 4.758.50) to a median of 0 (IQR: 05.50) post intervention, which
reached significance (p = 0.042).
Discussion
The Argentine tango dance intervention was found to be feasible for this sample of
people with comparatively mild PD. It was shown to be safe with no serious adverse
events, such as falls, injuries, or medical emergencies, occurring. The minor adverse
events were mostly related to comorbidities, and were readily managed with
modifications to dance routine and steps. Modifications were, however, made
infrequently. All documented modifications reflected the recommendations for tango
classes for adults with PD developed by Hackney and Earhart (18), and Rios Romenets,
Anang (16). It is evident that the safety of the intervention was enabled by the presence
of supervisors to monitor instability and to advise appropriate modifications. Formal
education of dance instructors on screening and monitoring for adverse responses to
interventions may result in earlier modifications to the interventions and a subsequent
minimization of adverse outcomes (33). The selected dosage was shown to be safe and
appropriate, and none of the participants reported pain, stiffness, or fatigue after classes.
Recruitment in the short time frame available was challenging. Researchers continued to
receive expressions of interest in the month following commencement of the dance
program, indicating a 3-month recruitment period may have successfully recruited eight
participants. Recruitment difficulties are common in PD research (34), with similar issues
reported by Batson (33), who rescheduled her dance program secondary to recruitment
difficulties, and Duncan and Earhart (14), who reported only 50% of participants
screened were eligible to participate in a tango dance intervention. It is possible that the
potential benefits of dance are not widely understood, narrowing those who volunteer to
98
participate (33). People with Parkinsons were more reluctant to participate if they had to
commute long distances. This is supported by research identifying transportation as a
barrier to exercise uptake for individuals with movement disorders (35).
Adherence to the Argentine tango dance program was high, satisfying feasibility criteria
(25). Adherence has only been reported in a small number of studies evaluating dance
therapy for PD. Duncan and Earhart (14) reported 78% adherence over 12 months of
tango, Volpe et al. (13) showed 90% adherence with 6 months of Irish dance, and 90%
adherence over 3 weeks of modern dance was reported by Batson (33). The high
adherence to dance therapy supports the hypothesis that therapeutic dance may facilitate
uptake and enjoyment (9). However, these findings may have been influenced by
selection bias, where individuals that volunteer to participate are more likely to adhere to
a program (36). Further research is warranted to explore adherence to a longer program,
and to determine if systematic differences in adherence exist between tango and a second
dance genre, or a comparison intervention. Attrition was relatively low over the short
intervention phase. While this narrowly fell short of a priori criteria, a 100% retention
rate was necessary to meet this criterion as the eventual sample included only six
participants. Importantly, data showed that the participant lost to post-intervention
assessment did not report dislike or disinterest in the intervention, citing personal reasons
for discontinuing.
This study adds to the limited body of evidence evaluating the influence of dance therapy
on outcomes related to QOL and well-being, which are important to a holistic
management of individuals with PD (28). This pilot study identified significant
improvements in depressive symptoms and a trend toward improved HRQOL. For BDI
scores, this was not only statistically significant but also research indicates a change from
5.5 to 0 may also be clinically meaningful (32). To the authors knowledge, this is the
first study that has found positive effects of dance for depressive symptoms in adults with
PD. The HRQOL findings support the work of Hackney and Earhart (37) and Volpe and
colleagues (13), who found small, non-significant improvements in HRQOL compared to
control and physiotherapy. Like this feasibility study, it is likely these preliminary trials
were underpowered and may have failed to identify significant effects.
99
There are a number of factors that could have contributed to these observed
improvements in depression and HRQOL. As a rehabilitative therapy, tango may improve
specific functional impairments (18) that are known to influence perceived QOL for
adults with PD (38). Research shows exercise to be an effective treatment for depression
(39), and Ballroom dance has been shown to improve depression in the geriatric
population (17). It is thought that dance may also improve well-being through enabling
emotional expression and engagement (17), as well as building social support networks
which may improve QOL for adults with PD (9).
There are a number of limitations of this pilot study. The small size of the sample
decreases the external validity of findings (19, 40). Similarly, the short duration of the
intervention phase means that few inferences can be made regarding the longer-term
adherence and retention in adults with PD. Without a pilot control group, it cannot be
determined if a comparison intervention (e.g., physiotherapy, exercise, or another dance
genre) is also feasible pertaining to a priori criteria or if there are systematic differences
between two intervention groups. Without a control group, this study could not counter
for other potential factors that may have contributed to the observed improvements in
therapy outcomes such as natural recovery or regression to the mean. Data were collected
on a sample that was homogenous in disease severity; thus, conclusions regarding the
safety of the dance intervention may not be applicable to individuals assessed as Hoehn
and Yahr stages III and higher where postural instability is a marked impairment (22).
This study did not evaluate participant acceptability of the intervention, which is
suggested to be an important variable in pilot research (19). Furthermore, this study did
not monitor if participants were concurrently undergoing active therapy for depression,
which could have contributed to the observed improvement.
To facilitate the safety of the intervention delivery, it is proposed that dance instructors
are educated regarding the disease processes, movement impairments, and likely
comorbidities experienced by adults living with PD. Practical sessions would be useful to
train instructors in pacing and movement selection (33). These sessions could educate
instructors in therapeutic cuing, which could maximize movement and enhance motor
learning for participants. Additional literature regarding community-based exercise
100
programs for PD advocates basic training in first aid, emergency procedures, and exercise
physiology (7).
It is recommended that the next stage of pilot research adopts a recruitment strategy
based on the projection of recruiting 810 eligible participants over a 3-month period.
Additionally, greater consideration should be given to location of the dance studio to limit
barriers associated with long travel.
It is necessary for participant safety that the appropriate supervisors are present to
monitor for fatigue, instability, and to provide appropriate suggestions regarding
modifications. Hackney and Earhart (18) suggest that physiotherapy students may
provide enthusiastic assistants, with the appropriate knowledge in risk management.
Conclusion
A 4-week Argentine tango program was safe and enjoyable for people with relatively
mild Parkinsons and was associated with alleviation of depression in some. There
remains a need to verify the safety of the intervention for people with PD, who are more
disabled or with a greater fall risk. Arguably, people with more advanced disease and
with a greater fall risk might show greater gains with this type of physical activity.
LB, MM, and WB participated in the design of the study, oversaw data collection,
data analysis, preparation of the manuscript, gave final approval of the version to
be published, and agreed to be accountable for all aspects of the work.
Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or
financial relationships that could be construed as a potential conflict of interest.
Acknowledgments
The authors would like to thank Rina Ohashi, who designed and instructed the dance
classes, to the physiotherapists that assisted with supervision, to Parkinsons Victoria who
helped with recruitment, and finally to the participants with Parkinsons who graciously
101
donated their time in participating in this trial. This research received no specific grant
from any funding agency in the public, commercial, or not-for-profit sectors.
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Keywords: Parkinsons disease, tango, feasibility, depression, quality of life
Citation: Blandy LM, Beevers WA, Fitzmaurice K and Morris ME (2015) Therapeutic
Argentine tango dancing for people with mild Parkinsons disease: a feasibility
study. Front. Neurol. 6:122. doi: 10.3389/fneur.2015.00122
Received: 05 March 2015; Accepted: 12 May 2015;
Published: 27 May 2015
Edited by:
Marta Bienkiewicz, Technische Universitt Mnchen, Germany
Reviewed by:
Maria Stamelou, University of Athens, Greece
Mariana Moscovich, Universidade Federal do Paran, Brazil
Copyright: 2015 Blandy, Beevers, Fitzmaurice and Morris. This is an open-access
article distributed under the terms of the Creative Commons Attribution License (CC
BY). The use, distribution or reproduction in other forums is permitted, provided the
original author(s) or licensor are credited and that the original publication in this journal
is cited, in accordance with accepted academic practice. No use, distribution or
reproduction is permitted which does not comply with these terms.
*Correspondence: Meg E. Morris, College of Science, Health and Engineering, School
of Allied Health, La Trobe University, Bundoora, VIC 3086, Australia,
m.morris@latrobe.edu.au
Source:- http://journal.frontiersin.org/article/10.3389/fneur.2015.00122/full
108
A dance movement therapy group for depressed adult
patients in a psychiatric outpatient clinic: effects of the
treatment
Pivi M. Pylvninen,1,2,* Joona S. Muotka,2 and Raimo Lappalainen2
Abstract
Go to:
Introduction
The global burden of disease studies show unipolar depression as the leading cause of
years lived with disability (YLD) in adult population throughout the world (WHO,
20131). In Finland in 2013, mental health problems were the reason for 40% of work
disability retirement, and in this group, depression was the most common problem.
Further, mental health problems have been the main reason for the early retirement since
the year 20002.
In Finland, the Current Care Guidelines3 base the treatment of depression on
comprehensive diagnostic, clinical, and psychosocial evaluation. The treatment consists
of medication and psychotherapy (see Kupfer et al., 2012; Holma, 2013). The
recommended brief psychotherapy forms are cognitive, interpersonal, psychodynamic,
and problem-solving focused psychotherapy. In practice, medication is often the main
intervention to treat depression. It is acknowledged that physical exercise can be
beneficial in the treatment of depression, but it cannot replace medication and therapy.
Treatment programs in hospital units, day hospitals and outpatient psychiatric clinics may
provide some physical activity, and sometimes also dance movement therapy (DMT) is
used.
The positive effects of physical activity in the prevention of depression (Brown et
al., 2005; Teychenne et al., 2010; Luoto et al., 2013) and in coping with depression
(Harris et al., 2005; Rimer et al., 2012) are frequently noted. The Cochrane review on the
impact of exercise as a treatment of depression by Rimer et al. (2012) included 39
studies, totaling 2326 subjects. The review indicated that exercise was equally effective
as antidepressants or psychological therapies in reducing the symptoms of depression.
Health care providers and sports researchers provide information on amounts of physical
exercise that would be the minimum needed to gain the health effects for preventing
illnesses, to support the level of functioning in the old age and to foster good mood and
happiness4. However, a physically active lifestyle is challenged, because the way of
living, the methods of transportation and many occupational and leisurely activities are
becoming increasingly sedentary. In Finland, collectively, the population is getting less
physical activity (Husu et al., 2011) and thus the connectedness to one's embodiment is
weakening. Lack of movement and physicality is not only a problem of physical fitness,
but also seems to have repercussions on the experiential level, i.e., on the level of body
image (Pylvninen, 2003, 2012; Koch et al., 2013), which affects social interaction, self-
109
awareness, cognition, and coping. Interestingly, while physical activity in the population
has decreased, there are statistical records from the years 19902010 documenting a
steady increase in the consumption of antidepressants in the Finnish population (Finnish
Medicines Agency and Social Insurance Institution, 2012). Patients with depression often
suffer from ailments, pain-problems, fatigue, and dissatisfaction with one's own body.
When depressed, it is a challenge to overcome the experiential and emotional barriers and
reach the benefits of physical exercise and activity. A treatment intervention such as
DMT, which includes both physical engagement as well as emotional and social
exploration, starting on the level where the patient is, would be feasible to increase self-
awareness and emotional and social flexibility among depressed patients (Kiepe et
al., 2012; Kolter et al., 2012).
DMT is a form of therapy, which integrates the physical, emotional, cognitive, and social
aspects into treatment (Stanton-Jones, 1992; Meekums, 2002; Bloom, 2006;
Payne, 2006a; Chaiklin and Wengrower, 2009). DMT aims to engage the patients in
physical and verbal exploration of their experiences generated in movement based
interaction. DMT can be carried out as individual treatment or in groups. It can be applied
to various populations ranging from children to the elderly, and from people with severe
psychiatric problems to high-functioning people, who may be interested in strengthening
their resources and self-development.
One focus in DMT is engaging with movement: becoming concretely involved in
movement activity in the here and now. The other locus of activity is to be attentive to the
movement experiences and to develop the skills to be conscious and reflective of them
and to communicate about them in words. The relevant interactional elements in DMT
are the engagement of moving body, the development of body awareness and
mindfulness, and the verbal reflection of the movement experiences, which focuses on
the qualities of the experience (Meekums, 2002; Capello, 2009; Koch and
Fischman, 2011; Nolan, 2014). It is assumed, that this enables the patient to connect with
the emotional core of his/her experience.
The early meta-analysis of the effects of DMT by Ritter and Low (1996) included five
studies on people with depression. Two of these studies included psychiatric patients.
Revisiting this meta-analysis, Koch et al. (2007) summarize DMT outcome research on
depression in a conclusion that the effect sizes in the treatment of depression have ranged
from moderate to strong. A Cochrane review of the effects of DMT on depression by
Meekums et al. (2015) examined the effects of DMT for depression compared to no
treatment or to standard care, to psychological interventions, drug treatment, or other
physical interventions. Only three studies met the Cochrane review inclusion criteria,
totaling 99 adult subjects and 40 teenage subjects. When the authors compared group
DMT to standard treatment in adults with depression, DMT reduced symptoms of
depression at follow-up measure, as indicated by clinical observation using the HAM-D.
Due to the poor methodological quality of the studies and small sample size, the findings
of the effectiveness of DMT could not be considered conclusive. A recent meta-analysis
of the effects of DMT and dance on health-related psychological outcomes included the
evidence of 23 primary studies (Koch et al., 2014). The meta-analysis showed moderate
effects for quality of life and for depression and anxiety.
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In the treatment of psychiatric patients the impact of DMT has been positive on body
image, the perception of the body and self, affect, motility and well-being, perception of
relationships, and biography (Koch et al., 2007, 2014). Goodill's (2005) review of the
DMT outcome research in clinical populations concludes that the treatment brings
favorable changes in the following dependent variables: vitality, mood, anxiety, mastery,
coping-skills, and body image.
Punkanen et al. (2014) conducted a pilot study where DMT group was used in the
treatment of depressed patients. Twenty-one depressed adult participants were recruited
to participate in 20 sessions of group DMT, twice weekly. The psychometric
questionnaires were taken before and after the intervention. The mean score of the
primary outcome measure, the BDI, decreased significantly from the pre- (M =
21.67, SD = 5.26) to post-measurement (M = 10.50, SD = 5.50), showing that the short-
term, group DMT intervention had a positive effect on patients with depression.
As depression is so widespread in the population, it is important to develop its treatment,
and if possible, to augment the choices of effective treatments. Research on a current
clinical practice in a natural setting is relevant for improving the treatment of depression.
Thus, for the development of outpatient psychiatric care, we were interested in
investigating the effect of DMT in an outpatient psychiatric clinic. This study plans to
add to the knowledge of the effects of DMT in the treatment of psychiatric outpatients
diagnosed with depression. The main research question concerned, whether DMT-group
intervention produces alleviation in the symptoms of depression. We compared DMT +
treatment as usual (TAU) with TAU. Thus, we were interested in whether adding DMT to
TAU has benefits as compared with TAU alone. This information may provide
legitimation for the choices made on the use of DMT in psychiatric outpatient care.
Go to:
Methods
Recruitment procedure
The research plan was approved by the City of Tampere Research Board, which also is a
regional board for ethical research practices. All participants in the study were recruited
from a psychiatric outpatient clinic, which is a part of specialized public health care. The
patients enter the clinic on a referral from a physician. The patients' treatment is carried
out by a multi-professional team, which includes a psychiatrist, a psychiatric nurse, a
psychologist, and a social worker. The clinic offers pharmacological treatment, individual
counseling, and a selection of group interventions. There are various psycho-educational
groups focusing on coping with psychiatric disorder and its symptoms. The DMT group
(812 sessions) has been one option in the available treatment since 2007. The clinic does
not provide physical exercise groups as a treatment option.
Announcements of the study were posted in the lobbies of the clinic. The staff received e-
mails about the study, inviting them to tell to patients with depression about the
opportunity to participate. The patient information described the study aiming at
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exploring the treatment of depression and its outcome by comparing TAU and the DMT
group intervention.
The inclusion criteria were: depression diagnosis and depression as primary symptom.
The exclusion criteria were psychosis, suicide attempts or clear suicide plans, diagnosis
of severe personality disorder, diagnosis of current alcohol or substance abuse problem,
or debilitating somatic symptoms. Patients entered the study voluntarily and could choose
between participating in the DMT group or in the TAU group, where they received the
other treatment options the clinic provides. At the clinic, the common practice is that the
patient can choose, which of the recommended groups to join. Group participation is
never imposed on the patient. Patients participating in the study received information
about it, their contribution and freedom to withdraw from the study at any time without
consequences for their access to treatment. All the participants in the study were recruited
between August 2011 and September 2012 and provided written consent to participate in
the study.
Patients joining the TAU group signed the consent, which was then sent to the researcher.
The TAU group participants were mailed the set of assessment measures at the start of the
research period, after 3 months (12 weeks) and after 6 months since the first
measurement point. The replies could be sent in stamped, addressed envelope.
Patients interested in joining the DMT group came to a recruitment interview according
to the normal practice. At the end of the interview the patient could decide whether to
agree to participate in the research and sign the consent form. After the interview, the set
of self-evaluation measures was sent to the patient via mail and s/he mailed them back in
a stamped addressed envelope. This procedure aimed at distancing the research aspect of
the group and the therapy process. Similarly to the TAU group, the measurements were
completed at the start of the intervention period (pre), after the 3-months (12-weeks)
DMT intervention (post) and after 3 months (follow-up).
During the data collection period, a total of 25 patients were recruited for the DMT
groups. Sequentially, they formed four groups. The therapist/researcher worked with one
group at a time. Four patients were excluded from the sample on the basis of the
inclusion criteria. Thus, 21 patients could be included in the study, and 19 completed all
measures. Two patients did not respond to the self-evaluation measures after the
treatment or at the follow-up measurement, but they were included in the statistical
analysis. In the DMT group, 84% of the participants stayed in the study and in analyses.
The TAU groups were collected at the same time as the DMT groups. A total of 18
patients joined and provided written consent. Twelve patients answered the pre-
measurement self-evaluations and were included in the study. However, only eight
patients completed the self-evaluations at all three measurement points. In the TAU
group, 67% of the initial participants who completed the first evaluation stayed in the
study. Supplementary Figure A summarizes flow of the data collection.
Selecting the sample and assigning the groups this way creates a quasi-experimental
research design, as there is no randomization. This limits the validity of the results, but
this design was chosen in order to remain close to the everyday practices of the clinic.
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Also, it was assumed that self-selection to the groups would minimize the drop-out rate in
the DMT group.
Participants
The background information presented on the participants is based on the patient records
(see Table Table1).1). About 60% (57.5%) of the participants had two or more psychiatric
diagnoses. On the basis of the patient records, in the TAU group the most common
diagnoses were F32.1moderate depressive episode (42%) and F32.2depression
severe/major without psychotic symptoms (25%). In the DMT group the most common
diagnosis was F32major depressive disorder, single episode (29%) and the total
percentage of patients with F32-range diagnoses was 43%. In the DMT group, 19% of the
participants had an F33 diagnosisrecurrent depressive episode. During the treatment
period at the clinic, the medical examination indicated the severity of depression to be
moderate or severe in the majority of patients in both groups.
Table 1
Participant data at the pre-measurementdepression characteristics.
Descriptives of subjects at pre-measurement DMT group TAU group Total
N 21 12 33
Gender Male 5(23.8%) 4(33.3%) 9(27.7%)
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Female 16(76.2%) 8(66.7%) 24(72.7%)
Age M (SD) 42(12.7) 38(10.4) 41(11.9)
Min 20 Min 22 Min 20
Max 59 Max 55 Max 59
Number of diagnosis 1 7(33.3%) 7(58.3%) 14(42.4%)
2 10(47.6%) 4(33.3%) 14(42.4%)
3< 4(19.1%) 1(8.3%) 5(15.1%)
Severity of depression (psychiatrist's recorded Mild 5(23.8%) 1(8.3%) 6(18.2%)

assessment)
Moderate 9(42.9%) 7(58.3%) 16(48.5%)
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Severe 5(23.8%) 4(33.3%) 9(27.3%)
Not assessed 2(9.5%) 0(0.0%) 2(6.1%)
Years since first episode of depression 1 1(4.8%) 4(33.3%) 5(15.2%)
23 4(19.1%) 1(8.3%) 5(15.2%)
48 11(52.4%) 3(25.0%) 14(42.5%)
925 5(23.8%) 4(33.3%) 9(27.1%)

M = 7.9 years M = 6.4 years M = 7.4 years
Significant relational stress in history or Yes 20(95.2%) 12(100%) 32(97.0%)

currently
No 1(4.8%) 0(0%) 1(3.0%)
Table 1
In the whole group, there were five patients, whose primary diagnosis was of anxiety or
eating disorder or in the personality disorder range. This reflects the common clinical
situation in specialized psychiatric care, that patients' depression is rarely just plain
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depression. This is also reflected a in the second diagnoses the patients had. Of the whole
group 58% had a second diagnosis. Twenty-four percent of these second diagnoses
related to soma: pain, heart, lungs, diabetes, hyperkinesis. Fifteen percent of the second
diagnoses related to anxiety. In the whole group, 18% of the patients reported a history of
alcohol abuse.
The mean duration of time since the first episode of depression was 6.4 years in the TAU
group and 7.9 years in the DMT group. The mean length of the current treatment period
was 16 months in the TAU group and 21 months in the DMT group. At the pre-
measurement, for the majority of the patients, the length of the current treatment period
was less than 12 months.
In the TAU group, all the patients were taking antidepressant medication (Table
(Table2).2). In the DMT group, 57% of the participants were taking antidepressant
medication, 43% (nine patients) were not. The difference in the use of medication
between the DMT and TAU groups was statistically significant (x2 = 7.07, df = 1, p <
0.01). One reason for the referral to the psychiatric unit was a medication resistant
depression, where the patient did not benefit from antidepressants. In the DMT group,
38% of the patients were taking some other medication for psychiatric reasons, and in the
control group 42%.
Table 2
Participant data at the pre-measurementtreatment features.
Descriptives of participants at baseline DMT TAU group Total

group
N 21 12 33
Duration of the current treatment period >6 months 10(47.7%) 5(41.7%) 15(45.5%)
712 months 6(28.5%) 4(33.3%) 10(30.3%)
1335 months 3(14.4%) 1(8.3%) 4(12.0%)
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group
3696 months 2(9.5%) 2(16.6%) 4(12.0%)

M = 21.1 M = 15.8 M = 14.24
Antidepressant medication Yes 12(57.1%) 12(100%) 24(72.7%)
No 9(42.9%) 0(0%) 9(27.3%)
Other psychotropic medication Yes 8(38.1%) 5(41.7%) 13(39.4%)
No 13(61.9%) 7(58.3%) 20(60.6%)
Frequency of individual counseling/therapy 1x/week 1(4.8%) 0(0.0%) 1(3.0%)

at pre-measurement
every other week 3(14.3%) 3(25.0%) 6(18.2%)
every 34 weeks 7(33.3%) 5(41.7%) 12(36.4%)
5 or more weeks 9(42.9%) 4(33.3%) 13(39.4%)
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group
interval
none 1(4.8%) 0(0.0%) 1(3.0%)
Psychoeducational group experience Yes 4(19.0%) 11(91.7%) 15(45.5%)
No 17(81.0%) 1(8.3%) 18(54.5%)
Psychotherapy experience Yes 12(57.1%) 3(25.0%) 15(45.5%)
No 9(42.9%) 9(75.0%) 18(54.5%)
In the DMT group, 57% of the patients had experience of psychotherapy and in the TAU
group 25%. At the pre measurement, in the TAU group 92% of patients had experience of
psychoeducational groups and in the DMT group 19%. The difference was statistically
significant (x2 = 16.24, df = 1, p < 0.01), and was due to the fact that seven patients (64%)
in the TAU group were participating in a psychoeducational group for depressed patients
during the evaluation of the intervention.
Intervention procedure
Both the DMT and the TAU group received individual counseling during the study. In the
TAU group 33% of the patients had an individual counseling appointment every 5 weeks
or less frequently, and 25% had counseling every 12 weeks. In the DMT group 67% of
the patients had counseling every 5 weeks or less frequently, and 20% every 12 weeks.
The DMT intervention was delivered by a psychologist and dance movement therapist
trained in the DMT methods of Marian Chase and in authentic movement. The essence of
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the Chacian approach is engaging in improvised, shared movement, and creating an
interactional space through movement (Levy, 1992; Fischman, 2009). The Chacian
method is primarily a DMT form of group therapy. Authentic movement, initially
developed by Mary Whitehouse and Janet Adler, can be applied as a method in individual
or group therapy (Payne, 2006b). The application of authentic movement based practices
in DMT in psychiatric outpatient care means emphasizing the non-judgmental empathetic
witnessing of movement expression as it appears, the cultivation of conscious awareness
of movement, and the allowing of the person to be visible and seen in his/her movement
(Adler, 1999; Penfield, 2006). Both the Chacian method and authentic movement
promote the integration of intra-actional (within the individual) and interactional (relating
with the environment) systems (Capello, 2009).
The DMT group intervention consisted of 12 dance/movement therapy sessions (one
session a week for 12 weeks). Each session was 90 min long and included discussion
(2040 min), movement warm-up and process (3040 min) and a verbal reflection and
closure of the movement experience (1530 min) facilitated by a dance/movement
therapist-psychologist. The therapy groups were small with 47 participants. The guiding
principles for the group facilitation were:
supporting the safety in the body by paying attention to grounding in the
movement, body boundaries, respect for personal space, and the mover's position
as a modulator of his/her own movement
supporting the sense of agency by emphasizing the choice making in movement,
paying attention to the ways one uses one's body in movement and interaction,
recognizing the resources the body offers
supporting mindfulness skills by paying attention to the experience of the body
sensations, movements, and states, fostering the ability to verbalize these as well
as the emotions and imagery relating to the body sensations
being attentive to interaction by paying attention to body responses in the group
interaction situations, acknowledging the impact of expectations, and anticipation
in the body responses
fostering the interaction by being present and attentive to the patients, conveying
seeing and hearing them as they are, respecting the body experience, and
encountering via shared movement qualities
As DMT is based on interaction, the group facilitation in practice was an integration of

these principles, pre-planned structures and themes, and responses to the needs and
themes of the group in the moment. The same therapist working with each group was the
constant factor. All sessions included a discussion at the start and after the movement
explorations. The discussions were oriented toward expressing embodied experiences and
reflecting on them. Discussions also echoed the process and needs of the group. Table
Table33 presents a model of the 12-sessions group process.
Table 3
A group model based on the integration of the four different DMT group processes.
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Theme Process exercises
1 Introduction, start Circular motion in joints.

Improvisation with name gestures.
With picture cards, expressing one's expectations of the DMT
group.
2 Familiarizing with the space, moving, and Exploring the space/room by moving in it in various ways
collaboration and acknowledging the others.
In a dyad, reflecting each other's movement.
3 Safety and agency, playfulness Recognizing how one directs attention: outwards, inwards.
Sensing body boundaries.
Moving eyes open or closed.
Exploring the spatial options in movement.
4 Playfulness, agency, finding different Exploring spine motility.

options Imagery and improvisation: If you were an animal, how
would the animal move?
In a circle, moving by holding hands.
5 Intuition, sensitivity Activation of the body, starting from the feet.

Playing with different movement qualities.
Mindfulness skills and breathing: sensing one's walking.
6 Relieving achievement pressure Sensing hands through different movements.
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Breathing exercises.
Bartenieff Fundamentals* basic exercises.
Mindfulness skills: breathing and seeing the other.
Polarity: familiar and unfamiliar in movement.
7 Boundaries, distances, directions Activating hands and breathing, sensing body boundaries,
sensing center/core also with strength.
Movement improvisation with a focus on near space, middle
space, far space.
Walking in a dyad and sensing the connection.
Drawing a picture of one's experience.
8 Space for motion, boundaries, surfaces Self-nurturing movement and moving on the floor level.
balancing being, and action Bartenief Fundamentals* basic exercises.
Getting into vertical slowly and through different postures.
9 Emotionacceptance and agency in one's Movement improvisation from the words selected to express
life and in relation with one's present state.
environment/others Exploring earth, water, air, and fire through movement
improvisationexpressing and describing associated
feelings.
10 What do I needattention and focusing in In a dyad, hand massage.

action On a tape line, improvising movement in relation to the line;
working with a partner who accompanies the movement in
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the way one asks for.
11 Accepting needsnurturing, simplicity, Moving with breath, gradually engaging the whole body.
freedom Simple qigong exercise (breath, clear movement pattern, a
sense of opening/stretching, focusing).
Requesting from a pair something one needs in movement
and/or presence.
Homework: to write a poem of one's experiences in this
group.
12 Closurewhat have I learnt? Activating the body, grounding, being aware of the body.
Simple qigong exercise (same as in the session 11) Poems:
sharing them, improvising movement on them.
Feedback of the process.
*
See Bartenieff and Lewis, 1980.
Outcome measures
The background information assessment included the patient's gender, date of birth,
diagnosis, duration of illness, severity of depression, use of medication, and the treatment
received by the time of answering the inquiry. The researcher/therapist had also had
access to the research subjects' patient records. The self-evaluation measures used in the
study and reported in this paper were: BDI-II, HADS, SCL-90, and CORE-OM.
BDI-II (Beck Depression Inventory) and HADS (Hospital Anxiety and Depression Scale)
measure mood. BDI-II (Beck et al., 1961, 1996; Dozois et al., 1998) measures depressive
symptoms. The score range is 063. Higher points indicate more severe depression (013
indicates no or very few depressive symptoms, 1419 indicates mild depression, 2028
moderate depression and 2963 severe depression). HADS screens for depression and
anxiety symptoms (Norton et al., 2013). HADS is indicating symptoms, when the score is
above 8 in anxiety (HADS-A) and depression scales (HADS-D), respectively (Bjelland et
122
al., 2002), or when the total score is 9 (Kjrgaard et al., 2014). Both BDI-II and HADS
are frequently used in clinical assessment of depression.
The SCL-90 (Symptoms Check List- 90) is a psychiatric self-report inventory consisting
of 90 questions. The questions assess a wide range psychiatric symptoms, including
depression, anxiety, and somatization (Holi, 2003). Many of the symptoms reflect bodily
states and autonomous nervous system arousal. A single number representing the severity
of the patient's condition is GSI (global severity index), which is the average score of the
90 questions of the inventory.
CORE-OM (Clinical Outcomes in Routine EvaluationOutcome Measure) shows the
patient's experience of his/her mood and interactions with others and environment. It
addresses the patient's global distress and portrays the dimensions of well-being,
problems, life functioning, and risk for aggressive/suicidal behavior. Between the general
and clinical populations, the clinical cut-off point is 10 points (Connell et al., 2007) or as
a total mean score for women 1.29 and for men 1.19 (Evans et al., 2002). CORE-OM is
sensitive to change in condition. The CORE-OM all-items score has a correlation of 0.81
with BDI-II and 0.88 with SCL-90-revised version. CORE-OM is applicable to a wide
range of populations. It can be used for assessing clinical effectiveness of various models
of therapy (Evans et al., 2002).
The self-evaluation measurements were presented to the participants at the start (pre-
assessment), after 3 months (post assessment), and 3 months after the end of the
intervention (follow-up assessment).
Statistical analysis
Baseline between-group differences in demographic data and pre-treatment measures
were analyzed with independent t-tests and chi-square tests, or using Mplus statistics (see
below). The effects of interventions were analyzed using hierarchical linear modeling
(HLM) in Mplus (version 7) (Muthn and Muthn, 2012). The most important advantage
in using HLM with full information maximum likelihood (FIML) estimation method
instead using repeated measures ANOVA/MANOVA is that it uses all the available
information. Thus all participants who started the study (DMT, n = 21, TAU, n = 12) were
included in the analyses. The missing data in HLM&FIML is supposed to be Missing At
Random (MAR). ANOVA/MANOVA approach uses listwise deletion requiring that the
missing data have to be Missing Completely At Random (MCAR). This listwise deletion
has a greater effect on statistical power than the HLM/FIML method. The HLM uses a
full information approach, with standard errors that are robust in the case of a non-normal
distribution (MLR estimator in Mplus). The analyses were as follows. First, the group x
time interaction was tested with Wald test. Secondly, if the interaction was statistically
significant the group differences were tested for the intervention period (pre to post), and
follow-up period (post to follow-up) separately.
Effect sizes (ES) were calculated as follows. The between-groups ES was calculated after
the treatment and at follow-up by dividing the difference between the DMT group mean
and the TAU group mean by the pooled standard deviation of the two conditions.
The within-group ES was calculated for both the post- and follow-up measurements by
123
dividing the mean change from pre-measurement by the combined (pooled) standard
deviation (SD) (Feske and Chambless, 1995; Morris and DeShon, 2002). Due to possible
differences between groups at pre-measurement, between-group ES differences at post-
and at follow-up measurements were corrected by the pre-measurement difference. Thus,
corrected between-group ES were reported. A between-group effect size of 0.2 was
considered small, 0.5 was medium, and 0.8 was large. A within-group ES of 0.5 was
considered small, 0.8 was medium, and 1.1 was large (Roth and Fonagy, 1996;
st, 2006).
Go to:
Results
Symptom measurements
At the pre-measurement, the groups were statistically significantly different in their BDI-
II -scores (DMT group m = 25.00, sd = 11.70; TAU group m = 32.50, sd = 7.60; Estimate
= 7.50, p = 0.026) and CORE-scores (DMT group m = 17.00, sd = 6.61; TAU group m =
20.65, sd = 3.55; Estimate = 3.66, p = 0.036). BDI and CORE described the depression
symptoms and psychiatric condition to be more severe in the TAU group than in the
DMT group at the pre-measurement. Based on the HADS and SCL-90 scores, the groups
were not statistically significantly different at the pre-measurement.
Symptoms (SCL-90) decreased more in the DMT group than in the TAU group during the
study period. When the intervention and follow-up periods were analyzed separately it
was observed that SCL-90 scores changed statistically significantly differently in the
DMT and TAU groups during the intervention (Estimate = 0.425, p = 0.011) but not
during the follow-up (Estimate = 0.031, p = 0.086). In the HADS scores, there was a
trend for a significantly different change over the three measures. During the intervention
the scores changed statistically significantly differently between the DMT and TAU
groups (Estimate = 6.295, p = 0.024), but not during the follow-up (Estimate =
0.741, p = 0.714). In the BDI-II- and CORE-scores there was a greater reduction in the
DMT group than in the TAU group, but over time, the groups did not change statistically
significantly differently (Table (Table44).
Table 4
Mean scores and standard deviation for depression (BDI-II), anxiety and depression
(HADS), physical and psychological symptoms (SCL-90), and global distress
(CORE) at pre, post, and 3-month follow-up.
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Out-come Pre M (SD) Post M (SD) Fup 3-mo M (SD) Wald test df = 2 P-value
BDI-II 2.93 0.231
DMT 25.00(11.70) 14.89(13.60) 16.24(13.62)
TAU 32.50(7.60) 28.97(8.65) 29.66(9.85)
d 0.67 0.60
HADS 5.39 0.068
DMT 20.81(7.99) 13.43(10.24) 14.22(9.85)
TAU 24.58(4.65) 23.54(6.47) 23.15(7.75)
d 0.97 0.79
SCL-90 8.23 0.013
DMT 1.39(0.76) 0.95(0.74) 0.91(0.67)
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Out-come Pre M (SD) Post M (SD) Fup 3-mo M (SD) Wald test df = 2 P-value
TAU 1.59(0.41) 1.58(0.37) 1.53(0.55)
d 0.70 0.67
CORE 4.14 0.126
DMT 17.00(6.61) 11.95(7.96) 12.31(7.02)
TAU 20.65(3.55) 20.05(4.55) 19.78(6.04)
d 0.85 0.73
Between-group effect-sizes (d) are also presented (corrected with pre-measurement difference).
To assess the size of the treatment effects, effect sizes were analyzed (see Supplementary
Table 1). Between groups ES showed large differences (d 0.80) at post measurement in
HADS and CORE, and medium size (d 0.50) in BDI-II and SCL-90. At follow-up
between groups ES were medium in favor of the DMT group (d = 0.600.79). The
difference in HADS at 3-month follow-up was close to large (d = 0.79). In the DMT
group, the with-in group ESs were medium or close to medium size at post measurement
BDI-II (d = 0.87), HADS (d = 0.92), and CORE (d = 0.76), and small in SCL-90 (d =
0.57). In the follow-up the within ES were medium for HADS (d = 0.83) and close to
medium in BDI-II (d = 0.75). ESs were small for CORE (d = 0.71) and SCL-90 (d =
0.62). In the TAU group the within ESs were small (BDI-II, d = 0.47) or very small
(HADS, d = 0.23; SCL-90, d = 0.02; CORE, d = 0.18) at post measurement. The within
ESs were also small in the follow-up (BDI, d = 0.37; HADS, d = 0.31; SCL-90, d = 0.15;
CORE, d = 0.26). Thus, in the DMT group the within ESs at the 3-month follow-up
varied from 0.62 to 0.82 as compared to TAU 0.150.37.
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Differences between the groups on the basis of the use of antidepressants
When analyzing the data on the subjects' use of medications, it was revealed that all the
patients in the TAU group (n = 12) were on antidepressive medication, but in the DMT
group there were nine patients, who were not taking antidepressants, leaving 12 with
antidepressants. Table Table55 presents the differences that can be observed when the
subjects are grouped on the basis of the DMT intervention and the use of medication.
Table 5
Differences between outcomes in the DMT and TAU groups when the subgroup
distribution is based on DMT intervention and taking antidepressants.
Variable DMT group, pts taking DMT group, no TAU group, pts taking
antidepressants n = 12 antidepressants n = 9 antidepressants n = 12
Mean duration of the 17 months 10 months 15 months

treatment period
Years since first 10 years 5 years 6 years

episode of depression
(mean)
INVENTORY M SD M SD M SD
BDI-II Pre 25.58 10.43 24.22 13.16 32.50 7.60
Post 18.02 13.76 11.55 11.92 28.97 8.65
Follow-up 19.59 11.88 13.36 14.77 29.66 9.85
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Variable DMT group, pts taking DMT group, no TAU group, pts taking
antidepressants n = 12 antidepressants n = 9 antidepressants n = 12
HADS Pre 20.67 7.00 21.00 9.13 24.58 4.65
Post 15.67 10.57 11.00 9.06 23.54 6.47
Follow-up 16.96 10.01 11.22 8.57 23.15 7.75
SCL-90 Pre 1.45 0.67 1.30 0.86 1.59 0.41
Post 1.06 0.80 0.81 0.63 1.58 0.37
Follow-up 1.03 0.75 0.77 0.54 1.53 0.55
CORE Pre 17.54 5.53 16.13 7.95 20.65 3.35
Post 13.44 7.79 10.21 7.70 20.05 4.55
Follow-up 13.36 7.07 10.77 6.50 19.78 6.04
The duration of the participants' illness, the length of the current treatment period, and the
measurements score level differed according to the use of antidepressant medication.
Compared to no-antidepressants patients, patients taking antidepressive medications had
128
suffered longer from their illness and had more severe psychiatric symptoms at the pre-
measurement point. The TAU group participants on antidepressive medication had the
most severe psychiatric symptoms in this material. However, the mean duration of their
illness and the length of the current treatment period were shorter than in the subgroup of
DMT antidepressant users. Since medication could have affected the results we decided
to conduct additional analyses. We were especially interested to ascertain, if the DMT
group on medication showed a different change pattern from that in the TAU group (on
medication). Further, we were also interested in comparing the members of the DMT
group with medication and without medication.
Wald test showed that the DMT group with medication changed differently from the TAU
group (on medication) during the intervention regarding the scores on SCL-90, Wald test
= 13.46, df = 2, p = 0.001. In this comparison, the change was statistically significantly
different during the intervention period (Estimate = 0.378, p = 0.008), but not during the
follow-up period.
The HADS scores showed a tendency for a statistically significantly different change
pattern when comparing the DMT with no medication and the TAU group (Wald test =
5.472, df = 2, p = 0.06). In this comparison, the change was statistically significantly
different during the intervention period (the Estimate = 8.936, p = 0.026). During the
follow-up period there was no statistically significant change.
In all other comparisons Wald test did not reveal any statistically significant difference.
As there were no statistically significant differences between the score changes of the
DMT group with no medication and DMT with medication subgroups, DMT appears to
be effective whether the patient is taking antidepressive medication or not.
At the post-measurement, assessing the clinical significance of the changes after the
intervention period, the greatest improvements in the condition appeared in the group of
DMT participants who were not on antidepressant medication (see Supplementary
Table 2). In this group, the within-group pre to post effect sizes ranged from d = 0.56
to d = 1.07, i.e., from small to medium. The effect sizes in the pre- followup
measurements comparison ranged from small to large, d = 0.621.10. The DMT
participants on antidepressants had also clearly improved, but the within-ES changes
were slightly smaller than for the DMT participants not on antidepressants. In the DMT
group on antidepressants the range of effect sizes (d) was 0.590.76 at the pre-post
measurements comparison, and at the pre-follow-up comparison the range was from d =
0.53 to d = 0.71; thus in this group the ESs were small. In the TAU group, where all the
patients were on antidepressant medication, the changes in the scores during the data
collection time were minor. The range of within-group effect sizes (d) was 0.020.47.
Go to:
Discussion
This study investigated the effect of adding dance/movement group therapy (DMT) to the
treatment of psychiatric outpatients with a diagnosis of depression. Compared to the
TAU, adding DMT seemed to improve the effect of the treatment. There was a tendency
129
for the effect of DMT to be slightly better with patients who were not taking
antidepressive medication.
Between-group effect sizes between the DMT + TAU and TAU indicated medium or
large differences (d = 0.600.85) in the four measures used in this study in favor of the
DMT + TAU. In addition, the within-group effect sizes were considerably larger among
patients attending to the DMT group. This suggests, that the favorable changes observed
when the DMT was added to the TAU may have clinical significance. However, more
studies are needed to confirm the clinical effects of DMT.
The indication of a statistically significantly greater improvement between the DMT +
TAU and TAU groups appeared in the SCL-90 measuring psychiatric symptoms and
HADS measuring depression and anxiety symptoms. In these self-evaluation
assessments, the verbal content of the statements is geared toward bodily felt sensations,
symptoms, and emotions. In the SCL-90 one third of the questions refer to somatization
or phenomena that relate to autonomous nervous system arousal. This may be one reason
why the change was expressed more clearly through these measurements. In addition to
these changes, the DMT group showed favorable changes, although not statistically
significant, in symptoms of depression (BDI-II) and global distress (CORE-OM). These
observations are in line with the study by Punkanen et al. (2014) using a similar DMT
group intervention. In their study the mean decrease on the BDI from baseline to post-
measurement was 11.17 points compared to 10.11 points in the present study. Both these
studies produced a similar favorable outcome in the treatment of depression. Punkanen et
al. (2014) used a 20-session group intervention provided twice a week while the present
study applied a 12-session intervention. This suggests that favorable changes could also
be achieved using a shorter DMT group intervention.
The observations made in this study are also in accordance with the previous reviews by
Meekums et al. (2015), Koch et al. (2014), and Papadopoulos and Rhricht (2014). These
suggested positive effects of DMT on quality of life and on depression and anxiety. One
focus in DMT is engaging with movement activity in the here and now. Further, the aim
of activity is to be attentive to the movement experiences and to develop the skills to be
aware of experiences, and to communicate about them in words (Meekums, 2002; Koch
and Fischman, 2011; Nolan, 2014). Thus DMT involves experiential exercises including
mindfulness skills and attention training. There are several other studies suggesting that
this type of training, which includes experiential exercises, could be beneficial to the
patients (Hayes et al., 2011; Michalak et al., 2012; Horst et al., 2013; Payne, 2015). It
could also be speculated that DMT increases psychological flexibility, which has been
shown to be associated with wellbeing and quality of life (Hayes et al., 2011; Keng et
al., 2011), as the skills for observation, reflection and body state modulation improve.
Thus, given that DMT is a useful intervention method for patients with depression
symptoms, more studies are needed to examine the possible mechanism of change.
A tendency was observed for the greatest improvement the be achieved when the patient
participated in the DMT group and was not on antidepressive medication. However, it
should be noted that the patients in the DMT group without or with antidepressant
medication benefited from the intervention, and no statistically significant differences
were observed between the groups. Thus, more studies are needed to investigate the
130
impact of DMT interventions with or without medication. The importance of observing
medication in the treatment is emphasized by the fact that the more difficult
symptomology appears to go along with more complex diagnosis set, longer treatment
period, and taking of medication. We observed that those patients not taking medication
had typically had current treatment periods under 6 months (67% of the patients) and
only one diagnosis (44% of the patients). Those patients, who used medication at the pre-
measurement, had typically two or more diagnosis (63% of the patients) and had more
than 6 months of treatment (63% of patients).
When comparing DMT + TAU to TAU among patients on antidepressant medication, it
was observed that all the four outcome measures tended to improve more in the DMT
group, with especially SCL-90 showing significantly larger change. It is of particular
interest that at the pre-measurement point in the DMT group, the patients on
antidepressive medication and those without antidepressive medication had a fairly
similar level of symptoms, but the score differences between these two subgroups had
clearly increased at the post-measurement, in favor of no antidepressants sub-group. The
question arises as to whether the DMT participants on antidepressants had a more
difficult type of depression and the medication had alleviated their symptoms so that their
symptom scores were on the level of a less complicated depression at the pre-
measurement point. If this was the case, it could be assumed that the smaller score
changes after the intervention could have been due to the more difficult type of
depression.
This study has limitations to be born in mind when drawing conclusions from the results.
One concern is the use of self-evaluation measures only, and the lack of movement based
assessment of the effects of the intervention. Videotaping the sessions was not part of the
usual clinical practice at this clinic, and the goal was to study the natural clinical practice.
Without video recordings it is difficult to produce any reliable movement assessment of
the four groups. Even with video recordings, movement observation of group activity
would have been challenging to carry out reliably.
The participants joined the research groups on the basis of self-selection. They were not
randomly divided among the groups. Thus, we cannot ignore the possibility that the
selection bias has affected the results. In fact, at the pre-measurement point the TAU
group reported significantly higher value for depression symptoms and global distress
compared to the DMT + TAU. On the other hand, the DMT group had a slightly longer
history of illness, more frequently two diagnoses and more frequently an experience of
psychotherapy than the TAU group patients. Also, as more patients in the DMT group had
experience of psychotherapy, it is possible that DMT attracts patients who are positively
disposed to therapeutic work, willing and able to use self-reflection and interaction as
means for their recovery. Both the DMT and the TAU group participants may have had
expectations about the treatment they received. As we did not systematically assess their
expectations, we can draw no conclusions of the impact of expectations on the results.
Further, the follow-up time was relatively short (3 months), thus in light of the current
data it is difficult to draw firm conclusions about the long-term effects of DMT. Another
limitation is the small number of participants included in the study. In the TAU group
there was a fairly high drop-out rate. However, we applied hierarchical linear modeling in
131
data analyses, since it included all the patients who started the treatment. According to the
patient records, all the patients who left the research did continue their treatment at the
psychiatric clinic over the study period. No data were collected about their reasons for
leaving the study.
The TAU patients were not interested in joining the DMT group, but this study offers no
information about their reasons for this. Compared to the TAU group, a higher percentage
of the DMT group patients continued in the study. This prompts a question, whether the
participation in the DMT group, personal commitment and joining the interaction
supported the motivation for treatment and also the alleviation of depression. If this was
the case, DMT seems to offer a suitable social context to be utilized in health care to offer
new interactional experiences and learning through them.
The TAU did not significantly improve the patients' wellbeing. This study suggests that
experiential treatment methods such as DMT could improve the effects of treatment.
However, not all clients want to join a DMT group as was observed in this study. In the
future, more attention could be devoted for increasing patients' motivation for
experiential and action based treatment methods.
The results indicated that adding DMT to TAU is beneficial in the treatment of patients
with depression. These results encourage the use of creative, interactive, psycho-physical,
and experiential therapy interventions in the treatment of depression.
Conflict of interest statement

Go to:
Acknowledgments
PP wants to acknowledge her gratitude to the City of Tampere Psychiatric Clinic for
providing a base for this research. This paper forms a part of her doctoral studies in
psychology at the University of Jyvskyl.
Go to:
Footnotes
1
http://www.who.int/healthinfo/statistics/GlobalDALYmethods.pdf
2
http://www.findikaattori.fi/fi/76
3
Kyphoitosuositus, http://www.kaypahoito.fi/web/english/guidelineabstracts/guideline?
id=ccs00062&suositusid=hoi50023
4
e.g., http://www.ukkinstituutti.fi/filebank/64-physical_activity_pie.pdf; www.health.gov/paguidelines/gui
delines/default.aspx#toc
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Articles from Frontiers in Psychology are provided here courtesy of Frontiers Media SA
Cochrane Database Syst Rev. 2015 Feb 19;(2):CD009895. doi:

10.1002/14651858.CD009895.pub2.
Dance movement therapy for depression.

Meekums B1, Karkou V, Nelson EA.
136
Author information
Abstract
BACKGROUND:
Depression is a debilitating condition affecting more than 350 million people worldwide
(WHO 2012) with a limited number of evidence-based treatments. Drug treatments may
be inappropriate due to side effects and cost, and not everyone can use talking
therapies.There is a need for evidence-based treatments that can be applied across
cultures and with people who find it difficult to verbally articulate thoughts and feelings.
Dance movement therapy (DMT) is used with people from a range of cultural and
intellectual backgrounds, but effectiveness remains unclear.
OBJECTIVES:
To examine the effects of DMT for depression with or without standard care, compared to
no treatment or standard care alone, psychological therapies, drug treatment, or other
physical interventions. Also, to compare the effectiveness of different DMT approaches.
SEARCH METHODS:
The Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register
(CCDANCTR-Studies and CCDANCTR-References) and CINAHL were searched (to 2
Oct 2014) together with the World Health Organization's International Clinical Trials
Registry Platform (WHO ICTRP) and ClinicalTrials.gov. The review authors also
searched the Allied and Complementary Medicine Database (AMED), the Education
Resources Information Center (ERIC) and Dissertation Abstracts (to August 2013),
handsearched bibliographies, contacted professional associations, educational
programmes and dance therapy experts worldwide.
SELECTION CRITERIA:
Inclusion criteria were: randomised controlled trials (RCTs) studying outcomes for
people of any age with depression as defined by the trialist, with at least one group being
DMT. DMT was defined as: participatory dance movement with clear psychotherapeutic
intent, facilitated by an individual with a level of training that could be reasonably
expected within the country in which the trial was conducted. For example, in the USA
this would either be a trainee, or qualified and credentialed by the American Dance
Therapy Association (ADTA). In the UK, the therapist would either be in training with, or
accredited by, the Association for Dance Movement Psychotherapy (ADMP, UK). Similar
professional bodies exist in Europe, but in some countries (e.g. China) where the
profession is in development, a lower level of qualification would mirror the situation
137
some decades previously in the USA or UK. Hence, the review authors accepted a
relevant professional qualification (e.g. nursing or psychodynamic therapies) plus a clear
description of the treatment that would indicate its adherence to published guidelines
including Levy 1992, ADMP UK 2015, Meekums 2002, and Karkou 2006.
DATA COLLECTION AND ANALYSIS:

Study methodological quality was evaluated and data were extracted independently by
the first two review authors using a data extraction form, the third author acting as an
arbitrator.
MAIN RESULTS:
Three studies totalling 147 participants (107 adults and 40 adolescents) met the inclusion
criteria. Seventy-four participants took part in DMT treatment, while 73 comprised the
control groups. Two studies included male and female adults with depression. One of
these studies included outpatient participants; the other study was conducted with
inpatients at an urban hospital. The third study reported findings with female adolescents
in a middle-school setting. All included studies collected continuous data using two
different depression measures: the clinician-completed Hamilton Depression Rating Scale
(HAM-D); and the Symptom Checklist-90-R (SCL-90-R) (self-rating scale).Statistical
heterogeneity was identified between the three studies. There was no reliable effect of
DMT on depression (SMD -0.67 95% CI -1.40 to 0.05; very low quality evidence). A
planned subgroup analysis indicated a positive effect in adults, across two studies, 107
participants, but this failed to meet clinical significance (SMD -7.33 95% CI -9.92 to
-4.73).One adult study reported drop-out rates, found to be non-significant with an odds
ratio of 1.82 [95% CI 0.35 to 9.45]; low quality evidence. One study measured social
functioning, demonstrating a large positive effect (MD -6.80 95 % CI -11.44 to -2.16;
very low quality evidence), but this result was imprecise. One study showed no effect in
either direction for quality of life (0.30 95% CI -0.60 to 1.20; low quality evidence) or
self esteem (1.70 95% CI -2.36 to 5.76; low quality evidence).
AUTHORS' CONCLUSIONS:
The low-quality evidence from three small trials with 147 participants does not allow any
firm conclusions to be drawn regarding the effectiveness of DMT for depression. Larger
trials of high methodological quality are needed to assess DMT for depression, with
economic analyses and acceptability measures and for all age groups.
Source:- https://www.ncbi.nlm.nih.gov/pubmed/25695871/
138
Compilers Recommendation 1
Recommendation 1
Individuals suffering from Movement Disorders should be given discounted prices to

enter dances and concerts where dancing takes place. This would a requirement for the
Parish Council and or police giving permission for these events to be held.
The individual with Movement Disorder purchase his or her ticket against his or her
identification card issued by the Jamaica Council For Individuals with disabilities.
Individuals who are victims of mental health disorders take the same approach to
entering places where Jazz or Classical music is played.
Family doctors should prescribe that these individuals attend monitored dance sessions at
the nearest community college where there is a trained dance teacher or at the Edna
Manley School of Dance. The same for individuals who are obese and those who are
depressed.
139
The dance teacher would submit monthly reports to the prescribing doctor on the
attendance, participation and performance of the referred patient.
The National Health Fund could underwrite the cost of those individuals who are not
covered by health insurance, for individuals covered by health insurance, these classes
would be booked at selected pharmacies and paid for at these pharmacies by health
cards.
Selected pharmacies should be permitted to dispense marijuana and small smoking pipes
to these individuals with Movement Disorders and for individuals suffering from intense
chronic pain.
Dedicated to the late Rubber Dub Morgan who while suffering from Parkinson Syndrome
would normally go to "Dances" to sell and while doing so would enjoy both music and
dance and as a consequence his gait and sense of balance did not deteriorate as bad as it
could it have, for example he did not at any point need a walking aid. While his speech
was affected he spoke very clearly. The role played by his sister, his family and the
community should not be under estimated. Parkinson Syndrome did not stop Rubber
Dubb from playing dominos a game he loved with a passion. May his memory inspire
others.
End
A Good Time to Dance? A Mixed-Methods Approach

of the Effects of Dance Movement Therapy for
Breast Cancer Patients During and After
Radiotherapy.
Ho RT1, Lo PH, Luk MY.
Author information
Abstract
BACKGROUND:
Dance movement therapy (DMT) is premised on an interconnected body and mind. It has
known benefits for cancer patients' physical and psychological health and quality of life.
OBJECTIVE:
To offer greater insight into a previous randomized controlled trial, the present study
qualitatively explored the beneficial elements of DMT over the course of radiotherapy. To
better understand the uniqueness of DMT intervention for patients receiving radiotherapy,
the study statistically compared them with patients who received DMT after treatment
completion.
140
METHODS:
Participants were randomized into radiotherapy and postradiotherapy control groups. The
radiotherapy group received DMT (6 sessions at 90 minutes each) as they were
undergoing radiotherapy. The postradiotherapy group was provided with the same DMT
intervention at 1 to 2 months after completing radiotherapy.
RESULTS:
One hundred and four participants identified 5 main benefit categories. Dance movement
therapy helped them (1) cope with cancer, treatment, and physical symptoms; (2)
improve mental well-being, attention, and appreciation for the self and body; (3) improve
total functioning; (4) bridge back to a normal and better life; and (5) participate in shared
positive experiences. The radiotherapy group reported categories 1 and 2 more
prominently than did the postradiotherapy group.
CONCLUSIONS:
The findings reinforced the benefits of DMT while adding the new perspective that
delivering DMT intervention throughout cancer treatment can have different and even
additional benefits for patients.
IMPLICATIONS FOR PRACTICE:

The pleasure of dancing and the psychological and physical relief from DMT help
patients cope with daily radiation treatments. This could decrease treatment dropout rates
when administered in clinical settings.
Overcoming Disembodiment: The Effect of

Movement Therapy on Negative Symptoms in
Schizophrenia-A Multicenter Randomized
Controlled Trial.
Martin LA1, Koch SC2, Hirjak D3, Fuchs T3.
Author information
Abstract
OBJECTIVE:
Negative symptoms of patients with Schizophrenia are resistant to medical treatment or
conventional group therapy. Understanding schizophrenia as a form of disembodiment of the
141
self, a number of scientists have argued that the approach of embodiment and associated
embodied therapies, such as Dance and Movement Therapy (DMT) or Body Psychotherapy
(BPT), may be more suitable to explain the psychopathology underlying the mental illness
and to address its symptoms. Hence the present randomized controlled trial
(DRKS00009828, http://apps.who.int/trialsearch/) aimed to examine the effectiveness of
manualized movement therapy (BPT/DMT) on the negative symptoms of patients with
schizophrenia.
METHOD:
A total of 68 out-patients with a diagnosis of a schizophrenia spectrum disorder were
randomly allocated to either the treatment (n = 44, 20 sessions of BPT/DMT) or the control
condition [n = 24, treatment as usual (TAU)]. Changes in negative symptom scores on the
Scale for the Assessment of Negative Symptoms (SANS) were analyzed using Analysis of
Covariance (ANCOVA) with Simpson-Angus Scale (SAS) scores as covariates in order to
control for side effects of antipsychotic medication.
RESULTS:
After 20 sessions of treatment (BPT/DMT or TAU), patients receiving movement therapy had
significantly lower negative symptom scores (SANS total score, blunted affect, attention).
Effect sizes were moderate and mean symptom reduction in the treatment group was
20.65%.
CONCLUSION:
The study demonstrates that embodied therapies, such as BPT/DMT, are highly effective in
the treatment of patients with schizophrenia. RESULTS strongly suggest that BPT/DMT
should be embedded in the daily clinical routine.
142
143
Interaction of the factors Group and Time for the variable SANS-TS. Error bars
represent standard errors. Contrasts comparing SANS-TS of treatment and control group
independently for the two testing times, reveal significant differences between the groups
at T1, which even out at T2. Contrasts analyzing treatment and control group over time
show an insignificant increase of negative symptoms in the control group and a
significant reduction of negative symptoms in the treatment group. SANS-TS, Scale for
the Assessment of Negative Symptoms Total Score; T1/T2, Measuring Time 1/Measuring
Time 2.
Creative people ARE prone to suffering mental illness: Actors,

dancers and musicians 'more likely to have the genes
causing schizophrenia and bipolar disorder'
Artistic types are more likely to have genes causing mental illness
This is compared to those with practical jobs, like fisherman and farmers
'Results are unsurprising as creativity involves thinking outside the box'
By Fiona Macrae, Science Editor For The Daily Mail
PUBLISHED: 16:43 BST, 8 June 2015 | UPDATED: 09:38 BST, 9 June 2015
It is often said that theres a fine line between genius and madness.
Now scientists have shown there is some truth in the saying.
144
They have found that artistic types are more likely than those with down-to-earth jobs to
have some of the genes that cause schizophrenia and bipolar disorder.
For instance, an actor is more likely to have some of the genes than a farmer.
The find, by Icelandic scientists, suggests that the DNA that causes the manic energy and
unconventional thinking of some psychiatric conditions also helps fuel creativity.
Psychiatry and music

Shamsul Haque Nizamie and Sai Krishna Tikka
Abstract
INTRODUCTION
Music is the art of sound in time, expressing ideas and emotions in significant forms
through the elements of melody, harmony and color.[1] Tones or sounds occurring either
in in a single line (i.e., melody) or in multiple lines (i.e., harmony) and the feeling of
movement of sound in time (i.e., rhythm) are the essential elements of music. The Oxford
dictionary defines music as vocal and/or instrumental sounds combined in such a way as
to produce beauty of form, harmony and expression of emotion. Today, music and its
technology is in vogue particularly the use of electronic devices and computer software.
From classical Carnatic to Latin folk, from tiny I-pods to high voltage rock performances,
every human being is accompanied by music anytime and anywhere. Music energizes
mood, music is a great stress buster, music drives away blues, music soothes
souls - from a mental health professional point of view, these statements invoke thoughts
like since how long has been this association between music and mind there? What
aspects of mental health does music impact? Can music treat mental illnesses? And if
yes how? This review makes an attempt to answer such questions. Particularly, we have
tried to focus the role of Indian forms of music and Indian contribution to music therapy.
HISTORY OF MUSIC AND MIND - A FOCUS ON INDIAN

CLASSICAL MUSIC
Ancient Greek philosopher, Plato (428-347 BC), quoted music gives wings to mind.
Plato considered that music played in different modes would arouse different emotions.
[2] Much ancient is the association between music and mind. It can be dated back to the
vedic age, where attempts were made to relate the seven basic notes of music and the
eight basic moods identified in the Indian drama theory. The seven basic notes are -
sadaja, rishaba, gandhara, madhyama, panchama, dhaibata and nishada; whereas, the
145
eight basic emotions are - sringar (love), hasya (laughter), karuna (compassion), vira
(heroism), raudra (wrath), bhayanaka (fear), bibhatsa (disgust) and adbhuta (wonder).
Love and laughter are associated with madhyama and panchama notes; wrath, wonder
and heroism with sadaja and rishaba; nishada and gandhara with compassion; and
dhaibata with disgust and fear.[3]
More intriguing is the relation between raga and rasa. raga is described as a
particular arrangement of sounds in which notes and melodic movements appear like
ornaments to enchant mind.[3] This forms the basic melodic structure of the Indian
classical music and is not just the sum of the basic notes but rather forms a gestalt. On
the other hand, rasa is described as the psychological reaction or the reverberation
occurring in persons in response to listening music. It is assumed to represent both
primary and responding emotions.[4] Pleasure being the end product of any art form,
the rasa concept assumed an abstract connotation of elements or essence in the
Upanishads especially in the Bribadranyak Upanishad, whereas in the Taittariya
Upanishad rasa denotes the ultimate reality, which is the basis of ananda or highest
state of bliss.[5]
As raga is analogous to the concept of harmoniai of ancient Greece,[6] rasa resembles
the ethos expressed in the same culture or the similar phenomena in the music of
renaissance and baroque periods of the West, particularly to the Affectnlehre of the late
nineteenth century.[4]
MUSIC AND THE BRAIN

History of the relation between music and the mind is skewed to the effects of music on
one function of the mind - emotion. However studies investigating the neurobiological
basis of music have intrinsically linked music to various other brain functions as well.
Human nervous system processes music in different ways - perceptual processing,
emotional processing, autonomic processing, cognitive processing and behavioral or
motor processing.
Perceptual processing
Although, music stimulates some skin receptors by changes in local pressure, it is
primarily made of sound waves that enter the primary acoustic circuit through the outer
ear. Human primary acoustic circuit involves auditory nerve, brainstem, medial
geniculate body of the thalamus and the auditory cortex.
The transduction of music into a neural signal occurs in the cochlea. Music signals are
perceived through shearing of hair cells within the cochlea. Cochlea filters these signals
and the outputs are ordered tonotopically. The highest frequencies (pitches) are
represented near the cochlear base, the lowest near its apex. The basilar membrane is the
structure within the cochlea that separates scala media and the scala tympani. For
different pitches, different regions on this membrane are activated. For frequencies below
1 kHz or in the range between 1 and 4 kHz or between 4 and 20 kHz there are as many
cells on the membrane being sheared. There is a linear relation between position of cells
146
on the membrane being activated and frequency, up to 500 Hz. And between 500 and
8000 Hz, for distances on the membrane there is a doubling in frequency.[7]
The auditory brainstem processes the neural signals from cochlea and sends them to the
thalamus, which projects them into the auditory cortex.[8] The primary auditory cortex is
located on the transverse gyri of Heschl in the lateral fissure, with a small part of it
extending into the lateral surface of the temporal lobe. Organization of the primary
auditory cortex is such that different parts of this area can be activated by music of
different pitches. The secondary auditory cortex, the posterior and the anterior auditory
fields are also involved in processing of music.[9] All these areas carry out perceptual
analysis in terms of pitch (generally tones are physically referred to as frequencies, but in
respect to music they are referred as pitches), timbre (the quality of a musical sound that
distinguishes different types of sound production), rhythm (the organizational pattern of
sound in time or the timing of musical sound), intensity and roughness. Functional
auditory projections are also found between medial geniculate body, amygdala, cingulate
gyrus and medial orbitofrontal cortex.[9,10] Different brain regions are assumed to
perform a specific function in the processing of music: Musical aptitude (primary
auditory cortex and heschl's gyrus); musical syntax (frontal operculum); musical
semantic (superior temporal sulcus); and language of music (perisylvian cortical language
areas).[11] Table 1 shows involvement of various brain regions in different aspects of
processing of music.
Table 1
Brain regions involved in music processing (adapted from Lin et al., 2011[10])
Emotional processing
Now, amygdala, cingulate gyrus and medial orbitofrontal cortex are involved in
processing of emotional behaviors. Hence, as these structures are found to have auditory
projections, these are proposed to be involved in emotional processing of music. There is
evidence also to suggest that music activates these regions.[9,11] Table 2 shows the
relation between various structural parameters of the music and different emotions. There
is no specificity in the association of a particular parameter with one particular emotion,
i.e., same emotions can be perceived by different musical parameters.
147
Table 2
Structural parameters of the music and emotions (adapted from Gabrielsson and
Lindstrm, 2001)
Research on different neuronal responses to pleasant and unpleasant music has found
that:
1. Brain activity is present predominantly in the frontal lobes for pleasant music and
in the temporal lobes for unpleasant music.[12]
2. Pleasant music activates the inferior frontal gyrus, inferior brodmann's area of the
neocortex, anterior superior insula, ventral striatum, heschl's gyrus, as well as the
rolandic operculum and unpleasant music activates the amygdala, hippocampus,
parahippocampal gyrus and temporal lobes.[13]
3. There exists a complex relationship between the intrinsic happy-sad character of
music and the subjective perception, i.e., sadness can sometimes be a source of
pleasure in music, whereas in most other forms of creative art it is negatively
perceived.[14]
4. Left frontal asymmetry, associated with positive affect or decreased negative
affect in response to musical stimuli and right frontal asymmetry associated with
negative affect or decreased positive affect is found on electroencephalography
(EEG).[15]
5. EEG findings also suggest that in men, pleasant emotions are processed in the left
hemisphere and unpleasant emotions in the right hemisphere, whereas in women,
pleasant emotions are processed in the left hemisphere and unpleasant emotions
bilaterally.[16]
Autonomic processing
Music has been found to induce relaxation and to alter pain perception, blood pressure
and respiratory and heart rates.[17,18] Soft, slow, non-lyrical music significantly
decreased systolic blood pressure, heart rate, respiratory rate and oxygen saturation.[18]
Music with a faster tempo significantly increased heart rate, minute ventilation, blood
pressure and sympathetic nervous activity and that music with complex rhythms
increased, though insignificantly, the same parameters.[19]
Cognitive processing
Cognitive processing of music is hypothesized under two mechanisms: Affective or
indirect mediation and non-affective or direct mediation. Affective mediation basically
148
refers to activation of certain cognitive networks by means of activation of emotional
music processing networks.[20]
Direct or the non-affective processing of music basically means activation of regions
involved in a particular cognitive function by music. It can further be explained based on
two mechanisms. Firstly, neuronal network priming, according to which exposure to
one type of material improves learning or identification of another related type of
material, i.e., prior exposure to complex music primes the neuronal networks that
would also be recruited to perform specific cognitive tasks.[20] In other words, musical
activity strengthens inherent neural firing patterns that are also utilized by cognitive
tasks. Specific cognitive functions that are found to be processed via music are spatial-
temporal performance including abstraction[21,22] and verbal learning.[23,24] Studies
have also found that musically enhanced spatial-temporal performance correlated
significantly with increases in frontal and temporal EEG power and coherence.[25,26]
The second mechanism that explains direct processing is synaptic plasticity. It has been
established that the brain can be permanently modified by music training, i.e., cortical
areas associated with finger control and size of the corpus callosum are found to be larger
in musicians.[20] Many skills associated with music training can be explained on the
basis of synaptic plasticity; these include fine tuning of sensorimotor coordination,
extensive memorization and sustained attention, spatial-temporal visualization[27] and
reading performance.[28]
Behavioral or motor processing

Behavioral response to music is most evident in the form of dancing. Functional brain
imaging has shown that music activates the cerebellum, basal ganglia and motor area.
These areas are reported to coordinate motor movement in response to music.[29,30]
Activation of the mirror neurons, the precuneus region of the parietal lobe, pre-
supplementary motor area, the supplemental motor area, the dorsal premotor cortex, the
dorsolateral prefrontal cortex, the inferior parietal lobule and lobule VI of the cerebellum
is seen during dancing or tapping to musical beats.[31] Medial geniculate nucleus
processes complementary movements that occur while listening to music, such as a body
sway, foot tap, or simple head nod.[31]
Hemispheric heterogeneity
Although the music is traditionally thought to be mainly processed (i.e., perceptually) in
the right hemisphere, according to modular theory of music perception different aspects
of music are processed in distinct, although partly overlapping, neuronal networks in both
cerebral hemispheres with considerable subjective variability.[32] Goodman[1] stated
that music might prove to be a means of transfer between the right and left hemispheres.
Melody processing is proposed to be a specialization of the right hemisphere, whereas
left hemisphere is postulated to be specialized in rhythm processing.[11] Emotional
processing of music however, is noted to primarily involve the right hemisphere, with
some contribution from the left frontal lobe.[9,14] Further, this hemispheric variability
has been found to be gender specific (as described earlier).[16] Affective prosody, the
term referred to the poetic rhythm and emotional tone of language is a function of the
149
right hemisphere.[33] It has been observed that patients with right hemisphere brain
lesions lacked prosody, while having intact other major language skills.[34]
Neurochemistry
Dopamine is postulated to be involved in the enjoyment of music.[9] It is demonstrated to
be released from the ventral striatum and in the ventral tegmental area in subjects
listening to pleasant music.[35] In addition, role of endorphins/endocannabinoids and
nitrous oxide in emotional perception of music and in producing physical effects such as
vasodilatation, local warming of the skin and a reduction in blood pressure as a response
to listening music respectively are described.[9] A study[36] has found that listening to
techno-music is accompanied by a significant increase in plasma norepinephrine, -
endorphin, adrenocorticotropic hormone, cortisol and growth hormone. However, while
listening to classical music, no significant changes were detected in hormonal
concentrations.[36]
PSYCHOANALYSIS AND MUSIC

Apart from a dominant biological perspective, music can also be considered from a
psychological view point. Music expresses the forms of feelings which the individual is
not able to express otherwise, which are basically non lingual and non-discursive
including experiences anchored in the early childhood of the individual as well as the
unconscious traumatic experiences.[37] Here, the listeners who associate those
experiences are able to do so without pain and anxiety;[38] music helps to bring those
memories spontaneously. Psychoanalysis has a distinct contribution in describing the
relationship of the human psyche with that of music listening. Most psychoanalytic
theorists (including those of ego psychologists) subscribe to the view that there are three
possible functions of music - emotional catharsis for repressed wishes (Id), mastering
the threats of trauma (ego) and enjoyable submission to rules (super-ego).[1,3]
Conceptually, psychoanalytic theory of music depends on upon the libido as an energetic
source; the transformation of unconscious content in analogy with dreams, imagination
and humor; the dominance of the sublimitive mechanism and; the relative flexibility of
the repressive mechanism.[39] Apart from such mature defenses, primary process
mechanisms like displacement, condensation and inversion are also suggested to operate
in a music intervention.[1]
Winnicott[40] suggested that sounds initiated by a child before falling asleep, which
soothes him at the time of anxiety (loss) is extended to his later cultural life in the form of
music. It has also been suggested that all music (1) reaches down into the preverbal realm
of the listener, composer and performer (2) engages his/her emotive life in some way and
to some degree and (3) appeals to his/her sense of form as that sense has come to be
inextricably bound up with affective and perceptual tendencies.[41] In other words, music
is a language that represents emotional life and is suggested to be more easily liable to
evade the defenses and to reach the unconscious.[42] Further, music has the capacity to
attain all the Maslow's hierarchy of human needs - physiological, safety, belonging,
esteem and self-actualization; and Jung's four functions of the psyche - thinking, feeling,
sensation and intuition are integral components of the musical experience.[1]
150
Apart from implying communication, these psychic mechanisms associated with listening
music signify a couple more related mental activities. The first is the individualistic
responses to a tune, which is claimed to be derived from the projection of his/her, own
emotions rather than being solely a direct consequence of music.[43] From this
perspective, a musical tune acts rather in the same way a projective test of personality
does, (like Rorschach Ink Blot Test), where a subject is induced to ascribe his own
thoughts and attitudes to someone or something outside himself.[3] And the second is
that in spite of the fact that some music may evoke negative feelings, individuals do not
get very much disturbed and even sometimes benefited by that. This second theme refers
to the age old practice of catharsis.[3]
DEVELOPMENTAL PSYCHOLOGY AND MUSIC

Tones or sounds occurring either in in a single line (i.e., melody) or in multiple lines (i.e.,
harmony) and the feeling of movement of sound in time (i.e., rhythm) are the essential
elements of music. These are linked to human early development. As a primitive
response, melody appears first when an infant's voice assumes differentiated crying and
then babbling. Attending to mother's voice during infancy is the first melodic affective
experience. Rhythm on the other hand has its origin in utero itself, i.e., prenatally. It starts
with production of heart beat and chest and limb movements rhythmically. Experience of
rhythm occurs when these movements are responded by the fetus through sounds
transmitted by vibrations.[1] Rhythm is dynamically invested in various stages of early
post natal development like, various cries that change in rhythm at different periods,
rhythms of neonatal sucking and mouthing, neonatal movement patterns, etc., Rhythm
has a special significance as it is suggested to be the driving factor for music as the
pattern or manner in which it is expressed determines the amount of energy invested in
responding to music.[1]
If we consider Piagetian framework, development of music evolves in the same stages of
development proposed by Piaget. Infant emits sound and reacts to changes in sound
(sensorimotor stage), sounds begin to acquire commonly shared meaning (symbolic
stage), child is able to voice a set of organized sounds to one another (concrete
operational stage) and the child is able to analyze a music composition and is able to
invent certain patterns of music (formal operational stage).[1]
PSYCHOPATHOLOGY AND MUSIC
Musical hallucinations
Musical hallucinations as a particular type of auditory hallucinations are a disorder of
complex sound processing in which the perception is formed by instrumental music,
sounds, or songs.[44] Perception can be unilateral or bilateral.[45] Although well-known
they are rare phenomenon in neurological and psychiatric patients. Its prevalence ranges
from 0.16%[46] to 2.5%.[47] Prevalence is usually higher in elder population and
specifically highest among patients with obsessive compulsive disorder (OCD).[48]
Moderate or severe acquired loss of hearing ability or deafness is broadly the main
etiological factor.[45] Perceptual release theory best explains this psychopathology.[49]
151
The phenomenon of musical hallucinations is heterogeneous in terms of clinical
characteristics and etiology. They are found in many psychiatric disorders such as
schizophrenia, major depression, bipolar disorder, anxiety disorders etc.,[48] focal brain
lesions, general brain atrophy and epilepsy[45] and intoxication with various substances -
opioids,[50] baclofen, ketamine,[51] tricyclic anti-depressants.[52,53] Content of these
hallucinations can either be familiar or unfamiliar, popular radio songs or unpopular,
childhood and religious songs and classical or folk.[45]
Many heterogeneous mechanisms have been proposed to explain the pathophysiology of
musical hallucinations. De-afferentiation phenomenon - hallucination become prominent
when the surrounding noise is low, inner ear disease pathology, dysfunction of the left
temporal cortex, parasitic memory - musical perception in most cases is never unlearned
and represents a so-called autonomic, that is unchangeable, memory feature which is then
experienced by chance or by external stimuli etc.,[45] are some of the proposed theories.
Musical obsessions
Prevalence of musical halluciantions was specifically found to be highest among patients
with OCD.[48] The questionnaire used in the study has been reported not to have
differentiated hallucinations from obsessive imagery of music.[54] When compared to
musical hallucinations, musical obsessions are more common and represent a mild
symptom of obsession.[55] Musical obsession was first described by Kraepelin as a mild
form of OCD and subsequently there have been occasional case reports in which musical
obsessions were documented.[55] OCD patients with musical obsessions usually explain
that the symptoms are irrational music or nonsense musical tunes (e.g. a commercial
jingle) recurrently and persistently sounding in their mind and they often attempt to
suppress the obsessions by substituting other thoughts without any covert or mental
compulsion.[56] The pathophysiology of musical obsessions is understood on the basis of
abnormalities in the fronto-cortico-basal-subcortical circuits.[55]
Go to:
MUSIC THERAPY
Definition and classification

It is defined as a systematic process of intervention wherein the therapist helps the client
to promote health, using music experiences and the relationships developing through
them as dynamic forces of change.[57] Music experiences here mean musical
interaction, which can be either free or improvised. It includes either active music playing
by patients or active listening to music or both. Other modes include playing composed
music on instruments, singing and writing songs. Discussing, reflecting or interpreting
themes related to music help clients to understand the potential meaning of the
experience. Therapist helps these clients to relate this meaning to situations in the client's
life.[58] According to the World Federation of Music Therapy and the American Music
Therapy Association, music therapy is defined as the clinical and evidence based use of
music and/or its elements (sound, rhythm, melody, harmony, dynamic and tempo) by a
152
qualified music therapist to accomplish individualized goals within a therapeutic
relationship with one client or a group.[59] Use of the term a qualified music therapist
in this definition helps us to distinguish music therapy from the concept of music
medicine, in which music is employed as a supplementary therapy by those who are not
necessarily specialized music therapy. Another term with which it distinguishes from is
music training. Here, along with the element that sessions are delivered by a musician
untrained in music therapy, the delivery of the intervention is in a non-trial situation.[60]
Different schools of psychology - behavioral, psychoanalytic, educational, humanistic,
contribute to the various approaches in music therapy. Broadly two basic types of music
therapy are described - active and receptive. In the active form, the client makes music
either alone or with a therapist or within a group, whereas in the receptive form the client
is made to listen to music, exclusively. Receptive or combined approaches are most
commonly used in the US, whereas in Europe, active approaches are the most prevalent.
[61] Receptive forms are influenced by cognitive-behavioral or humanistic schools and
involve the use of adjunctive techniques such as relaxation, meditation, reminiscing etc.,
Music experiences and music interaction is the main focus of the active form and this
from is psychoanalytically oriented.[61]
Music therapies can also be classified based on the level of structuring as structured and
flexible. Structured music therapy is where more structured forms of music-making are
used and activities are selected before the sessions. On the other hand, flexible form
refers to therapy where structure of music-making and selection of activities is done
during dialogue with the client. Most of the studies use some structure as well as some
flexibility and extreme forms are rarely observed.[58] Another method of classifying
music therapies is based on the focus of attention. Focus of attention may either be on the
processes taking place within the music itself or on the verbal reflection of the client's
issues triggered by these musical processes.[58]
History of music therapy

Goodman[1] has identified three phases that describe the healing ability of music -
magical, religious and scientific healing. Magical healing phase is the one where the
primitive man believed that certain sounds in the nature were the media with which man
can communicate with the invisible, supernatural spirit. The next phase - the religious
healing phase is the one where man believed that music and musical instruments are gifts
from god and he used them in ritual purification treatments. The scientific phase started
with Greek philosophers like Socrates, Aristotle and Plato. Although Aristotle was the
first to recognize the cathartic power of music, Plato identified specific harmonic rhythms
and modes for different emotions. Further the emergence of renaissance gave a new lease
to music therapy in terms of psychology and physiology.
The origin of modern music therapy dates back to post-world war II period, where
several musicians visited various hospitals around United states of America to play music
for people suffering from post-war physical and emotional traumas.[59] Here, clinicians
started hiring musicians at their clinics as they observed significant benefits of music on
health of post-war sufferers. Since then there have been many significant milestones in
the field of music therapy across the globe [Table 3].
153
Table 3
Significant milestones in the field of music therapy (adapted from Rose and Bartsch,
2009[59])
Music therapy in India

Traditional systems of healing in India such as Ayurveda and Yoga systems include
various musical treatment approaches.[62] Indian system of music treatment is defined as
an individualistic, subjective and spiritual art, aiming at personal harmony with one's
own being and not at symphonic elaborations.[63] Indian music therapy in contrast to
the Western form, which has its theoretical background predominantly based on
psychotherapy, involves expression of devotional feelings as a key factor.[64] Most
common approach used in the Indian form of music therapy is the raga-based approach.
It basically involves the application of musical pieces focusing on the swara patterns.
This approach is found to be stimulating, anxiolytic and sedative. It has been found that it
also increases attention and additionally the approach is able to target musical preference
and listening pattern.[62] Despite its strong connections to tradition, music therapy
currently is in its nascent stage of development. A reason which can be clearly understood
is lack of scientific evidence.
First conference of Indian music therapy was organized and held at the Nada Center for
Music Therapy, Chennai in 2006.[65] Delivering comprehensive training in music
154
therapy, alleviating daily stress in otherwise healthy people, targeting specific populations
such as pregnant women to achieve therapeutic effects with music are some of its
objectives.[66] It aims at achieving international standards while honoring the
distinctiveness of the Indian music.[67]
Music within a psychiatric setting

Music has numerous applications within a psychiatric setting. It can be in the form of
background music, group singing sessions and music to accompany dance apart from
music therapy per se. There are numerous benefits of the application of music in a
therapeutic environment such as making positive alteration in mood and emotional states,
improving concentration and attention span, developing coping and relaxation skills,
exploring self-esteem and personal insight, enhancing awareness of the self and the
environment and improving social interactions.[68] Such benefits were acknowledged
decades ago at the Central Institute of Psychiatry, Ranchi, which held weekly dance and
music socials since its establishment in 1918. Since early 1920s, the hospital had a
music band too of its own.[69] Currently, each of the 14 inpatient wards have a music
stereo facility with which patients listen to classical as well as modern music. Specifically
such facility makes the ward environment socially more interactive. This mode of
delivering can be broadly conceptualized under music medicine (describe earlier). We
believe that every psychiatric in-patient facility should have such a commodity.
Music as therapy in psychiatry - emphasis on efficacy

Various psychiatric conditions are treated with either psychopharmacological or
psychotherapeutic approaches or a combination of both. Specific to the approach chosen
or to that particular disorder, these treatment approaches have been shown to be
efficacious in many but not in all patients and not without limits. For example in
depression, only small differences have been found between anti-depressants and active
placebos.[70] This implied the need for additional, innovative forms of therapy for
treating psychiatric conditions. Music therapy is one such innovative form of therapy.
The first formal report on music therapy was published in as early as 1964.[71] However,
until the early 1990s, majority of publications were case studies and implication of music
therapy in terms of scientific evidence for meager.[59] Last 15-20 years has seen a
significant upshift in the number of clinical studies and reviews in music therapy,
especially those on psychiatric disorders.
Although the type of disorder influences the therapist's choices, attitudes and behaviors
during music therapy, it is usually designed for an individual patient and his/her specific
symptoms or needs rather than for a specific psychiatric diagnosis. Or putting in other
words, indications for music therapy in psychiatry or in mental health at large may be
based on various aspects, one of which is the primary clinical diagnosis.[58] Clinical
studies and reviews on music therapy in psychiatry, however, are based on the primary
clinical diagnosis. Psychiatric disorders that have been studied to investigate the effect of
music therapy can be broadly classified into - adult and pediatric categories. Among the
adult psychiatric disorders are depression, schizophrenia and other psychoses, substance
use disorders and dementia, whereas pediatric or child and adolescent psychiatric
155
disorders are autism, attention deficit hyperactivity disorder, learning disorder and mental
retardation.
Depression and music therapy

Maratos et al.,[61] a Cochrane review identified 16 studies, of which they included five
studies in their review. Four studies were randomized trials, one was controlled trial;
three studies compared music therapy plus standard care to standard care alone, one study
compared music therapy plus standard care with cognitive behavioral therapy (CBT) plus
standard care and another compared music therapy plus standard care, CBT plus standard
care and standard care alone. The duration of treatment varied between 6 weeks and 10
weeks. Three studies focused on older adults aged between 60/70 and 77/85 years; one on
adults aged between 21 and 62 years; and another on adolescents aged 14-15 years.
Sample sizes ranged between 19 and 68 participants. One study used the active form
(individual therapy) and the rest used the receptive technique (three group and one
individual therapy). Sessions lasted from 60 to 90 min, 1 to 6 times a week. Drop-out
rates in all five studies were very low, with two studies reporting no drop-outs. Marked
variations in the type of interventions used and in the populations studied quantitative
data analysis was not applicable. However, four studies reported greater reductions in
symptoms of depression among those randomized to music therapy and one study
reported no change. None of the studies reviewed compared any two forms of music
therapy.
Studies included in the review compared music therapy with either standard care or with
CBT or a combination of both. Hsu and Lai,[72] not included in the review, assessed the
effectiveness of soft music versus simple bed rest for treatment of major depressive
disorder. They found significantly lesser depressive scores in the music group. Another
study, Jones and Field[73] assessed the effects of massage therapy and music therapy on
frontal EEG asymmetry in depressed adolescents and reported significantly attenuated
frontal EEG asymmetry during and after the massage and music sessions. No report of
significant difference between the groups is on depression reported.
Most of the studies in the literature have focused on either adolescents or older adults.
Argsttter et al., (2009)[74] in their review of 10 meta-analyses and four reviews found
that music therapy was particularly effective when applied to child and adolescent
populations. This proposition may have been influenced by the bias in the number of
studies.
Gold et al.[58] studying the dose-response relationship in music therapy have shown that
dosage was a highly significant predictor, with the number of sessions explaining 73% of
the variance in effects on depressive symptoms; whereas design and disorder showed no
relation to the effect size. This finding implies that more number of sessions of music
therapy is required to treat depressive symptoms irrespective of the underlying disorder.
Literature search was conducted to find studies conducted after the Cochrane review.
Erkkil et al.[75] published the study protocol, according to which they were to examine
the efficacy of active music therapy in an individual setting on 85 (largest sample size of
all studies) adults aged between 18 and 50 years with depression. As proposed, Erkkil et
156
al.[76] compared active music therapy with standard care in biweekly sessions that went
on for 3 months. However, they could only include 79 (still the largest sample size)
participants out of 91 participants initially assessed. Patients receiving music therapy
showed greater improvement than those receiving standard care alone in depression
symptoms. Similarly, Choi et al.[77] found that fifteen sessions of music intervention
significantly improved depression compared with a control group.
Indian studies
Among these, two studies were conducted in India with Indian classical music.
Deshmukh et al.[78] studied 50 individuals diagnosed with major depressive disorder.
Participants in the music group were made to listen to music with selected ragas while the
control group received treatment with psychotropics. Depression scores improved with
the music group comparable to the control group and these effects persisted beyond the
treatment period. Four out of the 18 participants, included in the other Indian study by
Rumball,[79] were diagnosed of depression and all four of them scored significantly
lesser depression scores on the self-rated questionnaire both during and after the sessions.
Major limitations of this study were lack of randomization and extremely small sample
size. The sessions included a short quiet prayer (5-10 songs) for 1 h with discussion of
the feeling of the song; this pattern lacked a proper standardization.
Among other Indian studies, Singh and Khess[80] (unpublished dissertation) assessed the
efficacy of music therapy as an adjuvant treatment for patients with major depressive
disorder. Participants in the music group were compared with a control group that
received treatment with psychotropics. Results showed that both the experimental and
control groups improved significantly over a period of 4 weeks and there was
significantly greater improvement in the music group than the group receiving only
psychotropic medications. Another study, Gupta and Gupta,[81] which lacks a clinical
setting and randomization, has used Indian music, i.e., listening to one raga, played on the
flute (without lyrics) for 30 min a day for 20 days and has found a significant decrease in
the scores on depression, state and trait anxiety in study participants compared with the
pre-test measurements.
Overall, studies on depression and music therapy suggest that music therapy has
significant efficacy on depression. Further, it can be recommended for treating depression
that is associated with other psychiatric disorders.
Schizophrenia and music therapy

Apart from case studies, one of the earliest studies reported on the effect of music in
schizophrenia patients is Margo et al.[82] They investigated the effect of variations of
auditory output (according to the amount of structure present and its attention
commanding properties) on duration, loudness and clarity of hallucinations. They
concluded that both stimulation per se and the amount of structure determine
hallucinatory experiences. However Pfeiffer et al.[83] was the first to study the effect of
music therapy in patients of schizophrenia. Literature search revealed that since 1987,
more than 25 studies on music therapy in schizophrenia patients have been published in
157
MedLine/PubMed indexed journals. Of which, eight are randomized control trials, five
are review cum meta-analysis and the rest non-controlled or partially controlled studies.
Summary of the non- or partially controlled studies

Most studies compared music therapy plus standard care with standard care alone, others
were pre-post designs. Gold et al.[84] compared music plus standard care, standard care
alone and no treatment groups, while one study, i.e., Leung et al.[85] studied the
comparative efficacy of karaoke singing and simple singing. Sample size ranged from
8[86] to 81.[87] Schizophrenia population included had both acute[60,88] and chronic
patients. Both, group and individual, active and receptive forms were studied. Frequency
of sessions varied from 1/week[83,88,89,90,91] to 5/week.[60] Duration of therapy lasted
from 2 weeks[60] to 6 months.[83]
Most of the studies found positive results except Pfeiffer et al.[83] which found no
improvements in psychopathology as well as recreational and social behaviors. Outcome
measures in these positive results were clinical symptoms - auditory hallucinations,[92]
positive and negative symptoms,[60,87,93] specifically negative symptoms[84,88,94,95]
and general clinical status;[89,96] and social symptoms - contact making and emotional
expression,[96] social interaction and relations,[85,90,91,94] quality of life and intimate
non-verbal communication,[89] social disability,[95] attitude toward help seeking,[86]
psychosocial orientation[88] and overall social functioning.[84] In addition, Jin[93]
found that and the mean dosage of medication required in the experimental group was
significantly less than in the control group.
Randomized control trials

Recently, a Cochrane review, Mssler et al.[97] reviewed the eight randomized controlled
trials (RCTs) done in music therapy on schizophrenia. The duration of studies ranged
from 1 to 4 months. Short-term effects were investigated in five studies and three studies
reported medium-term effects. Three studies restricted their inclusion to only
schizophrenia, one each to chronic and type II subtypes of schizophrenia. Most of the
studies were conducted on in-patients, whereas one study included both in- and out-
patients. Sample size ranged from 30 to 81. All studies compared music therapy plus
standard care with standard care alone. The setting varied from individual therapy (in one
study) to group therapy (in six studies). One other study used a combination of the group
and individual music therapy. Four studies included exclusive receptive modality, two
trials included exclusively active mode and two used both active and receptive forms.
More structured form of therapy was used in six studies (one study - exclusively fixed),
whereas in the remaining two it was more flexible and process oriented. The frequency of
sessions varied greatly from 1 to 6/week. Total number of sessions varied from 7.5 to 78.
The results showed a significant effect of music therapy on global state. Music therapy
showed moderate to large effects on general mental state, negative symptoms, depression
and anxiety. There were the difference between individual studies and they were
explained based on the number of sessions (music therapy providing more than 20
sessions showed significant effects on most mental state scores) and quality of music
therapy applied. Significant effect on social functioning has been found for high-dose
158
music therapy whereas no significant effects were found on cognitive functions for low-
dose music therapy (note: Studies examining cognitive tasks delivered less number of
sessions). Quality-of-life showed no significant effect and was addressed only in one
low-dose study.
Other review cum meta-analyses

Apart from the Cochrane review, we found four other review-cum meta-analyses on
music therapy and schizophrenia. Yi et al.[98] reviewed 11 articles, synthesized six RCTs
and concluded that short-term effect of music therapy is positive for patients with chronic
schizophrenia. They too concluded that short-term effect of music therapy (especially on
negative symptoms and general psychopathology) is positive for patients with chronic
schizophrenia. Silverman[99] conducted meta-analysis on 19 studies and indicated that
music therapy has proven efficacy on psychosis. In addition, they commented that no
differing effects of live versus recording, active versus receptive and classical versus non-
classical forms were noted. Gold et al.[58] combined all existing prospective studies and
examined the influence of study design, disorder type and number of sessions. They
found that in schizophrenia patients, music therapy when added to standard care has
significant effects on negative symptoms, depression, anxiety and global functioning.
Indian studies
Among the two published studies is Rumball,[79] which studied nine schizophrenia
patients and found that in all the nine patients energy (sluggishness) improved and this
was implicated as improvement in negative symptoms. Study by De souse and De
souse[100] is the largest randomized control trial in terms of sample size (272 chronic
schizophrenia patients). Music therapy given as an adjunct to medications found that
scores on positive and negative syndrome scales and on the anergia, activation and
depression subscales of the positive and negative syndrome scale (PANSS) improved
significantly and also were significantly better than in the control group.
Three studies were conducted at the Central Institute of Psychiatry, Ranchi on music
therapy examining various outcome factors in schizophrenia patients. Chakrabarty et al.
[3] (unpublished dissertation) divided 60 patients into two groups (experimental-
receiving music therapy, i.e., 15 alternate day sessions lasting 45 min each plus standard
care and control group-receiving standard care alone) by random sampling and found that
experimental group had significantly lower scores on thought disturbance, depression and
percentage of disability than the control group. Other two studies examined the effect of
music therapy on cognitive functions. Banerjee et al.[101] (unpublished dissertation)
studied 32 patients and found significantly better performance on reading time in Part W
and Part C of the stroop test in schizophrenia patients receiving music therapy. Recently,
Sitaram et al.[102] (unpublished dissertation) that studied 40 patients with schizophrenia
and found that the experimental group that received music therapy (3/week for 6 weeks)
showed significantly higher improvement in positive symptoms, negative symptoms,
general psychopathology scores, quality-of-life as well as performance on the trail
making (A and B) test and auditory and visual working memory.
159
Dementia and music therapy
Promising pharmacological interventions are available for the treatment of dementias, but
have a restricted ability to treat many of its features. Non-pharmacological treatments and
research into this dimension is relatively ignored. Common approach in dementia
treatment is to limit the extent and rate of progression of the pathological processes and
slow down the cognitive decline. Music therapy is one of the novel approaches proposed
for achieving such targets. Greatest advantage of music therapy is that it creates an
alternate mode of communication to patients who have limited ability to speak and
understand language.
Vink et al.,[103] a Cochrane review, analyzed 10 randomized control trials. Seven of
them were parallel and three were crossover designs. Three were receptive and
individual, whereas seven were active and group music therapy interventions. Out of the
three crossover design studies, two received receptive forms (one of them studied
preferred vs. classical music) and one received active form of music therapy. Sample size
ranged from 18 to 60 (in two studies) participants. Duration of each treatment session
was 30 min in all studies except one. Frequency of sessions varied from 1/day to 2/week.
Duration of total therapy ranged from 15 days to 6 months.
Outcome measures were very heterogeneous. Discrete measures rather than a
comprehensive set of outcomes were studied in most papers. They were aggression,
agitation (in two studies), wandering behaviors or behavioral problems in general (in
three studies); language functioning; and anxiety and depression. Only one study
investigated social, cognitive and emotional functioning together. Both individual
receptive and active group music therapy were more effective than control or no
intervention on behavioral problems; have doubtful effect on cognitive skills; and are
effective on social and emotional functioning including depression and anxiety.
What type of dementia responds well to such forms of therapy? What is the predictive
ability of age of onset of dementia in the effect of music therapy? Such queries are still
unanswered.
Indian studies
No study conducted in India has investigated the role of music therapy on dementia.
Substance use disorders and music therapy

Alcohol portrayals in music videos and listening to music and songs that refers to
substance use in one way or the other effect the substance use or seeking behavior in
patients with substance use disorders. When society mourns for rock stars, who die from
overdoses; then people especially at risk like adolescents believe all role models use
drugs and its okay to use drugs. Moreover recently, Kornreich et al.[104] has shown that
alcohol dependent patients who are completing detoxification have impaired capacity to
recognize emotions in music. Here, music rather than being a help to persons with
psychiatric disorders is being seen as a taboo. However, all is not worse for music with
respect to substance use disorders. Koordeman et al.[105] has recently concluded that on-
160
screen alcohol exposure does not affect everyone and not all media alcohol portrayal
provokes substance use. In addition, music therapy has been shown to be able to engage
patients with substance use disorders into other usual therapies used in these disorders.
[106]
Indian studies
No study is published until date from India with respect to substance use and music.
Ongoing dissertation Choudhary et al.,[107] at the Central Institute of Psychiatry, Ranchi
is investigating the effect of music therapy in patients with alcohol dependence
syndrome.
Pediatric psychiatric disorders and music therapy

As discussed earlier, there has been a lot of work on adolescent depression. The other
major disorder in the child and adolescent age group is autism and autism spectrum
disorders. Four systematic reviews are available in the literature on the effect of music
therapy on autism. Whipple[108] concluded that music therapy is effective for people
with autistic spectrum disorders and Ball[109] concluded that effects of music therapy on
autism are unknown. A more comprehensive systematic Cochrane review, Gold et al.,
[110] included three controlled studies (two crossover- and 1 parallel design). Most of the
participants included in the studies were boys and were in the age group of 2-9 years. The
duration of therapy ranged between 1 and 4 weeks. Mental retardation was mild to severe
and autism was mild to moderate in the patients. All three studies included individual
daily sessions. Two used receptive form whereas one delivered active music therapy. All
studies compared music therapy to placebo activity, which matched the music therapy
condition, but there was no music used. Outcome measures were communication skills
and behavioral problems. The results showed a significant effect of music therapy on
communication skills and only marginal effect on behavioral problems. Recently, in
another review, Simpson and Keen[111] identified 20 experimental studies. Interestingly
in contrast to Gold et al.,[110] they found that most studies used active or improvisational
music therapy technique. Outcome measures in the identified studies included
socialization in addition to communication and behavior. Overall, the conclusion was that
the evidence to generalize the finding that music therapy is effective is limited. A
proposed randomized controlled trial of improvisational music therapy in 235 children
with autism spectrum disorder, Geretsegger et al.[112] has taken up this issue of
generalizability. In addition, Lanovaz and Sladeczek[113] studied the effects of music
intensity manipulation on vocal stereotypies in children with autism and found that
although, non-contingent access to music reduced immediate vocal stereotypies, it had
only slight effects on subsequent engagement.
Among other pervasive developmental disorders, children with Rett syndrome have been
shown to benefit from music therapy in terms of indulgence in music, minute motion,
language, personal relation and sociality.[114] Other psychiatric disorders where music
therapy has been studied are attentional deficit hyperactivity disorder, learning disorder
and epilepsy. Contrasting findings are reported in patients with attention deficit
hyperactivity disorder (ADHD). Rickson[115] found that music therapy contributes to
161
reduction in a range of ADHD symptoms in the classroom setting, Pelham et al.[116] has
shown no additional effects of music on the classroom behavior and performance. In
determining the efficacy of using music as a remedial strategy to enhance the reading
skills, Register et al. (2007)[117] found that students a specific reading disability
receiving music therapy improved significantly on word decoding, word knowledge,
reading comprehension and the test total. Lin et al.[118] found that epileptiform
discharges in 18 children with epilepsy with well-controlled seizures decreased
significantly after listening to Mozart music for 8 min once a day before bedtime for 6
months.
Indian studies
Sairam[119] has designed three methods of music training for children with special
needs. Music with rapid fire orchestral rhythms has to increase the participation and
alertness and manage anger; and music without rhythms to induce relaxation; and
repeated rhythms to regulate the emotions.
Go to:
WHEN TO USE WHAT?

So far we have discussed the effect of music therapy on various psychiatric disorders.
Coming to the question of what type of music therapy to be used in a particular disorder,
we see that it is the active/improvisational form of music therapy that is predominantly
used. Gold et al.[58] has suggested that active music therapy techniques can be more
useful in severely disturbed patients and that more receptive approaches can be of better
efficacy in milder conditions. Apart from this there are no other guidelines, which suggest
the indication of other types, i.e., group versus individual etc., indication of duration and
frequency of each session and others.
Go to:
HOW DOES IT WORK?

Next question is how does music therapy work? Practice of music therapy in the modern
day is mostly based on the scientific evidences. This section would deal with the
scientific evidences that explain how music therapy works. Apart from the neuroscience
explanation (discussed earlier), there are other answers to it too.
1. The phenomenon that is able to generate tension can also assist in reducing it.[59]
2. An underlying assumption is that everyone is endowed with a basic musicality.
[120]
3. Music as a medium for emotional expression may help patients to improve their
expressive range and diminish affective flattening. Music may be used as a safe
and socially acceptable form in which they can express feelings with ease.[97]
4. Making music together is always a social endeavor, inherently connected to
forming and building social relationships and may therefore help patients to
overcome social deficits ease.[97]
162
5. Making music is in itself motivating, hence work well in those who otherwise
have little or no motivation.[121]
6. Lack of pleasure and meaningfulness in life associated with psychiatric disorders
are made to overcome through esthetic experience inherent to music therapy.[122]
7. Rather obvious, the act of playing musical instruments requires purposeful
physical movement and hence it improves psychomotor activity. Playing
instruments may improve gross and fine motor coordination in dementia patients
with motor impairments.[103]
8. Relational dimension in the pre-verbal interaction stage of parent-baby relation,
we first learn how to take pleasure in the possibilities that the world around us has
to offer-experiences of musicality. From this perspective, the role of the
therapist can be seen as neo-parental, i.e., musically nurturing the patient in order
to facilitate a similar process of discovery of self and self in relation to others.
[122] This is the rationale for using music therapy for individuals with
communication disorders, i.e., autism.[110]
9. Singing critically depends upon right-hemispheric structures; hence it can be
exploited to facilitate speech reconstruction in patients suffering from dementias,
with predominantly left-hemisphere lesions.[117]
10. In patients with dementia, singing can further help the development of
articulation, rhythm and breathe control. Musical rhythm may help them to
organize time and space.[103]
Although, music therapy based on scientific evidences is being practiced predominantly,

even today practice of music as religious healing is apparent. Indian music healing
methods especially are more based on religious healing and a perfect blend of religious
and scientific methods might create wonders for Indian form of music therapy.
Go to:
Footnotes
Source of Support: Nil
Conflict of Interest: None declared
Go to:
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PsyMot: An instrument for psychomotor

diagnosis and indications for
psychomotor therapy in child
psychiatry
Abstract
Psychomotor therapy is a movement-oriented and body-oriented therapy which resembles
dance movement psychotherapy, although some differences remain. Despite historical
differences, theoretical backgrounds as well as practical methods of both therapies
converge at large. Both fields are in need of assessment development to support diagnosis
and treatment. In this article, we present a recently developed systematic tool for
psychomotor assessment and diagnosis of children, the PsyMot. The construction of this
instrument was inspired by the International Classification of Functioning, children's
version, of the World Health Organization. The PsyMot consists of an assessment
procedure, guidelines for scoring items and a computer program for converting item
scores into scores for clusters of treatment goals. Initial studies suggest that the PsyMot
has adequate psychometric qualities, but further research is needed. Possibilities for the
use of the PsyMot in different groups are currently being explored.
Academic paper: PsyMot: An instrument for psychomotor diagnosis and indications for
psychomotor therapy in child psychiatry. Available from:
https://www.researchgate.net/publication/233143860_PsyMot_An_instrument_for_psych
omotor_diagnosis_and_indications_for_psychomotor_therapy_in_child_psychiatry
[accessed Apr 10, 2017].
170
+3
171
+3
172
Creative types are more likely to suffer mental illness, a study found. Both actress
Catherine Zeta-Jones and comedian Stephen Fry both suffer from bipolar disorder, which
is also known as manic depression
Many well-known actors, comedians and writers have spoken about their struggle with
mental illness.
Stephen Fry and Catherine Zeta-Jones both suffer from bipolar disorder, which is also
known as manic depression.
And painter Van Gogh and author Jack Kerouac were both hailed as geniuses but
displayed self-destructive behaviour.
The latest study began by looking at the genes carried by people with schizophrenia and
bipolar disorder.
The researchers then showed that healthy Icelanders who are professional actors, dancers,
musicians are more likely than others to have some of these genes.
Similarly, people from the Netherlands and Sweden were more likely to be in creative
professions if they had some of the genes.
However, farmers, salesmen, fishermen and builders had no more of the genes than
average.
In all, more than 250,000 people were studied for the research, which is published in the
journal Nature Neuroscience.
173
+3
Creative types were more likely to have the genes causing schizophrenia and bipolar
disorder than practical types. Builders, farmers, salesmen and fishermen had no more of
the genes than average (file photo)
Lead researcher, Kari Stefansson, of genetic research firm deCODE, said: We are using
the tools of modern genetics to take a systematic look at a fundamental aspect of how the
brain works.
The results should not be a surprise because to be creative you have to think differently
from the crowd.
The Reykjavik firm added that it is likely that the artistic types didnt have enough key
genes to be diagnosed with mental illness or hadnt had certain life experiences that
magnify the effects of the genes.
A previous British study found that that professional comedians have many of the
personality traits found in schizophrenia and bipolar disorder.
174
The Oxford University researchers said that making people laugh for a living may be a
form of self-medication to alleviate a low mood.
Read more: http://www.dailymail.co.uk/health/article-3115620/Creative-people-prone-

suffering-mental-illness-Actors-dancers-musicians-likely-genes-causing-schizophrenia-
bipolar-disorder.html#ixzz4dtB9rAfv
Follow us: @MailOnline on Twitter | DailyMail on Facebook
175
Ascott High School In Greater Portmore, St. Catherine Has Both Teachers and Space ,
Ready To Work With Family Doctors and Local Pharmacists To Organize and
Carry Out Directed And Monitored Movement Therapy, Be It In The Form Of
Dance , Drama or Field Activities, The School Stands Ready.
PsyMot: An instrument for psychomotor diagnosis and

indications for psychomotor therapy in child psychiatry
Abstract
Psychomotor therapy is a movement-oriented and body-oriented therapy which resembles
dance movement psychotherapy, although some differences remain. Despite historical
differences, theoretical backgrounds as well as practical methods of both therapies
converge at large. Both fields are in need of assessment development to support diagnosis
and treatment. In this article, we present a recently developed systematic tool for
psychomotor assessment and diagnosis of children, the PsyMot. The construction of this
instrument was inspired by the International Classification of Functioning, children's
version, of the World Health Organization. The PsyMot consists of an assessment
procedure, guidelines for scoring items and a computer program for converting item
scores into scores for clusters of treatment goals. Initial studies suggest that the PsyMot
has adequate psychometric qualities, but further research is needed. Possibilities for the
use of the PsyMot in different groups are currently being explored.
176
PsyMot: an instrument for psychomotor diagnosis and

indications for psychomotor therapy in child psychiatry
Claudia Emck
*
and Ruud J. Bosscher
Research Institute Move, Faculty of Human Movement Sciences,
VU University, Amsterdam
(Received 17 October 2008; final version received 9 November 2009)
Psychomotor therapy is a movement-oriented and body-oriented therapy
which resembles dance movement psychotherapy, although some differ-
ences remain. Despite historical differences, theoretical backgrounds as
well as practical methods of both therapies converge at large. Both fields
are in need of assessment development to support diagnosis and treatment.
In this article, we present a recently developed systematic tool for
psychomotor assessment and diagnosis of children, the PsyMot. The
construction of this instrument was inspired by the International
Classification of Functioning, childrens version, of the World Health
Organization. The PsyMot consists of an assessment procedure, guidelines
for scoring items and a computer program for converting item scores into
scores for clusters of treatment goals. Initial studies suggest that the
PsyMot has adequate psychometric qualities, but further research is
needed. Possibilities for the use of the PsyMot in different groups are
currently being explored.
Keywords: children; assessment; observation; diagnosis; ICF; treatment
plans; psychomotor therapy; psychomotricity
Introduction
Psychomotor therapy (PMT) for children, as it was developed in the
Netherlands, has much in common with dance movement (psycho) therapy
(DMT) as practised in the UK and US. Both make use of movement and body
experiences to stimulate psychosocial development, decrease psychological and
behavioural disturbances, relieve psychiatric symptoms or diminish the impact
of these symptoms on the functioning and participation of a particular child in
daily life (Berrol, 2006; Emck & Bosscher, 2004; Hammink, 2003; Levy, 1988;
Loman, 1998; Petzold, 1996).
Recently, Rohricht (2009) described dance movement psychotherapy and psychomotor

therapy (i.e. psychomotricity) as both belonging to the heterogeneous field of body-
oriented psychotherapy (BOP) with the unity of body and mind as an important
common conceptual ground. Other shared theoretical concepts refer to developmental
psychology, the embodied mind theory, phenomenological and neuroscientific
approaches to body experience and movement behaviour.
Furthermore, both PMT and DMT make use of the exploration of movement
177
characteristics and body experiences of the client in order to optimise the
therapeutic process (see e.g. Cruz & Berrol, 2004; Payne, 2006b; Vermeer,
Bosscher, & Broadhead, 1997).
Differences between PMT and DMT are predominantly historical in

nature. In the UK, practitioners educated as professional dancers and dance
teachers introduced body-oriented and movement-oriented therapies in mental
health institutions (Levy, 1988; Payne, 2006a). In the Netherlands, physical
education teachers were the first to offer movement and exercise programmes
to psychiatric patients, emphasising the importance of body experiences
(Vermeer et al., 1997). Although both DMT and PMT strongly rely on
movement observation in the diagnostic process, their specific methods reflect
these historical differences.
For instance, DMT uses, amongst others, Laban and Kestenberg Movement Analysis to
interpret movement behaviour (Koch, Cruz, & Goodill, 2001; Laban, 1928; Loman &
Merman, 1996). In PMT, more or less standardised movement activities which are based
on basic categories of human movement, such as walking, running, throwing and
catching, jumping and balancing, are used to evaluate performance in qualitative and
quantitative terms.
Furthermore, movement-related and sports-related individual or group activities are used

to observe behavioural characteristics which may or may not be typical for disorders in
the field of child psychiatry. Besides movement activities stemming from physical
education practice, exercises aimed at relaxation, expression, creativity and body
awareness (Brooks, 1974; Dijkstra, 2009; Feldenkrais, 1990; Gendlin, 1981; Pesso, 1973,
1988) have also been integrated into PMT for children (see e.g. Petzold &
Metzmacher, 1997).
Interestingly, comparable activities have been mentioned for DMT with children.
Besides formalised dance, improvisation, (ball)games, play, developmental movement
and a variety of props are also used (Bannerman-Haig, 2006; Erfer, 2006). Thus, although
DMT and PMT have roots in different fields of practice it seems their methods clearly
overlap.
Basic in psychomotricity is that bodily play is relevant for children, and that
movement represents meaningful behaviour that is deeply rooted in human
nature. As Sheets-Johnstone (2003, p. 413) states: .play is a complex kinetic
phenomenon demanding close attention in its own right as the developmental,
evolutionary and the experientially meaningful phenomenon that it is.
For instance, from an evolutionary point of view, pleasure and movement have
been described as closely interlinked; locomotor rotational play, like running,
leaping, rolling and cavorting, is clearly fun for human and non-human
youngsters. Additionally, from a developmental point of view, rough and
tumble play enables us to learn (about) our bodies and the bodies of others; we
178
become kinaesthetically attuned to each other (Sheets-Johnstone, 2003).
Taken together, movement and bodily experiences are important issues for developing
children and thereby worth investigating when (neuro)developmental problems
occur. Moreover, it is not surprising that motor problems in children often go
hand in hand with emotional, behavioural and pervasive developmental
problems, indicating a neurobehavioural link between psychopathology and
movement behaviour (Emck, Bosscher, Beek, & Doreleijers, 2009; Stins,
Ledebt, Emck, Van Dokkum, & Beek, 2009).
In the Netherlands, children are referred to psychiatric centres by a general
practitioner in case of serious emotional or behavioural problems.
Subsequently, a diagnostic team, often including a psychomotor therapist,
assesses diverse aspects of adaptive and maladaptive functioning and formu-
lates a treatment plan. While psychiatric and (neuro)psychological assessment
is rather standardised, the procedure of psychomotor assessment has varied to
date.
However, evidence-based practice is increasingly required, which stresses

the importance of theory-based assessment instruments, much in the same way
as mentioned for DMT by Cruz and Berrol (2004).
In this article we present a recently developed tool for psychomotor

assessment and diagnosis that is currently being implemented in clinical
practice in the Netherlands. Although research on validity and reliability is still
ongoing, we deem it interesting to share our work with colleagues in a field that
is close to psychomotricity. We will therefore describe the instrument and
illustrate its use in two children, for this purpose named Joan and Dennis. Since
our main goal is to introduce the instrument, no full details and comments on
the cases are presented
Joan is an 11-year-old girl, intellectually highly gifted, who fails to mingle with
peers. She has no friends and does not participate in games or play. Both her
parents and teacher are concerned about her social-emotional development and
consult an out-patient child psychiatric centre. The question has been raised
whether she suffers from an emotional disorder (anxiety, depression) or a pervasive
developmental disorder (Asperger)(DSM-IV; American Psychiatric Association,
1994).
Dennis is an 8-year-old boy with learning difficulties. Both at home and at school he
is hyperactive and oppositional. He quickly starts a fight with other children and hits
his mother when he has a tantrum. His single mother is unable to control him so
psychiatric day treatment was indicated. Dennis may suffer from ADHD or ODD
(DSM-IV), while a negative self-image and impaired coping behaviour may be
contributing factors to his behaviour
179
The development of the PsyMot
The PsyMot is a diagnostic tool in which the therapist makes use of two
sources of information: (a) psychomotor behaviour observation and
(b) self-reported subjective movement and body experiences (Emck,
Hammink, & Bosscher, 2007). Thereby, we aim to combine the strength of
two psychological assessment methods, i.e. the interview as an individualised
procedure that enables us to collect personal and subjective information about
the child, and the test as a sample of the childs behaviour under controlled
conditions (Cruz & Berrol, 2004; Walsh & Betz, 1990)
In line with earlier work of Hammink (2003), the International
Classification of Functioning (childrens version) of the World Health
Organization (ICF) (www3.who.int/icf) was chosen as the umbrella framework
for the construction of the PsyMot.
In clinical settings, the ICF is used for functional status assessment, goal setting,
treatment planning and monitoring, as well as for outcome measurement.
The ICF distinguishes four domains related to health and health behaviour:
(1) Body functions: physiological functions of body systems, including
psychological functions;
(2) Activities and participation: the execution of a task or action by an
individual and involvement in a life situation;
(3) Environmental factors: physical, social and attitudinal environment in
which people live and conduct their lives;
(4) Personal factors: individual characteristics such as gender, race,
education and developmental level (www3.who.int/icf).
Each ICF domain is operationalised in subdomains that include specific

aspects. For instance, the domain body functions includes the subdomains
mental functions and sensory functions and the domain activities and partici-
pation includes subdomains such as mobility and communication.
For the construction of the PsyMot, we followed the procedure as described

by Walsh and Betz (1990). We selected ICF subdomains relevant to
psychomotor diagnoses and therapy; next, we selected aspects within these
subdomains to create an item pool.
Each item was carefully defined on the basis of the official ICF definition and additional
information from several handbooks of developmental psychology and child psychiatry
(Cicchetti & Cohen, 2006; Cole & Cole, 2004; Rutter, Taylor, & Hersov, 2004). The
items were administered to a sample of children with psychiatric disorders, after
which item analysis was carried out with the help of an expert panel. This
resulted in several adjustments.
180
Finally, the complete PsyMot was administered by several therapists to children who
were referred to psychomotor therapists, which led to slight adaptations of the procedure
In line with earlier work of Hammink (2003), the International
Classification of Functioning (childrens version) of the World Health
Organization (ICF) (www3.who.int/icf) was chosen as the umbrella framework
for the construction of the PsyMot. In clinical settings, the ICF is used for
functional status assessment, goal setting, treatment planning and monitoring,
as well as for outcome measurement. The ICF distinguishes four domains
related to health and health behaviour:
(1) Body functions: physiological functions of body systems, including
psychological functions;
(2) Activities and participation: the execution of a task or action by an
individual and involvement in a life situation;
(3) Environmental factors: physical, social and attitudinal environment in
which people live and conduct their lives;
(4) Personal factors: individual characteristics such as gender, race,
education and developmental level (www3.who.int/icf).
Each ICF domain is operationalised in subdomains that include specific
aspects. For instance, the domain body functions includes the subdomains
mental functions and sensory functions and the domain activities and partici-
pation includes subdomains such as mobility and communication.
For the construction of the PsyMot, we followed the procedure as described
by Walsh and Betz (1990). We selected ICF subdomains relevant to
psychomotor diagnoses and therapy; next, we selected aspects within these
subdomains to create an item pool. Each item was carefully defined on the
basis of the official ICF definition and additional information from several
handbooks of developmental psychology and child psychiatry (Cicchetti &
Cohen, 2006; Cole & Cole, 2004; Rutter, Taylor, & Hersov, 2004). The items
were administered to a sample of children with psychiatric disorders, after
which item analysis was carried out with the help of an expert panel. This
resulted in several adjustments. Finally, the complete PsyMot was administered
by several therapists to children who were referred to psychomotor therapists,
which led to slight adaptations of the procedure.
The item list

The final item list of the PsyMot is shown in Table 1.
1
Space limitation prevents inclusion of all definitions but two examples may be
illustrative: Exploration (item 3): the disposition to act in an initiating manner, moving
towards persons or things rather than retreating or withdrawing.
In psychomotor therapy this item is evaluated by observing the way a child

(actively) explores the therapy room and its materials by moving towards objects,
and by touching, testing and trying them.
181
Joan hesitates when she is asked to explore the room. After several encouraging
interventions, she walks around, touching some materials, while she is continuously
looking at the therapist to seek approval
Table 1. The item list of the PsyMot.
Domain: functions (126) Domain: activities and participation (2763)

1 Consciousness 27 Learning movement skills
2 Orientation 28 Solving movement problems
3 Exploration 29 Undertaking movement tasks
4 Energy and drive: persistence 30 Managing level of activity
5 Impulse control 31 Managing bodily signals
6 Attention 32 Coping with emotions
7 Movement expression 33 Coping with stress
8 Movement coordination 34 Switching over to movement situations
9 Appropriateness of emotions 35 Understanding body language
10 Regulation of emotions 36 Using body language
11 Range of emotions 37 Object control
12 Insight 38 Locomotion
13 Body awareness 39 Moving around using equipment
14 Body perception 40 Body care
15 Body image 41 Getting dressed
16 Gender identity 42 Handling potential danger
17 Self image 43 Respect and warmth
18 Perceived motor competence 44 Tolerance
19 Reality testing 45 Handling feedback and criticism
20 Sensation of pain 46 Handling social cues
21 Sensory integration 47 Handling physical contact
22 Breathing 48 Trusting and helping
23 Exercise tolerance 49 Taking turns
24 Weight maintenance 50 Playing alone
25 Muscle power 51 Fantasy play
26 Flexibility 52 Onlooker play
53 Parallel play
Domain: environmental factors (64, 65) 54 Cooperative play
64 Protective factors 55 Competitive play
[description] 56 Handling play materials
65 External stressors 57 Flexibility in play behaviour
[description] 58 Winning and losing
Domain: personal factors (66, 67) 59 Handling rules
66 Internal stressors 60 Handling social space
[description] 61 Interacting with peers
67 Need for structure 62 Movement experience in school
low / medium / high 63 Movement experience in leisure time
Note: Items 163 are scored, for items 6467 the therapist provides a short description.
182
Body awareness (item 13): specific mental function related to the representation
and awareness of ones body. It also includes awareness of body boundaries, the
position of limbs and bodily sensations.
In psychomotor therapy, we focus on the subjective experience of the body; body
awareness concerns feeling, recognising and differentiating bodily sensations in
relation to emotions and feelings. For instance: Does the child have an idea where
his or her arms and legs are located and elbows, knees, heart, lungs? Is the child
able to describe bodily sensations, like heart beating, or feeling warm? Are there
any negative bodily sensations, such as having pain, being tired, feeling stiff,
tense, heavy, weak, cold, or warm? What about feelings of dissociation? Does the
child experience his or her body as belonging and pleasurable
During the exercise, Dennis can name a few body parts. The therapist then helps him
to focus on his legs. He experiences strange sensations that frighten him and he
becomes agitated
Clusters of treatment goals

In addition to the item list, the PsyMot contains seven clusters of treatment
goals for which a child may be classified on the basis of item scores. These
clusters, derived from qualitative research by Hammink (2003), are not
mutually exclusive, but present the main topics in psychomotor therapy for
children.
They include body acceptance, participation and enjoyment in

movement activities, self-perceived physical and motor competence, motor
performance, self-control, self-confidence and self-expression, and playing and
interacting with peers. Here, we will not elaborate on the various theoretical
concepts that may be related to these clusters, but instead, we provide a short
description of each cluster.
A. Body acceptance
Therapy in this cluster aims to develop a positive body experience, improve
awareness of and contact with ones own body, and reduce psychosomatic
tendencies. A main focus is to become aware of bodily feelings and sensations.
In some cases, a childs negative experiences may have hampered the
development of body awareness. In other cases, the child may misinterpret
body signals or show impaired conscious awareness of bodily feelings and
sensations. Goals such as attending to bodily sensations, perceiving and
becoming aware of bodily feelings, and finally accepting and interpreting
bodily sensations all belong to this cluster.
183
B. Participation and enjoyment
Therapy in this cluster is focussed on participating in movement activities,
reducing fear and anxiety, and stimulating feelings of safety and relaxation.
The aim is to break the chain of avoidance behaviour and fear of movement
games and play in order to offer children the possibility of acquiring positive
body and movement experiences. In conjunction with reducing bodily tension
and promoting enjoyment of movement activities, this supports the develop-
ment of adequately and positively perceived motor competence (see cluster C).
C. Perceived physical and motor competence

This cluster helps children to obtain knowledge of their physical and motor
competence, by experiencing and exercising a broad range of movement
activities, exercises, games and play. Treatment goals focus on developing an
adequate idea of ones movement skills and abilities in order to develop an
adequate body-image and self-image. Negative expectations as well as a
positive illusionary bias may be the focus of attention in this cluster.
D. Motor performance
Therapy in this cluster aims to improve gross motor skills (locomotion and
object control), to enhance spatial and body orientation as well as sensorimotor
development. These treatment goals can also be accomplished by child physical
therapists, occupational therapists and remedial (PE) teachers. However, if
impaired motor performance is associated with problems or impairments in
one of the other clusters, a psychomotor therapist is preferable for carrying out
the treatment.
E. Self-control
This cluster is designed to help children to control impulses, regulate energy,
improve concentration, tolerate frustration and to act independently and
autonomously. In this cluster the self-regulation of behaviour is most
important. The aim is to help the child to control his impulses, actions,
feelings and behaviour, and to demonstrate age-appropriate coping behaviour.
For instance, reducing conflict situations by learning to cope with success and
failure, or winning and losing, are goals within this cluster.
F. Self-confidence and self-expression

Here, goals are to act assertively, express oneself and ones emotions and act
spontaneously. Goals in this cluster are focused on helping children who tend
to internalise behaviour or who are inhibited in behaviour and movement
184
expression.
For instance, acquiring behavioural skills (like standing up for oneself and
acting self-confidently) are goals that belong to this cluster. To feel more at
ease in ones own body, to move more freely, to obtain a positive body attitude
are more specific psychomotor goals.
G. Playing and interacting with peers

Goals in this cluster focus on social behaviour, on learning to engage in
interaction and subsequently to maintain interactions and relationships with
peers and adults. The primary goal of this cluster is to develop adequate
(movement) behaviour while interacting with peers.
For example, learning how to match and mingle with other children, playing together
cooperatively, demonstrating fair play in competitive games and adopting social
perspectives while playing. Furthermore, adequate interaction with adults and behaviour
such as keeping an appropriate distance and learning to play by the rules can be
a goal in this cluster
The assessment procedure
The items of the PsyMot are scored in three semi-structured psychomotor

sessions, varying from 30 to 60 minutes per session. The elements of the session
are chosen so that each item of the item list can be observed at least two times.
For each session, the activities and verbal and nonverbal interventions are
prescribed but during the session the therapist is allowed to make adaptations
to improve the working alliance and enhance the childs commitment.
The role of the therapist is characterised by active participation, and a supportive,

encouraging and playful attitude during the movement activities. During the
body-oriented exercises, the therapist is patient in helping the child to focus on
bodily sensations, legitimates reported feelings and sets boundaries in case of
overwhelming anxiety.
Subsequently, the child is invited to report subjective experiences to which the therapist
responds empathically. Additionally, a limited amount of feedback on actual behaviour is
given in a non-intruding and non-judgmental way, and the reaction of the child is
carefully acknowledged and registered by the therapist.
In the first session, the therapist interviews the child in a semi-structured

manner. The topics of the interview are concerned with the childs own ideas of
his or her problems, past movement experiences, sports and playing with peers,
somatic complaints, body awareness, body image, self image, feelings and
185
emotions, trauma, coping and motivation.
The questions are formulated in accordance with the level of understanding of a 612-
year-old with average cognitive abilities. Therapists may rephrase the questions if
necessary.
Joan tells the therapist she is always afraid of being ridiculed during physical
education class. In the past, children from her gym club taunted her which made her
angry, but she did not stand up for herself. She felt stupid afterwards. Nowadays, she
often feels ashamed of herself and her physical appearance.
It is important to note that if the attention span of the child is limited, the
interview can be split into several parts while movement activities of the next
two sessions can be introduced in-between. The intake is used to gather
information about the child so that it can be processed and used in the
following sessions.
The second session is an individual movement observation combined with

specific topics in an interview with the child, such as self-perceived motor
competence, subjective experiences, choices and motivations.
This session consists of five elements which are fully described in the guidelines of the
PsyMot. They are summarised below:
(1) Introduction. The therapist supports and invites the child to explore the
therapy room and its materials;
(2) Free running. The child is invited to choose tempo, route, figures,
duration and stop moment;
(3) Basketball test. The child is asked to throw a basketball from five
different angles and distances and is questioned about his or her
expectations of success
(4) Ball game. The therapist throws a ball and verbally and nonverbally
stimulates and encourages the child to react to various playful actions;
(5) Free choice activity for the child, with specific prescriptions to intervene
for the therapist, such as giving the child feedback on movement
behaviour.
When the therapist throws the ball a bit faster than before, Dennis fails to catch
it. Instantly, he lashes out at the therapist and kicks a plastic cone. He then
notices the small emergency light near the door which he begins to study
obsessively.
The third session is a movement observation with a carefully selected peer,

also combined with specific topics on which the child is questioned. In this
session, bodily play and interactions with a same aged child are the topic of
interest. Preferably, the therapist asks the child to choose a peer with whom he
or she is familiar and feels at ease. If that cannot be realised, the therapist
186
carefully selects a cooperative child and provides extra time for mutual
introduction:
(1) Introduction. Additional exploration of the materials, some small

talk followed by an explanation of the rules for the interactive
games;
(2) Hindrance track. The children are asked to build together an exciting -
but safe enough - track and demonstrate their skills;
(3) Get hold of the treasure. The therapist introduces a fantasy game in
which one child will play the guard and the other child plays the
conqueror of an imaginary treasure (a gold coloured ball). Each child
plays one shift in each role;
(4) Steely Stan and Loosy Floosy. The therapist gives directives to the
children to act like a stiff (Steely Stan) or a relaxed (Loosy Floosy)
puppet and to regulate their muscle tone and breathing. In the second
part, the children are invited to place small objects on each others back
and focus on sensory awareness;
(5) Free choice activity for the children, with specific interactional
interventions by the therapist.
After playing a waiting game for several moments, Joan eventually takes the
initiative to conquer the golden ball. She circles around the guard while she
cautiously avoids bodily contact. In the end, she fails to get hold of the
treasure.
Evaluation and scoring
After the sessions, the therapist scores the item list and writes down additional
information about specific behaviour during the sessions. The therapist
evaluates problematic experiences and behaviour as seen in the sessions and
herapist needs to consider the specific item scores as well.
Dennis demonstrates impaired motor control and appears clumsy. He often

stumbles, falls and fails to catch and throw balls in an age appropriate manner.
His rigid behaviour and excessive focus on irrelevant details complicate the learning
of new motor skills. At the same time, he seems to overestimate his motor abilities
and when confronted with the resulting failure, he vents his frustration on others or
on the equipment. Cooperative play leads to conflict: Dennis is unable to adapt his
actions to others and becomes upset by physical contact that is initiated by others.
Furthermore, he gets easily lost in his frightful fantasies during games.
187
Future research and development
As the case illustrations may have demonstrated, the PsyMot is a tool that only
can be used by an experienced therapist, because it represents a judgmental
approach to assessment (Walsh & Betz, 1990). On the one hand, quantifiable
information processed by a computer is used in an objective approach; on the
other hand the information must be cognitively processed by the therapist.
Furthermore, realising a working alliance with the child within the context of
the semi-structured assessment procedure requires clinical skills that, in
general, can only be expected from an experienced therapist.
Because the PsyMot was developed for clinical use and research, validity
and reliability are important issues. We have conducted two small studies
which suggest that the psychometric qualities are fair to excellent. Nevertheless,
the reliable use of the PsyMot can be improved by therapist training.
Moreover, since the PsyMot is still lengthy and time-consuming, a short
version is in preparation. Future studies will have to show whether this
adaptation will be of acceptable psychometric quality. At present, we are
exploring its use in different populations, such as adolescents with psychiatric
disorders and children with learning problems and (mild) intellectual disability.
One of the most important future developments in our view, suggesting
large shared aspects of psychomotor and dance movement therapy, is
investigating the usefulness of (elements of) the PsyMot in DMT. At present
we are translating the assessment procedure into English. Based on the growing
interest in the evaluation of movement and body-oriented psychological
treatments (Ro
hricht, 2009) and the necessity for assessment development

(Cruz & Berrol, 2004), we are looking forward to a more extensive dialogue
188
with colleagues in the field of DMT with respect to assessment, diagnosis and
treatment plans. To paraphrase Dijkstra (2009): the different brands of body
and movement-oriented psychotherapy, whether rooted in gymnastics, sports,
dance, play or body-oriented psychology, have enough in common to justify a
common ground for the study of biopsychosocial aspects of movement and
psychotherapy in children. Therefore, clinical assessment and diagnosis in
children might be a good starting point and an outstanding opportunity for
further cooperation between dance movement and psychomotor therapists and
researchers.
Graph not download, please use links to find table in the original article.- Compilers
recommendation.
JOAN DENNIS mild moderate severe extreme max

Figure 1. Standardised cluster and domain scores of Joan and Dennis.
Note: numbers on the Y-axis represent standardised cluster and domain scores; higher
scores indicate more problematic behaviour or more impaired functioning
Because the PsyMot was developed for clinical use and research, validity
and reliability are important issues. We have conducted two small studies
which suggest that the psychometric qualities are fair to excellent. Nevertheless,
the reliable use of the PsyMot can be improved by therapist training.
Moreover, since the PsyMot is still lengthy and time-consuming, a short
version is in preparation. Future studies will have to show whether this
adaptation will be of acceptable psychometric quality. At present, we are
exploring its use in different populations, such as adolescents with psychiatric
disorders and children with learning problems and (mild) intellectual disability.
One of the most important future developments in our view, suggesting
large shared aspects of psychomotor and dance movement therapy, is
investigating the usefulness of (elements of) the PsyMot in DMT. At present
we are translating the assessment procedure into English. Based on the growing
interest in the evaluation of movement and body-oriented psychological
treatments (Rohricht, 2009) and the necessity for assessment development
(Cruz & Berrol, 2004), we are looking forward to a more extensive dialogue
with colleagues in the field of DMT with respect to assessment, diagnosis and
treatment plans.
To paraphrase Dijkstra (2009): the different brands of body

and movement-oriented psychotherapy, whether rooted in gymnastics, sports,
dance, play or body-oriented psychology, have enough in common to justify a
common ground for the study of biopsychosocial aspects of movement and
psychotherapy in children. Therefore, clinical assessment and diagnosis in
children might be a good starting point and an outstanding opportunity for
further cooperation between dance movement and psychomotor therapists and
researchers
189
Notes on contributors
Claudia Emck, Msc., is qualified as a teacher in physical education, registered
psychomotor therapist and clinical psychologist. Currently, she works as assistant
professor and researcher at the VU University of Applied Sciences Windesheim in
Zwolle, the Netherlands. She published about psychomotor therapy in general,
treatment of adolescents with psychotic disorders and psychomotor characteristics of
children with psychiatric disorders in particular.
Ruud J. Bosscher, PhD., is qualified as a teacher in physical education, and movement
scientist. Currently, he works as professor in Movement and Behavioural Interventions
at the University of Applied Sciences, Windesheim in Zwolle, and as senior lecturer and
researcher at the VU University Amsterdam, the Netherlands. He has published about
psychomotor therapy in general, qualify of life and exercise for the elderly and running
therapy with depressive patients in particular.
Note
1. Although elaboration on several concepts used in the item list would be
informative, it goes beyond the aim of this paper.
References
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disorders (4th ed.). Washington, DC: Author.
Bannerman-Haig, S. (2006). Stretching, tensing, kicking. Aspects of infantile movement
in dance movement therapy with children and adolescents in special education.
In H. Payne (Ed.), Dance movement therapy. Theory, research and practice (2nd ed.,
pp. 8799). London: Routledge.
Berrol, C.F. (2006). Neuroscience meets dance/movement therapy: mirror neurons, the
therapeutic process and empathy. The Arts in Psychotherapy, 33, 302315.
Brooks, C. (1974). Sensory awareness. New York: Viking Press.
Cicchetti, D., & Cohen, D.J. (Eds.) (2006). Developmental psychopathology. New York:
Wiley.
Cole, M., & Cole, S.R. (2004). Development of children. New York: Freeman.
Cruz, R.F., & Berrol, C.F. (2004). Dance/movement therapists in action. A working guide
to research options. Springfield: Charles C. Thomas.
Dijkstra, A. (2009). Crossing Borders: Fourth European Congress for
Psychomotricity, Amsterdam, The Netherlands, 2123 May 2008. Body,
Movement and Dance in Psychotherapy, 4, 6771.
Emck, C., & Bosscher, R.J. (2004). Psychomotorische interventies: bewegingservaring
op maat [Psychomotor interventions: Tailored movement experiences]. In G. Pool,
F. Heuvel, A. Ranchor, & R. Sanderman (Eds.), Handboek psychologische
interventies bij chronisch somatische aandoeningen [Handbook of psychological
interventions for people with chronic somatic diseases] (pp. 368386). Assen:
van Gorcum.
Emck, C., Bosscher, R., Beek, P., & Doreleijers, Th. (2009). Gross motor performance
and self-perceived motor competence in children with emotional, behavioural and
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Neurology, 51, 501517.
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Emck, C., Hammink, M.N., & Bosscher, R.J. (2007). PsyMot: Psychomotorische
diagnostiek en indicatiestelling voor kinderen van 6 tot 12 jaar [PsyMot: psychomotor
diagnosis and treatment indications for children aged six to twelve years]. Utrecht:
t Web.
Erfer, T. (2006). Moving toward cohesion: Group dance/movement therapy with
children in psychiatry. The Arts in Psychotherapy, 33, 238246.
Feldenkrais, M. (1990). Awareness through movement: Health exercises for personal
growth. San Francisco: Harper Collins.
Gendlin, E.T. (1981). Focussing (Rev. ed.). New York: Bantam Books.
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chiatrisch zorgveld [Psychomotor diagnosis in child psychiatric care]. PhD thesis.
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Source:-
Dietary Intake of Patients with Schizophrenia

Martin Strassnig, MD, Jaspreet Singh Brar, MBBS, MPH, and Rohan Ganguli, MD

Go to:
Background
Body weight variations in patients suffering from schizophrenia have been described long
before the introduction of neuroleptic medication. For example, Kraepelin noted that in as
early as 1919 that the taking of food fluctuates from complete refusal to the greatest
voracity. Sometimes, in quite short periods, very considerable differences in the body
weight are noticed1 He also argued that sometimes weight gain and remission went
hand in hand. Similarly, Jaspers, describing schizophrenia patients, noted a great
weight gain during convalescence2
The introduction of neuroleptic medication signified a quantum leap in the treatment of
psychotic states. Chlorpromazine, the first agent, was made available in 1950. Similar
agents, such as fluphenazine, perphenazine, and later haloperidol, followed. Interestingly,
though, it was soon noted that metabolic effects of some of these neuroleptics drugs were
very common. For example, Planansky in 1958 stated that it is clear that the
introduction of tranquillizing treatment on a mass scale has brought an entirely new
problem into the wards of mental hospitalsobesity on a mass scale3 Some of the
newer antipsychotics, including clozapine, olanzapine, and quetiapine, seem to have even
higher propensity to introduce clinically meaningful body weight gain than some of the
older agents.4
192
Overall, though, it may be hypothesized that an a priori increased risk of obesity seems
to be associated with schizophrenia per se as depicted by historical observations, and
such a trend is further aggravated by treatment with antipsychotics. Consistently, patients
with schizophrenia in North America tend to be overweight.5 Even though obesity in
mentally healthy Americans is increasing at a fast pace, it seems that this trend is even
more prevalent in the group of schizophrenia patients.6,7 They seem to be at even higher
risk for obesity and indeed are often obese to a considerable degree.810
Physical health risks of excess body weight are numerous and include insulin resistance,
diabetes mellitus, and hyperlipidemia. Obesity has been associated with gallbladder
disease, sleep apnea, chronic hypoxia and hypercapnia, degenerative joint disease, and
certain cancers. Obesity is an independent risk factor for death from coronary heart
disease.11 Apart from higher morbidity and mortality rates, overweight subjects are also
more likely to experience impaired quality of life.12
While variations in dietary intake are known to predict the prevalence of body weight and
thus physical morbidity and, consequently, dietary modifications and weight loss improve
physical health status,13 a possible influence of diet on mental health has been neglected.
There is some evidence that obesity indirectly contributes to psychopathology.14
16
Schizophrenia patients experience overweight as distress.17 Their a priori poor quality
of life is also significantly worsened by overweight.18
Yet, while the exact mechanisms of weight gain in schizophrenia are not known, it is
generally accepted that the above-average obesity rates in patients are a result of poor
dietary choices.19 Thus, the interesting question arises as to whether the disproportionately
high rates of obesity in patients with schizophrenia stem from a diet different to the diet
observed in the general population and, if so, what constitutes these differences.
Go to:
Dietary Intake of Patients with Schizophrenia

Surprisingly, only a few studies have so far systematically examined the diet in patients
with schizophrenia. In a nutritional assessment among people living in mental health
residential houses in Sydney, Australia, it was observed that the respondents had a
significantly higher prevalence of obesity (including abdominal obesity) than the general
population.20 Also, no subject met the recommended dietary intake for certain
standardized healthy food groups, such as fruits or vegetables.
Brown, et al., assessed the food intake of 102 subjects with schizophrenia living semi-
independently in long-term mental health housing in the UK.19 The patients' diets were
found to contain more total fat and less fiber than diets of a reference population matched
for age, gender, and social class. Intake of unsaturated fat was similar in both groups.
Notably, not a single patient met the official British recommendations for a healthy diet,
such as daily intake of five portions of fruit or vegetables.
Similarly, McCreadie et al. examined 30 patients suffering from schizophrenia living in
assisted-living facilities in Scotland for their dietary intake.21 Results were again
compared to diets of a control group matched for sex, age, smoking, and employment
193
status. Most schizophrenia patients in their sample were overweight or obese, and
saturated fat intake was higher than recommended. Conversely, patients consumed
significantly less energy, total fiber, retinol, carotene, vitamin C, vitamin E, and alcohol
than the reference population. They also consumed fewer fruits and vegetable portions.
In 2003, McCreadie, et al., conducted another similar trial, this time incorporating a
larger sample of community-dwelling people with schizophrenia.22 One-hundred and two
patients were assessed for their dietary habits (with special emphasis on fruit and
vegetable intake) and smoking behavior. Resulting cardiovascular risk factors were
estimated as well. Again, a significant number of patients (73%) were overweight. When
compared to Scottish reference intakes, male patients consumed a diet containing less
cooked green and root vegetables, fresh fruit, skimmed or semi-skimmed milk, raw
vegetables, or salad, potatoes, pasta, rice, and pulses. Female patients ate fewer potatoes,
less pasta and rice, raw vegetables or salad, and also consumed less skimmed milk
products. Regarding biochemical markers, more than half of the patients (53%) were
outside the recommend low-density lipoprotein (LDL) to high-density lipoprotein (HDL)
cholesterol ratio indicating increased saturated fat intake. There were no significant
between-group differences in plasma glucose and serum lipid levels or in body mass
index (BMI) between patients receiving long-acting intramuscular typical antipsychotic
medication with or without other antipsychotics (27%); those receiving oral typical
medication with or without atypicals (22%); and those receiving atypicals alone (43%) or
no psychiatric medication at all (6%). Forty-two percent of subjects were below the
recommended reference range for beta-carotene intake, whereas serum vitamin C content
met recommended standards. Smokers (70% of the sample) had even lower fruit and
vegetable intake than non-smokers. The authors concluded that patients made poor
dietary choices; with males especially susceptible to poor dietary patterns.
Gothelf, et al., prospectively monitored food intake and concurrent energy expenditure of
adolescent male inpatients with schizophrenia over a four-week observation period.23 A
dietitian closely monitored food intake for two consecutive days. All foods, beverages,
and snacks were weighted before and after meals. Patients were allowed to choose freely
what they wanted to eat. These authors found significantly increased caloric intake in a
subgroup treated with the atypical antipsychotic olanzapine compared to a subgroup
receiving haloperidol. The relative dietary percentages of protein, carbohydrates, and fat
did not differ. Rather, the subgroup receiving the atypical antipsychotic simply ate more
of the same foods and thus ended up with significantly higher weight gain. As a side note,
physical activity was also measured via accelerometry monitor and a heart rate monitor.
Ninety percent of subjects spent less than 10 continuous minutes a day in moderate
activity despite intensive staff efforts to promote exercise.
Our group examined a total of 146 adult community-dwelling outpatients suffering from
schizophrenia for their dietary habits.24 We compared the elicited nutritional values (i.e.,
caloric, protein, fat, and carbohydrate intake) to age- and gender-matched US population
standards obtained from the NHANES III (National Health and Nutrition Examination
Survey, Cycle 3). NHANES is a periodical public health survey that publishes thorough
estimates of the average nutritional status for the US population and subgroups.25,26 Table
1 shows our results.
194
Table 1
Dietary intake of key nutrients in schizophrenia patients and the US population*
Although not intentionally sampled, most patients in our sample were overweight or
obese. Mean body mass index was 32.8 (7.8). Mean BMI of male subjects was 30.8
(7.3), and of female subjects 35.1 (8.0).
As a group, patients ate considerably more calories derived from quantitatively higher
protein, carbohydrate, and fat intake than observed in the age- and gender-matched US
population. Yet, the relative percentages of protein, carbohydrates, and fat comprising
dietary intake were not different from the pattern observed in the general population.
Thus, our patients appeared to make dietary choices similar to subjects in the population
would make, but they simply ate more of the same food.
Go to:
Synopsis
Overall, schizophrenia patients do not appear to have decreased intake of the protein,
carbohydrates, or fat comprising the bulk of foods. Rather, their caloric intake is equal to
or higher than the pattern observed in various population samples and evidently
contributes to the consistently reported disproportionately high rates of overweight and
obesity. Patients also do not seem to prefer or crave a certain nutrient group, such as fat
or sugar, but eat more of all available food when given the opportunity.23 Yet, higher
quantitative intake does not simply translate into better food quality. Several studies point
to decreased intake of healthful food, such as fruits and vegetables, which carry
important micronutrients, such as vitamins and minerals. Whereas it has been shown that
vitamin C intake was adequate in a sub-sample of schizophrenia patients, they lacked
dietary beta-carotene at the same time.22 It may be hypothesized that the overall increased
dietary intake may make up for some deficits associated with poor dietary quality, but
micronutrient deficits may still be expected.
From a physical health perspective, the observed pattern of above-average caloric intake
from a diet rich in saturated fat and sugar seems worrisome. Health burdens of such a
constellation are apparent. High fat intake per se, for example, has been linked to a
variety of medical problems such as coronary artery disease, hypertension, and cancer.27 It
may also predispose schizophrenia patients to premature death from complications of
these disorders.28 They already have a decreased life expectancy,29 and the overtly high
total fat intake together with a pattern of low fruit and vegetable consumption may only
accelerate this trend.
195
From the mental health perspective, the patients' subjective assessment of quality of life
is considered to be a critical outcome variable in the care of individuals with
schizophrenia.30 Patients already suffer from low quality of life inherent to the chronic
nature of their illness.31 Overweight only further impairs quality of life.17 Distress related
to high body weight is a modifiable factor, and the quality of life of schizophrenic
patients can be improved substantially by proper weight management, apart from obvious
advantages for physical health.15
Fortunately, excess body weight is a modifiable risk factor. While weight gain is
undoubtedly a complex occurrence and many factors, including use of antipsychotic
medication, are involved, the main contributors to the currently observed public health
obesity crisis are easily sidelined. The ongoing obesity epidemic is primarily fueled by
increased per capita caloric consumption and larger portion sizes, along with a lack of
adequate physical exertion.32
In the clinical care of schizophrenia patients, however, body weight management has not
been a primary concern. Usually, overweight becomes the focus of attention only after
related medical comorbidities occur. Such situations, though, may be easily avoided.
Contrary to popular belief, most schizophrenia patients seem to be well aware of their
weight status and are willing to lose weight, but need proper guidance to do so.33Several
structured weight loss programs tailored to the needs of patients with schizophrenia have
been developed.34,35 In fact, clinically meaningful reversal of weight gain while patients
were still receiving antipsychotic medication has been reported. For example, O'Keefe, et
al., showed successful weight control and, in several instances, weight loss through
simple behavioral interventions among patients treated with neuroleptics.36 Other more
radical and invasive procedures have also been suggested for morbidly obese patients
with schizophrenia.37 These authors report excellent results from a small case series of
schizophrenia patients refractory to conservative weight loss methods who underwent
bariatric surgery and showed very similar rates of weight loss to a control group of
mentally healthy yet equally obese individuals.
Additionally, schizophrenic patients tend to be sedentary,23 and encouragement to engage
in physical activity seems to be a largely neglected intervention.38 Just as for mentally
healthy individuals, a combination of dieting and exercise seems the most appropriate
way to achieve long-term weight loss.39 Along those lines, Menza, et al., reported results
from a 52-week-long prospective, controlled study with subjects suffering from
schizophrenia.40 The authors employed a multimodal weight loss program that included
both exercise and nutrition interventions and a behavioral therapy approach. Subjects
participating in this program experienced significant weight loss and improvement in
several associated health parameters (e.g., blood pressure and hemoglobin A1c levels),
whereas a control group receiving no such intervention did not show these positive
changes. Overall, increasing awareness in the field of schizophrenia care regarding the
possibility to change diet and lifestyle factors is but a starting point to improve patient
care, and ultimately, to prevent associated serious medical comorbidities.
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pyramid. J Am Diet Assoc. 2004;104(7):11417. [PubMed]
33. Strassnig M, Brar JS, Ganguli R. Self-reported body weight status and dieting
practices in community-dwelling patients with schizophrenia. Schizophr Res. [in
press] [PubMed]
34. Ganguli R, Pandina G, Turkoz I, et al. The effectiveness of behavioural treatment for
weight loss in patients with schizophrenia. Presented at the 43rd Annual Meeting of the
New Clinical Drug Evaluation Unit (NCDEU); Boca Raton, FL, 2003.
35. Vreeland B, Minsky S, Menza M, et al. A program for managing weight gain
associated with atypical antipsychotics. Psychiatr Serv. 2003;54(8):11557. [PubMed]
36. O'Keefe CD, Noordsy DL, Liss TB, Weiss H. Reversal of antipsychotic-associated
weight gain. J Clin Psychiatry. 2003;64(8):90712. [PubMed]
37. Hamoui N, Kingsbury S, Anthone GJ, Crookes PF. Surgical treatment of morbid
obesity in schizophrenic patients. Obes Surg. 2004;14(3):34952. [PubMed]
38. Callaghan P. Exercise: A neglected intervention in mental health care? J Psychiatr
Ment Health Nurs. 2004;11(4):47683. [PubMed]
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J Psychiatr Res. 2013 Feb;47(2):197-207. doi: 10.1016/j.jpsychires.2012.10.005. Epub 2012 Nov 12.
The dietary pattern of patients with schizophrenia: a

systematic review.
Dipasquale S1, Pariante CM, Dazzan P, Aguglia E, McGuire P, Mondelli V.
Author information
Abstract
OBJECTIVE:
People with schizophrenia show a high incidence of metabolic syndrome, which is associated with a
high mortality from cardiovascular disease. The aetiology of the metabolic syndrome in schizophrenia
is multi-factorial and may involve antipsychotic treatment, high levels of stress and unhealthy
lifestyle, such as poor diet. As a poor diet can predispose to the development of metabolic
abnormalities, the aims of this review are to clarify: 1) the dietary patterns of patients with
schizophrenia, 2) the association of these dietary patterns with a worse metabolic profile, and 3) the
possible factors influencing these dietary patterns.
METHODS:
A search was conducted on Pubmed, The Cochrane Library, Scopus, Embase, Ovid, Psychoinfo and
ISI web of Knowledge from 1950 to the 1st of November 2011. 783 articles were found through the
investigation of such databases. After title, abstract or full-text reading and applying exclusion criteria
we reviewed 31 studies on dietary patterns and their effects on metabolic parameters in schizophrenia.
RESULTS:
Patients with schizophrenia have a poor diet, mainly characterized by a high intake of saturated fat and
a low consumption of fibre and fruit. Such diet is more likely to increase the risk to develop metabolic
abnormalities. Data about possible causes of poor diet in schizophrenia are still few and inconsistent.
CONCLUSION:
Subjects with schizophrenia show a poor diet that partly accounts for their higher incidence of
metabolic abnormalities. Further studies are needed to clarify the causes of poor diet and the role of
dietary intervention to improve their physical health.
Copyright 2012 Elsevier Ltd. All rights reserved.
199
Metabolic syndrome in bipolar disorder and schizophrenia:

dietary and lifestyle factors compared to the general
population.
Bly MJ1, Taylor SF, Dalack G, Pop-Busui R, Burghardt KJ, Evans SJ, McInnis MI, Grove
TB, Brook RD, Zllner SK, Ellingrod VL.
Author information
Abstract
OBJECTIVE:
Since a poor diet is often cited as a contributor to metabolic syndrome for subjects diagnosed with
bipolar disorder and schizophrenia, we sought to examine dietary intake, cigarette smoking, and
physical activity in these populations and compare them with those for the general population.
METHODS:
Individuals diagnosed with bipolar disorder (n = 116) and schizophrenia (n = 143) were assessed for
dietary intake, lifestyle habits, and metabolic syndrome and compared to age-, gender-, and race-
matched subjects from the National Health and Nutrition Examination Survey (NHANES) 1999-2000.
Additionally, matched subgroups within the patient populations were compared to elicit any
differences.
RESULTS:
As expected, the metabolic syndrome rate was higher in the samples with bipolar disorder (33%) and
schizophrenia (47%) compared to matched NHANES controls (17% and 11%, respectively), and not
different between the patient groups. Surprisingly, both subjects with bipolar disorder and those with
schizophrenia consumed fewer total calories, carbohydrates and fats, as well as more fiber (p < 0.03),
compared to NHANES controls. No dietary or activity differences between patient participants with
and without metabolic syndrome were found. Subjects with schizophrenia had significantly lower total
and low-density cholesterol levels (p < 0.0001) compared to NHANES controls. Subjects with bipolar
disorder smoked less (p = 0.001), exercised more (p = 0.004), and had lower body mass indexes
(p = 0.009) compared to subjects with schizophrenia.
CONCLUSIONS:
Counter to predictions, few dietary differences could be discerned between schizophrenia, bipolar
disorder, and NHANES control groups. The subjects with bipolar disorder exhibited healthier
behaviors than the patients with schizophrenia. Additional research regarding metabolic syndrome
mechanisms, focusing on non-dietary contributions, is needed.
200
2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
KEYWORDS:
atypical antipsychotics; bipolar disorder; dietary intake; metabolic syndrome; schizophrenia
Comment in
Relationship between metabolic syndrome and psychiatric disorders in patients with bipolar
disorder or schizophrenia. [Bipolar Disord. 2015]
Format: Abstract
Send to
J Psychiatr Res. 2013 Feb;47(2):197-207. doi: 10.1016/j.jpsychires.2012.10.005. Epub 2012 Nov 12.
The dietary pattern of patients with schizophrenia: a systematic review.

Dipasquale S1, Pariante CM, Dazzan P, Aguglia E, McGuire P, Mondelli V.
Author information
Abstract
OBJECTIVE:
People with schizophrenia show a high incidence of metabolic syndrome, which is associated with a
high mortality from cardiovascular disease. The aetiology of the metabolic syndrome in schizophrenia
is multi-factorial and may involve antipsychotic treatment, high levels of stress and unhealthy
lifestyle, such as poor diet. As a poor diet can predispose to the development of metabolic
abnormalities, the aims of this review are to clarify: 1) the dietary patterns of patients with
schizophrenia, 2) the association of these dietary patterns with a worse metabolic profile, and 3) the
possible factors influencing these dietary patterns.
METHODS:
A search was conducted on Pubmed, The Cochrane Library, Scopus, Embase, Ovid, Psychoinfo and
ISI web of Knowledge from 1950 to the 1st of November 2011. 783 articles were found through the
investigation of such databases. After title, abstract or full-text reading and applying exclusion criteria
we reviewed 31 studies on dietary patterns and their effects on metabolic parameters in schizophrenia.
RESULTS:
Patients with schizophrenia have a poor diet, mainly characterized by a high intake of saturated fat and
a low consumption of fibre and fruit. Such diet is more likely to increase the risk to develop metabolic
abnormalities. Data about possible causes of poor diet in schizophrenia are still few and inconsistent.
201
CONCLUSION:
Subjects with schizophrenia show a poor diet that partly accounts for their higher incidence of
metabolic abnormalities. Further studies are needed to clarify the causes of poor diet and the role of
dietary intervention to improve their physical health.
Copyright 2012 Elsevier Ltd. All rights reserved.
J Med Food. 2014 Jan;17(1):43-56. doi: 10.1089/jmf.2013.3049.
The traditional Korean dietary pattern is associated with decreased risk

of metabolic syndrome: findings from the Korean National Health
and Nutrition Examination Survey, 1998-2009.
Lee KW1, Cho MS.
Author information
Abstract
The traditional Korean diet has several healthy components, including abundant vegetables, fermented
foods, a variety of foodstuffs, and a balance of animal and vegetable food intake. Although the
traditional Korean diet has many healthy components, few studies have been conducted on the health
advantages of the Korean dietary pattern. This study is intended to clarify the relationship between
Korean dietary patterns and chronic diseases using the Integrated Korean Dietary Pattern Score (I-
KDPS). I-KDPS is an index for measuring Korean dietary patterns based on traditional Korean meals
and reflects the complex and multifaceted characteristics of Korean food culture. I-KDPS is composed
of seven items to measure the level of balance and adequacy of Korean food consumption, with a
maximum score of 60. When I-KDPS was applied to the Korean National Health and Nutrition
Examination Survey (1998-2009), a nationwide survey, I-KDPS was closely related to the risk of
metabolic syndrome. Even though there were a few differences among the years surveyed, the risk of
metabolic syndrome, obesity, hypertension, and hypertriglyceridemia significantly decreased as I-
KDPS increased. These results indicate that risk of diseases, including metabolic syndrome, decreases
in individuals adhering to traditional Korean dietary patterns in adequate levels and those who eat a
balanced diet. The result of this study shows that the traditional Korean table setting, which comprises
side dishes, including seasoned vegetables, grilled dishes, and fermented products with cooked rice
(bap), soup (guk), and kimchi, contains traits that help prevent metabolic syndrome. I-KDPS coupled
with the basic study of the healthfulness of the Korean dietary lifestyle is expected to help establish a
foundation for continuous development of health promoting Korean foods and dietary culture.
202
203
Custom made, purpose driven designed probotics On A Jamaican Table -These
Are Not Usually Made In Jamaica However The Average
Jamaican Pharmacists or Medical Doctor Can If Need Be Make
Them With Great Ease.
Grains, vegetables, and fish dietary pattern is inversely

associated with the risk of metabolic syndrome in South
korean adults.
Kim J1, Jo I.
204
Author information
Abstract
BACKGROUND:
Dietary patterns are critical in the prevention and management of chronic diseases.
OBJECTIVE:
We examined the association between habitual dietary patterns and the risk of metabolic syndrome in
South Korean adults.
DESIGN:
The study sample was composed of 9,850 Korean adults (aged 19 years) who participated in the
second and third Korean National Health and Nutrition Examination Survey. Dietary data were
assessed by the 24-hour recall method. Metabolic syndrome was defined by the joint of interim
statement of the International Diabetes Federation and the American Heart Association/National
Heart, Lung, and Blood Institute.
RESULTS:
Four dietary patterns were derived using factor analysis (white rice and kimchi pattern; meat and
alcohol pattern; high fat, sweets, and coffee pattern; and grains, vegetables, and fish pattern). Each
dietary pattern explained 8.6%, 6.7%, 5.7%, and 5.7% of the variation in food intakes, respectively.
The meat and alcohol pattern was adversely associated with hypertriglyceridemia (P for trend 0.01)
and elevated blood pressure (P for trend 0.01) after adjustments for potential risk factors of metabolic
syndrome such as age, sex, body mass index, energy intake, alcohol intake, smoking status, and
physical activity. In contrast, the grains, vegetables, and fish pattern was associated with lower risk of
hypertriglyceridemia (P for trend 0.0002) and was also inversely associated with the risk of metabolic
syndrome after adjusting for risk factors of the metabolic syndrome (P for trend 0.02).
CONCLUSIONS:
Our study suggests that a specific Korean dietary pattern that includes grains, vegetables, and fish may
be associated with lower risk of metabolic syndrome in South Korean adults.
Copyright 2011 American Dietetic Association. Published by Elsevier Inc. All rights reserved.
How to Use Diet As a Treatment for Schizophrenia
205
by ELIZA MARTINEZ Last Updated: Jul 23, 2015
Schizophrenia is characterized by paranoia, delusions, hallucinations, disordered

thinking, social withdrawal and cognition problems, according to the National Institute of
Mental Health. If you or someone you love suffers from schizophrenia, you know first-
hand how this serious mental illness can affect life. Typically, schizophrenia is treated
through the use of medications and psychotherapy. However, people with the condition
have found relief from many of their symptoms through changing their diet. Talk with
your psychiatrist if you would like to try treating your schizophrenia with diet alterations.
Step 1
Reduce sugar, carbohydrate and caffeine intake. This will help your blood sugar stay
balanced. Many drugs prescribed to treat schizophrenia can mess with your blood sugar,
so avoiding excess stimulants can help keep it at a desired level. A study published by
Nutrition and Metabolism has indicated an alleviation of many symptoms associated with
schizophrenia by following a low-carbohydrate diet. Foods to avoid include candy, soda,
bread, crackers, some fruits and vegetables and coffee.
Step 2
206
Add foods containing essential fatty acids. According to FoodForTheBrain.org, people
with schizophrenia have reduced amounts of these fatty acids in their brains, so adding
foods that contain them can help treat the illness. Good sources include fish, nuts and
olive oil. Incorporating them into the diet can help you feel better and provide more
control over your schizophrenia.
Step 3
Increase your antioxidant levels. Antioxidants are responsible for counteracting oxidation
in your body that can cause other health concerns, such as cancer. Specifically, people
with schizophrenia experience increased oxidation in the brain. Adding foods that contain
vitamins A, C and E can help treat this issue. In addition, avoiding burnt and fried foods
reduces the amount of oxidation likely to occur in your brain. Antioxidant foods include
beans, berries, apples, plums and pecans.
Step 4
Take a daily multivitamin. Niacin deficiency can produce thought disorders,

hallucinations and depression, so taking a megadose of niacin daily can help you reduce
these symptoms associated with your schizophrenia. Your doctor will work with you on
how much you should get daily. In addition, adequate intake of B vitamins and folic acid
is responsible for maintaining the chemical balance in your brain. Increasing your intake
can help you achieve this balance, thereby alleviating the severity of your schizophrenia
symptoms. Finally, many mental illnesses result in a zinc deficiency, so your doctor may
recommend taking a multivitamin containing zinc. In some cases, you may have to take
these nutrients separately in supplement form because a traditional multivitamin might
not have the high levels of the vitamins that you need.
Step 5
Cut gluten out of your diet. Mental illness often produces a sensitivity to gluten, which
can result in many of the symptoms of schizophrenia. Eliminating gluten sources from
your diet will reduce these issues. Gluten is present in foods that contain wheat, rye,
barley and their byproducts. Read labels to be sure you are completely avoiding foods
that aren't gluten-free. Common foods you will need to avoid include bread, crackers,
many cereals, soy sauce, baked goods, beer and some other alcoholic drinks.
Things You'll Need
Foods with essential fatty acids
207
Gluten-free foods
Antioxidant-rich foods
Multivitamin
Source:- http://www.livestrong.com/article/248779-how-to-use-diet-as-a-treatment-for-schizophrenia/
About schizophrenia and psychosis

About one in a hundred people have schizophrenia and can have a variety of positive
symptoms, such as hallucinations, delusions or disordered speech/behaviour, and negative
symptoms such as problems with fluency of language and thoughts or with expression of
emotions.
As is the case with most mental illness, the cause of schizophrenia is not known. The
conventional treatment for schizophrenia is usually long-term treatment with antipsychotic
medication. A nutritional approach works alongside conventional treatment and may improve
both positive and negative symptoms, and also reduce the side-effects of medication.
Below is an outline of nutrition approaches that may be relevant:
o Correcting blood sugar problems made worse by excess stimulant and drug
use
o Addressing essential fat imbalances
o Increasing antioxidants; niacin (Vitamin B3) therapy
o Addressing methylation problems helped by B12 and folic acid
o Investigating pyroluria and the need for zinc and identifying any food
allergies
WHAT IS SCHIZOPHRENIA?
Schizophrenia is a loaded word, feared by patient and public alike. It conjures up images of
dangerous and crazy people. In truth, most members of the public have no real idea what is
meant by this word, often believing that sufferers have split personalities, like Jekyll and
Hyde. About one in a hundred people have schizophrenia and can have a variety of symptoms
which are known as positive symptoms and negative symptoms.
Positive symptoms include hallucinations, delusions, disorganised speech, disorganised
behaviour and inappropriate emotions.
Negative symptoms include alogia (problem with fluency of language and thoughts),
affective blunting (problems with expression of emotions and feelings), anhedonia (lack of
ability to experience pleasure), avolition (lack of ability to start things and follow through),
and attentional impairment (lack of ability to focus attention)
A person diagnosed with schizophrenia may have any or all of these, but at a level of severity
that makes them either unable to cope or others unable to cope with them.
208
Most of us have, at some time or other, experienced some level of psychosis, a temporary
losing touch with reality as we collectively know it. The normal person recovering from the
delusions brought on by a high fever can breathe a great sigh of relief at the thought that his
experience was only temporary. The person under the influence of the hallucinogenic drug
LSD can at least rely on the clock, since the drug-induced psychosis will wear off with time.
Some peoples experience of so-called schizophrenia can be likened to a nightmare state from
which they may awaken intermittently. For some, schizophrenia is like living in a nonstop
nightmare.
WHAT CAUSES SCHIZOPHRENIA?
As is the case with most mental illness, the cause of schizophrenia is not known. There are a
number of theories relating to neurotransmitter imbalances and functional magnetic
resonance imaging (fMRI) studies have shown a broad array of brain abnormalities.
The conventional treatment for schizophrenia is usually long-term treatment with
antipsychotic medication. While this can be quite effective for the positive symptoms, there is
often little improvement in negative symptoms meaning that the sufferer may have a poor
quality of life. On top of that, side-effects of medication can be considerable in some cases,
and the newer antipsychotics (known as atypical) can cause rapid and considerable weight
gain and increase the risk for diabetes and metabolic syndrome.
A nutritional approach works alongside conventional treatment and may improve both
positive and negative symptoms, and also reduce the side-effects of medication. In some
cases, the improvements are so great that the patients doctor may take the decision to cut
down or discontinue medication.
At the Brain Bio Centre, the best results weve seen in helping those with schizophrenia or
other psychotic disorders are achieved by investigating a number of possible avenues. These
include:
Blood sugar problems made worse by excess stimulant and drug use;
Essential fat imbalances;
Too many oxidants and not enough antioxidants;
Niacin (Vitamin B3) therapy;
Methylation problems helped by B12 and folic acid;
Pyroluria and the need for zinc;
Food allergies.
Quite apart from these nutritional factors, having good psychological support and a stable
home environment make a major impact upon those with mental health problems.
To find out more about these factors read on, or click on our action plan to overcome
schizophrenia.
DIET AND NUTRITION...WHAT WORKS
Balance your blood sugar and avoid stimulants
Your intake of sugar, refined carbohydrates, caffeine, alcohol and cigarettes, as well as
stimulant drugs, all affect the ability to keep ones blood sugar level balanced. On top of this
common antipsychotic medication may also further disturb blood sugar control. Stimulant
drugs, from amphetamines to cocaine, can induce schizophrenia. The incidence of blood
sugar problems and diabetes is also much higher in those with schizophrenia.
Therefore it is strongly advisable to reduce, as much as possible, your intake of sugar, refined
carbohydrates, caffeine and stimulant drugs and eat a low glycemic load diet.
209
Increase essential fats
We build our brain from specialised essential fats. Of course, this isnt a static process. We
are always building membranes, then breaking them down, and building new ones. The
breaking down, or stripping of essential fats from brain, membranes, is done by an enzyme
called phospholipase A2 (PLA2). This is often overactive in people with schizophrenia, and
this leads to a greater need for these fats, which are quickly lost from the brain. This explains
earlier findings that schizophrenic patients have much lower levels of fatty acids in the
frontal cortex of the brain. So, whats the evidence that increasing a persons intakes of
essential fats makes a difference?
The World Health Organization conducted a survey of the incidence and outcome of
schizophrenia in eight countries in Africa, Asia, Europe and the Americas. They found that
while the incidence was surprisingly similar in all countries, the outcomes were very
different. In some countries, schizophrenia seemed to be a relatively mild and self-limiting
disease, whereas in others it was a severe and life-long condition. Of all the factors
considered which might explain this, by far the strongest correlation was with the fat content
of the diet. Those countries with a high intake of essential fats from fish and vegetables, as
opposed to meat, had much less severe outcomes.
Dr Iain Glen from the mental health department of Aberdeen University found that 80 per
cent of schizophrenics are essential fat deficient. He gave 50 patients essential fat
supplements and reported a dramatic response. A larger placebo-controlled, crossover, 10-
month study of the effects of EFA supplementation in schizophrenics, including supplements
of zinc, B6, B3 and vitamin C with omega-6 fats, also produced significant improvements in
schizophrenic symptoms. Two trials giving omega 3 fish oil high in EPA produced significant
improvement. But not all results are positive. A trial using only omega-3 fats versus placebo
found no significant improvement in mental health.
Of even greater promise are the results of a study into the preventative benefits of omega-3.
This study, published in the British Journal of Psychiatry in 2010, identified 81 young adults
aged 13 to 25 years with ultra-high risk of developing psychosis. They were given (in a
randomised, double-blind fashion) 1.2g of omega-3 oil or placebo for a 12 week period and
then monitored for a further 40 weeks, so the total study period was 1 year. At the end of the
study only 5% of those taking the omega-3, compared with 28% of those taking placebo had
developed psychosis. And of the 5% taking the omega-3 who did develop psychosis, they had
significantly reduced symptoms (both positive and negative) and improved functioning.
Wheres the evidence? Search our evidence database and enter omegas' and schizophrenia'
into the search field for a summary of studies that demonstrate the effect of essential fats on
schizophrenia.
Side effects? Sometimes, when starting omega-3 fish oil supplements, you can experience
loose stools or fish-tasting burps. If this happens just try a lower dose.
Contraindications with medication? You shouldnt take high dose omega-3 oils if you are
also taking blood-thinning medication.
See our action plan for recommendations.
Up antioxidants
Theres another part to the essential fat story. These fats are also prone to destruction in the
brain, and in the diet, by oxidants. Indeed, there is evidence of more oxidation in the frontal
cortex of those with schizophrenia. Therefore, as well as increasing the intake of essential
fats, it makes sense to follow a diet (and lifestyle) that minimises oxidants from fried or burnt
food and maximises intake of antioxidant nutrients such as vitamins A, C and E. These alone
have been shown to help. Vitamin C is also an anti-stress vitamin and may counter too much
210
adrenalin, which is often found in those diagnosed with schizophrenia. Smoking is both a
source of oxidants and destroys vitamin C.
Vitamin C deficiency is also far more common than realised in people with mental health
problems, often because they dont look after themselves properly and eat poorly. Professor
Derri Shtasel from the department of psychiatry at the University of Pennsylvania, School of
Medicine in Philadelphia described a case of a woman who was confused and hearing voices,
as well as having physical symptoms. She was tested for vitamin C status and found to be
very deficient. After being given vitamin C she had fewer hallucinations, her speech
improved and she became more motivated and sociable. Vitamin C has been shown to reduce
the symptoms of schizophrenia in research trials, and a number of studies have shown that
people diagnosed with mental illness may have much greater requirements for this vitamin
often ten times higher and are frequently deficient.
Wheres the evidence? Search our evidence database and enter antioxidants' and
schizophrenia' into the search field for a summary of studies that demonstrate the effect of
antioxidants on schizophrenia.
Side effects? Excessive vitamin C can cause loose stools in some individuals. If this happens,
reduce the dose to a tolerable level.
Contraindications with medication? None known.
See action plan for our recommendations.
Consider niacin
One of the classic vitamin deficiency diseases is pellagra Niacin (vitamin B3) deficiency.
The classic symptoms of this condition are the '3 Ds' dermatitis, diarrhoea and dementia. A
more extensive list of symptoms might include headaches, sleep disturbance, hallucinations,
thought disorder, anxiety and depression.
If you have these symptoms you may need a lot more niacin than the basic RDA, sometimes
as much as 2,000mg or 100 times the RDA. We call this vitamin dependency, but of course
we are all vitamin dependent. Its just that some people need more, perhaps for genetic
reasons, than others.
The use of megadoses of niacin was first tried by Drs Humphrey Osmond and Abram
Hoffer in 1951. So impressed were they with the results in acute schizophrenics that, in 1953,
they ran the first double-blind therapeutic trials in the history of psychiatry. Their first two
trials showed significant improvement giving at least 3gs (3,000mg) a day, compared to
placebos. They also found that chronic schizophrenics, not first-time sufferers but long-term
inpatients, showed little improvement. The results of six double blind controlled trials
showed that the natural recovery rate was doubled. Later they found that even chronic
patients, treated for several years with niacin in combination with other nutrients, often
recovered.
Hoffers discovery was, however, side-lined partly due to some studies which gave niacin to
long-term schizophrenic patients who had been on medication for several years and failed to
respond to niacin in the short-term.
Since then, Dr Hoffer published ten-year follow-ups on schizophrenics treated with niacin,
compared to those not treated with niacin. In the niacin patients there were substantially
fewer admissions, days in hospital and suicides. He continued to treat acute schizophrenics
with niacin, plus other nutrients, including vitamin C, folic acid and essential fats, and
reported a high recovery rate in acute schizophrenics who follow his nutritional programme.
Over his long career Dr Hoffer recorded 4,000 cases and published double-blind trials. He
was convinced that his approach was a major breakthrough in the treatment of mental illness.
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Just how niacin works is still a bit of a mystery. Knowing that people with schizophrenia had
hallucinations, Dr Hoffers explanation was that niacin stops the brain from producing
adrenochrome from adrenalin, a chemical known to induce hallucinations. Working together
with vitamin B12 and folic acid, niacin helps keep adrenalin and noradrenalin levels in
balance, and prevent the abnormal production of adrenochrome in the brain. These nutrients
are methyl donors and acceptors, and act intelligently in the brain to keep everything in
check. Once again, some people may simply need more to stay healthy.
Niacin, through its flushing action improves oxygen supply to the brain. Niacin is also
needed for the brain to make use of essential fats. The happy neurotransmitter serotonin also
needs niacin. Serotonin is made from the amino acid tryptophan, but only in the presence of
enough niacin. So there are many possible ways this vitamin could affect brain function.
Wheres the evidence? Search our evidence database for studies on niacin.
Niacin comes in different forms. Niacin (formerly known as nicotinic acid) causes a harmless
blushing sensation, accompanied with an increase in skin temperature and slight itching. This
effect can be quite severe, and lasts for up to 30 minutes. However, if 500mg or 1,000mg of
niacin are taken twice a day at regular intervals, the blushing stops.
Some supplement companies produce a no-flush niacin by binding niacin with inositol. This
works, so it's probably the best form, but it is more expensive. Niacin also comes in the form
of niacinamide, which doesnt cause blushing either. It has to be said, however, that both of
these forms appear to be slightly less effective than niacin. This may be because the blushing
effect of niacin improves blood flow, and hence nutrient supply to the brain.
Contraindications with medication? None known.
Side effects? The amount of niacin thats needed is around 1 to 6g a day. A minimum
therapeutic level is 1g a day. These levels are in the order of 100 times the RDA. Levels of
niacin much higher than these, particularly in sustained-release tablets, can be liver toxic. Out
of perhaps 100,000 people taking megadoses of niacin at levels of several grams over the past
40 years, there have been two deaths due to liver failure. In a third case, jaundice resulted
from a slow-release preparation. When the same patient was placed back on standard niacin,
he no longer got jaundice. In any event, anything over 1g is best taken under the supervision
of a qualified practitioner. If you become nauseated, that is an indication to stop
supplementation and resume three days later, with a lower amount. If you have a history of
liver problems, you should have regular monitoring of liver enzymes.
Methylation, B12, folic acid and B6
Methylation is a critical process in the brain that helps maintain the right chemical balance.
An indicator of faulty methylation is having a high level of a toxic amino acid in the blood
called homocysteine. The body makes homocysteine from dietary protein and, provided you
are getting enough of certain vitamins1, especially folic acid, B12 and B6, homocysteine
levels decrease. Many people with schizophrenia, especially young males, tend to have a high
level of homocysteine, despite no obvious dietary lack of these vitamins. High levels of
homocysteine and low blood levels of folic acid have been reported by many research
groups. These unusually high levels dont appear to relate to diet or lifestyle factors, such as
smoking. People diagnosed with schizophrenia are more likely to have inherited a genetic
variation of a key homocysteine lowering enzyme, which may make them need more of these
and other nutrients.
Research at Kings College Hospital psychiatry department in London has found high doses
of folic acid to be highly effective in schizophrenic patients. They used 15mg a day, which is
212
75 times the RDA! Folic acid is not toxic at this level. We recommend starting with 1mg a
day, increasing the dose only under supervision of your health care provider.
Vitamin B12, which like folic acid is involved in methylation, has also been shown to help
schizophrenic patients. Vitamin B12 is difficult to absorb, especially in large amounts, and
some doctors have reported good results giving weekly, or twice-weekly, injections of 1mg of
vitamin B12. A form of B12, methyl B12, is more easily absorbed, and B12 can be taken in
sub-lingual form which is even better absorbed.
Supplementing a combination of folic acid, B12, B6, along with a methyl donor called TMG,
the mineral zinc and the antioxidant N-Acetyl-Cysteine has been shown to most effective in
improving mental health, and lowering the homocysteine levels of schizophrenia patients
with high homocysteine levels.
Wheres the evidence? Search our evidence database and enter folate' or 'folic acid' and
folic acid on schizophrenia.
Side effects? Folic acid supplementation can mask the symptoms of an underlying B12
deficiency, so we dont recommend supplementing folic acid on its own.
Contraindications with medication?
Are you pyroluric? The zinc link
Possibly one of the most significant undiscovered discoveries in the nutritional treatment of
mental illness is that many mentally ill people are deficient in vitamin B6 and zinc. But this
deficiency is no ordinary deficiency: you can't correct it by simply eating more foods that are
rich in zinc and B6. It is connected with the abnormal production of a group of chemicals
called pyrroles. A person with a high level of pyrroles in the urine needs more B6 and zinc
than usual, since they rob the body of these essential nutrients, increasing a persons
requirements to stay healthy. At the Brain Bio Centre, we find many people diagnosed with
schizophrenia have pyroluria.
The test for pyroluria is remarkably simple and very inexpensive. When you add a chemical
known as Erhlichs reagant to urine, it will turn mauve if there are krytpopyrroles present.
Dubbed mauve factor in the 1960s, this was found in 11 per cent of normal people, 24 per
cent of disturbed children, 42 per cent of psychiatric patients and 52 per cent of
schizophrenics. Dr Carl Pfeiffer and Dr Arthur Sohler at Princetons Brain Bio Center worked
out that these abnormal chemicals would bind to B6 and zinc, inducing deficiency. With this
knowledge, effective therapy was at hand.
The Signs and Symptoms of Pyroluria
Pyroluria is often a stress-related condition, with symptoms usually beginning in the teenage
years after a stressful event such as exams or the breakup of a relationship.
Pyrolurics often have weak immune systems and may suffer from frequent ear infections as a
child, colds, fevers and chills. Other symptoms include fatigue, nervous exhaustion,
insomnia, poor memory, hyperactivity, seizures, poor learning ability, confusion, an inability
to think clearly, depression and mood swings. In girls there can be irregular periods and in
boys relative impotence. The pyroluric patient can have bad breath and a strange body odour,
a poor tolerance of alcohol or drugs, may wake up with nausea, and have cold hands and feet
and abdominal pain.
A lack of dream recall is very common. It is normal to remember dreams, and many people,
whether or not they have mental health problems, report better dream recall once they start
supplementing optimal amounts of vitamin B6 and zinc. Other tell-tale signs include pale
213
skin, white marks on the nails and, in extreme cases, poor hair growth and loss of hair colour.
Often a person with pyroluria also has skin problems such as acne or eczema.
Not all these symptoms are present in all pyrolurics, but if you are experiencing a number of
them, it is well worth testing for.
Side effects? No single nutrient should be supplemented at high levels over the long-term
without retesting the need to do so as imbalances can occur. Vitamin B6 can be toxic at high
doses, the key symptom of which is tingling hands or fingers. If this occurs, stop the B6
immediately and the tingling will stop within 1-3 days. Once it has stopped, you could restart
the B6 at half the previous dose.
Contraindications with medication? None known
Check for allergy
Some people with mental health problems are sensitive to gluten, especially wheat gluten,
which can bring on all sorts of symptoms of mental illness. This has been known since the
1950s, when Dr Lauretta Bender noted that schizophrenic children frequently had coeliac
disease (severe gluten allergy). By 1966 she had recorded 20 such cases from among around
2,000 schizophrenic children. In 1961 Drs Graff and Handford published data showing that
four out of 37 adult male schizophrenics admitted to the University of Pennsylvania Hospital
in Philadelphia had a history of coeliac disease in childhood.
These early observations greatly interested Dr Curtis Dohan at the University of
Pennsylvania. He suspected that the two were linked and decided to test his theory by
randomly placed all men admitted to a locked psychiatric ward in a Veterans Administration
Hospital in Coatsville, Pennsylvania, either on a diet containing no milk or cereals, or on one
that was relatively high in cereals. (Milk was eliminated from the diet because some people
do not benefit when only glutens are removed.) All other treatment continued as normal.
Midway through the experiment, 62 per cent of the group on no milk and cereals were
released to a full privileges ward. Only 36 per cent of those patients receiving a diet
including cereal were able to leave the locked ward. When the wheat gluten was secretly
placed back into the diet, the improved patients once again relapsed.
These results have since been confirmed by other double-blind placebo-controlled trials. In
one, published in the Journal of Biological Psychiatry, 30 patients suffering from anxiety,
depression, confusion or difficulty in concentration were tested, using a placebo-controlled
trial, as to whether individual food allergies could really produce mental symptoms in these
individuals. The results showed that allergies alone, not placebos, were able to produce the
following symptoms: severe depression, nervousness, feeling of anger without a particular
object, loss of motivation and severe mental blankness. The foods/chemicals that produced
most severe mental reactions were wheat, milk, cane sugar, tobacco smoke and eggs.
However, more recent research hasnt found that coeliacs disease in more prevalent among
those with schizophrenia or vice versa. However, the possibility of allergy to other foods may
be worth investigating, especially if allergic symptoms, including eczema, asthma, digestive
problems, ear infections, sinusitis or rhinitis are also present. At the Brain Bio Centre we
frequently find that food intolerances to a range of foods appear to be contributing to
symptoms, so investigating all types of food sensitivities is recommended.
Wheres the evidence? Search our evidence database and enter allergies' and
allergies on schizophrenia.
References
214
Blood sugar
Vanable PA, Carey MP, Carey KB, Maisto SA.Smoking among psychiatric outpatients:
relationship to substance use, diagnosis, and illness severity. Psychol Addict Behav. 2003
Dec;17(4):259-65.
Hyperglycemia and diabetes in patients with schizophrenia or schizoaffective
disorders. Diabetes Care. 2006 Apr;29(4):786-91.
Omega-3
Cohen D, Stolk RP, Grobbee DE, Gispen-de Wied CC, Membrane phospholipid composition,
alterations in neurotransmitter systems and schizophrenia, Prog Neuropsychopharmacol Biol
Psychiatry. 2005 Jul;29(6):878-88.
D. F. Horrobin DF et al., Fatty acid levels in the brains of schizophrenics and normal
controls, Biol Psychiatry, Vol 30, 1991, pp. 795-805
D. F. Horrobin et al., The membrane hypothesis of schizophrenia, Schizophrenia Research,
Vol 13, 1994, pp. 195-207
O. Christensen and E. Christensen, Fat consumption and schizophrenia, Acta Psychiatr
Scand, Vol 78, 1988, pp. 587-91
K. S. Vaddadi et al., A double-blind trial of essential fatty acid supplementation in patients
with tardive dyskinesia, Psychiatry Res, Vol 27(3), 1989, pp. 313-23
Emsley R, Oosthuizen P, van Rensburg S, 'Clinical potential of omega-3 fatty acids in the
treatment of schizophrenia', CNS Drugs. 2003;17(15):1081-91.
W. S. Fenton et al., A placebo-controlled trial of omega-3 fatty acid (ethyl eicosapentaenoic
acid) supplementation for residual symptoms and cognitive impairment in
schizophrenia, Am J Psychiatry, Vol 158(12), 2001, pp. 2071-4
G. Paul Amminger, et al (2010) Long-Chain Omega-3 Fatty Acids for Indicated Prevention of
Psychotic Disorders: A Randomized, Placebo-Controlled Trial. Arch Gen
Psychiatry 67(2):146-154
Antioxidants
D. Shtasel et al., Psychiatric Services, Vol 46(3), March 1995, p. 293
G. Milner, Brit J Psychiat, Vol 109, 1963, pp. 294-99
K. Suboticanec et al., Biol Psychiatry, Vol 28, 1990, pp. 959-66
Homocysteine, B12 and methylation
B. Regland et al, J Neural Transm Gen Sect, vol. 100, no. 2 (1995), pp. 165-169
Goff DC et al Am J Psychiatry. 2004 Sep;161(9):1705-8
Levine J et al Am J Psychiatry. 2002 Oct;159(10):1790-2.
Applebaum J et al J Psychiatr Res. 2004 Jul-Aug;38(4):413-6.
Regland B et al J Neural Transm. 1997;104(8-9):931-41
Lewis SJ et al Am J Med Genet B Neuropsychiatr Genet. 2005 Feb 23
M. W. Carney and B. F. Sheffield, Serum folic acid and B12 in 272 psychiatric in-
patients, Psychol Med, Vol 8(1), 1978, pp. 139-44
P. Godfrey et al., Enhancement of recovery from psychiatric illness by
methylfolate, Lancet, Vol 336(8712), 1990, pp. 392-5
B. Regland et al., Homocysteinemia and schizophrenia as a case of methylation
deficiency, J Neural Transm Gen Sect, Vol 98(2), 1994, pp. 143-52
Levine J et al., Homocysteine-Reducing Strategies Improve Symptoms in Chronic
Schizophrenic Patients with Hyperhomocysteinemia
Roffman JL et al., (2013) Randomized multicenter investigation of folate plus vitamin B12
supplementation in schizophrenia, JAMA Psychiatry, 70: 481-9
Pyroluria
215
P. O. O'Reilly et al., The mauve factor: an evaluation, Dis Nerv Syst, Vol 26(9), 1965, pp.
562-8
Food allergy
L. Bender, Childhood schizophrenia, Psychiatric Quarterly, Vol 27, 1953, pp. 3-81
H. Graff and A. Handford, Celiac syndrome in the case history of five
schizophrenics, Psychiatric Quarterly, Vol 35, 1961, pp. 306-13
F. C. Dohan et al., Relapsed schizophrenics: more rapid improvement on a milk and cereal-
free diet, Brit J Psychiat, Vol 115, 1969, pp. 595-6
D. S. King, Can allergic exposure provoke psychological symptoms? A double-blind
test, Biol Psychiatry, Vol 16(1), 1981, pp. 3-19
W. Philpott and D. Kalita, Brain Allergies, Keats Publishing (1980)
West J, Logan RF, Hubbard RB, Card TR. Risk of schizophrenia in people with coeliac
disease, ulcerative colitis and Crohn's disease: a general population-based study. Aliment
Pharmacol Ther. 2006 Jan 1;23(1):71-4.
Source:- http://www.foodforthebrain.org/nutrition-solutions/schizophrenia-and-
psychosis/about-schizophrenia-and-psychosis.aspx
3 Ways Aerobic Exercise Improves Schizophrenia Symptoms

Aerobic exercise improves cognitive function for people with
schizophrenia.
Posted Aug 12, 2016
In recent years, the neuroprotective powers of aerobic exercise to ward

off cognitive declinewhile improving mood and lowering your risk
for anxiety and depressionhave been confirmed by countless studies.
This morning, a first-of-its-kind study was published which reports that 12 weeks of
aerobic exercise training significantly improved schizophrenia patients' brainfunctioning.
In conjunction with medications, aerobic exercise augmented patients ability to cope
with the long-term mental health symptoms of schizophrenia by improving cognitive
function.
The acute phase of schizophrenia is generally marked by hallucinations and delusions,

which are typically treated with pharmaceuticals. Although the medications can be
effective, many schizophrenia patients taking prescription drugs experience pervasive
cognitive deficits that include: slower information processing, loss of concentration, and
poor memory.
For this analysis, researchers from the University of Manchester Institute of Brain,
Behaviour and Mental Health in the UK conducted a meta-analysis that combined data
from 10 independent clinical trials with a total of 385 patients with schizophrenia.
216
The August 2016 paper, 'Aerobic Exercise Improves Cognitive Functioning in People
with Schizophrenia: A Systematic Review and Meta-Analysis, by Joseph Firth, Dr.
Brendon Stubbs, and Professor Alison Yung was published today in Schizophrenia
Bulletin.
This meta-analysis showed that schizophrenia patients who are treated with moderate-to-
vigorous aerobic exercise programsin combination with medicationimproved their
overall brain functioning more than those who were treated solely with medications.
The areas of cognitive improvement that benefitted most from aerobic training were
patients' ability to understand social situations, increased attention spans, and better
working memorywhich is a reflection of how much information someone can hold in
his or her mind at one time.
3 Ways Aerobic Exercise Improves Schizophrenia Symptoms by

Firth et al.
1. Ability to Understand Social Situations

2. Attention span
3. Working Memory
According to the researchers, there was also dose-response evidence from these studies
showing that aerobic training programs which included greater amounts of exercise had
the greatest effects on cognitive functioning. In a statement, Joe Firth said:
"Cognitive deficits are one aspect of schizophrenia which is particularly problematic.

They hinder recovery and impact negatively upon people's ability to function in work and
social situations.
Furthermore, current medications for schizophrenia do not treat the cognitive deficits of
the disorder. We are searching for new ways to treat these aspects of the illness, and now
research is increasingly suggesting that physical exercise can provide a solution."
Conclusion: Exercise Can Reduce Neurocognitive Deficits Associated

with Schizophrenia
Joe Firth concluded: "These findings present the first large-scale evidence supporting the
use of physical exercise to treat the neurocognitive deficits associated with schizophrenia.
Using exercise from the earliest stages of the illness could reduce the likelihood of long-
term disability, and facilitate full, functional recovery for patients."
217
In an April 2016 Psychology Today blog post, What Makes Aerobic Exercise Like
Miracle-Gro for Your Brain? I reported on groundbreaking research by Keith
Nuechterlein, and a team of researchers at a free schizophrenia clinic at UCLA, who
discovered that schizophrenia treatments improved dramatically when they are
turbocharged with aerobic exercise.
The UCLA researchers concluded that helping young adults with schizophrenia as soon
as possible after their first psychotic breakdown with the triad of: aerobic exercise,
neurocognitive training, and antipsychotic medication could be a winning formula.
Typically, the early stages of schizophrenia are when individuals tend to be capable of
making long-lasting improvements, which is why early intervention is of paramount
importance.
Although the findings from UCLA focused on a specific subgroup of young adults with
schizophrenia, a wide range of other studies have shown the Miracle-Gro power of
aerobic exercise to trigger the production of brain-derived neurotrophic factor (BDNF)
for people from all walks of life. Hopefully, these findings will lead to more effective
treatments for schizophrenia and serve as motivation for all of us to be more physically
active throughout our lifespans.
Source:- https://www.psychologytoday.com/blog/the-athletes-way/201608/3-ways-aerobic-exercise-improves-
schizophrenia-symptoms
Exercise for Mental Health

Ashish Sharma, M.D.,1 Vishal Madaan, M.D.,2 and Frederick D. Petty, M.D., Ph.D.3
Sir: In this era of exponential growth of the metabolic syndrome and obesity, lifestyle
modifications could be a cost-effective way to improve health and quality of life.
Lifestyle modifications can assume especially great importance in individuals with
serious mental illness. Many of these individuals are at a high risk of chronic diseases
associated with sedentary behavior and medication side effects, including diabetes,
hyperlipidemia, and cardiovascular disease.1 An essential component of lifestyle
modification is exercise. The importance of exercise is not adequately understood or
appreciated by patients and mental health professionals alike. Evidence has suggested
that exercise may be an often-neglected intervention in mental health care.2
Aerobic exercises, including jogging, swimming, cycling, walking, gardening, and
dancing, have been proved to reduce anxiety and depression.3 These improvements in
mood are proposed to be caused by exercise-induced increase in blood circulation to the
brain and by an influence on the hypothalamic-pituitary-adrenal (HPA) axis and, thus, on
the physiologic reactivity to stress.3 This physiologic influence is probably mediated by
the communication of the HPA axis with several regions of the brain, including the limbic
system, which controls motivation and mood; the amygdala, which generates fear in
218
response to stress; and the hippocampus, which plays an important part in memory
formation as well as in mood and motivation.
Other hypotheses that have been proposed to explain the beneficial effects of physical
activity on mental health include distraction, self-efficacy, and social interaction.4 While
structured group programs can be effective for individuals with serious mental illness,
lifestyle changes that focus on the accumulation and increase of moderate-intensity
activity throughout the day may be the most appropriate for most patients.1Interestingly,
adherence to physical activity interventions in psychiatric patients appears to be
comparable to that in the general population.
Exercise improves mental health by reducing anxiety, depression, and negative mood and
by improving self-esteem and cognitive function.2 Exercise has also been found to
alleviate symptoms such as low self-esteem and social withdrawal.3 Exercise is especially
important in patients with schizophrenia since these patients are already vulnerable to
obesity and also because of the additional risk of weight gain associated with
antipsychotic treatment, especially with the atypical antipsychotics. Patients suffering
from schizophrenia who participated in a 3-month physical conditioning program showed
improvements in weight control and reported increased fitness levels, exercise tolerance,
reduced blood pressure levels, increased perceived energy levels, and increased upper
body and hand grip strength levels.5 Thirty minutes of exercise of moderate intensity,
such as brisk walking for 3 days a week, is sufficient for these health benefits. Moreover,
these 30 minutes need not to be continuous; three 10-minute walks are believed to be as
equally useful as one 30-minute walk.
Health benefits from regular exercise that should be emphasized and reinforced by every
mental health professional to their patients include the following:
1. Improved sleep
2. Increased interest in sex
3. Better endurance
4. Stress relief
5. Improvement in mood
6. Increased energy and stamina
7. Reduced tiredness that can increase mental alertness
8. Weight reduction
9. Reduced cholesterol and improved cardiovascular fitness
Mental health service providers can thus provide effective, evidence-based physical
activity interventions for individuals suffering from serious mental illness. Further studies
should be done to understand the impact of combining such interventions with traditional
mental health treatment including psychopharmacology and psychotherapy.
Go to:
Footnotes
The authors report no financial or other affiliation relevant to the subject of this letter.
219
Go to:
References
1. Richardson CR, Faulkner G, and McDevitt J. et al. Integrating physical activity
into mental health services for persons with serious mental illness. Psychiatr Serv.
2005 56:324331. [PubMed]
2. Callaghan P.. Exercise: a neglected intervention in mental health care? J Psychiatr
Ment Health Nurs. 2004;11:476483. [PubMed]
3. Guszkowska M.. Effects of exercise on anxiety, depression and mood [in
Polish] Psychiatr Pol. 2004;38:611620. [PubMed]
4. Peluso MA, Andrade LH.. Physical activity and mental health: the association
between exercise and mood. Clinics. 2005;60:6170. [PubMed]
5. Fogarty M, Happell B, Pinikahana J.. The benefits of an exercise program for
people with schizophrenia: a pilot study. Psychiatr Rehabil J. 2004;28:173
176. [PubMed]
Articles from Primary Care Companion to The Journal of Clinical Psychiatry are provided here courtesy
of Physicians Postgraduate Press, Inc.
The influence of physical activity on mental well-being.

Fox KR1.
Author information
Abstract
OBJECTIVE:
The case for exercise and health has primarily been made on its impact on diseases such coronary
heart disease, obesity and diabetes. However, there is a very high cost attributed to mental disorders
and illness and in the last 15 years there has been increasing research into the role of exercise a) in the
treatment of mental health, and b) in improving mental well-being in the general population. There are
now several hundred studies and over 30 narrative or meta-analytic reviews of research in this field.
These have summarised the potential for exercise as a therapy for clinical or subclinical depression or
anxiety, and the use of physical activity as a means of upgrading life quality through enhanced self-
esteem, improved mood states, reduced state and trait anxiety, resilience to stress, or improved sleep.
The purpose of this paper is to a) provide an updated view of this literature within the context of
public health promotion and b) investigate evidence for physical activity and dietary interactions
affecting mental well-being.
220
DESIGN:
Narrative review and summary.
CONCLUSIONS:
Sufficient evidence now exists for the effectiveness of exercise in the treatment of clinical depression.
Additionally, exercise has a moderate reducing effect on state and trait anxiety and can improve
physical self-perceptions and in some cases global self-esteem. Also there is now good evidence that
aerobic and resistance exercise enhances mood states, and weaker evidence that exercise can improve
cognitive function (primarily assessed by reaction time) in older adults. Conversely, there is little
evidence to suggest that exercise addiction is identifiable in no more than a very small percentage of
exercisers. Together, this body of research suggests that moderate regular exercise should be
considered as a viable means of treating depression and anxiety and improving mental well-being in
the general public.
Aerobic Exercise Improves Cognitive

Functioning in People With
Schizophrenia: A Systematic Review
and Meta-Analysis
Joseph Firth
Brendon Stubbs
Simon Rosenbaum
Davy Vancampfort
Berend Malchow
Felipe Schuch
Rebecca Elliott
Keith H. Nuechterlein
221
Alison R. Yung
Schizophr Bull sbw115.
DOI:
https://doi.org/10.1093/schbul/sbw115
Published:
12 August 2016
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Abstract
Cognitive deficits are pervasive among people with schizophrenia and treatment options
are limited. There has been an increased interest in the neurocognitive benefits of
exercise, but a comprehensive evaluation of studies to date is lacking. We therefore
conducted a meta-analysis of all controlled trials investigating the cognitive outcomes of
exercise interventions in schizophrenia. Studies were identified from a systematic search
across major electronic databases from inception to April 2016. Meta-analyses were used
to calculate pooled effect sizes (Hedges g) and 95% CIs. We identified 10 eligible trials
with cognitive outcome data for 385 patients with schizophrenia. Exercise significantly
222
improved global cognition ( g = 0.33, 95% CI = 0.130.53, P = .001) with no statistical
heterogeneity ( I2 = 0%). The effect size in the 7 studies which were randomized
controlled trials was g = 0.43 ( P < .001). Meta-regression analyses indicated that greater
amounts of exercise are associated with larger improvements in global cognition ( = .
005, P = .065). Interventions which were supervised by physical activity professionals
were also more effective ( g = 0.47, P < .001). Exercise significantly improved the
cognitive domains of working memory ( g = 0.39, P = .024, N = 7, n = 282), social
cognition ( g = 0.71, P = .002, N = 3, n = 81), and attention/vigilance ( g = 0.66, P = .
005, N = 3, n = 104). Effects on processing speed, verbal memory, visual memory and
reasoning and problem solving were not significant. This meta-analysis provides
evidence that exercise can improve cognitive functioning among people with
schizophrenia, particularly from interventions using higher dosages of exercise. Given the
challenges in improving cognition, and the wider health benefits of exercise, a greater
focus on providing supervised exercise to people with schizophrenia is needed.
physical activity, cognition, neurocognitive, neurocognition, psychosis
Topic:
physical activity
aerobic exercise
exercise
heterogeneity
cognition
memory, short-term
mental processes
problem solving
schizophrenia
memory
cognitive ability
reasoning
social cognition
Issue Section:
Regular Article
Introduction
223
Schizophrenia is associated with impairments in cognitive functioning. 1Deficits of 12
SDs below the general population are evident in various domains of cognition from the
onset of illness and persist over time. 2 These cognitive impairments contribute
significantly to the poor functional outcomes and long-term disability often observed
among patients. 1Antipsychotic medications have little impact on improving
cognition, 3 and other pharmacological approaches towards treating cognitive deficits
have demonstrated limited efficacy thus far. 4
Nonpharmacological interventions have been developed to specifically target cognitive
symptoms, including cognitive remediation therapy (CRT). CRT involves completing
tasks designed to train various cognitive functions such as memory, attention, and
problem-solving skills. A meta-analysis of 40 studies with 2104 participants found that
CRT improves cognitive functioning significantly more than control conditions, with
effect sizes within the moderate range. 5 However, CRT has only a small effect on
psychiatric symptoms, and improvements are lost over time. 5
Novel nonpharmacological strategies that can improve cognition, symptoms, and socio-
occupational functioning would provide valuable adjunctive treatments for schizophrenia.
A number of recent meta-analyses have shown that physical activity, and particularly
structured exercise, can significantly improve positive symptoms, negative symptoms,
and social functioning in this population. 68 Furthermore, by increasing cardiorespiratory
fitness and metabolic health, exercise may also reduce the physical health problems
associated with schizophrenia, such as obesity and diabetes, which contribute towards
reduced life expectancy. 9
In the general population, exercise has been shown to have modest effects on attention,
processing speed, memory, and executive functioning, 10 perhaps through stimulating
neuroplasticity. 11 Exercise has also been found to increase hippocampal volume and
white matter integrity in healthy older adults 12 , 13 and those with
schizophrenia. 14 , 15 Additionally, cross-sectional research in people with schizophrenia has
demonstrated that physical activity and fitness are associated with better cognitive
performance, 16 greater grey and white matter volumes, 17 and higher levels of
neurotrophic factors which promote brain plasticity. 18 A number of narrative reviews
have also discussed the potential benefits of exercise on brain health and cognition. 19
224
21
However, earlier meta-analyses of exercise in schizophrenia have not been able to
determine the effects on cognition due to insufficient data (including only 24 aerobic
exercise trials for each cognitive domain), 8 although many additional studies have since
been published.
The aim of this meta-analysis was to assess the effect of exercise on global cognition in
people with schizophrenia, along with examining which domains of cognitive functioning
are most sensitive to exercise interventions. We also sought to explore the impact of
various patient and intervention characteristics which affect the outcomes of exercise
interventions, using meta-regression analyses.
Methods
This meta-analysis followed the PRISMA statement 22 to ensure comprehensive and

transparent reporting of methods and results.
Search Strategy
Two independent authors (J.F. and B.S.) conducted an electronic database search of
Cochrane Central Register of Controlled Trials, Health Technology Assessment Database,
AMED (Allied and Complementary Medicine), HMIC Health Management Information
Consortium, Ovid MEDLINE, PsycINFO, Embase from inception to April 2016. The
search terms used were: schizo* or psychosis or psychotic and exercise or
physical activity or fitness or aerobic or resistance training and neuro* or
cogniti*. A search of Google Scholar was conducted using the same key words to
identify any additional relevant articles. The reference lists of retrieved articles were also
searched. Only English-language research articles were included in the review.
Eligibility Criteria
We aimed to include all published studies examining the neurocognitive outcomes of
exercise interventions for people with schizophrenia, in comparison to a control
condition. Eligible populations included any sample in which the majority of patients
225
were being treated for schizophrenia or schizoaffective disorder. Specifically, studies
which included a broad spectrum of psychiatric disorders were only included if >80% of
the sample had a clinically diagnosed nonaffective psychotic disorder. Data from studies
in which <80% of the sample had a nonaffective psychotic disorder were only eligible if
the outcome data specifically for the schizophrenia/nonaffective psychosis subgroup
could be accurately determined.
For the purpose of this review, exercise was defined as structured and repetitive physical
activity that has an objective of improving or maintaining physical fitness. 23 Interventions
using only yoga or tai-chi were excluded from the analyses, as these theoretically confer
benefits for cognition which are distinct from the physical activity itself. 24 Studies which
implemented physical activity as an active-control condition for cognitive training
interventions were not used in the analyses (unless a passive control arm was also
available for comparisons with exercise). Interventions which combined exercise with
other psychosocial or pharmacological treatments were only included if the nonexercise
aspects of the intervention were controlled for in the comparison conditions.
Data Extraction
Articles were independently screened by 2 reviewers (J.F. and B.S.) to assess eligibility.
Disagreements were resolved through discussion until consensus was reached. A
systematic tool was used to extract all of the following data from each study:
1.
Primary outcomeglobal cognition: This was defined as average change in all clinically
validated measures of cognitive functioning following an exercise intervention (or control
condition). Where changes in multiple cognitive tasks/domains were reported, a
composite change score was calculated from the average change in each individual
task/cognitive domain. This method has been applied in previous meta-analyses
examining the effects of cognitive training interventions in schizophrenia. 5, 25 All
neurocognitive tasks used to calculate these composite scores are shown
in supplementary material 1 .
226
2.
Secondary outcomesindividual cognitive domains: Effects of exercise in individual

cognitive domains were examined with respect to the categories established by the
NIMH-MATRICS Neurocognition Committee, based on factor analytic studies of the
structure of cognition in schizophrenia, 26 and subsequently used to guide the structure of
the MATRICS Consensus Cognitive Battery (MCCB). 27 This specifies 7 individual
domains of cognition which are: speed of processing, attention/vigilance, working
memory, verbal learning and memory, visual learning and memory, reasoning and
problem solving, and social cognition. Where studies had not used the gold-standard
MCCB itself, the tasks used were categorized into their respective domains, 26 as in
previous meta-analyses. 5 , 25supplementary material 1 displays the categorization of all
cognitive tasks used in meta-analyses.
3.
Potential moderators: Data on factors which may influence the effect size of exercise
interventions were also extracted from each study, including sample characteristics (age,
gender distribution, years of illness duration), exercise intervention characteristics
(minutes of exercise per week, length of intervention in weeks, improvements in
fitness/maximal oxygen uptake, professional background of instructor), and study design
(control condition used and trial quality).
Where unreported study data were required to determine eligibility or for meta-analyses,
the corresponding authors of respective studies were contacted up to 2 times to request
the variables of interest.
Statistical Analyses
All analyses were performed in Comprehensive Meta-Analysis 2.0, 28 with a random-
effects model applied throughout to account for the expected heterogeneity between
studies. 29 Pooled effect sizes for exercise on both global cognition and each individual
cognitive domain were calculated as Hedges g using the mean change scores (and SDs)
in exercise and control conditions. Where raw means were not reported, the effect size
was computed from F -statistics or t values. The heterogeneity between studies was
227
quantified using Cochrans Q and I2 values, which estimate the amount of heterogeneity
resulting from between-study variance, rather than by chance. The risk of bias for each
study was examined using the Cochranes Collaboration risk of bias tool 30 which assesses
6 aspects of trial methodology (sequence generation, allocation sequence concealment,
blinding of participants and personnel, blinding of outcome assessment, incomplete
outcome data, and selective outcome reporting) that could potentially introduce different
sources of bias. To account for publication bias, the Eggers test was applied and the Fail-
Safe Number 31 was calculated to determine the number of unpublished null studies which
would be required to invalidate our findings ( P > .05). We also performed sensitivity
analyses to assess if comparable effects were still observed following the removal of low-
quality or nonrandomized controlled trials.
The relationship between continuous moderators and effect size estimates were explored
with meta-regression analyses. These were performed for putative patient and treatment
characteristics which may impact upon the cognitive outcomes of exercise in
schizophrenia. Patient moderators included age, gender, and duration of illness.
Treatment moderators were intervention length, weekly amounts of exercise, and
improvements in cardiorespiratory fitness. The impact of categorical moderators of
exercise supervision and intervention content were assessed using subgroup analyses.
Results
Search Results
The initial database search was performed on April 9, 2016. The search returned 2115
results reduced to 1668 after duplicates were removed. A further 1625 articles were
excluded after reviewing the titles and abstracts for eligibility. Full text versions were
retrieved for 43 articles, of which 7 were eligible for inclusion. Reasons for exclusion and
full details of the search results are summarized in figure 1 . A further 2 articles were
identified from a similar search of Google Scholar, and one in-press publication was
retrieved from its corresponding author. A total of 10 articles, each with unique samples,
were eligible for inclusion. Additional data for 3 studies was obtained from the
corresponding authors. 3234
228
Fig. 1.
View largeDownload slide

PRISMA flow diagram of systematic search and study selection.
Included Studies and Participant Details

Study characteristics and intervention details are displayed in table 1 . Two studies were
conducted in the United States, 2 in Germany, 2 in China, and 1 each in Brazil, Portugal,
Netherlands, and India. There was a total of 592 psychiatric patients across the studies:
221 were assigned to exercise, 234 to control conditions, and 137 to ineligible study arms
including tai-chi 35 and yoga. 36 , 37 In the eligible samples, 92.1% had
schizophrenia/schizoaffective disorder and 7.9% had other nonaffective psychotic
disorders. The mean age was 37.3 years (range = 22.755 y), mean duration of illness
was 13.4 years (9.2 mo to 30.7 y) and 56% were male.
Table 1.
Details of Included Studies
Sample
Characteristics Exercise Intervention Study Details
Cog
nitiv
e
Do
mai
Con Sess Wee Co ns Risk
trol Mea % ion Sup ks + mpa Exa of
(n) n Mal Con ervi Sess rato min Bias
Age e tent sion ions r ed a
17 22 31.8 76.2 60- Yog 12- Wait Soci Low

min a wk list al
Nat instr sessi (ran cogn
ional ucto ons dom ition
Fitn r per ized)
ess wee
Corp k:
229
Sample
Cog
nitiv
e
Do
mai
s
prog
ram,
cons
istin
g of
brisk
walk
ing,
jogg
ing,
and
exer
cises
in
stan
ding
and
sittin
g
post
ures. NS
13 16 39.4 72.8 20m Reh 8wk, TAU Proc High

in of abili 2 (non essin
an tatio per rand g
230
Sample
Cog
nitiv
e
Do
mai
inter n wee omiz spee

activ cent k ed) d
e er
phys staff
ical
activ
ity
vide
oga
me
Mo
ve4
Heal
th.
This
dem
ands
uppe
r
and
lowe
r
limb
mov
eme
nts
231
Sample
Cog
nitiv
e
Do
mai
in
vari
ous
grap
e-
relat
ed
gam
es.
Inte
nsity
and
diffi
culty
incre
ases
over
time
.
51 49 54.9 50.0 60m Men 12w Wait Wor Low

in tal k, 3 list king
desi healt per (ran me
gned h wee dom mor
to prof k ized) yb
matc essio
232
Sample
Cog
nitiv
e
Do
mai
h nals
phys
ical
exert
ion
of
tai-
chi
(50
%
60%
maxi
mal
oxyg
en
cons
ump
tion)
.
Con
sists
of
stret
chin
g
and
233
Sample
Cog
nitiv
e
Do
mai
joint
mov
eme
nts,
walk
ing,
step
ping
,
mild
weig
ht
train
ing,
and
cool
-
dow
n.
13 13 36.9 64 60m Phys 12w TAU Proc Low

in of ical k, 3 (ran essin
mixe train per dom g
d er wee ized) spee
aero k d
234
Sample
Cog
nitiv
e
Do
mai
bic
exer
cise
at
60%

75%
VO 2
peak
.
Sess
ions
cont
ain a
mixt
ure
of
tread
mill
runn
ing,
ellip
tical
train
ing,
and
235
Sample
Cog
nitiv
e
Do
mai
inter
activ
e
vide
31 33 24.9 0.0 45 Yog 12w TAU Proc Low
60m a k, 3 (ran essin
in of instr per dom g
aero ucto wee ized) spee
bic r k db
exer
cise
at
50%

60%
VO 2
max.
War
m
up,
tread
mill,
236
Sample
Cog
nitiv
e
Do
mai
stati
onar
y
cycli
ng,
follo
22 21 36.5 72.0 30m Spor 12w Tabl Proc High

in of ts k, 3 e essin
stati scie per foot g
onar ntist wee ball spee
y k + d
cycli CR
ng at (non
an rand
indi omiz
vidu ed)
ally
defi
ned
237
Sample
Cog
nitiv
e
Do
mai
inten
sity
(bas
ed
on
bloo
d
lacta
te
conc
entra
tions
7 9 22.7 73.0 30 Phys 10w CR Proc High
238
Sample
Cog
nitiv
e
Do
mai
45m ical k, 4 (non essin

in of train per rand g
aero er wee omiz spee
bic k ed) db
wor
k-
out
vide
o at
60%

80%
of
max.
heart
rate.
Wor
kout
vide
os
inclu
ded
calis
theni
cs
(eg,
239
Sample
Cog
nitiv
e
Do
mai
lung
es,
squa
ts,
push
ups)
and
simp
le
mov
eme
8 11 42.3 44.4 45- Phys 4wk, Rela Proc Low
min ical 3 xatio essi
wor train per n ng
kout er wee train spee
240
Sample
Cog
nitiv
e
Do
mai
with k ing db
war +
m- CR
up (ran
(10 dom
min) ized)
,
follo
wed
by
circu
it
train
ing
(25
min)
usin
g
tram
poli
nes,
weig
hts,
phys
iothe
rapy
241
Sample
Cog
nitiv
e
Do
mai
balls
,
stav
es,
and
flexi
bars
at
60%

70%
of
max.
heart
rate
and
endi
ng
with
a
cool
-
dow
n
phas
e
242
Sample
Cog
nitiv
e
Do
mai
(10
min)
8 8 35 100 30m Stud 12w Tabl Wor Low
in of y k, 3 e king
stati inve per foot mem
onar stiga wee ball ory
y tor k (ran
cycli dom
ng at ized)
an
indi
vidu
ally
defi
ned
inten
sity
(bas
ed
on
bloo
d
lacta
te
243
Sample
Cog
nitiv
e
Do
mai
conc
entra
tions
)
that
was
grad
ually
16 17 30.1 81.7 40m Phys 24w Occ Glob Low
in of ical k, 2 upati al
aero train per onal only
bic er wee thera (IQ)
train k py
ing (ran
(cycl dom
ing, ized)
tread
mill,
244
Sample
Cog
nitiv
e
Do
mai
ellip
tical
) at
up
to
75%
of
max.
heart
rate
follo
wed
by
20m
in of
resis
tanc
e
train
ing.
Note : Bold indicates statistically significant improvement in exercise group

compared to control condition for cognitive subdomain. CR, cognitive
remediation; IQ, intelligence quotient; NS, nonsignificant; TAU, treatment as
usual.
a
Assessed with Cochrane Risk of Bias tool.
245
b
Intention-to-treat data available for cognitive domain analysis.
Intervention details are shown in table 1 . Exercise programs were, on average, 12.2
weeks long (range = 424wk) with 2.9 sessions per week (range = 24 sessions) of 2060
minutes in duration. All primarily focused on aerobic exercise, although 3 also
incorporated resistance-based (muscle strengthening) training. 15 , 35 , 38 The common
modalities were aerobic machines such as cycle ergometers/treadmills ( N = 5),
bodyweight exercises ( N = 3), interactive video games ( N = 2), and free-weights ( N =
2). Three interventions combined exercise with cognitive remediation (CR) but were still
included in the analyses, since their comparison conditions controlled for this using CR
alone, 33 CR with table football, 34 or CR with relaxation training. 38 Other control
conditions were table football alone ( N = 1), occupational therapy ( N = 1), and
treatment-as-usual ( N = 5). Risk of bias assessments identified 3 nonrandomized studies
with high risk of bias influencing results. 33 , 34 , 39 The 7 studies which were randomized
controlled trials (RCTs) rated low risk of bias for most items, although 1 had used
nonblinded outcome assessments and 2 were at risk of bias from incomplete outcome
data with no intention-to-treat (ITT) analyses. Bias assessment results for individual
studies are displayed in supplementary material 2 .
Meta-Analysis of the Neurocognitive Outcomes of

Exercise
Outcome data were available for 186 participants in the exercise group and 199 in control
groups. The effect of exercise on global cognition is displayed in figure 2 ( N = 10, n =
383). This shows exercise interventions significantly improved overall cognitive
performance ( g = 0.33, 95% CI = 0.130.53, P = .001). There was no evidence of
statistical heterogeneity in the pooled effect size ( Q = 7.0, P = .64, I2 = 0%). Eggers
regression test showed no evidence of publication bias ( t = 0.786, P = .454). The fail-
safe N was 20, indicating that 20 additional null studies would be needed for the
observed P value to exceed .05.
Fig. 2.
View largeDownload slide
246
Meta-analysis of exercise effects on global cognition in comparison to control conditions. Box size
represents study weighting. Diamond represents overall effect size and 95% CIs.
A sensitivity analysis was performed on the RCTs only while also excluding studies with
high risk of bias (see table 2 ). Among the RCTs ( N = 7, n = 297), the effect size was g =
0.41 (95% CI = 0.190.64, P < .001) with low heterogeneity between studies ( Q =
2.32, P = .88, I2 = 0%).
Table 2.
Cognitive Outcomes of Exercise Interventions in People With Schizophrenia
Meta-Analysis Heterogeneity
Studie Total Hedges PVa

s n g 95% CI lue QValue PValue I2 %
Global cognition
Overall 10 383 0.334 0.13 0.53 .001 7.00 .64 0
RCTs
only 7 297 0.412 0.19 0.64 <.001 2.32 .88 0
Exercise
instructor
6 197 0.466 0.19 0.75 <.001 2.44 .79 0
Other
instructor
4 186 0.196 0.09 0.48 .178 2.81 .42 0
Exercise
alone vs
standard
control 7 307 0.377 0.15 0.60 .001 3.56 .74 0
Exercise + 3 76 0.209 0.33 0.75 .447 2.73 .23 26.8

CRT vs
CRT
247
Meta-Analysis Heterogeneity
Studie Total Hedges PVa

s n g 95% CI lue QValue PValue I2 %
control
Cognitive domains
Working
memory 7 282 0.390 0.05 0.73 .024 10.9 .09 45.1
Processing
speed 6 195 0.125 0.15 0.40 .375 4.97 .42 0
Verbal
learning
and
memory 6 166 0.284 0.09 0.64 .138 7.76 .17 35.6
Reasoning
and
problem
solving 4 146 0.100 0.42 0.22 .528 1.36 .72 0
Attention/v
igilance 3 104 0.663 0.20 1.12 .005 2.51 .07 20.3
Social
cognition
3 81 0.712 0.27 1.15 .002 1.23 .54 0
Visual
learning
and
memory 3 61 0.004 0.45 0.52 .889 0.67 .71 0
248
Note : Bold values represent a statistically significant difference between
exercise and control conditions. CRT, cognitive remediation therapy; RCT,
randomized controlled trial.
Factors Associated With Intervention Effectiveness

All exercise interventions were delivered in a supervised setting. Therefore, subgroup
analyses were performed to examine interventions that were supervised by a physical
activity professional versus those which were not ( table 2 ). Exercise interventions
supervised by physical activity professionals (including physical trainers and yoga
teachers) significantly improved global cognition ( N = 6, n = 197, g = 0.47, 95% CI =
0.190.75, P < .001, Q = 2.44, I2 = 0%) whereas those supervised by other professionals
(ie, mental health support and research staff) did not ( N = 4, n = 186, g = 0.2, 95% CI =
0.09 to 0.48, P = .5, Q = 1.81, I2 = 0%), although the difference between subgroups was
not significant ( P = .19). Exercise as a stand-alone intervention was compared to
treatment as usual or time- and attention-matched control conditions in 7 trials and was
found to significantly improve global cognition ( N = 7, n = 307, g = 0.38, 95% CI =
0.150.60, P < .001, Q = 3.56, I2 = 0%). Three trials (total n = 76) examined the
additional benefits of exercise as an add-on to CRT, in comparison to CRT as a control
condition. Random-effects meta-analysis found no significant differences between
exercise plus CRT vs CRT control conditions ( g = 0.21, 95% CI = 0.33 to 0.75, P = .
45, Q = 2.73, I2 = 26.8).
Meta-regression analyses suggested that a greater amount of exercise (in minutes per
week) was associated with a larger improvement in global cognition ( supplementary
material 3 ), which closely approached statistical significance ( N = 9, n = 344, B =
0.0054, SE = 0.0029, Z = 1.85, P = .065). Improvements in fitness had a nonsignificant
tendency to correlate with intervention effect size ( N = 7, n = 222, B = 0.61, SE = 0.352,
Z = 1.74, P = .082). None of the other intervention factors (length in weeks, sessions per
week) or sample characteristics (age, duration of illness, % male) were associated with
effects on cognitive performance (all P .1).
249
Effects of Exercise on Individual Cognitive Domains
We also examined the effects of exercise in the 7 individual cognitive domains
established by the MATRICS Neurocognition Committee 26 , 27 ( supplementary material
1 ). Effects across all domains are displayed in table 2 . The most widely assessed was
working memory ( N = 7, n = 282), within which exercise resulted in significant
improvements vs control conditions ( g = 0.39, 95% CI = 0.050.73, P = .024) with
medium heterogeneity ( Q = 10.92, P = .091, I2 = 45.1%). Processing speed and verbal
learning and memory were each assessed by 6 studies ( n = 195, n = 166) but showed no
significant difference from control conditions (processing speed: g = 0.13, 95% CI =
0.15 to 0.40, P = .38, I2 = 0%; verbal learning: g = 0.28, 95% CI = 0.09 to 0.64, P = .
14, I2 = 35.6%). Reasoning and problem solving, assessed in 4 studies also showed no
benefits from exercise ( g = 0.10, 95% CI = 0.42 to 0.22, P = .53, n = 146, I2 = 0%).
The remaining 3 domains were assessed by 3 studies each. Significant effects of exercise
were observed in tasks of social cognition ( g = 0.71, 95% CI = 0.271.15, P = .
002, n = 81, I2 = 0%) and attention/vigilance ( g = 0.66, 95% CI = 0.201.12, P = .
005, n = 104, I2 = 20.3%), although there were no significant differences from control
conditions for visual learning and memory ( g = 0.004, 95% CI = 0.45 to 0.52, P = .
889, n = 61, I2 = 0%).
Discussion
This meta-analysis set out to examine the effects of exercise on cognitive functioning in
people with schizophrenia. Ten studies with 385 participants were eligible; most of which
used aerobic exercise interventions. Pooled effect sizes across all cognitive outcomes
showed that exercise improves global cognition significantly more than control
conditions ( figure 2 ). This was a robust finding, with little statistical heterogeneity
between studies and an effect size of g = 0.33 across all studies (95% CI = 0.130.53, P =
.001). Subgroup analyses suggest that supervision from physical activity instructors
results in better cognitive outcomes. Meta-regression analyses indicate that higher weekly
duration of exercise tends to be associated with greater improvement in cognition ( P = .
065). Domain-specific analyses found that exercise is particularly beneficial for social
cognition ( g = 0.71), working memory ( g = 0.39), and attention ( g = 0.66). This also
250
suggests aerobic exercise may be more effective for cognition in schizophrenia than yoga,
which previous meta-analyses have found to only be effective for long-term memory
(with a smaller effect size of g = 0.32). 8
In this meta-analysis, the effect size in RCTs was 0.43 (95% CI = 0.210.66), indicating
that exercise has similar effects on cognition in schizophrenia to CRT, which has an
average effect size of g = 0.45 (95% CI = 0.310.59) in randomized trials. 5 Studies in
healthy populations have shown that interventions which combine aerobic exercise with
cognitively demanding tasks confer maximal benefits for cognition. 40 Animal research
suggests this is due to aerobic exercise and learning tasks having independent but
complementary effects on neurogenesis; with the combination of these 2 activities
leading to 30% more new neurons than either alone. 41 Specifically, this may be attributed
to exercise stimulating cell proliferation, and learning tasks supporting the survival of
new cells. 42 Three studies identified in this review assessed the effects of exercise plus
CRT in comparison to CRT alone. 33, 34 , 38 However, there was substantial heterogeneity
between the exercise training programs used, and pooled effect size found no significant
benefits of CRT plus exercise compared to CRT control conditions ( g = 0.21, P = .45)
for global cognitive performance. Nonetheless, individual studies have shown
significantly greater improvements from combining CRT with aerobic exercise for
various cognitive subdomains (including social cognition, working memory), along with
significantly greater reductions in negative symptoms of schizophrenia. 33 , 34
The cellular processes through which exercise increases neurogenesis and cognitive
performance is not fully understood, although evidence from human and animal studies
indicates that it is related to an increase in brain-derived neurotrophic factor
(BDNF). 43 BDNF is the most abundant growth factor in the human brain and is
upregulated in response to aerobic exercise. 44 , 45 There is also some preliminary evidence
supporting the role of BDNF as a mediating factor for cognitive improvements from
exercise in schizophrenia. 32 , 33However, the benefits of exercise in schizophrenia cannot
be attributed to BDNF alone, given the lack of available data examining other potential
mechanisms.
For instance, it is possible that positive effects on cognition occur indirectly, since
exercise has previously been shown to improve psychiatric symptoms, quality of life, and
251
social functioning in people with schizophrenia 68 all of which are associated with
neurocognition. 46 Physiological changes that occur in response to exercise, such as
weight-loss and improved cardiorespiratory fitness, are also linked with increased
cognitive performance. 47 , 48 Indeed, our meta-regression analyses revealed a
nonsignificant tendency for an association between improvements in cognition and
cardiorespiratory fitness, although this was underpowered to detect a significant effect
( P = .08). Nonetheless, 3 of the studies included in this review did report significant
correlations within their respective samples between increased fitness and improvements
in brain structure and function. 14 , 15 , 32 Further exploration of the potential mechanisms
through which exercise can improve cognition in schizophrenia is an important step for
understanding these effects, and for informing the design and delivery of future
interventions.
Only the interventions which were supervised by physical activity professionals
significantly improved global cognition ( g = 0.47, P < .001). This may be due to
increased exercise engagement among participants or better program delivery resulting in
more favorable outcomes. Exercise dosage appears to be an important factor for
achieving cognitive enhancement, as previous studies have shown that the amount or
dose of exercise achieved by participants during an intervention is a significant predictor
of cognitive improvements. 49 , 50 In our meta-regression analyses, minutes per week of
exercise closely approached significance as a moderator variable ( P = .065). Although
other dose-related variables (ie, duration [wk] of the exercise intervention and number of
sessions per week) did not have any relationship with intervention effectiveness, this may
be due to the lack of variation across the included studies preventing our meta-regression
analyses from detecting a relationship, as most interventions were between 8 and 12
weeks long, with 2 or 3 sessions per week ( table 1 ). Furthermore, we were unable to
analyze how exercise intensity may influence outcomes due to how this variable was
reported across trials. Kimhy et al 50 previously examined the relative influence of
exercise duration, frequency, and intensity on cognitive improvements following a 12-
week exercise program in schizophrenia and found that intensity was the best predictor
variable. Thus, along with determining required doses in minutes per week, future
252
research should also aim to establish the length, frequency, and intensity of exercise
training required to improve cognition.
Among the different domains assessed ( table 2 ), social cognition showed the greatest
improvements in response to exercise ( g = 0.71, 95% CI = 0.271.15, P = .002). Social
cognitive impairments persevere from the onset of illness across the course of
schizophrenia. 51 They are negatively associated with employment and independent
living, 52 , 53 and social cognition is more strongly predictive of real-world functioning than
neurocognitive performance. 54 Thus, the large effects in this domain are encouraging,
suggesting that the cognitive benefits of exercise may generalize to improve psychosocial
and occupational outcomes for people with schizophrenia.
The 2 other domains which showed significant changes in response to exercise were
attention ( g = 0.66) and working memory ( g = 0.39). Since these factors are strong
predictors of functional recovery after a first episode of schizophrenia, 55 implementing
exercise interventions from the early stages of illness may facilitate functional recovery.
Indeed, exercise may confer even greater benefits in the early psychosis, as cognitive
enhancement interventions are more effective at this time than later in
illness. 56 Consistent with this, 3 recent studies in young patients with first-episode
psychosis (aged 2326) have observed large cognitive improvements from
moderate/vigorous exercise after just 1012 weeks. 33 , 36 , 46 With the currently limited
evidence, it is unclear whether this high level of responsiveness to exercise among first-
episode patients is due to their younger age or their earlier stage of illness. It is also
possible that exercise interventions could be particularly beneficial for older patients with
schizophrenia, whom typically have greater health-related comorbidities (such as
hypertension, obesity, and diabetes)since these conditions adversely affect cognitive
functioning, 57 , 58and yet improve in response to exercise training. Additionally, future
studies should examine how the effects of exercise are influenced by other biological
variables, such age, body mass index, and genetic variation in BDNF secretion (ie, BDNF
val66met polymorphism), as these have previously been shown to modulate effects of
exercise on neurocognition. 5860
One limitation of this meta-analysis is that several of the included studies did not use ITT
analyses and failed to report outcome data for 15.8% and 10.7% of participants enrolled
253
in the exercise and control conditions, respectively. In CRT studies, while earlier meta-
analyses of smaller trials found moderate effects on cognitive functioning, 2 recent
multisite RCTs with ITT analyses have found no benefits of CRT beyond control
conditions. 61 , 62 Therefore, large-scale RCTs of exercise with complete outcome data (or
ITT analyses) should now be conducted to establish the efficacy for improving cognition
in schizophrenia. If proven effective, exercise could present a widely beneficial and cost-
effective intervention for policy makers to consider for dissemination, since it has also
been found to improve cardiovascular health and symptoms in schizophrenia. 6 , 63
Some cognitive subdomains were only measured in a small number of studies ( N = 3),
which limits the strength of findings for these domains. It should also be noted that the
differences in the effects of exercise across specific cognitive domains could be
attributable to discrepancies in cognitive measures used. This is because cognitive tasks
vary in their sensitivity to detect improvement, depending on various psychometric
properties such as task difficulty, reliability, and standard variance in performance.
A further consideration is that all interventions primarily used aerobic exercise. Single-
arm studies (ineligible for this meta-analysis) using resistance training methods in people
with early psychosis 46 and long-term schizophrenia 64 have demonstrated significant
benefits for verbal memory and processing speeddomains which did not show
improvement from aerobic exercise in this meta-analysis. Furthermore, a recent RCT of
20-week resistance training for schizophrenia found significant increases in
BDNF. 65Despite the positive effects of resistance training for cognition observed in other
populations, 66 , 67 no RCTs have measured this in schizophrenia to date.
In conclusion, the available evidence indicates that exercise improves cognitive
functioning in people with schizophrenia, particularly within domains of social cognition,
working memory, and attention, all of which are predictive of socio-occupational
outcomes. Our data suggest that supervision from physical activity professionals and
higher levels of weekly exercise are important for promoting the cognitive benefits of
exercise. Future research should aim to explore the mechanisms of exercise-induced
cognitive improvements, determine if this is related to increased cardiorespiratory fitness,
establish required dosages of exercise, and investigate the effectiveness of resistance
training. Furthering current understanding in these areas will help to develop optimal
254
programs, which may involve combining exercise training with CRT. Given the known
benefits of exercise for psychiatric symptoms, social functioning, and physical health, 6
8
feasible and accessible methods for delivering exercise in clinical practice should be
explored and implemented. 21
Supplementary Material
Supplementary material is available at http://schizophreniabulletin.oxfordjournals.org .
Funding
J.F. is funded by an MRC Doctoral Training Grant. D.V. is funded by the Research
Foundation Flanders (FWO-Vlaanderen). S.R. is funded by a Society for Mental Health
Research Early Career Fellowship (Australia). K.H.N. is funded by NIMH, Janssen,
Stanley Medical Research Institute, and Posit Science. B.M. is funded by the German
Federal Ministry of Education and Research (BMBF: 01EE1407AE).
Acknowledgments
We would like to acknowledge the assistance of Prof. David Kimhy (Columbia

University) for kindly agreeing to share study data necessary for the meta-analysis. The
authors have declared that there are no conflicts of interest in relation to the subject of
this study.
Please Use Link Provide Below For References.
The Author 2016. Published by Oxford University Press on behalf of the Maryland
Psychiatric Research Center.
This is an Open Access article distributed under the terms of the Creative Commons
Attribution License ( http://creativecommons.org/licenses/by/3.0/ ), which permits
unrestricted reuse, distribution, and reproduction in any medium, provided the original
work is properly cited.
Source:-
https://academic.oup.com/schizophreniabulletin/article/doi/10.1093/schbul/sbw
115/2503725/Aerobic-Exercise-Improves-Cognitive-Functioning-in
255
Metabolic issues in patients affected by schizophrenia:
clinical characteristics and medical management
Antonio Ventriglio,* Alessandro Gentile, Eleonora Stella, and Antonello Bellomo
Abstract
Introduction
Patients diagnosed with psychotic disorders report a reduced expectancy of life and show
higher rate of physical co-morbidities said to be mostly due to an unhealthy life style and
as a result of treatment by antipsychotic drugs (Saha et al., 2007; Fleischhacker et
al., 2008).
It has been described that patients affected by schizophrenia show a 23-fold increased
risk of death compared to the general population as a result of suicide and cardiovascular
and metabolic diseases (Saha et al., 2007; Fleischhacker et al., 2008). In 2004, the
American Diabetes Association (ADA) defined the Cardio-metabolic Risk (CMR) as a
cluster of many risk factors (ADA website1). Some of them are considered to be
modifiable with dietary changes, physical exercise (e.g., overweight/obesity, high blood
glucose, hypertension, abnormal lipid metabolism, physical inactivity, smoking) whereas
others are seen as non-modifiable (e.g., age, race, ethnicity, gender, family history). The
prevalence and relative risk of modifiable factors are not only higher in the patients
affected by psychotic conditions but such individuals may also show relatively poor
access to health care system and higher levels of unhealthy lifestyle (Druss et al., 2001;
Cradock-O'Leary et al., 2002; Newcomer, 2005; Correll, 2007; Fleischhacker et
al., 2008).
Antipsychotic agents (APs) have been shown to greatly influence those modifiable risk
factors leading to weight gain and metabolic changes among all patients treated
(Newcomer, 2007; Nasrallah, 2008; Papanastasiou, 2013). In particular, Metabolic
Syndrome (constituting a cluster of clinical conditions such as abdominal obesity, insulin
resistance, dyslipidaemias, hypertension) is well known to be highly prevalent among
individuals affected by psychosis. Metabolic syndrome is also well recognized as being
associated with an increased cardiovascular risk and resulting mortality
(Papanastasiou, 2013). Patients diagnosed with schizophrenia have been shown to be
overweight/obese (4555%, RR: 1.52), smokers (5080%, RR: 23), to report diabetes
(1015%, RR: 2), hypertension (1958%, RR: 23), dyslipidemias (2569% RR 5) and
metabolic syndrome (3763%, RR: 23) (Correll, 2007). The median all- causes
standardized mortality ratio (SMR) for people affected by schizophrenia has increased
over the decades from 1.84 in the 1970s to 3.20 in 1990s (De Hert et al., 2009a). Also,
cardiovascular mortality in patients with schizophrenia also increased in those decades
especially among men (Osby et al., 2000). As stated above, medical co-morbidities lead
256
to a 20% shorter lifespan among patients diagnosed with psychoses (Harris and
Barraclough, 1998; Castillo Snchez et al., 2014; Ifteni et al., 2014; McLean et al., 2014).
In particular, schizophrenia is significantly associated with premature mortality and a
higher rate of sudden, unexpected death mostly as a result of cardiovascular, respiratory,
and neurological disorders (Ifteni et al., 2014). Early recognition and treatment of such
co-morbidities should, therefore, be a priority for clinicians who treat patients with
psychoses since the standard risk assessment underestimates the risk of death in
schizophrenia (Harris and Barraclough, 1998; Ifteni et al., 2014). Also, evidence from
past few decades has confirmed that there may be a link between major mental illness
and metabolic conditions without any influence of treatments since metabolic
disturbances have been found in drug-nave patients with first-episode illness (Ryan et
al., 2003).
Genetic links between diabetes and schizophrenia were recognized by Henry Maudsley in
his 1897 textbook The Pathology of Mind (Mausdley, 1897). Similarly, weight gain and
abnormal eating behaviors were recognized by Kraepelin and Bleuler in the beginning of
the twentieth century. These observations have been recently confirmed in recent studies
showing that first- episode and drug nave patients with psychosis report impaired fasting
glucose, insulin- resistance and higher levels cortisol than healthy controls (Ryan et
al., 2003; Thakore, 2004). They also show higher rates of visceral obesity related to a
subtle disturbance of the hypothalamic-pituitary-adrenal axis as alterations of hormonal
and immune pathways are recognized in the blood samples of patients with schizophrenia
(Thakore, 2004). Van Beveren et al. suggest that the presence of a molecular
endophenotype including the disruption of insulin and growth factor also signals
pathways as a risk factor for schizophrenia (Phutane et al., 2011; van Beveren et
al., 2014). Moreover, drug nave/first episode schizophrenia patients present increased
levels of IL-1, IL-6, and TNF- and higher adiponectin levels that may play a pro-
inflammatory role leading to later metabolic syndrome (Song et al., 2013).
Obviously, cardio-metabolic risk factors are lower among drug-free/first episode patients
than treated schizophrenia patients, and the cardiovascular risk is not significantly higher
at this stage of illness. This indicates that first- episode patients should be screened in
order to put primary prevention of cardiovascular morbidity and mortality in place
(Phutane et al., 2011; Mitchell et al., 2013).
The role of antipsychotic agents

Psychopharmacological agents are effective and necessary for the management and
relapse- prevention of psychotic disorders: untreated psychotic patients show much
higher mortality and suicide rates, more hospitalizations and worst outcomes of illness
with greater cognitive and functional impairment (Tiihonen et al., 2006; De Hert et
al., 2009a).
However, there is a considerable literature on the metabolic adverse effects of
antipsychotic agents and, in particular, Second Generation Antipsychotics (SGAs) appear
to induce more weight gain and metabolic abnormalities than First Generation
Antipsychotics (FGAs) (Newcomer, 2007; Nasrallah, 2008; De Hert et al., 2009a;
Papanastasiou, 2013).
257
Clinicians employing newer antipsychotics deal with metabolic side effects more
frequently than extrapyramidal symptoms and tardive dyskinesia. SGAs are responsible
of new cases of diabetes, probably due to specific diabetogenic actions, in particular by
drugs such as clozapine and olanzapine (Reynolds and Kirk, 2010; Stahl, 2013). The
diabetogenic mechanism may involve a muscarinic M3- receptor antagonism (which is
perhaps more relevant for olanzapine and clozapine) since M3 receptors are localized on
beta- cells of pancreas and regulate the insulin release and glucose levels homeostasis
(Stahl, 2013). Also, M3- receptors blockage might alter glucose metabolism leading to
diabetes, diabetic ketoacidosis, hyperosmolar syndrome, all observed in patients treated
with olanzapine and clozapine (Reynolds and Kirk, 2010). Weight gain and dyslipidemias
(in particular hypertriglyceridemia) are also known to be trigger factors for diabetes and
are frequently induced by antipsychotics like olanzapine and clozapine, whereas
aripiprazole and ziprasidone are associated with some weight- loss or poor weight-gain
(Reynolds and Kirk, 2010; Stahl, 2013; Table Table1).1). Weight gain might also be
induced by 5HT2C- and H1- receptor affinity of antipsychotic molecules: H1- receptors
are localized in the hunger and satiety centers held in the hypothalamus and are
responsible for hyperphagia (Reynolds and Kirk, 2010; Stahl, 2013). Other receptor
mechanisms may have additive or synergistic effects. For example, dopamine D2
receptor antagonism can enhance 5-HT2C-mediated effects on food intake, as well as
influencing lipid and glucose metabolism via disinhibition of prolactin secretion
(Reynolds and Kirk, 2010; Stahl, 2013). SGAs also have an impact on the hypothalamic
regions involved in the control of food-intake for example, olanzapine increases NPY
(neuropeptide Y) expression in the ARC (Arcuate Nucleus) (Reynolds and Kirk, 2010;
Stahl, 2013).
Table 1
Side effects of SGAs (adapted from American Diabetes Association/American
Psychiatric Association, 2004; De Nayer et al., 2005; Cohn and Sernyak, 2006; De
Hert et al., 2006; Tschoner et al., 2007; Leucht et al., 2009b).
Weight Dyslipidemia Diabetes EPS Prolactin Sedation QT- interval

gain increase prolongation
Amisulpride + + + +++
Aripiprazole +/ +
258
Weight Dyslipidemia Diabetes EPS Prolactin Sedation QT- interval
gain increase prolongation
Asenapine +/ +/ ++
Clozapine +++ ++ +++ +++ +
Olanzapine +++ ++ +++ +++
Quetiapine ++ + ++ ++
Risperidone ++ +/ ++ + +++ + ++
Ziprasidone +/ + ++
+++, high incidence;++, moderate incidence, +, low incidence, , very low incidence; EPS, extra-
pyramidal symptoms.
Between 15 and 72% of patients affected by psychotic disorders report a significant

weight gain during the acute and maintenance treatment of their illness (De Hert et
al., 2009a). Studies have shown a significant 10-weeks weight gain during the
antipsychotic treatment which ranges widely with different medications. For example,
this weight gain for clozapine is around (+4.45 kg) higher than that gained by olanzapine
(+4.15 kg) which is higher than quetiapine and risperidone (+2.1 kg) which in turn are
higher than those occurring as result of treatment with aripiprazole and ziprasidone (< 1
kg) (Allison et al., 1999; De Hert et al., 2009a). These findings have been confirmed by
clinical trials such as CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness)
and EUFEST (European First Episode Schizophrenia Trial) Studies (Goff et al., 2005;
Lieberman et al., 2005; Daumit et al., 2008; De Hert et al., 2009a; Leucht et al., 2009a).
259
Clinical factors associated with higher weight gain are younger age, lower initial BMI,
personal and family history of obesity, non-white ethnic background, tendency to overeat
in time of stress, cannabis use and first episode psychosis (De Hert et al., 2009a). Weight
gain is not related to SGAs doses used, except for olanzapine and clozapine (Simon et
al., 2009).
There are some putative genes involved in the drug- induced weight gain: the most
replicated findings are regarding the genes for melanocortin 4 receptor (MC4R),
serotonin 2C receptor (HTR2C), leptin, neuropeptide Y (NPY) and cannabinoid receptor
1 (CNR1) (Shams and Mller, 2014).
Causality between antipsychotic usage and the onset of diabetes can be difficult and as
noted earlier, people with psychotic disorders tend to show an increased risk for diabetes
even when drug- nave or untreated (De Hert et al., 2009a).
Approximately 15% of patients with psychosis go on to develop type 2 diabetes (Bushe
and Holt, 2004). Since the prevalence of diabetes among schizophrenia patients is higher
than in the general population (2-fold increased risk), in 2008 the Canadian Diabetes
Association (CDA) defined schizophrenia as an independent risk factor for type 2
diabetes including the usage of second generation antipsychotics in the list of risk factors
(Canadian Diabetes Association Clinical Practice Guidelines Expert Committee et
al., 2013).
In addition, clozapine and olanzapine might influence insulin secretion with a direct
stimulating effect on pancreatic -cells (Melkersson et al., 2004). A significantly higher
increase of HbA1c levels with: olanzapine (0.4%) > quetiapine (0.04%) > risperidone
(0.07%) > perphenazine (0.09%) > ziprasidone (0.11%) has been demonstrated thereby
suggesting that not all drugs are the same (Lieberman et al., 2005).
According to the evidence, a baseline assessment of fasting- glucose is relevant in order
to screen new cases of diabetes developing as a result of antipsychotic treatments.
Clinicians managing patients affected by chronic psychoses need to make better and more
focused efforts to prevent diabetes and respond to it early when it does occur (Ventriglio
et al., 2014).
Coronary Artery Disease (CAD) includes the increase of low-density lipoprotein
cholesterol (LDL-C) and/or decrease of high-density lipoprotein cholesterol (HDL-C).
Studies have shown that the usage of antipsychotic drugs is associated with an increase of
LDL-C and a decrease of HDL-C (Goff et al., 2005; Daumit et al., 2008). The increase of
LDL cholesterol may differ depending on which anti-psychotic drugs are used. As seen
before, clozapine and olanzapine are two compounds which are associated with the
higher increase LDL and triglycerides in serum (Goff et al., 2005; Daumit et al., 2008). It
is important that the clinicians respond rapidly in the early phase of treatment when
weight gain is most likely to occur (Goff et al., 2005; Daumit et al., 2008). It has been
recommended that clinicians should measure lipid levels every 23 months following the
commencement of treatment and also once weight- gain has reached stable levels (De
Hert et al., 2009a). Lipid concentration can be reduced rapidly following a psycho
educational and monitoring program focused on diet, physical exercise and better life-
style (Ventriglio et al., 2014).
260
Increase in levels of blood pressure may occur sporadically, mostly during the clozapine
treatment (Gardner and Teehan, 2011). In contrast, reduction of blood pressure with
associated symptoms of feeling weak is a common occurrence with many antipsychotic
treatments. Syncopal episodes related to orthostasis may happen, mostly due to low-
potency first-generation antipsychotics (1-Adrenergic and calciumreceptors blockage
is generally involved in this adverse effect). Posture-related drops in blood pressure are
especially common with first-generation antipsychotics. A slower dosage titration has
been recommended and with most drugs, tolerance develops with continued use, and
these effects appear to recede (Gardner and Teehan, 2011).
Metabolic syndrome and psychosis

The Metabolic Syndrome (MetS; also known as Syndrome X or Reaven's syndrome)
constitutes of a cluster of different clinical conditions, including abdominal obesity,
insulin resistance, dyslipidaemias, and elevated blood pressure. All components of the
MetS have been recognized as independent risk factors for cardiovascular disease, pro-
thrombotic state, pro-inflammatory state, non-alcoholic fatty liver disease and
reproductive disorders (Papanastasiou, 2013).
Criteria for definition of MetS have developed over the decades as more information has
emerged. World Health Organization (WHO) produced the definitions in 1985, European
Group for the Study of Insulin Resistance in 1999, National Cholesterol Education
Program's Adult Treatment Panel III (NCEP-ATP III) in 2001 (modified in 2003),
American Association of Clinical Endocrinologists in 2003 and finally by the
International Diabetes Federation (IDF) in 2006 (Papanastasiou, 2013).
MetS is diagnosed when 3 out of the following 5 criteria are recognized in the same
patients:
1. Increased waist circumference, M > 102 cm/F > 88 cm (IDF: M 94 cm/F 80
cm);
2. Elevated triglycerides (150 mg/dl) or drug treatment for dyslipidaemia;
3. Reduced high-density lipoprotein (HDL) (< 40 mg/dl) or being on drug treatment
for hypercholesterolaemia;
4. Elevated blood pressure (systolic 130 mmHg, diastolic 85 mmHg) or a history
of hypertension or drug treatment for hypertension;
5. Elevated levels of fasting glucose (100 mg/dl) or being on medication treatment
for hyperglycaemia.
Papanastasiou (2013) observed that the prevalence rates of MetS vary across samples
reported depending upon the variety of patients, their age, sex, ethnicity, medication
status, smoking, duration, and outcomes of illness. Generally, the prevalence rates of
MetS vary from 3.9 to 68%, including patients treated with FGAs and/or SGAs. It has
been noted that of the prevalence of MetS peaks in the fourth/fifth decade of life. Again,
clozapine and olanzapine appeared to be related to higher rates of MetS compared with
other antipsychotic agents (Centorrino et al., 2012). Also, the comparisons between
previously unmedicated and currently treated patients show an increase in prevalence
from 24.7 to 49.6% of MetS. Not surprisingly, patients treated with SGAs show much
261
higher rates of MetS compared to those treated with FGAs (27.8 vs. 9.8%) (De Hert et
al., 2009b; Papanastasiou, 2013).
Recently it has been reported that MetS may influence the cognitive functioning in
patients with chronic psychosisespecially in immediate memory, delayed memory, and
attention (Li et al., 2014).
Prolactin levels
Hyperprolactinemia induced by antipsychotic medication is mostly due to D2-receptors
blockade in the tubero-infundibular dopaminergic system of the hypothalamus. The
magnitude of hyperprolactinemia correlates strongly with dopamine D2 receptor
blockade- potency of the medication being taken. Prolactin levels may produce clinical
signs and consequences: galactorrhea, gynecomastia, oligomenorrhea, amenorrhea,
reduced libido, dyspareunia, vaginal dryness for women; reduced libido, erectile
dysfunction, ejaculatory dysfunction for men (Gardner and Teehan, 2011; Li et al., 2014).
Osteoporosis, hypogonadism, and breast cancer have been associated with prolactinomas,
in which prolactin levels can exceed 5000 ng/ml (Gardner and Teehan, 2011; Li et
al., 2014). It has been recommended that, prolactin should be measured at baseline and
over the follow-up period (monitoring hyperprolactinemia-related signs and symptoms)
(Ventriglio et al., 2014). Prolactin levels range from 0 to 20 ng/ml (0424 mIU/l) in non-
pregnant women: whereas levels for pregnant women are lower than 200 ng/ml (4240
mIU/l). For men the levels should range from: 0 to 15 ng/ml (0318 mIU/l) (Kratz et
al., 2004).
Hyperprolactinemia occurs more frequently in females than males, despite lower doses
used in women. Return to normal prolactin levels occurs rapidly upon discontinuation of
treatment (Halbreich et al., 2003; Gardner and Teehan, 2011).
Hyperprolactinemia associated with antipsychotic medication has been observed with
effects from risperidone = paliperidone = amisulpride = haloperidol (at 7491%) which is
greater than that for olanzapine (220%) which is higher than that related to quetipaine
(not significant increase) which is higher than that for aripiprazole = ziprasidone (not
significant increase) (Halbreich et al., 2003; Gardner and Teehan, 2011).
When prolactin levels are high, but lower than 150 ng/ml, clinician must consider a
switch from the current antipsychotic to another which is not associated with a significant
increase in prolactin levels while taking into account the risk of rebound in psychotic
symptoms. They may consider introducing a dopamine agonist like cabergoline,
bromocriptin, pergolide. If prolactin levels are higher than 150 ng/ml, then advice from
an endocrinologist may help along with neuro-imaging investigations to exclude pituitary
and juxtasellar adenomas (De Hert et al., 2014).
QT- interval prolongation

Using electro-cardiogram the functioning of the heart is assessed and in this context, QT
interval is a measure of the time between the start of the Q wave and the end of the T
wave in the heart's electrical cycle. In general, the QT interval represents electrical
depolarization (Na+ and Ca++ intake in the cells) and repolarization (K+ output) of the
262
ventricles. QT is corrected for heart rate (QTc) derived from the heart rate (HR) as 60
beats per minute according to Bazzett's formula.
Although QT may vary according to age, sex, circadian rhythms; a lengthened QT
interval is a marker for the potential of ventricular tachyarrhythmias like torsades de
pointes and a risk factor for sudden death. A QTc value above 500 ms or an increase of 60
ms (20% from baseline) is strongly associated with arrhythmias and torsade de pointes
(TdP).
Antipsychotic agents may prolong QTc interval depending on their binding- potency to
IKr channels of ventricle repolarization (HERG channels). Second generation
antipsychotic mostly involved with QTc- prolongation are ziprasidone, risperidone,
paliperidone, clozapine, quetiapine. aripiprazole, olanzapine, and asenapine are associate
with lower variations in QTc- interval (Gardner and Teehan, 2011; Hasnain and
Vieweg, 2014).
First generation antipsychotics are responsible for a higher QTc- prolongations, in
particular drugs like haloperidol. Thioridazine, sertindole have consequently been
withdrawn worldwide since these drugs lead to arrhythmias and sudden death. There is
no doubt that good clinical practice demands that antipsychotic should be prescribed with
caution for patients affected by cardiovascular diseases (congenital long QT syndrome,
myocardial infarction, cardiac failure, arrhythmias) or other risky conditions (previous
TdP or hypokalaemia) (Gardner and Teehan, 2011; Hasnain and Vieweg, 2014).
Finally, it has been reported that myocarditis may occur during the treatment with
clozapine, in particular in the first 2 months of it (in up to 85% of cases). Also, patients
treated with chlorpromazine or fluphenazine may develop myocarditis. If clinical signs of
myocarditis are suspected (e.g., tachycardia), the drug should be stopped immediately
(Gardner and Teehan, 2011).
Monitoring metabolic disorders among patients affected by

chronic psychosis
There have been many attempts by several international societies to develop guidelines
for screening and monitoring metabolic consequences of psychosis and antipsychotic
treatments. The aim of such procedures is to reduce those modifiable factors associated to
the risk of cardiometabolic conditions among patients affected by schizophrenia (De Hert
et al., 2009a). Guidelines developed by the European Psychiatric Association (EPA),
supported by the European Association for the Study of Diabetes (EASD) and the
European Society of Cardiology (ESC), also known as EPA/EASD/ESC Position
Statement are very helpful in clinical settings (De Hert et al., 2009a; Table Table22).
Table 2
EPA/EASD/ESC Position Statement (adapted from De Hert et al., 2009a).
263
Baseline AP Prescription W 1 W 2 W 3 W 4 W5 W6 W12 M6 M9 1 year
Weight
Height
BMI
Waist circ.
FBG
TC
TG
LDL-C
HDL-C
HbA1c
264
Baseline AP Prescription W 1 W 2 W 3 W 4 W5 W6 W12 M6 M9 1 year
Blood
pressure
HR
Chest
auscul.
Pulse
ECG
Other*
Circ., circumference; auscul., auscultation. If patient is suffering from diabetes, HbA1c should be measured
3-monthly. Urinary albumin, creatinine, ophtalmology visit, and feet check- up should be planned annually.
BMI, body mass index; FBG, fasting blood glucose; TC, total cholesterol; TG, triglycerides; LDL-C, low
density lipoprotein cholesterol; HDL-C, high density lipoprotein cholesterol; HbA1c, glycated hemoglobin;
HR, heart rate; ECG, Electrocardiography.
ECG should be repeated yearly and in case of drug and dose changes.
*
Any other medical assessment, if needed; W, week; M, month.
For a number of reasons, these recommendations have been poorly followed and
employed in the clinical settings. It is well known that when applied, these guidelines
appear to improve the metabolic outcome of patients affected by schizophrenia and
bipolar disorders (De Hert et al., 2009a, 2011; Ventriglio et al., 2014).
The baseline examination of patients should include history of previous cardiovascular
diseases, diabetes or other related disease; family history of premature CVD, diabetes or
265
other related disease; smoking habits, food selection, physical activity; weight and height
in order to calculate body mass index (BMI) and waist circumference; fasting blood
glucose levels; fasting blood lipids: total cholesterol, triglycerides, LDL cholesterol (by
calculation) and HDL-C; blood pressure (measured twice and average taken), heart rate,
heart and lung auscultation, foot pulses; ECG (De Hert et al., 2009a).
If metabolic parameters are within the normal range in patients on antipsychotic
treatment for more than 12 months, it is recommended that clinicians must repeat
previous factors annually. If values are in normal ranges at baseline in drug- nave
patients, monitoring has to be repeated at week 6, 12, and annually (paying particular
attention to weight gain within the 6 week of treatment) (De Hert et al., 2009a).
In presence of one or more risk factors, the antipsychotic treatment must be selected
carefully, matching the efficacy and safety (metabolic) perspective. Specific treatments
may be required to reduce the cardiovascular risk. Clinicians have to involve general
practitioners in order to collaborate with them in managing the risk factors. EPA
guidelines recommend that BMI should be 25 kg/m2, waist circumference < 102 cm
(men)/<88 cm (women), blood pressure 140/90 mmHgtriglycerides < 190 mg/dL
LDL < 115 mg/dL in non-diabetic patients. The, glycosylated hemoglobin < 7%blood
pressure 130/80 mmHgtriglycerides < 175 mg/dLLDL < 100 mg/dL should be the
recommended levels in patients with diabetes. Patients with diabetes should have their
glycosylated hemoglobin levels measured 3-monthly and microalbuminuria, renal
functioning, ophtalmological and feet examination yearly (De Hert et al., 2009a).
Conclusions
Metabolic consequences of treatment with antipsychotic medication increase the risk of
mortality among patients affected by chronic psychosis and many of the factors are
preventable. Patients with psychoses appear to show higher levels of cardiometabolic co-
morbidites in comparison with general population and 23-fold increased risk of
premature death. Clinicians need to employ international guidelines and procedures to
screen and monitor these co-morbid conditions in order to reduce mortality rates among
patients affected by psychotic disorders and improve the outcome of illness, including
patients' global functioning and quality of life.
Funding
The research has been conducted in the absence of grant funding.

The reviewer Marcello Nardini declares that, despite having collaborated on an article
with authors Antonio Ventriglio and Antonello Bellomo in 2014, the review was
conducted objectively and no conflict of interest exists. The authors declare that the
research was conducted in the absence of any commercial or financial relationships that
could be construed as a potential conflict of interest.
266
Footnotes
1
ADA Cardiometabolic Risk
Initiative: http://professional.diabetes.org/resourcesforprofessionals.aspx?cid=60379 (ac
cessed 02.08.2015).
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Articles from Frontiers in Neuroscience are provided here courtesy

of Frontiers Media SA
The psychophysiological effects of Tai-chi and exercise in

residential Schizophrenic patients: a 3-arm randomized
controlled trial
Rainbow Tin Hung HoEmail author,
Adrian Ho Yin Wan,
Friendly So Wah Au-Yeung,
Phyllis Hau Yan Lo,
Pantha Joey Chung Yue Siu,
Cathy Pui Ki Wong,
Winnie Yuen Han Ng,
Irene Kit Man Cheung,
Siu Man Ng,
Cecilia Lai Wan Chan and
Eric Yu Hai Chen
BMC Complementary and Alternative MedicineThe official journal of the International

Society for Complementary Medicine Research (ISCMR)201414:364
DOI: 10.1186/1472-6882-14-364
271
Ho et al.; licensee BioMed Central Ltd. 2014
Received: 27 August 2014
Accepted: 23 September 2014
Published: 27 September 2014
Open Peer Review reports
Abstract
Background
Patients with schizophrenia are characterized by high prevalence rates and chronicity that
often leads to long-term institutionalization. Under the traditional medical model,
treatment usually emphasizes the management of psychotic symptoms through
medication, even though anti-psychotic drugs are associated with severe side effects,
which can diminish patients physical and psychological well-being. Tai-chi, a mind-body
exercise rooted in Eastern health philosophy, emphasizes the motor coordination and
relaxation. With these potential benefits, a randomized controlled trial (RCT) is planned
to investigate the effects of Tai-chi intervention on the cognitive and motor deficits
characteristic of patients with schizophrenia.
Methods/design
A 3-arm RCT with waitlist control design will be used in this study. One hundred and
fifty three participants will be randomized into (i) Tai-chi, (ii) exercise or (iii) waitlist
control groups. Participants in both the Tai-chi and exercise groups will receive 12-weeks
of specific intervention, in addition to the standard medication and care received by the
waitlist control group. The exercise group will serve as a comparison, to delineate any
unique benefits of Tai-chi that are independent of moderate aerobic exercise. All three
groups will undergo three assessment phases: (i) at baseline, (ii) at 12 weeks (post-
intervention), and (iii) at 24 weeks (maintenance). All participants will be assessed in
terms of symptom management, motor coordination, memory, daily living function, and
stress levels based on self-perceived responses and a physiological marker.
Discussion
Based on a promising pilot study conducted prior to this RCT, subjects in the Tai-chi
intervention group are expected to be protected against deterioration of motor
coordination and interpersonal functioning. They are also expected to have better
symptoms management and lower stress level than the other treatment groups.
Trial registration
The trail has been registered in the Clinical Trials Center of the University of Hong Kong
(HKCTR-1453).
272
Keywords
Tai-chi Exercise Schizophrenia Chinese Randomized controlled trial (RCT) Salivary

cortisol
Background
Effectiveness of exercise interventions in psychiatric disorders
The traditional medical model of schizophrenia prioritizes self-care and management of
symptoms and functional abilities, both in daily patient care and in research; physical and
psychological well-being are considered secondary treatment goals. Patients with
schizophrenia have comparatively shorter life expectancies than the general population.
This is thought to be due to physical factors (such as higher rates of cardiovascular and
metabolic diseases, including obesity) as well as psychological factors (i.e. depression
and suicidality) [1, 2, 3, 4]. However, these outcomes may be partially attributable to the
side effects of medication and poor lifestyle factors such as high-fat low-fiber diets,
heavy smoking or a lack of exercise [5]. Hence, the promotion of physical and
psychological well-being through exercise is likely to be of benefit to patients with
schizophrenia.
Exercise is known to be of psychosocial benefit to patients. Levin and Gimino [6]

showed that aerobic exercise reduces depression, anxiety and obsessive-compulsive
symptoms in hospitalized patients with schizophrenia, relative to non-exercise-based
treatment regimes. Similar interventions have been shown to improve mood, anxiety,
depression, self-esteem, energy, concentration, quality of life and social interactions in a
range of psychopathological disorders [7, 8]. A 10-week exercise program implemented
by Faulkner and Sparkes was found to reduce auditory hallucinations, raise self-esteem
and improve sleep patterns as well as general behaviors in patients with schizophrenia
[9]. More recent research has uncovered anatomical changes associated with aerobic
exercise, most notably increases in hippocampal volume [10], that may improve short-
term memory in participants with schizophrenia. In addition to symptom-related
outcomes, a lack of physical activity was associated with poorer health-related quality of
life indices [11].
Multiple benefits of Tai-chi as a physical and mental exercise

Based on Eastern health philosophies which focus on the interrelatedness of body and
mind, Tai-chi is a form of moderate aerobic exercise that places emphasis on mental well-
being [12, 13]. The basic principles of Tai-chi center on physical relaxation, mental
alertness, movement sequencing and coordination [14]. In targeting the mind and body,
Tai-chi may be particularly beneficial in patients with mental illnesses: there is now an
increasing body of empirical evidence demonstrating its physical and mental benefits in
clinical populations suffering from depression, posttraumatic stress disorders and
traumatic brain injury [15, 16, 17]. The multiple benefits of Tai-chi were established in a
recent review of 42 RCTs on Tai-chi [12]. Tai-chi was found to improve cardiovascular
fitness, bone health, motor coordination, balance, flexibility, and to prevent falls
273
[12, 18, 19]. Immunity, a crucial factor in physical health associated with illness
prevention and prognosis, also improved after Tai-chi [20]. Furthermore, it was shown to
facilitate psychological focus and relaxation [21], and to alleviate mood disturbances,
anxiety, stress, tension, depression, anger and fatigue [16].
In addition to alleviating symptoms, Tai-chi can be used to target motor and cognitive
deficits [22], which are subtle manifestations of cerebellar abnormalities and changes in
neurological pathways [23]. Psychotropic drugs often induce severe motor deficits,
including parkinsonism, dyskinesia and akathisia. Problems in movement and memory
can potentially be alleviated by the practice of Tai-chi. The strength of the Wu-style
(Cheng form) of Tai-chi [24] is its emphasis on rhythm and coordination. Participants
name each movement while practicing; this process demands attention, concentration,
memory and physical exertion within the exercise routine. Continual practice is highly
encouraged after the completion of classes.
Despite efforts to investigate the impact of Tai-chi on psychological health outcomes,

only one study has been published on the effectiveness of Tai-chi in schizophrenia. This
study, conducted over 12 weeks, reported a reduction in negative symptoms in patients
who had practiced Tai-chi [25]. It is postulated that the focus required for Tai-Chi
encourages identification with the inner self, allowing problems of dissociation and
attention, characteristic of schizophrenia, to be addressed. Nonetheless, little is known
about the specific cognitive benefits of Tai-chi, or of the possible physiological
mechanisms involved.
Schizophrenic Symptoms and the HPA Axis

Salivary cortisol, a neuroendocrine indicator of stress and immunity, can provide insight
into the possible physiological mechanisms underlying schizophrenia [16]. Patients with
schizophrenia tend to have altered cortisol levels and stress responses, though studies
conducted thus far have demonstrated both hyper- and hypo-function of the
hypothalamicpituitaryadrenal (HPA) axis which regulates cortisol levels [26].
Abnormally blunted cortisol responses have also been recorded in patients with
schizophrenia [27]. Both hyper- and hypo-activity of the HPA axis have adverse effects
on physical and psychological health. For patients with schizophrenia, increased cortisol
levels are associated with more severe negative symptoms [28] and worse cognitive
functioning in terms of verbal memory [29]; blunted cortisol responses are also
associated with poorer quality of life [30]. While a previous study has demonstrated the
effectiveness of Tai-chi in lowering salivary cortisol concentrations [31], the effects of
lowered cortisol concentrations on symptoms, and other physical and psychological
deficits that impair patient well-being, are virtually unknown. Alleviation of symptoms,
other deficiencies and psychological health challenges can benefit patients overall
functioning and quality of life. Tai-chi has been shown to confer these benefits in a
number of chronic conditions [32].
274
Research objectives
The present study protocol aims to explore the effects of Tai-chi on the symptoms (both
positive and negative), motor and cognitive deficits (in terms of motor coordination,
motor sequencing and memory), general functional disabilities, stress and salivary
cortisol levels in patients with schizophrenia. The effectiveness of Tai-chi practice will be
compared to an alternative exercise regimen and a waitlist control group.
Methods/design
A non-blind, 3-arm randomized controlled trial (RCT) with waitlist control design will be
used. Eligible participants will be randomized into (i) Tai-chi, (ii) exercise or (iii) waitlist
control groups, on a 1:1:1 basis. The research is conducted in compliance with the
Helsinki Declaration, and ethical approval has been obtained from Institutional Review
Board of the University of Hong Kong/ Hospital Authority Hong Kong West Cluster
(Ref: UW 11481) before participant recruitment and randomization take place. Human
Research Ethics Committee for Non-Clinical Faculties of the University of Hong Kong.
The exercise control will serve as a comparison to delineate the unique benefits of Tai-chi
that cannot be accounted for by similar levels of moderate aerobic exercise. This
comparison will facilitate a deeper understanding of the positive benefits of Tai-chi, such
as attainment of mental tranquility and relaxation, which cannot be explained by physical
exercise alone. While exercise is known to confer stress-reducing benefits, there are few
studies that compare Tai-chi with alternative exercise interventions [33].
The waitlist control group will continue to receive regular medication and care during the
intervention phase. Participants in this group will be offered the Tai-chi or exercise
classes on a voluntary basis following completion of the study. Three assessment phases
will be carried out for all groups at three time points: (i) baseline, (ii) 12th week (post-
intervention time-point), and (iii) 24th week (maintenance time-point).Figure 1 illustrates
the treatment received by the intervention group, the waitlist control condition received
by the control group, and the data collection points of the study.
275
Figure 1
Flow diagram of intervention/waitlist control and data
collection points.
276
Participant recruitment
Patients diagnosed with chronic schizophrenia, residing in a Hong Kong mental health
rehabilitation complex providing both long-term care and halfway house services will be
recruited to the study. Patients will be invited to participate by their respective social
workers, based on specific inclusion and exclusion criteria.
Inclusion criteria will be as follows: a) fulfillment of DSM-IV TR criteria for

schizophrenia, or diagnosis by a psychiatrist, b) age between 18 and 65 years, c) ability to
understand and speak Cantonese, and d) no formal training in or regular practice of Tai-
chi.
Exclusion criteria will be as follows: a) diagnosis of acute schizophrenia requiring

hospitalization, b) presence of unstable or severe schizophrenic symptoms (e.g. persistent
withdrawal) that would limit ability to interact or participate in the class, c) history of
brain trauma or organic mental disorders (e.g. mental retardation or dementia), d)
presence of physical disabilities, e) presence of other severe illnesses which may impair
cognitive or visuo-motor function, cause physical pain or limit life expectancy to 10 years
or less.
In determining the sample size, we have taken into consideration multiple independent
variables, using multiple regression modeling with a medium effect size (f2) of 0.15, at
0.8 power and a significance level of 0.05. Experimental, clinical and demographic
variables anticipated to affect the intervention outcome were included in the model. An
attrition rate of approximately 25% is expected, based on prior community trials of Tai-
chi interventions in elderly patients, and exercise programs for patients with severe
mental illnesses [33]. Thus, a total of 153 participants will be targeted for the study.
Upon application of inclusion and exclusion criteria, a trained research assistant will
obtain informed consent from participants at the rehabilitation complex. Eligible and
consenting participants will then be randomized into one of the three treatment
conditions, and baseline data collection will be arranged at least one week prior to the
commencement of group programs.
Intervention
The Tai-chi intervention is based on the first segment of the Wu-style Cheng-form Tai-chi
chuan, comprising 22 simple movements [24]. The basic principal of this form is the
emphasis on attention and coordination. Learning the names of each move will promote
concentration and focus during practice. Results from the pilot study were used to
optimize this program, to maximize learning and memory of the movements while
encouraging practice. This will involve the use of flash cards with descriptive diagrams
of the movement forms. The intervention will be conducted by mental health
professionals with formal training in Tai-chi, who have attended 12 training sessions for
instructors at the professional Tsui Woon Kwong Tai-chi Institute.
277
To design a control exercise regime of comparable intensity, a pilot control study was
conducted with four schizophrenic patients (two male and two female) with former Tai-
chi experience. The patients heart rates were measured by a portable heart rate monitor
while they practiced a full set of Tai-chi movements. Based on the data collected, a
qualified fitness instructor then devised a moderate aerobic exercise routine designed to
achieve 5060% maximal oxygen consumption (VO2 max) for the exercise group. The 1-
hour exercise intervention, to be led by mental health professionals, will include a warm
up, stretching and joint movements (15 minutes), walking (10 minutes), stepping
(10 minutes), mild weight training (10 minutes) and cool down stretching (15 minutes).
For both the Tai-chi and exercise groups, a 1-hour weekly class will be held for 12
consecutive weeks. Sessions will be conducted in groups of 20. Participants will also be
invited to a 45-minute, twice-weekly training session under the guidance of mental health
professionals in between trainer-led classes. The waitlist group will receive routine care
and be offered a similar Tai-chi or exercise class after the 24-week assessment period.
Setting
All assessment and interventions will be conducted in a residential long-term care hostel
for psychiatric patients in Hong Kong.
Instruments
The PANSS is a psychiatric rating system that will be used to assess the positive and
negative symptoms of schizophrenia exhibited in the week prior to assessment. It is based
on information from the reports of family members or primary care staff, as well as a 40-
minute semi-structured psychiatric interview with the patient. The patient will then be
rated on a scale of 1 to 7 on 30 different symptoms pertaining to 3 different subscales
positive, negative, and general psychopathologywith internal consistency rats ranging
from 0.73 to 0.83.
Assessments will be conducted by trained researchers using the following devices:
1. 1.
Psychiatric Symptoms - The Positive and Negative Syndrome Scale

(PANSS 30) [34]
2. 2.
Motor Coordination and Sequencing Neurological Evaluation Scale

(NES) [35]
1. 2.1
278
Motor Coordination Subscale: motor coordination will be measured using four tasks,
including (i) tandem walk, (ii) rapid alternation movements, (iii) finger/thumb opposition,
and the finger-to-nose test [36]. The ability of the patient to perform each of the above
tasks will be rated on a 3-point scale based on the number of mistakes.
2. 2.2
2.2 Sequencing of Complex Motor Acts Subscale: this will consist of four tasks
associated with the sequencing of motor acts, including (i) the fist-ring test (right and left
hands), (ii) the fist-edge-palm test (right and left hands), (iii) the Ozeretski test, and (iv)
the rhythm tapping test [36]. Performance will be rated on a 3-point scale based on the
number of mistakes.
3. 3.
Digit Span Wechsler Adult Intelligence Scale, Third Edition Chinese

version (WAIS-III) [37] The digit span sub-scale is composed of two parts: forward
movement of digits, and backward movement of digits. Participants will be invited to
repeat movements of 3 9 digits forward and 2 9 digits backward. Clinically, the sub-
scale evaluates participants short-term memory, attention, and concentration.
4. 4.
Barthels Activities of Daily Living (ADL) index Chinese version (Barthels

ADL) [38] Barthels ADL index evaluates basic self-care. The index comprises 10 tasks,
including feeding, transferring, grooming, toilet use, bathing, walking, climbing stairs,
dressing, and bowel and bladder continence. The items are weighted according to a
scheme developed by the authors.
5. 5.
Lawtons Instrumental Activities of Daily Living (IADL) scale Chinese version [39]
This self-report scale covers 8 domains of complex daily life, such as ability to use the
telephone, shopping, food preparation, housekeeping, laundry, traveling on public
transport, self-medication, and the ability to handle finances.
6. 6.
Stress
1. 6.1
279
Perceived stress scale (PSS) [40] The PSS measures how often participants experience
general stressfulness within a given month on a 10-item, 5-point Likert scale. Higher
scores indicate greater stress. The Chinese version of the PSS was translated and utilized
by the research team with good internal consistency.
2. 6.2
Salivary cortisol Collection will be conducted by participants themselves under the

guidance of mental health professionals. Saliva samples will be collected at four
prescribed times (upon awakening, 30 minutes post-awakening, at 11:30 am and at
7:30 pm) using the collection device Salivette (Starstedt, Ag & Co., Nmbrecht,
Germany), which includes a cotton swab to place under the tongue. Smoking, eating and
drinking will be prohibited for half hour prior to saliva collection. The samples collected
will be stored at 20C until analysis.
3. 6.3
Daily condition measures with salivary cortisol Measures of participants health-related

behaviors and activities on the day of saliva collection will be collected in conjunction
with salivary cortisol. These measures include (i) self-reported sleep quantity that day
(hours of sleep at night and nap hours), (ii) subjective sleep quality rated on a scale of 1
to 10, (iii) smoking habit and the number of cigarettes consumed that day, (iv)
alcohol/coffee drinking habits and the approximate amount consumed that day, and (v)
subjective evaluation of dietary habits and the quality of diet on the day of collection
rated on a scale of 1 to 10. All the above measures will affect the diurnal cortisol rhythm
and hence must be taken into account during data interpretation.
7. 7.
Socio-demographic and clinical informat ion Patients socio-demographic

and clinical information will be obtained from personal and medical records. Socio-
demographic data include age, gender, education level and marital status. The frequency
and duration of exercise or relaxation practices will also be recorded. Clinical
information includes the time since psychiatric diagnosis and condition severity,
including acute and chronic extrapyramidal symptoms, particularly drug-related
movement disorders such as parkinsonism, akathisia and dyskinesia [41]. Medication and
other adjunctive treatments, including institutional care, will also be recorded. These
factors can represent important confounding variables when modeling outcomes.
Data analysis
Effectiveness of the Tai-Chi intervention
Repeated measures analysis of variance using SPSS software will be used to explore the
effectiveness of the Tai-chi intervention over the three assessment time points, relative to
the exercise and waitlist control groups. Ordinary least squares (OLS) regression will be
280
used to assess the relationship between the dependent variables (outcomes) and
independent variables (covariates). A model of the role of Tai-chi with respect to other
influencing variables, such as clinical prognosis or frequency of practice, will deepen
understanding of the true effects of Tai-chi in this clinical population. All levels of
significance will be set at p<0.05. Intention-to-treat analysis will be used to prevent
participant selection bias due to study discontinuation.
Analysis of salivary cortisol

To obtain cortisol levels the saliva samples will first be thawed and centrifuged at
3000 rpm for 15 minutes at room temperature. The levels will be determined in the HKU
Clinical Oncology Lab using an enzyme-linked immunosorbent assay (EIA) kit
(Salimetrics Inc., USA). The assay sensitivity for this kit is 0.007 g/dl (i.e. 0.193 nmol/l)
and the intra- and inter-assay coefficients of variation are 3% and 10%, respectively.
Due to the skewed distribution of salivary cortisol data, a natural logarithm will be used
to normalize raw cortisol data. Mean cortisol levels will be calculated across four
collection time points. Total cortisol levels will be expressed as area under the curve
(AUC), and diurnal cortisol rhythm will be calculated by linear regression analysis of
log-transformed cortisol levels at time of collection.
Relationship between cortisol levels and physical and

psychological deficits
Using baseline data from all participants, correlation analyses will be used to explore the
interrelationship between diurnal cortisol patterns and subjective stress, psychiatric
symptoms, motor deficits, memory test and general functioning.
To trace individual changes in salivary cortisol levels over time, and to evaluate the
complex relationships between different variables, the two-level individual growth curve
model [42] and MPlus software will be used for analysis. This method is a variant of
multiple regression modeling appropriate for the nested structure of our data sets. In the
study, salivary cortisol measures at four time points over the day are nested within
participants.
Discussion
While physical exercise has been researched extensively, this RCT will represent one of
the first investigations into mind-body exercises in patients with schizophrenia. The
results of a pilot study demonstrated attenuated deterioration in motor coordination and
daily functioning in patients practicing Tai-chi. With a larger sample size, and using an
exercise group for comparison, the aims of this RCT are to confirm previous findings and
to provide new insight into how Tai-chi may provide unique benefits to patients with
schizophrenia, above the effects of moderate aerobic exercise. Analysis of salivary
cortisol levels will elucidate the effect of Tai-chi on physiological stress. The results will
281
establish the feasibility and efficacy of integrating mind-body exercises into routine care
as complementary treatment for psychiatric conditions.
Declarations
Acknowledgements
This study is funded by the General Research Fund, Research Grants Council (GRF/HKU
744912). The authors would like to acknowledge the staff of The Providence Garden for
Rehab, Hong Kong, for their provision of support and coordination for this study.
Authors' original submitted files for images
Below are the links to the authors original submitted files for images.
12906_2014_1932_MOESM1_ESM.pdf Authors original file for figure 1
Competing interests
This study is funded by the General Research Fund, Research Grants Council (GRF/HKU
744912). The authors declare that they have no competing interests.
Authors contributions
Conceptualization and design of the study: RTHH, FSWAY, WYHN, AWHY, CPKW,
PHYL; Preparation of proposal for funding application: RTHH, PHYL, IKMC, SMN,
CLWC, EYHC; Preparing the manuscript: RTHH, AWHY, PHYL, JCYS; Reviewing the
manuscript: RTHH, AWHY, JCYS, PHYL, FSWAY, CPKW, SMN, CLWC, EYHC. All
authors read and approved the final manuscript.
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Pre-publication history
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286
Pets and Animal-Assisted Therapy
In the average Jamaican community, there are no shortages of dogs or cats which can be
used by the communitys Family Doctor or his or her assistant in the carrying out of
animal assisted therapy. It is assumes the presence of a willing community which is able
to provide the Family Doctor will a good pup or kitten of trainable age, the willingness of
the Psychatry Department of the local hospital to train either the Family Doctor or his or
her Assistant with the training required and the Canine Division of The Jamaica
Constabulary Force to train the animal in keeping with the requirements of the Doctor
and the local restaurants to assist in the feeding of the animal. Were this approach to be
persued the cost of Pet and Animal Assisted Therapy would be affordable to most
working Jamaicans assuming the participation of the Health Insurance Companies and
The National Health Fund.
287
CurrentGerontologyandGeriatricsResearch
Volume2014(2014),ArticleID623203,9pages
http://dx.doi.org/10.1155/2014/623203
Review Article
The Benefit of Pets and Animal-Assisted Therapy to
the Health of Older Individuals
E. Paul Cherniack1,2 and Ariella R. Cherniack3
1
The Geriatrics Institute, University of Miami Miller School of
Medicine, Division of Geriatrics and Gerontology, The Geriatrics
and Extended Care Service and Geriatric Research Education,
Clinical Center (GRECC) of the Miami Veterans Affairs Medical
Center, Miami, FL, USA
2
Bruce W. Carter Miami VA Medical Center, Room 1D200, 1201
288
NW 16 Street, Miami, FL 33125, USA
3
Shaarei Bina TAG, 1557 NE 164 Street, North Miami Beach, FL
33162, USA
Received 22 July 2014; Revised 23 October 2014; Accepted 26
October 2014; Published 16 November 2014
Academic Editor: Tomasz Kostka
Copyright 2014 E. Paul Cherniack and Ariella R. Cherniack. This
is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution,
and reproduction in any medium, provided the original work is
properly cited.
Abstract
Many studies utilizing dogs, cats, birds, fish, and robotic
simulations of animals have tried to ascertain the health benefits
of pet ownership or animal-assisted therapy in the elderly.
Several small unblinded investigations outlined improvements in
behavior in demented persons given treatment in the presence of
animals. Studies piloting the use of animals in the treatment of
depression and schizophrenia have yielded mixed results.
Animals may provide intangible benefits to the mental health of
older persons, such as relief social isolation and boredom, but
these have not been formally studied. Several investigations of
the effect of pets on physical health suggest animals can lower
blood pressure, and dog walkers partake in more physical activity.
Dog walking, in epidemiological studies and few preliminary
trials, is associated with lower complication risk among patients
with cardiovascular disease. Pets may also have harms: they may
be expensive to care for, and their owners are more likely to fall.
Theoretically, zoonotic infections and bites can occur, but how
often this occurs in the context of pet ownership or animal-
assisted therapy is unknown. Despite the poor methodological
quality of pet research after decades of study, pet ownership and
animal-assisted therapy are likely to continue due to positive
subjective feelings many people have toward animals.
1. Introduction
Two-thirds of all US households [1, 2] and close to half of elderly
individuals own pets [3]. Investigations involving pets and other
289
animals attempting to improve the health of older individuals
have involved many species, including dogs, cats, and
manufactured simulations of animals [4]. In this paper, the
evidence for the impact of animals on the health of the elderly is
assessed. Given the small number of published manuscripts, a
systematic review was not attempted. Rather, the studies
considered were obtained by performing a PubMed search using
terms including pets, elderly, and animal-assisted. Additional
articles were obtained from the reference lists of the original
articles found.
2. Potential Benefits of Animals

2.1. Effects on Mental Health
The most frequently studied use of animals with elderly
participants has been to alleviate manifestations of cognitive
disorders, such as agitation [5]. All of the studies were unblinded,
not all were controlled, but most, though not all, showed small
but statistically significant improvements in behavioral symptom
scores in the animal-assisted interventions.
One trial, the sole study that used a bird, uniquely noted that
animals conferred psychological benefits to cognitively
unimpaired older individuals; 144 persons without cognitive
impairment in nursing homes in Italy were exposed to either a
canary, a plant, or neither of the two [ 6]. The individuals assigned
to care for a canary or plant were provided with care instructions
and participated in a three-month intervention, the details of
which were not specified in the paper. Subjects who cared for the
bird had significantly better scores at the end of the intervention
on subscales of psychological symptoms in the Brief Symptom
Inventory and LEIPAD-II-Short Version, which subjects in the other
two groups did not.
Other investigations explored the effects of animals on demented
elderly individuals (see Table 1). A dementia unit for US veterans
piloted the use of a pet dog to elicit for socialization. Twelve
demented patients exhibited a significant larger number of social
behaviors, such as smiling or speaking in the presence of the
dog, implying that animals might create benefit apart from any
effect on cognition [7].
Table 1: Studies on use of animals in dementia.
290
Another uncontrolled trial suggested that animals could help
alleviate problematic behaviors in demented individuals. This trial
enrolled elderly residents of two US nursing homes who had
MMSE scores of 15 or below who were treated with animal-
assisted therapy [8]. The participants, in a recreational room for
one hour a day, met with a dog and its trainer. They could engage
in a variety of activities including feeding, petting, grooming the
animal, socializing with the trainer, and discussing pets the
subjects previously owned. Subjects achieved a mean 25 percent,
significantly better scores on the CMAI index of behavioral
disturbance after the intervention.
Two further studies, in addition, piloted the efficacy of animal-
assisted therapy on cognition and mood in cognitively impaired
older persons. Twenty-five moderately demented residents of a
nursing home were divided into two groups [9]. In the
intervention group (mean Folstein Mini-Mental (MMSE) score 15.3,
mean fifteen-question Geriatric Depression Scale (GDS) score
5.9), the subjects experienced a weekly hour and a half activity
for 60 days in which they interacted with trained pet therapy
dogs. The participants either walked, played with, petted, or held
the animals under the supervision of a trainer. In the control
group (mean MMSE score 18.3, mean GDS score 7.4, which was
not significantly different than in the intervention group) the
subjects watched the animals enter the nursing home but did not
interact with them. Unfortunately, after the intervention, both
groups increased their MMSE and lowered their GDS scores, but
the changes in both groups between pre- and postintervention
values were not significant. A second small study examined four
moderately to severely demented residents of a nursing home
who were videotaped for behavioral responses prior to and during
an animal therapy session with a dog [ 10]. The residents
displayed significantly fewer signs of agitation and more social
behaviors during animal therapy.
An additional trial uniquely explored the possibility that animals
might confer physical benefits to older persons with dementia
and, furthermore, used fish, which did require the subjects to
handle the animals. In this study, demented individuals in several
nursing homes successfully gained weight after fish tanks were
installed [11]. Sixty-two older persons who resided in the
dementia units of three different nursing homes containing tanks
in recreational and dining rooms that allowed a twenty inch
viewing area with background lighting to compensate for
291
potential resident visual impairment were compared with another
group of residents who had a scenic ocean picture added to
similar rooms. Residents in each of the homes had different
exposure times to either the fish tanks or the pictures. When the
data from the subjects who were exposed to the fish tanks was
pooled together, there was a mean 1.65lb weight gain between
three months before the tanks and four months after the tanks
were placed () but no gain in the control group.
Animals might provide other benefits to demented individuals,
such as improving their ability to socialize, as suggested in
several trials. In one study, which was not blinded, 33 individuals
who lived in a nursing home were exposed to animals during 41.1
hours of animal-assisted therapy and 33.8 hours of recreational
therapy without animals [12]. Long conversations between alert
participants were more likely to occur in therapy groups when
animals were present, but brief conversations were more likely
when animals were absent. In another trial, a videotape captured
the social interactions between 36 nursing home residents in
ninety-minute occupational therapy sessions with or without a
dog present [13]. Residents were more likely to have verbal
interactions with the dog in the session. In a third investigation,
thirteen demented residents were exposed to a plush mechanical
toy dog that could sit up and wag its tail, or a robotic dog that
could respond to seventy-five commands [ 14]. Subjects
responded to both objects, similarly, by talking to it or clapping
their hands when it moved.
Nurses have written their personal, qualitative observations that
animals relieve loneliness and boredom, foster social interaction,
and add variety to the lives of such persons, indirectly suggesting
other possible advantages to human interactions with animals
not thus far documented in clinical trials [5, 15]. In one survey,
the nursing staff of an intermediate care unit delineated their
perceptions of cat mascots, animals that spend the day in the
unit [16]. There was no formal regulation of the interaction
between the cats and the patients, nor any formal measures of
the interaction. However, the nurses did state their opinions that
the cats increased patient interactivity with their other people
and their environment, and that the patients enjoyed their
presence.
Pets may also positively influence the behavior of demented
elderly owners. In one comparison survey, demented pet owners
were less likely to exhibit verbal aggression but were otherwise
292
similar to non-pet owners in likelihood of vegetative, hyperactive,
or psychotic behaviors [17].
Thus far however, none of these studies on the use of animals in
demented subjects have suggested a mechanism for how animals
might alter the behavior of such individuals. One might speculate
that animals might create a distraction to inhibit disruptive
behavior or serve as a surrogate for human interaction to learn or
practice social behavior.
Several investigations have also piloted the use of animals in the
treatment of depression with mixed results. One small trial
showed even a brief intervention conferred some benefit. Thirty-
five individuals who were about to receive electroconvulsive
therapy (ECT) spent 15 minutes with a dog and animal trainer or
the same period of time reading magazines before ECT treatment
sessions [18]. All subjects had both types of pretreatment every
other day. Individuals reported lower levels of fear about the
upcoming ECT rated on visual analogue scales when they had
sessions with the dog. In a similar trial, forty-two depressed
patients spent time waiting for ECT in rooms with or without
aquariums. The presence of aquariums did not influence the
pretreatment anxiety, fear, or depressive symptoms the patients
experienced [19].
Animal-assisted therapy has been considered in the treatment of
depression in institutionalized individuals in a number of studies.
In one investigation, twenty-eight residents of an Italian nursing
home had three-hour treatment sessions once a week for a
month and a half with a cat or no change in their usual routine
[20]. A nurse supervised individuals in a therapy room, who could
pick up or play with the cat. The individuals who interacted with a
cat did not have any significant difference in Geriatric Depression
Screen score, or cognition as measured by MMSE, but did have
sixteen-point lower systolic blood pressure () and five-point lower
diastolic blood pressure () than subjects who were not exposed to
the cat. In an additional survey, subjective rankings of pet
attachment were actually associated with higher ratings of
depressive symptoms in older individuals living in rural areas
[21]. In another trial of 68 nursing home residents in Australia,
individuals who visited a dog reported less fatigue, tension,
confusion, and depression [22]. Cancer patients undergoing
chemotherapy were divided into two groups, one of which had a
weekly hour-long session of therapy with a dog and one of which
293
did not [23]. Those patients at sessions at which a dog was
present rated their symptoms of depression and anxiety half as
severe as those who did not. Taken together, these studies imply
a rather modest benefit at best for animals in depressed
individuals.
A meta-analysis was conducted of five studies of the use of
animal-assisted activities therapy in the treatment of depression
in institutionalized subjects [24]. None of the five studies whose
data was pooled for the meta-analysis was ever published in a
scientific journal; four were printed in doctoral dissertations and
the fifth was published in a book chapter almost thirty years ago.
The meta-analysis concluded that such therapy could alleviate
depressive symptoms with a medium effect size. Neither the
meta-analysis nor the previously referenced manuscripts
commented on possible mechanisms of an effect.
Other studies have examined if pets might assist the treatment of
individuals with schizophrenia. Two investigations suggested that
animals could improve social behaviors in elderly schizophrenics.
Twenty schizophrenics, at least sixty-five years old, had three-
hour visit every week for a year with a dog or cat and a therapist
[25]. The subjects were taught to ambulate with the animals on a
leash, bathe, feed, or groom them. A control group had a weekly
news discussion session simultaneously with the animal therapy
group. Schizophrenics exposed to animals had significantly
improved mean scores on social functioning as part of the Social-
Adaptive Functioning Evaluation scale which members of the
control group did not. There were no differences between groups
on survey instruments describing the subjects impulse control or
self-care.
In another investigation, 21 schizophrenic inpatients were divided
into an intervention and control group [ 26]. Both had 45-minute
meetings twice weekly with a psychologist for a total of 25
sessions. In the intervention group, a therapy dog and handler
participated. The dog was the focus of interventions tailored to
improved communication, social skills, and cognitive
rehabilitation. The control group had similar sessions, except
without the dog. Subjects in the intervention group had
significantly better scores on the social contact score in of the
Living Skills Profile and total score on the Positive and Negative
Symptoms Score scale.
Not all investigations noted that schizophrenics derive benefit
from animals. Fifty-eight older psychiatric inpatients in one trial
294
were randomized to spend five sessions of either an hour a day
with either pet therapy or an exercise group [ 27]. There was no
difference in a forty-question psychiatric symptom score between
groups. In addition to the trials of animal therapy in older persons
with mental illness, qualitative research comprising focus groups
of individuals recovering from acute episodes of psychiatric
disease has outlined what subjects perceive to be benefits of pet
ownership, such as companionship and a reinforced sense of self-
worth [28]. However, subjects sometimes were troubled by their
pet care responsibilities and grieved over the loss of pets.
Furthermore, several studies have implied that animals offer
psychological or social benefits to the elderly independent of
disease state. In one investigation, the effects of animals on the
degree of loneliness of long-term care residents were assessed
using a survey instrument [29]. Thirty-five people who lived in a
nursing home had an experience in which, for two and a half
months, they interacted with several animals including dogs,
cats, and rabbits for two hours each [ 30]. They scored
significantly higher on the Patient Social Behavior Score during
and after the intervention. In another study, forty-five residents of
three facilities were divided into those who received thirty-minute
animal-assisted therapy once a week for a month and a half, the
same therapy three times a week, or not at all. Residents who
received any animal therapy scored significantly lower on the
UCLA Loneliness Scale than those who did not. In a case series, a
robotic dog improved the loneliness scores on one assessment
instrument of five medically ill elderly persons [ 31]. In a
qualitative survey, dog owners over age of 70 in Austria stated
that dogs provided companionship and a sense of purpose [32].
However, finally, in few cases, animal-assisted therapy has even
been utilized to provide subjective benefit to critically ill patients
in intensive care units [33].
2.2. Effects on Physical Health
Numerous studies have recorded evidence of the effects of
animals on the physical health of elderly individuals. Several have
attempted to quantify physiological benefits of the presence of
animals on the effects of stress (see Table 2). One study exposed
hypertensive pet owners to the stress of solving an arithmetic
problem and making a speech [34]. The investigators instructed
half of the subjects to acquire a pet, and the total subject
population was restudied after six months. Those who owned a
pet had significantly lower increases in systolic and diastolic
295
blood pressure in response to the stressor than those who did
not. In an additional investigation, the presence of a dog in the
room alleviated an increase in blood pressure in response to the
stress of public speech [35]. Eleven community-dwelling older
individuals with hypertension, mean age 81.3, were asked to
speak in the presence or absence of a dog while blood pressure
was being recorded. Participants who spoke in the presence of a
dog had a significantly lower diastolic blood pressure (mean
difference = 12.8mmHg, ) than in the absence of the dog.
Another 10 healthy dog owners of a canine achieved a significant
systolic and diastolic blood pressure reduction and subjective
measures of anxiety after performing a stressful task whether
their own dog or not was used [ 36]. There was a greater
improvement of outcome measures when the subjects own dog
was used, which lasted up to an hour. Finally, in a small case
series of community-dwelling elderly individuals aged 65 to 91,
one group of participants received a weekly visit from a nurse
with a dog for a month, while one group had visits without the
dog [37]. Those who were in contact with the dog had a
significantly lower mean systolic and diastolic blood pressure
than those who did not (mean decrease 8mmHg systolic and 4
mmHg diastolic, difference in the intervention group from
baseline). Taken together, these investigations imply ameliorating
effect of pet ownership on the physiologic effects of stress.
Table 2: Studies on the use of animals on blood pressure.

Epidemiologic studies suggest pet owners may acquire physical
benefits, such as improved blood pressure and greater physical
activity. Among 5741 individuals in Australia, those who
possessed pets had a significantly lower resting systolic blood
pressure, a mean 5mg/dL lesser cholesterol, and 84mg/dL
triglyceride levels which were statistically significant [ 38]. In
another survey of 1179 elderly persons (mean age 70), pet
owners had comparatively reduced systolic mean arteriolar and
pulse pressure, and lesser risk of hypertension (O.R. = 0.62) [ 39].
Other investigations imply that dog walking encourages
individuals to take part in physical activity (see Table 3). In
another study, dog owners in Canada (not exclusively elderly, but
including participants up to age 80) were more likely to visit
multiuse or walk-through parks than individuals who did not
possess dogs [40]. An investigation of 5902 individuals in the US
noted a positive relationship between dog walking and amount of
296
total walking time [41]. Dog owners were more likely to walk at
least 150 minutes a week (O.R. 1.69; 95% CI 1.131.59) and were
more likely to involve themselves in any physical activity during
leisure time (O.R. 1.69; 95% CI 1.332.15). Dog walking was also
associated with likelihood of walking in 608 Washington state
residents () [42]. A recent analysis of a cohort of 545 Scottish
participants, all at least 65 years old, dog owners were more
likely to report themselves at the highest level of physical activity
than those not possessing dogs [ 43]. Among 3,075 elderly
individuals (aged 7082) in Memphis and Pittsburgh, dog owners
were twice as likely but non-dog owners half as likely to take part
in physical activity compared to people who did not own pets
[44].
Table 3: Studies on the use of animals on physical activity.

Dog walking may encourage participants to take part in other
beneficial physical activities and to preserve their functionality. In
the largest survey to date, the California Health Interview Survey,
comprising more than 55,000 individuals, dog owners more
commonly walked as a leisure time activity than those who did
not own a pet (O.R. 1.6; 95% CI 1.51.8) but were less likely to
walk for transportation (O.R. 0.91; 95% CI .85) [ 45]. In an
epidemiological survey of more than one thousand elderly
persons at least 65 years old in Canada, the loss of ability to
perform activities of daily living of persons who did not own pets
progressed at a greater rate than for pet owners [ 46]. In a
Japanese survey of 5283 adults up to age of 79, dog owners were
1.54 times more likely to obtained recommended amounts of
physical activity [47]. Among 127 elderly persons in Colorado,
those possessing pets ambulated longer distances () and had
lower triglycerides () than those without animals [48].
However, dog ownership may not be enough to guarantee
greater physical activity. In one Australian study, owners of large
dogs spent more time walking than those who owned small dogs,
and dog ownership per se was not associated with greater
probability of obtained recommended activity levels [ 49]. While
none of the manuscripts considering the effect of dog walking on
physical activity specifically considered mechanism, one might
speculate that, rationally, the need to walk a dog might create a
need to walk more, and that increased physical activity might be
more associated with the pets needs than those of their owners.
297
Pet ownership may confer additional benefits to patients with
cardiovascular disease (see Table 4). Participants in a treatment
trial of antiarrhythmia drugs who owned dogs were less likely to
die over a year than others, including those who owned other
types of animals [50]. Patients owning pets who were released
from a coronary care unit were significantly more likely to survive
after one year [51]. Individuals who had sustained a myocardial
infarction in the past year and walked their dogs for fifteen
minutes three times daily improved their exercise capacity on
stationary bicycles () [52]. Further analysis of a trial in which 460
pet owners were implanted with a defibrillator (mean ) revealed
that possession of pets rendered participants less likely to die ()
in the following 2.8 years [53]. In another survey, seventy-six
persons with congestive heart failure were divided into three
groups, one of whom visited a dog for 12 minutes, one of whom
visited a person for 12 minutes, and one of whom did not receive
either [54]. Those who were exposed to the dog had a lower
systolic pulmonary artery or capillary wedge pressures, and
reduced serum epinephrine concentrations. Sixty-nine in-patients
with congestive heart failure participated in an ambulation
training program in which they walked with a dog and a trainer
[55]. When matched with a historical sample of congestive
heart failure patients, subjects who walked with a dog walked
twice as far as the historical sample (mean 230.07 steps/day
versus 120.2 steps/day, ). Not all studies imply that pets are
beneficial for cardiovascular disease; in one follow-up study of
patients admitted to a unit for acute coronary syndrome those
owning a pet were more prone to death or rehospitalizations a
year later [56]. Nevertheless, given the preponderance of the
evidence, the American Heart Association has released a
statement acknowledging the relationship and causality of pet
ownership in the attenuation of cardiovascular disease risk [57].
Table 4: Studies on the use of animals in cardiovascular disease.
3. Harms of Animals
While the use of pets and animal therapy might confer several
potential health benefits to older persons, harms also exist. Pet
owners fall and sustain fractures as a result of their animals. The
US Center for Disease Control and Prevention noted that there
were 86,629 falls a year attributed to dogs and cats, with a mean
298
injury rate of 29.7 per 100.000 persons a year from 2001 to 2006
[58]. Older persons above 75 had the highest injury rates (68.8
for those 6574, and 70.6 for those 75 and older), twice as high
as those between 35 and 44 (28.6). A case series from Australia
also reported 16 fractures to elderly individuals who were at least
aged 65 [59]. Most of the injured were women, and individuals
commonly tripped over the pets or fell while bending down to
feed them. The pets were most commonly dogs and cats, but
they also included birds, a goat, and a donkey.
Other harms may be present, as well. Pets can be expensive,
time-consuming, and complex to care for. The average lifetime
cost of an average-sized dog can be $10,000 and a cat $8,000
[1]. The pets need adequate food, housing, hygiene, and
veterinary care [60]. Elderly persons may, because of physical or
cognitive limitation, be less able to provide such care than
younger persons. In addition, the pets might damage an elderly
persons property, although there are no reports in the published
medical literature. Pets that are not safeguarded properly by their
owners might also be a threat to other people and to the
environment. The pets could potentially injure others, harm their
property, or create fear or mistrust. The animals might damage
the environment (e.g., destroying animals and plants, creating
waste).
Institutionalized elderly may also be less able to interact
appropriately with animals. One qualitative report of the reactions
of staff to an institutional cat mascot stated that residents placed
the cat in garbage and toilet and nearly ran over its tail with
wheelchairs [16].
Animals have the potential to cause human infection and trauma.
Concern about human infections caused by pets has been
mentioned as a possible adverse consequence to pet ownership
in the elderly [61]. Greater than 200 different zoonotic infections
exist [62]; however their exact incidence in the elderly who own
pets or participate in animal-assisted treatments has not been
documented and remains unknown. Similarly, there may be
traumatic injury from animal bites or scratches, but similarly, how
frequently this takes place as well as the impact of any events is
uncertain. The aforementioned report of an institutional cat
mascot mentioned that a cat scratched a patient but did not give
further details as to this or other human injuries [16].
Pets might also cause psychological harm. Humans can become
very attached to their pets, and when they lose them, they may
299
undergo grief reactions similar to those with loss of other people
[32, 60]. The results of any investigations of such losses on
human health in the elderly have not been published.
4. Future Directions and Conclusions

Preliminary studies have suggested the potential benefits of
animals on the physical and psychological health in humans.
Despite over four decades of research, these studies remain
preliminary. They are compounded by methodologic problems
including small sample size and lack of adequate controls and
blinding. A review of animal research more than a decade ago
outlined barriers [63] that still need to be overcome, including
access of animals to subjects in institutional settings, fear of
zoonotic diseases, lack of standardized survey instruments, and
recruitment of animal handlers. There have yet to be blinded
animal investigations.
In addition, the potential influence of the differences in
demographic characteristics of human subjects (e.g., differences
in education, ethnicity, and income) remains uncertain. In one
study, elderly Latino pet owners, mean age 66, responded to a
survey of their attitudes toward their dogs and health [64]. Two-
thirds considered the dogs to be their best friends and reason
for getting up in the morning and their health to be better than
most people, and seventy-five percent deemed their health
excellent. Future investigations can clarify such influences.
Thus far, studies on the effects of animals on both mental and
physical health have reported modest benefits. Trials of animal-
assisted therapy demonstrated improvements in behavioral
symptom scores in small numbers of subjects of limited duration.
Investigations on the influence of animals on physical health,
particularly epidemiological studies, that imply that the presence
of animals can reduce cardiovascular risk, are more robust
methodologically, but prospective trials demonstrating clinical
benefit still need to be performed. New uses of animals may be
piloted in the future. For example, in one preliminary report, a
dog was trained to detect human melanomas by smell [ 65]. The
use of animals as pets and in therapy may also have harms, but
their incidence is rare, and these hazards have been even less
well documented than the benefits. There has been no formal
determination if whether these benefits outweigh the costs of
feeding and caring, which are listed for comparison in Table 5.
300
However, many reports describe participants subjective positive
feelings towards animals. These positive subjective feelings that
people have toward animals together with growing evidence of a
potential role in the treatment of cardiovascular disease may
motivate their continued use of therapy and ownership.
Table 5: Potential benefits and risks of animals in the elderly.
Conflict of Interests
The authors declare that there is no conflict of interests regarding
the publication of this paper.
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Source:- https://www.hindawi.com/journals/cggr/2014/623203/
Animal Assisted Therapy

(AAT) Program As a
Useful Adjunct to
Conventional
Psychosocial
Rehabilitation for
Patients with
Schizophrenia: Results of
a Small-scale Randomized
Controlled Trial
Paula Calvo , 1,2*
Joan R. Fortuny , 3
Sergio Guzmn , 3
Cristina Macas , 3
Jonathan Bowen , 1,4
Mara L. Garca , 3
Olivia Orejas ,3
Ferran Molins , 3
Asta Tvarijonaviciute , 5,6
Jos
J. Cern ,5
Antoni Bulbena 1,2,3
and Jaume Fatj 1,2
308
1
Chair Affinity Foundation Animals and Health, Department of Psychiatry and
Forensic Medicine, Universitat Autnoma de Barcelona, Bellaterra, Spain
2
Hospital del Mar Medical Research Institute, Barcelona, Spain
3
Centres Assistencials Emili Mira, Institut de Neuropsiquiatria i Addiccions,
Parc de Salut Mar, Santa Coloma de Gramenet, Spain
4
Queen Mother Hospital for Small Animals, The Royal Veterinary College,
Hertfordshire, UK
5
Interlab-UMU, Campus de Excelencia Mare Nostrum, Universidad de
Murcia, Murcia, Spain
6
Department of Medicine and Animal Surgery, Universitat Autnoma de
Barcelona, Bellaterra, Spain
Currently, one of the main objectives of humananimal

interaction research is to demonstrate the benefits of animal
assisted therapy (AAT) for specific profiles of patients or
participants. The aim of this study is to assess the effect of an
AAT program as an adjunct to a conventional 6month
psychosocial rehabilitation program for people with
schizophrenia. Our hypothesis is that the inclusion of AAT into
psychosocial rehabilitation would contribute positively to the
impact of the overall program on symptomology and quality of
life, and that AAT would be a positive experience for patients. To
test these hypotheses, we compared preprogram with post
program scores for the Positive and Negative Syndrome Scale
(PANSS) and the EuroQoL-5 dimensions questionnaire
(EuroQol-5D), presession with postsession salivary cortisol
and alphaamylase for the last four AAT sessions, and adherence
rates between different elements of the program. We conducted a
randomized, controlled study in a psychiatric care center in
Spain. Twentytwo institutionalized patients with chronic
schizophrenia completed the 6month rehabilitation program,
which included individual psychotherapy, group therapy, a
functional program (intended to improve daily functioning), a
community program (intended to facilitate community
reintegration) and a family program. Each member of the control
group (n = 8) participated in one activity from a range of
therapeutic activities that were part of the functional program. In
place of this functional program activity, the AATtreatment
309
group (n = 14) participated in twiceweekly 1h sessions of AAT.
All participants received the same weekly total number of hours
of rehabilitation. At the end of the program, both groups (control
and AATtreatment) showed significant improvements in
positive and overall symptomatology, as measured with PANSS,
but only the AATtreatment group showed a significant
improvement in negative symptomatology. Adherence to the
AATtreatment was significantly higher than overall adherence
to the control groups functional rehabilitation activities. Cortisol
level was significantly reduced after participating in an AAT
session, which could indicate that interaction with the therapy
dogs reduced stress. In conclusion, the results of this smallscale
RCT suggest that AAT could be considered a useful adjunct to
conventional psychosocial rehabilitation for people with
schizophrenia.
Introduction
Interactions with companion animals appear to have positive effects on
physiological, psychological, and social aspects of human wellbeing
(Fine, 2010). Animal assisted therapies (AAT) seem to produce
therapeutic benefits in different kinds of patients, from those with
physical ailments, such as cardiovascular disease, to those with mental
disorders ranging from dementia to depression (Pedersen et al., 2011)
and schizophrenia (Barak et al., 2001). It has been suggested that AAT
might help to develop the therapeutic relationship between patients and
healthcare professionals, and could improve the therapeutic atmosphere
(Fine, 2010; Julius et al., 2013); animals in AAT can act as social
facilitators, social modulators, and amplifiers of emotional reactivity
(Fine, 2010).
However, scientific evidence for the benefits of AAT is still very limited
(Nimer and Lundahl, 2007; Kamioka et al., 2014), partially due to
intrinsic difficulties of performing research with AAT (Nimer and
Lundahl, 2007; Kamioka et al., 2014). Typical methodological
310
limitations of AAT include: small sample size, difficulties of blinding,
lack of an adequate control group, selection bias due to including only
participants who like animals, lack of physiological evaluation, short
program duration and the limited number of professionals and animals
that currently participate in AAT. Some of these limitations are very
difficult to overcome, because of the nature of AAT interventions. For
example, in AAT, it is very difficult to find a comparable therapeutic
activity for the control group, and it is impossible to blind for the
presence of the animal. Since AAT is still considered an alternative
therapeutic approach, very few resources are dedicated to it within the
health system (Kaplan and Sadock, 1989). As a consequence of these
limitations it is important to compile studies with partial evidence for
AAT efficacy and applicability (Fine, 2010) and to improve and
standardize research methodologies (Kamioka et al., 2014).
Recent reviews of AAT research indicate that mental health disorders

are a good target for AAT interventions (Nimer and Lundahl,
2007; Villalta-Gil and Ochoa, 2007; Rossetti and King, 2010; Kamioka
et al., 2014). Some studies have shown that AAT programs could benefit
patients being treated for schizophrenia (Kovcs et al.,
2004, 2006; Nathans-Barel et al., 2005; Chu et al., 2009). Suggested
benefits include effects on self-esteem, self-determination, positive
symptomatology, emotional symptomatology, anhedonia, and daily
functioning (Nathans-Barel et al., 2005; Villalta-Gil and Ochoa,
2007; Villalta-Gil et al., 2009; Kamioka et al., 2014).
The aim of this study was to assess the effect of an AAT program as an
adjunct to conventional psychosocial rehabilitation for people with
schizophrenia.
Based on the hypothesis that inclusion of AAT in a rehabilitation

program would have a beneficial effect, our study had three objectives;
311
to analyze the impact on symptomatology and quality of life, to evaluate
the patients experience of the AAT sessions, and to assess stress relief
during the AAT sessions. For the first objective, the measures used were
the Positive and Negative Syndrome Scale (PANSS; Kay et al.,
1989; Peralta and Cuesta, 1994), and EuroQoL-5 Dimensions
questionnaire (EQ-5D; Bobes et al., 2005). For the second objective, we
used adherence (proportion of programmed sessions that a patient
attended). Adherence was used as an indicator of the relative appeal of
the AAT sessions, by comparing adherence for the AAT sessions with
combined adherence for the functional program attended by the control
group. For the last objective, since stress management is one of the main
objectives for the treatment of inpatients with mental disorders
(Klainin-Yobas et al., 2015), we evaluated the stress-relieving aspect of
the sessions by making a pre- versus post-session comparison of values
for salivary cortisol and alpha-amylase for the last four AAT sessions. To
our knowledge, previous research on the effects of AAT for patients with
schizophrenia has not included the combination of these three different
types of objectives (and the associated measures).
Our general objective was to present evidence that was different and
complementary to existing research and to identify interesting target
measures, such as adherence to treatment and physiological measures,
that could be used for future research.

Study Design
The study was a randomized, controlled trial (RCT).
In this study, primary outcomes for all participants were changes in

symptomatology (measured with PANSS) and changes in quality of life
(measured with EQ-5D). Secondary outcomes of this study consisted of
adherence to AAT sessions (AAT-treatment group) versus adherence to
312
other activities of functional rehabilitation (control group), and changes
in salivary cortisol and alpha-amylase during AAT sessions, as a
measure of stress relief (AAT-treatment group only).
Patients were randomly assigned to the control or AAT-treatment group.
The laboratory technicians who analyzed the saliva samples were only
given the patients ID numbers, and were blinded to whether patients
were in the control or AAT-treatment group. For practical reasons and
for issues relating to the availability of resources and personnel, the rest
of the process of the study could not be blinded. It was not possible for
patients to be blinded to the presence of dogs, and only one hospital
neuropsychologist was able to participate in the study (in charge of all of
the pre-treatment and post-treatment evaluations of the study, and
follow-up of all of the patients). A single researcher not only carried out
the collection of the data and saliva samples, but also acted as a guide
for the therapy dogs during the AAT sessions.
Sample
The study was conducted in a public psychiatric hospital within an
urban area of Spain. In order to avoid the confounding effects of
environmental variation, only patients from the same unit were included
(MILLE: Long and medium-stay unit). All eligible patients from the
MILLE unit who fulfilled the following criteria were included:
Diagnosis of schizophrenia, according to the Revised forth edition of

the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-
TR; American Psychiatric Association, 2000).
Enrolled in a psychosocial rehabilitation process.
With a projected minimum hospitalization term of 6 months.
A set of exclusion criteria was also applied, which included:
Compromised mobility.
313
Presence of allergies to animals.
Rejection of contact with companion animals.
Confirmed diagnosis of a coagulopathy.
These inclusion and exclusion criteria were adapted from previous AAT
protocols (Barak et al., 2001; Kovcs et al., 2004; Nathans-Barel et al.,
2005; Villalta-Gil et al., 2009; Fine, 2010; Lang et al., 2010). All patients
in the unit who met the criteria were included in the study.
Twenty-four adult patients (Mean age = 47.8 years of age; SD = 6.7)

fulfilled the requirements and were included in the study. The patients
mean age at diagnosis of schizophrenia was 20.5 years of age (SD = 5.0).
The patients mean scores for PANSS were: 43.8 (SD = 12.3) for General
PANSS, 24 (SD = 6.6) for Negative PANSS and 20.6 (SD = 6.6) for
Positive PANSS. The EQ-5D total score mean was 1.8 (SD = 1.5). See
Table 1 for an overview of all of the characteristics of the sample
population.
TABLE 1
TABLE 1. Characteristics of the sample.
The 24 patients who met the inclusion criteria were randomly assigned
to three groups, with eight patients in each group (AAT-treatment
groups A and B, and a control group C) (See Figure 1). Given the length
of the study (6 months), a high drop out rate was expected. Other
authors recommend that group size is kept small for AAT sessions
(Kovcs et al., 2004; Nathans-Barel et al., 2005; Chu et al., 2009; Fine,
2010). To comply with this recommendation, the 16 patients who were
to be given AAT were randomly allocated to one of two small therapy
314
groups (eight people in each). There were no differences in the
characteristics of these groups, or in the AAT-therapy they received. In
the analysis, data from patients in both therapy groups (A and B) was
therefore combined into a single group.
FIGURE 1. Shows the modified CONSORT flow diagram for individual RCTs of
non-pharmacologic treatment (Boutron et al., 2008; Schulz et al., 2010) applied to
this study.
315
Five therapy dogs that had previously been assessed and trained, and
had experience of participation in AAT work were used for the study.
There is no official dog therapy certification in Spain. A thorough
physical and behavioral examination of each dog was performed by a
panel of three board-certified specialists in veterinary behavioral
medicine. This examination included the Ethotest (Lucidi et al., 2005), a
test designed to identify suitable therapy dogs, and the C-BARQ (Hsu
and Serpell, 2003), a questionnaire for measuring behavior and
temperament traits in dogs.
Interventions
The study took place between October 2012 and May 2013. At the
psychiatric hospital where the study was conducted, the global
psychosocial rehabilitation process consisted of five types of programs:
individual psychotherapy, group therapy program, functional program
(to improve daily functioning), community program (with social
reintegration objectives), and family program. From Monday to Friday
every week, all patients treated in this global psychosocial rehabilitation
process had to participate in all five types of program.
Patients in all groups participated in the same total weekly number of

hours of activity within the psychosocial rehabilitation process. For the
AAT-therapy groups (A and B) the AAT program was one of these
activities. The AAT program consisted of 6-months of twice-weekly 1-h
sessions (Tuesday and Friday), so that each patient attended a total of
40 AAT sessions (taking into account public holidays). Control group
316
patients attended the same number of sessions in the functional
program.
The AAT-treatment involved three types of sessions:
(a) Sessions to develop the emotional bond between participants and

dogs: The participants were taught to handle and take care of the
dogs correctly. In this type of session, concepts of animal welfare
and responsible ownership were explained and practiced.
(b) Sessions involving walking the dogs: During the first half of the
program, the dogs were walked in a large natural park, so that the
patients could learn to walk the dogs in a calm and controlled
manner. For the rest of the program, the participants walked the
dogs in the city, where they could experience dog-walking in a social
context that is typical of that which is experienced by dog owners.
(c) Sessions to train and play with dogs: Patients learned to give
instructions to the dogs and train them using positive reinforcement
training techniques.
During an AAT session 4 of the 5 therapy dogs were always present to

interact with the patients. At the beginning of each session, participants
were asked to work in pairs. Each working pair was assigned a dog,
which they worked with for the remaining hour of the session. During
the program there was a rotation between the three types of sessions
(emotional bonding, dog walking, and dog training with play).
Each patient in the control group was assigned to a single activity from
the functional program on the basis of their therapists criteria, but
taking into account the individuals preferences. The choice was between
art therapy, group sports (football or basketball), dynamic psycho-
stimulation, and gymnastics. These activities were organized so that
317
they closely matched certain important characteristics of the AAT
program:
They were conducted outside the hospital unit where the patients
were resident.
They all involved a similar element of group work.
Group sizes were small (similar to the AAT sessions).
Patients were accompanied and supervised off-site by a mental

health professional (nurse or similar).
The activities continued throughout the period of trial (they were

unaffected by season).
The sessions were twice-weekly and of 1-h duration.
The difference between functional program activities and the AAT

sessions was, as far as was possible, restricted to content.
Instruments
To compare evolution in psychiatric symptoms between AAT-treatment
and control patients during the 6-month duration of the program, we
used the previously validated Spanish version of the Positive and
Negative Syndrome Scale (PANSS; Kay et al., 1989). PANSS has been
found to be a reasonably valid psychometric tool for people with
schizophrenia (Kay et al., 1989; Peralta and Cuesta, 1994), and is one of
the most widely used tools for the assessment of therapeutic results in
schizophrenia treatment. PANSS was administered to all patients during
individualized interviews with the hospital neuropsychologist. It was
completed for each patient several times in the month before the study
started, during the program and in the month after the end of the
program.
318
The same interview approach was used to assess quality of life, using the
EQ-5D (Bobes et al., 2005). The EQ-5D has been found to be reasonably
valid for use in people with schizophrenia (Knig et al., 2007) and is a
standard assessment instrument used in this hospital. The
neuropsychologist completed the EQ-5D twice with each patient, in the
month before the study started and in the month after the end of the
program.
Individual attendance at sessions of AAT and the functional program

was recorded. Adherence was calculated as the proportion of
programmed sessions that a patient attended during the 6-month
program period, expressed as a percentage.
In order to study the physiological effects of contact with the dogs

during an AAT session, pre- and post-session saliva samples were
collected for the last four AAT sessions of the program. Salivary alpha-
amylase (sAA) and cortisol were measured. As a biomarker of
psychosocial stress, salivary alpha-amylase can be considered to be a
measure of the level of activation of the sympathetic nervous system
(SNS; Rohleder et al., 2006; Holt-Lunstad et al., 2008). Salivary cortisol
is an indicator of the state of the hypothalamicpituitaryadrenal (HPA)
axis and is a general physiological biomarker of stress (Fortunato et al.,
2008; Holt-Lunstad et al., 2008). Saliva samples were collected using a
commercial saliva collection kit (Salivettes, Sarstedt), with the Salivette
remaining in the patients mouth for 1 min per sample. Two samples
were collected from each patient at each of the four sessions; one was
collected 30 min before the AAT session and the other 10 min after the
AAT session had finished. Saliva samples were stored in a dry-ice cooled
mobile fridge, in which they were delivered to the laboratory to be
processed and frozen to 80C for later testing. The maximum pre-
freezing storage time was 4 h. After the study was completed, all saliva
samples were thawed and analyzed. Cortisol was extracted and analyzed
319
using a commercial immunoassay (Siemens IMMULITE 2000, Siemens
Healthcare Diagnostics. Deerfield, IL, USA; Owen and Roberts,
2011; Tecles et al., 2014), and alpha-amylase was analyzed using a
commercial spectrophotometric assay (Olympus AU2700. Olympus
America Inc. Center Valley, PA, USA; Tecles et al., 2014).
Statistical Analysis
We analyzed data from all the participants who completed the 6-month
period of the study (N = 22). In the present study, patients were
included in the analysis regardless of their level of adherence to their
medication regime or any of the five elements of the psychosocial
rehabilitation process, and adherence to the AAT program was a main
outcome measure. As a result, the present study does not comply with
the requirements for a per protocol analysis, in which patients would
be excluded for any deviation from treatment. However, because we
excluded two patients who did not complete the study we also did not
carry out an intention to treat analysis, and so our protocol could be
described as a modified intention to treat.
Between-group (control and AAT-treatment) contrasts of PANSS and

EQ-5D scores were analyzed using Statistica 10 and GraphPad Prism 6.
Data was tested for normality using the ShapiroWilk test; parametric
data was tested using a t-test, and non-parametric data was tested using
the MannWhitney U (for unpaired data) or Wilcoxon test (for paired
data). For dichotomous variables (patient sex), a chi-square test was
used to compare proportions between groups. Multiple comparisons
were made in the EQ-5D analysis, so the Bonferroni correction was used
to adjust the value of p that was accepted for significance (for example,
for 20 comparisons, p = 0.05/20 = 0.0025).
Pre-program PANSS and EQ-5D scores were compared with post-

program scores, for the AAT-treatment and control groups separately.
320
After checking normality of data (with the ShapiroWilk test), a paired-
samples t-test was used with parametric data and the Wilcoxon test was
used with non-parametric data.
Adherence to treatment data was checked for normality using the

ShapiroWilk test. An unpaired t-test (for parametric data) or Mann
Whitney U (for non-parametric data) was used to compare adherence
levels between the AAT-treatment group and either overall compliance
or compliance for individual activities within the functional programs
(control group).
A paired t-test was used to compare pre- with post-session levels of

cortisol and alpha-amylase in the AAT-treatment group (data had been
found to be normally distributed using the ShapiroWilk test).
Ethics
The Clinical Research Ethics Committee of the Hospital del Mar Medical
Research Institute (IMIM) approved the clinical-protocol, patient
management, and participation of the patients.
The Department of Agriculture and Natural Environment of the

Catalonia Government approved the animal management protocol for
this study. All dogs that participated in the project were given a
thorough medical, behavioral, and welfare assessment before, during,
and after the AAT program.
All patients who were eligible for the study received documentation that
outlined the study, and they signed an informed consent form. They
were able to withdraw from the study at any time.
Animal assisted therapy technicians signed an informed consent form

that detailed their responsibilities (confidentiality and conformity)
within the project.
321
Spanish law 15/99 (regarding personal data protection) was applied to
all data collection.
Results
Sample Characteristics
There were no differences between control and AAT-treatment groups
with respect to sex [Chi-square test; 2(1) = 0.40], age or initial scores of
PANSS and EQ-5D (MannWhitney U; p < 0.05; See Table 2 for full
details).
TABLE 2. Initial scores of PANSS and EQ-5D of the analyzed patients of this
study.
During the program, two patients within the AAT-treatment group

withdrew from the study. One patient was discharged from the hospital
before the end of the AAT program. The other patient exhibited
behaviors that threatened to compromise the welfare of the therapy
dogs, and therefore stopped participating in the AAT activity (See
Figure 1).
Schizophrenic Symptomatology (PANSS)
At the end of the program, no significant differences were found
between control and AAT-treatment groups (MannWhitney U test, p <
0.05) with respect to final PANSS or change in PANSS (see Table 3 for
full details). However, there were significant differences in PANSS pre-
322
treatment and post-treatment scores in both control and AAT-treatment
groups (t-test; p < 0.05). In the AAT-treatment group, scores for all
PANSS subscales (positive, negative, and general) were significantly
lower after the AAT program (t-test; p < 0.05). In the control group,
only positive and general PANSS scores showed a significant decrease
after treatment (t-test; p < 0.05). For full details, see Table 4.
TABLE 3. Differences between control and treatment groups with respect to

final PANSS (after 6 months of treatment) or change in PANSS.
TABLE 4. Differences in PANSS pre-treatment and post-treatment scores in

both control and treatment (AAT) groups.
Quality of Life (EQ-5D)

No significant difference was found between AAT-treatment and Control
groups (MannWhitney U test; p < 0.0025 after Bonferroni correction).
In addition, almost none of the EQ-5D items were significantly different
after treatment (Wilcoxon test; p < 0.05; Table 5). Only the score for the
323
general health item (compared with 12 months before) of the EQ-5D was
significantly lower after the program in the AAT-treatment group
(Wilcoxon test; p < 0.05). For this item, low scores indicate higher
health status, meaning that AAT-treatment group patients perceived
themselves to be in a better state of health after the program. However,
after applying a Bonferroni correction none of the results of EQ-5D was
significant different after treatment (for eight comparisons, p = 0.05/8
= 0.0625).
TABLE 5. Differences in EQ-5D pre-treatment and post-treatment scores in both

control and treatment groups.
Adherence to Treatment
Although patients were encouraged, and expected, to attend all
scheduled activities, attendance was entirely voluntary. In the AAT-
treatment group, there was an overall 92.9% (SD = 4.7) adherence to
treatment for the AAT sessions. The majority of absences from the AAT
sessions were due to family or health issues. Only once did a patient not
want to attend an AAT session. In the control group, there was an
overall 61.2% (SD = 24.8) adherence to treatment for the assigned
activity from the functional program. This higher level of adherence to
the AAT sessions, compared with overall adherence to the functional
324
activities, was significant [t-test: t(20) = 4.7; p = 0.0001]. We could only
compare adherence to AAT-treatment with specific functional program
activities for which the number of attending patients was large enough
to justify a statistical test (art therapy and gymnastics). AAT showed
significantly better adherence than art therapy (Mann
Whitney U test; U = 2; p = 0.01) and gymnastics therapy (Mann
Whitney U test; U = 2; p = 0.01). All detailed data on adherence to
treatment are presented in Tables 6 and 7 and see Figure 2.
TABLE 6. Patients adherence to treatment.
TABLE 7. Differences in adherence to treatment between AAT and other types of

functional rehabilitation interventions.
325
FIGURE 2. Differences between AAT and other functional rehabilitation
interventions.
326
Salivary Cortisol and Alpha-Amylase
We collected 61 pre-session and 60 post-session saliva samples from the
AAT-treatment group. However, some of the saliva samples were too
small for analysis and were discarded. Cortisol analysis was performed
with 48 matched pairs of samples (matching every corresponding pre-
session and post-session sample for each session for which sufficient
sample was available). There was a significant decrease in cortisol after
participation in an AAT session (Wilcoxon Test; p < 0.05. Pair-matching
was confirmed using the Spearman test; p < 0.05). Fifty pairs of
matching samples were used to measure the effect of the intervention on
salivary alpha-amylase. sAA was increased after the AAT sessions, but
the difference was not quite significant (Wilcoxon Test; p = 0.059. Pair-
matching was confirmed using the Spearman test; p < 0.0001).
Discussion
In terms of age and gender, our sample of patients was consistent with
the general population of people with schizophrenia, as well as the
population of institutionalized people with schizophrenia (Jablensky,
2000; Uggerby et al., 2011). All participants were receiving at least one
psychotropic drug, as is common in people treated for this condition
(Jablensky, 2000; Uggerby et al., 2011). Our results could therefore be
relevant to other similar institutions that are considering the
implementation of an AAT program.
With regard to population size, our study was comparable with similar
studies that have investigated the effect of AAT in the treatment of
schizophrenia, suggesting some common methodological limitations
(Barak et al., 2001; Nathans-Barel et al., 2005; Kovcs et al.,
2006; Berget, 2008; Chu et al., 2009; Villalta-Gil et al., 2009). Apart
from the constraint of working with a limited total population of
patients within a single hospital unit, and the application of
exclusion/inclusion criteria, it should be remembered that AAT has to
327
be conducted in small groups for practical reasons such as the need for
proper supervision and a high animal-to-patient ratio (Fine, 2010).
One patient withdrew from the study due to the risk of harm to the
therapy dogs. This kind of problem should have been anticipated and
taken into account within the exclusion criteria. This should be
considered in future studies. Another patient withdrew very early in the
study (week 3), and prior to the collection of any outcome data. The
recommended approach for superiority studies is an intention to treat
analysis, whereby all patients included in the randomization are
included in the analysis, and by deviating from this approach in our
study we risk an overestimation of the treatment effect (Armijo-Olivo
and Magee, 2009). So, whilst the results are interesting and point to a
potential effect of treatment, they cannot be relied upon as general
evidence of efficacy in a clinical population.
People with a diagnosis of chronic schizophrenia who live in

institutionalized settings have very low levels of social functioning and
social activity (Kovcs et al., 2004). Individual or combined measures of
symptomatology, quality of life and adherence to treatment are
commonly used to assess the efficacy of a psychosocial rehabilitation
process for patients with schizophrenia (Wilson-dAlmeida et al., 2013),
but not together in the same study. By including these measures and
adding an assessment of salivary cortisol and alpha-amylase, our study
provides an interesting insight into the use of combined measures.
In terms of symptomatology, in the AAT-treatment group we observed

an improvement in negative symptoms of schizophrenia like apathy,
asociality, anhedonia and alogia, that could be partially explained by the
regular interaction between patients and animals. Previous work
suggests that AAT programs may be effective in the control of negative
symptoms of schizophrenia (Barker and Dawson, 1998; Barak et al.,
328
2001; Kovcs et al., 2004; Nathans-Barel et al., 2005). Therapy dogs
have been described as social catalysts or mediators of interactions
between patients and between patients and their therapists, and these
benefits could be extended outside the AAT sessions (Fine, 2010). Since
negative symptoms of schizophrenia are relatively insensitive to
pharmacological therapies and are associated with a chronic course and
high levels of social disability, it is very important to find effective
alternative interventions that can be added to standard treatment
protocols (Hammer et al., 1995; Liddle, 2000; Grwe and Levander,
2001). The beneficial effects of AAT on negative symptoms of
schizophrenia is therefore worthy of further investigation.
The trend toward an increase in alpha-amylase combined with the

significant decrease in cortisol after the AAT sessions suggests that the
interaction patients had with the dogs was perceived to be not only
engaging, but also relaxing. Increases in alpha-amylase and the
activation of the SNS can occur in positive emotional states (Fortunato
et al., 2008; Payne et al., 2014), and recent research indicates that
people with schizophrenia may experience a dysregulation of SNS tone
(Monteleone et al., 2015).
The lack of significance for the change in salivary alpha-amylase could

be due to the absence of an effect, but also due to the small population
size and the small number of collected saliva samples (saliva was only
collected for the last four AAT sessions, sample collection was not
always successful, and approximately 17% of collected samples had to be
rejected due to inadequate sample volume for analysis).
Regarding stress and cortisol levels, previous research has found

decreases in salivary cortisol during AAT sessions in other types of
patients, such as autistic children (Viau et al., 2010) and insecure
attached males (Beetz et al., 2012a). In a previous study with people
329
being treated for schizophrenia, cortisol levels were not been found to
change after interaction with animals (Nepps et al., 2014). However, in
comparison to our study, the AAT protocol for that study did not include
repeated sessions for each patient and the ratio of dogs per patient was
lower. Long-term and dose effects of AAT on stress levels of patients
with schizophrenia still need to be studied. Future studies could take
advantage of our experience by extending the measurement of salivary
cortisol to all AAT sessions within a program, and a control group, while
also looking for long-term and dose effects.
There were some difficulties in collecting saliva samples in this study,

both in terms of quantity and quality of saliva. The pharmaceutical
treatment of schizophrenia involves drugs that suppress salivation, and
as a consequence of their symptomatology, many people with
schizophrenia are smokers (Rae et al., 2014). Smoking increases cortisol
and decreases alpha-amylase (Granger et al., 2007a), so this could be a
confounding factor. Future studies should include data on patients
smoking level, particularly when comparing saliva measures between
groups, as between group matching could be important. In addition,
personal hygiene and dental care seems to be poor in many people with
schizophrenia (Velligan et al., 1997), and the presence of impurities in
saliva samples could interfere with the reliability of the measurements
(Granger et al., 2007b). Ideally, a patient should have rinsed his or her
mouth with water some minutes before saliva collection, but due to a
lack of patient cooperation this was rarely possible. Future research
should try to extend and optimize saliva sample extraction and analysis,
as it seems cortisol and alpha-amylase could be good markers of AAT
effects in people being treated for schizophrenia.
Quality of life measurements did not differ between pre-treatment and

post-treatment conditions in either of the two groups. Improvement in
symptomatology is not always related to improvement in quality of life
330
in people with schizophrenia as the latter can be affected by other
factors such us the level of insight (Wilson-dAlmeida et al.,
2013; Hayhurst et al., 2014; Margariti et al., 2015). Previous research
has shown that even patients with schizophrenia who are undergoing
treatment can experience a progressive decline in their quality of life
(Medici et al., 2015). Therefore, a lack of decline in overall quality of life
measurements could be interpreted to be a benefit of psychosocial
rehabilitation, particularly in chronic patients. Future research could
focus on specific domains of quality of life where AAT seems to have a
direct effect, such as anxiety and depression (Barker and Dawson, 1998)
and social relationships (Villalta-Gil et al., 2009).
In the present study, mean adherence to the alternative functional

rehabilitation interventions (art therapy, group sports, dynamic psycho-
stimulation, or gymnastics) was lower in the control group than the
AAT-treatment. Previously reported adherence rates to therapeutic
sport programs for people being treated for schizophrenia range from
50 to 82% (Beebe et al., 2005; Warren et al., 2011). In the present study,
there were intrinsic differences between the activities included in the
functional program, but they all shared certain features, such as
frequency, duration, and being conducted outside the hospital. Although
the added value of AAT sessions in terms of adherence could be due to a
novelty effect, attendance to sessions did not decline during the
program. Information about adherence is rarely reported in AAT
research, but it could be a very useful indicator in the context of
psychosocial rehabilitation, and deserves further research (Kamioka et
al., 2014).
Another factor that could be of importance in adherence to ATT is the

humandog relationship (Nagasawa et al., 2015). An initial bond may be
quickly established between a person and a dog, and this bond has a
strongly emotional element (Dwyer et al., 2006; Fine, 2010; Beetz et al.,
331
2012b), that leads to the development of attachment to the dog (Zasloff,
1996). This attachment could contribute to a persons sustained interest
in attending AAT sessions, but could potentially lead to problems when
the humananimal bond is disrupted at the end of the program. Further
research could monitor the development of the patientdog bond during
an AAT program, and the effects of ending such programs.
Taken together, the various significant results reported in this study

(reduction of negative symptomatology, high adherence to the AAT
program, and cortisol reduction after AAT sessions) could be explained
by the biology of humananimal interactions (Beetz et al.,
2012b; Nagasawa et al., 2015). When a person has a enjoyable contact
with a dog there is a release of oxytocin, dopamine, and endorphins, as
well as a decrease in cortisol (Beetz et al., 2012a,b; Julius et al., 2013).
This overall reaction seems to enhance pro-social behavior and decrease
anxiety and stress, mainly via the hypothalamic-pituitary axis
(HPA; Neumann et al., 2000). Oxytocin administration has previously
been proposed as a treatment for psychiatric patients because of its
broad pro-social effects on behavior and cognition (Zik and Roberts,
2014). Through the release of oxytocin, positive contact with dogs could
produce such psychosocial and psychophysiological benefits. Future
research in AAT might also try to study changes in oxytocin levels of
people being treated for schizophrenia during contact with animals.
The results of our study raise some questions that could be addressed in
future work. Adherence to treatment is a significant problem, especially
in lengthy rehabilitation programs with challenging patients. It would be
interesting to investigate whether the high level of adherence to AAT
that we observed is replicated in other therapeutic situations, and
whether adherence really is different from other closely matched
activities. It is possible that the mere presence of a dog in any type of
therapy session could improve adherence, especially if the patient has
332
developed a relationship with the dog during AAT, and this effect should
be investigated. In all rehabilitation programs resources are limited and
the inclusion of AAT could represent an opportunity cost by displacing
other activities. It is therefore important to find out whether patients
who have participated in AAT go on to experience significant long-term
benefits after the rehabilitation program has concluded, compared with
patients who have been involved in other activities.
Conclusion
Animal assisted therapy seems to be a worthwhile adjunct therapeutic
approach for people being treated for schizophrenia in a conventional
psychosocial rehabilitation process, with potential positive outcomes in
symptomatology, adherence to AAT program, and stress reduction
during AAT sessions.
The paper itself was written by PC, JF, and JB. The paper was reviewed
before submission by AB, JRF, SG, CM, OO, FM, AT, JC, and MG. All
authors contributed to the initiation and design of the study. PC, JF,
JRF, SG, CM, MG, and AB monitored the progress of the study. PC, JF,
and JB decided on the analytic strategy. JB, JRF, SG and CM equally
contributed to the total production of the study. PC is the guarantor of
the study.
Funding
This study was supported by the Affinity Foundation.
Conflict of Interest Statement

The Chair Affinity Foundation Animals and Health is sponsored by a
non-profit Foundation (Affinity Foundation). Any research The Chair
Affinity Foundation Animals and Health develops is not related to any
commercial product.
333
Acknowledgments
The authors are grateful to all of the patients, nurses, psychologists,
psychiatrists and animal assisted therapy technicians. We would
particularly like to thank the following professionals and technicians
who collaborated in this project: Rosa Cirac, Elena Garca, Ana Gimil,
Natalia Iorlano, Miriam Prez, Elia Sierra.
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Keywords: animal-assisted therapy, psychosocial rehabilitation, adherence to treatment,
schizophrenia, PANSS, EuroQol-5 dimensions, salivary cortisol, salivary alpha-amylase
Citation: Calvo P, Fortuny JR, Guzmn S, Macas C, Bowen J, Garca ML, Orejas O,
Molins F, Tvarijonaviciute A, Cern JJ, Bulbena A and Fatj J (2016) Animal Assisted
Therapy (AAT) Program As a Useful Adjunct to Conventional Psychosocial
Rehabilitation for Patients with Schizophrenia: Results of a Small-scale Randomized
Controlled Trial. Front. Psychol. 7:631. doi: 10.3389/fpsyg.2016.00631
Received: 31 December 2015; Accepted: 15 April 2016;
Published: 06 May 2016.
Edited by:
Chris J. Gibbons, University of Cambridge, UK
Reviewed by:
Xochitl Angelica Ortiz, Universidad Autonoma de Nuevo Leon, Mexico
Charlotte Garrett, University of Manchester, UK
Copyright 2016 Calvo, Fortuny, Guzmn, Macas, Bowen, Garca, Orejas, Molins,
Tvarijonaviciute, Cern, Bulbena and Fatj. This is an open-access article distributed
under the terms of the Creative Commons Attribution License (CC BY). The use,
distribution or reproduction in other forums is permitted, provided the original author(s)
or licensor are credited and that the original publication in this journal is cited, in
accordance with accepted academic practice. No use, distribution or reproduction is
permitted which does not comply with these terms.
*Correspondence: Paula Calvo, paula.calvo@uab.cat
Source:- http://journal.frontiersin.org/article/10.3389/fpsyg.2016.00631/full
345
Compilers Recommendation 2
In communities such as Portmore, Harbour View, Manley Meadows, Mona and other
similar communities special permits from the Municipality issued against a medical
doctor's recommendation and stamped by a mental health institution, could be given to
the elderly who live alone and individuals with intelligence deficit to rear chicken, rabbits
or pet fish provided the waste generated is used for gardening and or vegetable
production even if it means setting up side walk gardens, the private and public health
and social benefits of such supersedes any social inconveniences such activities might
generate once the community plays an active and positive role in assisting to manage and
encourage these activities.
It is better to have two rosters crowing in the morning than to have an elderly lady living
in the community who is visited by no one and spoken to by no one, it is better to have
five rosters crowing at 3.00 am in the morning than to have a mentally challenged young
man in the community who no one calls a friend and with no one caring how he will live
after his father dies.
Sustainable and good quality mental health care is not possible in communities of the
middle classes and the poor without the active participation of the family doctor, the
Community high school, the local police, the citizens and the families of victims of
impaired mental health.
End
A Back Yard Fish Farm In Cumberland, Portmore, St. Catherine, Jamaica W.I.
346
Animal-assisted interventions: making better use of the
human-animal bond
1. Daniel Mills, BVSc, PhD, CBiol, FSBiol, FHEA, CCAB, Dip
ECAWBM(BM), MRCVS1 and
2. Sophie Hall, BSc, PhD2
Author affiliations
Abstract
In the third of Veterinary Record's series of articles promoting One Health, Daniel Mills
and Sophie Hall discuss the therapeutic effects of companion animals, the influence of
pets on childhood development and how researchers are elucidating the true value of
animal companionship.
http://dx.doi.org/10.1136/vr.g1929
Statistics from Altmetric.com
IT HAS been proposed that the One Health initiative should be extended to One
Welfare, in recognition of the diverse links between the welfare of human beings and
other animals (Anon 2012). This is particularly true for companion animals, with a growing
body of evidence indicating the diverse stress-ameliorating effects of the relationships
between people and pets; however, their importance to mental and physical health from a
developmental perspective (particularly for people) is perhaps not given the attention it
deserves. This is potentially a serious oversight for healthcare professionals,
policymakers and government, at a time when there are concerns over the growing cost
of public healthcare in the industrialised world. Indeed, in the current economic climate,
there is perhaps a greater need than ever to consider novel approaches to preventive
healthcare, such as the value of animal companionship, since such approaches are
potentially more cost-effective and socially acceptable than technological solutions.
347
Companion animals should not be considered a luxury or unnecessary indulgence, but
rather, when cared forCompanion animals should not be considered a luxury or
unnecessary indulgence, but rather, when cared for appropriately, they should be seen as
valuable contributors to human health and wellbeing
appropriately, they should be seen as valuable contributors to human health and
wellbeing and, as a result, society and the broader economy.
FIG 1.
A National Guard veteran puts an arm over a horse during equine-assisted therapy
at Rocky Top Therapy Center, in Keller, Texas. The centre recently received a grant
for its new Horses for Heroes programme to work with veterans and their families
to treat post-traumatic stress disorder and other psychological injuries and
adjustment issuesPhotograph: Lara Solt/AP/Press Association Images
Emotional responses and development
The term animal-assisted activities (AAA) refers to the broad range of contexts in which
animals are used to support people from structured therapeutic interventions with
clearly defined objectives, such as animal-assisted therapies (AAT), to less structured
activities, like animal-assisted interventions (AAIs). The latter includes the facilitative
effects of animals in the treatment of mental health patients and hospitalised children,
brought about by the reduction in anxiety associated with the animal's presence (Lang and
others 2010
, Muoz and others 2011).
As well as improving individual quality of life, such effects have wider-reaching
economic implications (Headey 1999, Headey and others 2002). Reducing patient anxiety during medical
appointments can also facilitate clinical judgement by allowing the clinician to gain a
more accurate understanding of the normal state of the patient, as opposed to the patient's
348
state in a stressful situation. Additionally, clinician-patient time may be used more
effectively when the patient is less anxious. However, despite these potential benefits in
clinical practice, there are few controlled investigations into the effects of human-animal
companionship in medical settings.
Along with reducing overt emotional responses such as anxiety, there is evidence to
suggest that animal companionship can be highly influential in reducing a sense of
isolation. This might suggest that animals are a particularly useful vehicle for providing
social support.
The significance of social support as a protector against both mental and physical ill-
health is well acknowledged (Berkman and others 2000). Such effects are thought to be a
consequence both of effects on processes that influence susceptibility to physical and
mental health issues (for example, feelings of stability and self-worth improve adherence
to good health practices) and buffering effects (for example, by intervening between the
negative event and the physiological reaction) (Cohen and Wills 1985). The routine of animal care
can provide daily stability and feelings of worth (direct effects) as well as providing a
distraction from negative events (indirect effects). Indeed, cats have been found to
improve negative moods as effectively as a human partner (Turner and others 2003) and cat
ownership has been shown to ameliorate depressive moods of single adults (Rieger and Turner
1999
). Additionally, the constant companionship of an animal has been shown to reduce
feelings of loneliness in elderly care home residents (Banks and others 2008), suggesting that
animal companionship can ameliorate loneliness even in a group environment.
Furthermore, a study with patients in palliative care showed that the presence of a dog,
cat or rabbit improved the mood of patients (Kumasaka and others 2012). Similar mood changes
have also been observed in children with autism (Silva and others 2011) and Alzheimer's patients
(Mossello and others 2011).In the field of human health and medical psychology there is evidence
to suggest that dog and cat owners have better psychological and physical health than
non-owners
The supportive effects of animal companionship have also been observed in clinical and
forensic developmental psychology, with survivors of childhood sexual abuse rating their
animals as being more supportive than people (Barker and others 1997).
Future investigations are required to investigate specifically how AAI improves these
outcome measures. Is it by the direct effects of increasing self-worth and interest in life,
or a byproduct of the neurochemistry of social bonding, which antagonises the effects of
depression (Panksepp and Biven 2012) and promotes a healthy immune system (Charnetsky and others 2004),
or is it by therapeutic mechanisms, which reduce the negative physiological effects of
stress and anxiety, or perhaps a combination of both?
In the field of human health and medical psychology there is evidence to suggest that dog
and cat owners have better psychological and physical health than non-owners (Headey 1999).
Dog owners are reported to recover more quickly after serious mental (Wisdom and others 2009)
and physical (Friedmann and Thomas 1998) illness. Moreover, they make fewer visits to their doctors
(Headey and Grabka 2007).
Animal companionship also has positive effects on child development. With modern
society being more dynamic than ever and children changing locations, schools and
349
family units more frequently (Walsh 2003), it is increasingly important to consider the
protective role that companion animals can play in reducing the negative effects
associated with these instabilities. For instance, companion animals can provide
consistency and support throughout such transitions, which may diminish the negative
impacts that these events have. In particular, during transitional phases, it can be difficult
for a child to develop strong bonds and empathy with people. Because animals appear
relatively straightforward in their emotional displays, children find it easier to understand
them, which strengthens the bond and leads to heightened confidence and more positive
moods; importantly, these positive effects can transcend their relationships with people
(Melson 2003, Serpell 2008).
Although it could be argued that the daily care required by animals could mitigate against
the practical value of AAI in children, the evidence suggests that these responsibilities
may themselves have a direct positive influence on child development (Haggerty and others 1989)
in terms of task accomplishment, responsibility and regular positive reinforcement (for
example, a dog wagging its tail). All of these help to build a child's self-esteem, which is
essential for social competence and academic achievement. It has also been suggested
that children who are pet owners have better social encounters (MacDonald 1981) and are more
popular with their peers (Corson and O'Leary Corson 1987).
FIG 2.
A goat takes a rest on the lap of a resident at a senior citizens living community in
the USA. The therapy animal is brought in to aid and entertain the
residentsPhotograph: Kristin Streff/AP/Press Association Images
Underlying mechanisms
350
Despite the importance of animal companionship in reducing negative human emotions
and increasing positive emotions, we still do not have a good understanding of the
processes underlying these effects. It has been hypothesised that the human-animal bond
is instrumental in shaping a child's emotional development. But more broadly, attachment
is an emotional bond that supports a sense of closeness, wellbeing and security (Bowlby 1974).
Typically, people become highly attached to their pets, and more than 85 per cent of
owners view their pet as a member of their family (Cohen 2002). Vidovic and others (1999) reported that
children with greater attachment to their pets showed greater empathy and prosocial
behaviours and had a healthier family environment. However, other studies show that
levels ofDuring transitional phases, it can be difficult for a child to develop strong bonds
and empathy with people. Because animals appear relatively straightforward in their
emotional displays, children find it easier to understand them, which strengthens the bond
and leads to heightened confidence and more positive moods
attachment do not explain decreased feelings of loneliness or increased feelings of
support (Barker and others 1997).
An alternative, or perhaps concurrent, explanation relates to the value of animals in
acting as facilitators of social interaction between people (McNicholas and Collis 2000, Kruger and Serpell
2006
). Companion animals are thought to act as social lubricants (Gunter 1999) by encouraging
others to approach and engage in social conversation (McNicholas and Collis 2000). During
development, this type of experience may be particularly important in shaping future
coping mechanisms of the individual, with the non-evaluative nature of the companion
animal relationship possibly being important in providing feelings of support (Norris and others
1999
).
Both of the theories discussed so far focus on the nature of the relationship that arises
from certain types of interaction with the companion animal, but an alternative
hypothesis considers the importance of companion animals in fulfilling a basic biological
need of people. This is commonly referred to as the biophilia hypothesis, and is
predicated on the assumption that people have adapted to attend to and have empathy
with human and non-human life in their environment (Kellert 1997). It is argued that human
beings are innately driven to attend to animals in their environment, as a result of the prey
and predator relationships involved in historical human-animal interactions (Wilson 1984). It
has been suggested that, as a result of this, the presence of a companion animal increases
human attention to its positive influences (for example, their relationship with the
animal), which buffers negative emotional effects. The biophilia hypothesis has received
favour in some child development literature as an explanation for the positive effects of
animals in childhood development (Kahn and Kellert 2002), but strong specific evidence is still
lacking. The increased attention inherent in animal companionship might explain why
children with attention deficits can demonstrate improved behaviours in the presence of
animals (Katcher and Teumer 2006).
Cognitive development
The role of animals in empathy development is of increasing interest in the management

of a range of developmental disorders, such as autism (O'Haire 2013); autism has been
estimated to have cost the UK economy 28 billion in 2007 and to have a lifetime cost
351
per individual of between 3.1 and 4.6 million (Knapp and others 2007). However, the value of
companion animals in this context, as elsewhere, appears to extend beyond their
influence on the emotional development of individuals, with the animals often also
having a broader effect on human cognitive development.
Autism is a profound developmental disorder characterised by severe impairments in
social behaviour and communication and restricted interests and behaviours (American Psychiatric
Association 1994
). People with autism are often characterised by a lack of empathy towards
others (Auyeung and others 2009) and show over- and under-responsiveness to sensory stimuli, as
well as a lack of skilled motor functioning (Rogers 1998). The number of children diagnosed
with autism appears to be steadily increasing (Merrick and others 2004). Interventions aimed at
helping people with autism arePerhaps one of the real values of companion animals is
their flexibility and sensitivity to diverse needs in different individuals
highly variable in their efficacy and scientific grounding, reflecting both the individual
nature of the condition and our lack of understanding of it (National Institute for Health and Clinical Excellence
2013
).
Many therapies utilise elements of the sensory integration framework (Ayres 1972), which
highlights how difficulties in sensory perception and integration impair the ability to
attend to and appropriately respond to complex behaviour. Petting an animal increases
fine motor control skills (Chandler 2005), and therefore it may be that by encouraging children
to gently pet and communicate with an animal we can promote the integration of sensory
and motor information in a relaxed setting. This may be valuable to the development of
all children, but of particular therapeutic value to those with autism.
Additionally, in the light of research suggesting a positive relationship between animal
companionship and empathy in children (Poresky 1996, Vidovic and others 1999), it has been proposed
that AAI may promote the development of empathy in children with autism, including
behaviours such as offering to share and offering comfort (Grandgeorge and others 2012).
A recent review highlighted how AAI might improve a range of areas of functioning in
individuals with autism, including language skills and social interaction, as well as
decrease stress levels and problematic behaviours (O'Haire 2013), although such conclusions
are based largely on poor quality investigations. However, a controlled longitudinal study
at the University of Lincoln, in conjunction with the Parents Autism Workshops and
Support network, examining the effects of pet dog ownership on UK families with an
autistic child, has recently been completed and is due to report soon (Wright and others,
unpublished observations). Uniquely, this has examined the effects on the child, primary
carer and wider family, since it is hypothesised that all of these might benefit from the
companionship provided by a dog. Dogs provide a uniquely adaptable form of
intervention for complex problems affecting the quality of life of families in this
predicament and perhaps one of the real values of companion animals is their flexibility
and sensitivity to diverse needs in different individuals or the same individual at different
times.
352

FIG 3.
It has been suggested that, by being non-judgmental, reading dogs can help with
children's self-esteem when reading out loudPhotograph: S. Hall
Facilitating learning
There is a growing need for the value of animal companionship to be recognised in a

wider educational setting. The words dog and cat are among the most frequent words
in early infant vocabulary (DeLoache and others 2011), suggesting that young children are highly
motivated to learn and use words associated with animals. Children who are pet owners
have higher autonomy, self-concept and self-esteem (Van Houtte and Jarvis 1995). The presence of a
dog has been shown to build motivation, focus and task perseverance (Heimlich 2001, Barker and
Wolen 2008
). These are important characteristics for determining successful learning in the
classroom environment and such observations have encouraged psychologists to analyse
the potential role of animal companions as learning facilitators. Dolphins are frequently
used in an effort to promote interest in and motivation for learning activities and the
concentration span of people with severe learning disabilities (Nathanson and others 1997).
However, sound scientific evidence to support these effects is still lacking (Marino and Lilienfeld
2007
). In contrast, the presence of a dog has been shown to reduce anxiety and blood
pressure in children when reading aloud (Barker and Wolen 2008), suggesting that dogs make
reading a more enjoyable process by reducing psychological discomfort. Indeed, research
indicates that children have more positive attitudes towards school and learning when a
353
classroom dog is present (Beetz 2013). This may reflect the fact that children view a
classroom dog as a non-judgemental participant in their education (Friesen 2010).
The importance of dogs in reading development is central to the Reading Education
Assistance Dogs (READ) programme. There are currently over 3000 volunteers across
the USA and Europe who are trained, with their dog, to support children's reading in
school. In a typical session, children read to the handler and the dog for approximately 20
minutes. Many beneficial effects have been anecdotally observed with this programme,
including more confident readers who show increased enthusiasm for reading; however,
to date, only small-scale studies have been conducted exploring the effects of such
intervention programmes. In order to provide substantive evidence for the beneficial
effects of reading to dogs in the classroom, further controlled studies need to be
conducted. Given that poor literacy skills cost the UK around 2.5 billion a year (Gross 2009),
the potential of animal companionship to promote reading processes is clearly deserving
of further research. The READ scheme also shows how the beneficial effects of positive
emotional development (discussed previously) associated with animal companionship can
transcend into domains of cognitive development.
FIG 4.
An elementary school student interacts with a dog trained by Human Animal Bond
in Colorado (HABIC). The programme uses the human-animal bond to assist in
therapy and activities at schools, nursing homes, rehabilitation facilities and
354
detention centres. The group has 150 active human-animal partnerships using 149
dogs and one catPhotograph: V. Richard Haro/ AP/Press Association Images
Opportunities
It is clear that animal companionship has significant beneficial implications for the
development of human emotional and cognitive development, and these should not be
underestimated or obscured by inflating the risks posed by companion animals, which,
while real, often seem to attract greater media attention. The positive effects of animals in
reducing negative emotions and increasing positive emotions may improve not only
quality of life but can also help with the development of effective interventions. The
potential of AAA to enable clinical interventions with a broad range of patients (for
example, people with autism, Alzheimer's and victims of abuse) is exciting and deserves
scientific evaluation, so we can find out what is best for society. Furthermore, by
improving emotional development, animalGiven that poor literacy skills cost the UK
around 2.5 billion a year, the potential of animal companionship to promote reading
processes is clearly deserving of further research
companionship has considerable potential for facilitating learning, especially by children
in the classroom. Although positive effects of animal companionship and AAA are well-
documented, such reports often lack vigorous scientific support; however, we should not
confuse a lack of evidence with evidence of absence. Rather we should be curious about
all the ways companion animals can potentially help us and embrace the opportunities
provided by a greater appreciation of the impact of companion animals on our lives.
It is perhaps ironic that in a world that seems to be increasingly encouraging the
development of technologies to make our lives easier, an obvious answer to many of our
problems may be literally staring us in the face (or sitting on our lap).
Developing One Health

Veterinary Record is publishing a series of articles in 2014 on the theme of One Health.
The aim is to foster a wider appreciation of the potential benefits of One Health and
encourage its application. Previous articles in the series have included:
The evolution of One Health: a decade of progress and challenges for the future,
by Paul Gibbs (VR, January 25, 2014, vol 174, pp 85-91)
One Health and the food chain: maintaining safety in a globalised industry, by
Patrick Wall (VR, February 22, 2014, vol 174, pp 189-192)
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Article
The Effects of Animal-Assisted Therapy on Anxiety
Ratings of Hospitalized Psychiatric Patients
Sandra B. Barker, Ph.D., and Kathryn S. Dawson, Ph.D.
Published online: June 01, 1998 | http://dx.doi.org/10.1176/ps.49.6.797
Abstract
Section:
367
OBJECTIVE: Animal-assisted therapy involves interaction between patients and a
trained animal, along with its human owner or handler, with the aim of facilitating
patients' progress toward therapeutic goals. This study examined whether a session of
animal-assisted therapy reduced the anxiety levels of hospitalized psychiatric patients and
whether any differences in reductions in anxiety were associated with patients'
diagnoses. METHODS: Study subjects were 230 patients referred for therapeutic
recreation sessions. A pre- and posttreatment crossover study design was used to compare
the effects of a single animal-assisted therapy session with those of a single regularly
scheduled therapeutic recreation session. Before and after participating in the two types
of sessions, subjects completed the state scale of the State-Trait Anxiety Inventory, a self-
report measure of anxiety currently felt. A mixed-models repeated-measures analysis was
used to test differences in scores from before and after the two types of
sessions. RESULTS: Statistically significant reductions in anxiety scores were found
after the animal-assisted therapy session for patients with psychotic disorders, mood
disorders, and other disorders, and after the therapeutic recreation session for patients
with mood disorders. No statistically significant differences in reduction of anxiety were
found between the two types of sessions. CONCLUSIONS: Animal-assisted therapy
was associated with reduced state anxiety levels for hospitalized patients with a variety of
psychiatric diagnoses, while a routine therapeutic recreation session was associated with
reduced levels only for patients with mood disorders.
Within the last decade, studies supporting the health benefits of companion animals have
emerged (1,2,3,4). Cardiovascular effects are often the focus, due partly to findings from
a 1980 study that reported longer survival rates following myocardial infarction for pet
owners compared with people with no pets (5). More recent evidence of cardiovascular
benefit was documented in an Australian study involving 5,741 participants (6). The
authors found that pet owners had significantly lower blood pressure and triglyceride
levels compared with non-pet-owners, and the differences could not be explained by
differences in cigarette smoking, diet, body mass index, or socioeconomic profile.
Stress and anxiety are considered contributory factors to cardiovascular disease.

Investigators have hypothesized that companion animals may serve to lower levels of
stress and anxiety (4,7,8). Several authors have reported lower blood pressure readings
among adults and children when a previously unknown companion animal is present
during various stressful activities (5,9,10,11,12,13,14).
368
Animals have been associated with positive effects on patients in a variety of health care
settings (15). When animals were first introduced to these settings, they were generally
brought for visits that were incidental to the treatment program. Currently, animals are
purposely included in treatment through various interventions broadly known as animal-
assisted therapy.
Animal-assisted therapy involves the use of trained animals in facilitating patients'

progress toward therapeutic goals (16). Interventions vary widely, from long-term
arrangements in which patients adopt pets to short-term interactions between patients and
a trained animal in structured activities.
Although animals have typically been well received on psychiatric services, much of the
data attesting to their benefits has been anecdotal (17,18,19). Several decades ago,
Searles (20) and Levinson (21) addressed the therapeutic benefit of a companion dog for
patients with schizophrenia, contending that the caring, human-canine relationship helped
ground the patient in reality. Chronic mentally ill residents in supportive care homes who
were visited by puppies had decreased depression after the visits, compared with a
matched control group (22).
More recently, Arnold (23) described the use of therapy dogs with patients with
dissociative disorders. Benefits included the dog's calming influence, ability to alert the
therapist early to clients' distress, and facilitation of communication and interaction.
Others have proposed that an animal can serve as a clinical bridge in psychotherapy,
providing an entree to more sensitive issues (16,24,25).
On an inpatient psychiatric unit, animal-assisted therapy was found to attract the greatest
number of patients among those who selected groups to attend voluntarily and was found
to be the most effective in attracting isolated patients (26). Other researchers found that a
group meeting for psychiatric inpatients held in a room where caged finches were located
had higher attendance and higher levels of patient participation, and was associated with
more improvement in scores on the Brief Psychiatric Rating Scale, compared with a
matched group held in a room without birds (27). Anecdotally, psychiatric patients who
are withdrawn and nonresponsive have been described as responding positively to a
therapy dog with smiles, hugs, and talking (16). For elderly patients with dementia, lower
heart rates and noise levels were associated with the presence of a therapy dog (28), and
369
patients with Alzheimer's disease significantly increased socialization behaviors when a
therapy dog was nearby (29).
Based on the evidence in the literature associating companion animals with anxiety
reduction and with positive responses from clinical populations, this study investigated
the effect of an animal-assisted therapy group session on the anxiety levels of psychiatric
inpatients. Also of research interest was whether any anxiolytic effect found varied by
diagnostic group.
Methods
Section:
A pre- and posttreatment crossover design was used for this study. Changes in anxiety
ratings were compared for the same patients under two conditions: a single animal-
assisted therapy group session and a single therapeutic recreation group session that
served as a comparison condition. The setting for this study was the inpatient psychiatry
service of an urban academic medical center. The service treats adult patients with a full
range of acute psychiatric disorders. The average length of stay is seven to eight days.
The animal-assisted therapy session consisted of approximately 30 minutes of group

interaction with a therapy dog and the dog's owner. During the semistructured session,
which was held once a week, the owner talked generally about the dog and encouraged
discussion about patients' pets as the dog moved freely about the room interacting with
patients or carrying out basic obedience commands.
The comparison condition was a therapeutic recreation group session held on the unit on
the day following the animal-assisted therapy session. Therapeutic recreation sessions
were held daily on the unit. They varied in content, including education about how to
spend leisure time, presentations to increase awareness of leisure resources in the
community, and music and art activities. Coordination of both the animal-assisted therapy
sessions and the therapeutic recreation sessions was shared by three recreational
therapists.
The study used the state scale of the State-Trait Anxiety Inventory to measure patients'
levels of anxiety before and after the animal-assisted therapy session and the therapeutic
recreation session (30). The State-Trait Anxiety Inventory is a brief, easy-to-administer
self-report measure that is widely used in research and clinical practice.
370
The state scale, which measures the level of anxiety felt at the present time, has been
found to be sensitive to changes in transitory anxiety experienced by patients in mental
health treatment. The inventory consists of 20 items related to feelings of apprehension,
nervousness, tension, and worry. For each item, subjects circle one of four numbers
corresponding to ratings of not at all, somewhat, moderately so, or very much so.
Instruments are scored by calculating the total of the weighted item responses. Scores can
range from 20 to 80, with greater scores reflecting higher levels of anxiety.
The internal consistency for the state scale of the State-Trait Anxiety Inventory is high;
median alpha coefficient is .93 (30). The construct validity is supported by studies
showing that state scale scores are higher under stressful conditions.
Procedures
A total of 313 adult psychiatric patients consecutively referred for therapeutic recreation
over an eight-month period in 1996 were eligible for the study. Patients are referred for
therapeutic recreation as soon as they are stable enough to participate in group activities,
generally within 24 to 72 hours of admission.
When patients were initially referred for therapeutic recreation, they were asked to sign a
consent form to participate in a group session involving a therapy dog. Patients were not
eligible to participate if they had any known canine allergies, were fearful of dogs, or did
not sign a consent form. Study subjects attended both an animal-assisted therapy group
session and a therapeutic recreation group session. The two types of sessions were held
once a week on consecutive days at the same time on each day.
The three recreational therapists providing services to the inpatient psychiatry unit
volunteered to assist with the study. Because the therapists were not blind to the treatment
condition, steps were taken to minimize bias by training the therapists in standard data
collection procedures. At the beginning and end of each animal-assisted therapy group
session and the comparison therapeutic recreation group session the following day, the
recreational therapist administered the State-Trait Anxiety Inventory. The therapists read
the instrument verbatim to any patient who had difficulties reading. For the animal-
assisted therapy group, the pretreatment instrument was completed before the dog entered
the room.
371
Two female owners of therapy dogs volunteered to provide the animal-assisted therapy
sessions. The first volunteer provided the therapy for the initial four months of the study;
then she became ill and could not continue. The second volunteer agreed to continue the
study following the same format used by the first volunteer. Her participation required
reversing the days that the animal-assisted therapy session and the therapeutic recreation
session were offered.
The dogs and owners met hospital policy for participating in animal-assisted therapy,
including documentation of the dog's current vaccinations, controllability, and
temperament. The volunteers were advised of the animal-assisted therapy group session
and given direction on how to lead the therapy group.
Analysis
Instruments were scored twice for accuracy by one of the authors using the scoring keys for the
State-Trait Anxiety Inventory. A mixed-models repeated-measures analysis was used to compare
pre- and posttreatment differences in anxiety scores between and within the animal-assisted
therapy condition and the therapeutic recreation condition by diagnostic category.
Results
Section:
Because this study was conducted in a clinical setting, pre- and posttreatment measures
on all subjects under both conditions were difficult to obtain. Six patients refused to
participate because of canine allergies or fear of dogs. Of the 313 patients who were
eligible for the study, 73 percent (N=230) participated in at least one animal-assisted
therapy group session or one recreation group session and completed a pre- and a
posttreatment measure for the session. Fifty patients completed a pre- and a posttreatment
measure for both types of sessions. Failure to complete all four measures was primarily
due to time conflicts with medical treatments and patient discharges.
Patient characteristics
The meanSD age of the 313 patients referred for therapeutic recreation was 3712
years, and their mean length of stay was 10.988.88 days. A total of 174 patients were
women, and 139 were men. The majority were black (169 subjects, or 54 percent) and
single (195 subjects, or 63 percent). They had completed an average of 11.32.6 years of
education.
372
For analysis, patients were categorized by primary discharge diagnosis. The diagnoses
were collapsed into four categories: mood disorders, including all depressive, bipolar, and
other mood disorders, for 154 patients (49.2 percent); psychotic disorders, including
schizophrenia, schizoaffective disorder, and other psychotic disorders, for 80 patients
(25.6 percent); substance use disorders, for 52 patients (16.6 percent); and all other
disorders, including anxiety, cognitive, personality, and somatization disorders, for 27
patients (8.6 percent).
Comparison of therapy groups

Table 1 shows the mean scores of the 230 study participants on the State-Trait Anxiety
Inventory before and after attending an animal-assisted therapy group session and a
therapeutic recreation group session as well as the mean change scores. Change scores
were calculated using data from patients with measures at both pre- and posttreatment
time points. The F test and p values show the significance of the change across time. No
statistically significant differences in anxiety change scores were found between animal-
assisted therapy and therapeutic recreation. Although no significant between-group
differences were found, within-group differences were statistically significant for both
animal-assisted therapy and therapeutic recreation (F=6.71, df= 1, 194, p=.01, and
F=16.81, df=1, 194, p<.001, respectively).
Among patients who participated in therapeutic recreation, only patients with mood
disorders had a significant mean decrease in anxiety. Among patients who participated in
animal-assisted therapy, patients with mood disorders, psychotic disorders, and other
disorders had a significant mean decrease in anxiety. This finding suggests that animal-
assisted therapy reduces anxiety for a wider range of patients than the comparison
condition of therapeutic recreation.
Discussion and conclusions

Section:
Spielberger (30) provided normative State-Trait Anxiety Inventory scores for
neuropsychiatric patients based on data from male veterans. Compared with the
normative patients with depressive reaction, the patients with mood disorders in the study
reported here had somewhat lower mean pretreatment scores (47.58 12.73, compared
with 54.4313.02). The pretreatment scores of the patients with psychotic disorders in
this study were slightly higher than the scores for the normative patients with
schizophrenia (48.4715.26, compared with 45.7013.44).
373
In this study, no significant difference was found between the anxiety change scores after
patients participated in animal-assisted therapy and after patients participated in
therapeutic recreation. However, this lack of difference could be due to the small number
of patients (N=50) who completed all four study measures. A power analysis of the
magnitude of differences between the change scores for animal-assisted therapy and
therapeutic recreation indicated that larger samples would be needed to achieve an 80
percent power level at an alpha of .05: a sample of 300 patients with psychotic disorders,
125 patients with substance use disorders, and 61 patients with other disorders. For
patients with mood disorders, the difference in anxiety change scores was too small for
any reasonably sized study to detect a significant difference.
For within-group differences, a significant reduction in anxiety after therapeutic

recreation was found only for patients with mood disorders, whereas a significant
reduction after animal-assisted therapy was found for patients with mood disorders,
psychotic disorders, and other disorders. The size of these reductions was similar to
differences reported by Wilson (13) for college students whose anxiety scores were
measured under varying levels of stress.
No significant reduction was found in anxiety scores for patients with substance use
disorders after either animal-assisted therapy or therapeutic recreation. This lack of
difference may be due to the small sample size or due to a relationship between state
anxiety and physiological withdrawal that is less amenable to change within one session
of animal-assisted therapy or therapeutic recreation.
The reduction in anxiety scores for patients with psychotic disorders was twice as great
after animal-assisted therapy as after therapeutic recreation. This finding suggests that
animal-assisted therapy may offer patients with psychotic disorders an interaction that
involves fewer demands compared with traditional therapies. As Arnold (23) contends,
perhaps the therapy dog provides some sense of safety and comfort not found in more
traditional inpatient therapies. Alternatively, the dog may provide a nonthreatening
diversion from anxiety-producing situations (31). Or perhaps it is the physical touching
of the dog that reduces patients' anxiety, as has been reported for other populations (12).
In this study setting, animal-assisted therapy was offered only one day each week. It
would be interesting to study the effect of more frequent exposure to determine if the
reduced anxiety is partly due to novelty or if increased exposure results in further anxiety
374
reductions. Although some patients in the study remained hospitalized long enough to
participate in more than one animal-assisted therapy session, there were not enough such
patients to permit investigation of the effect of repeated exposure. Therefore, data from
their initial animal-assisted therapy and therapeutic recreation sessions were used for
analyses.
It is not possible to determine how much the dog or the owner contributed independently
to the reductions in anxiety found in this study. Although the study's purpose was to
examine the effect of animal-assisted therapy, further examination of the effect of its
components is needed.
Because many owners of therapy dogs volunteer their time to come to psychiatric units,
animal-assisted therapy appears to be a cost-effective intervention. However, volunteers
may not participate consistently. In this study, a second therapy dog and owner, a
potential confounding variable, were introduced after the first owner became ill. Use of
nonvolunteers could strengthen future studies by providing more consistent treatment
conditions.
Finally, although the results provide evidence of the immediate effect on state anxiety of
a single session of animal-assisted therapy, further study is needed to determine if
patients' overall level of anxiety is affected. Further studies of the effect of animal-
assisted therapy on psychiatry services are needed to replicate the findings from this
study and to advance our understanding of the therapeutic benefits of the human-animal
interaction.
Acknowledgments
The authors thank Al Best, Ph.D., for his assistance with statistical analysis and Pat
Conley, Helen Brown, and Claudette McDaniel for their assistance with data collection.
Dr. Barker is associate professor of psychiatry, internal medicine, and anesthesiology

and Dr. Dawson is affiliate assistant professor of biostatistics at the Medical College of
Virginia, Virginia Commonwealth University, P.O. Box 980710, Richmond, Virginia
23298. Dr. Barker's e-mail address is sbbarker@hsc.vcu.edu.
375
Table 1. Mean pretreatment, posttreatment, and change scores on the State-Trait
Anxiety Inventory for hospitalized psychiatric patients with various
diagnoses who participated in an animal-assisted therapy session or
therapeutic recreation
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mobileUi=0
Does Animal-Assisted Therapy Really Work?
What clinical trials reveal about the effectiveness of four-legged

therapists
Posted Nov 17, 2014
Source:
You hear a lot these days about dogs who alleviate Post Traumatic Stress Disorder, horses
who cure kids with ADHD, and dolphins who can relieve depression. These and other
forms of Animal Assisted Therapy (AAT) have become widely accepted by both the
public and professionals. My local hospital has an active animal assisted therapy
program. Dozens of clinicians listed in the Psychology Today directory of
therapists incorporate animal therapy into their practice, and Psych Today bloggers have
extolled the virtues of animal therapy (for examples, see here, here, and here.)
The idea that interacting with animals can heal our broken minds and bodies is certainly
appealing, particularly for those of us who love pets. But is there a mismatch between the
media coverage of AAT and the evidence that these therapies actually work? To answer
378
this question, I recently surveyed the research literature on the effectiveness of AAT. I
was surprised by what I found.
First the Good News
AAT enthusiasts will be happy to learn that the overwhelming majority of published
studies have reported that animals make excellent therapists. For example, Maggie
OHaire of Purdue University, reviewed 14 clinical trials on the effects of AAT on
children suffering from autism spectrum disorders (here). Together, these studies
measured 30 different outcomes variables. The results were impressive. All of the studies
found that AAT was effective. Indeed, children with autism who underwent AAT showed,
in stat-speak, statistically significant improvements on 27 of the 30 outcomes measures
Other researchers have found similar patterns of results in their examination of animal
assisted therapy studies. Erika Friedmann and Heesook Son reviewed 28 AAT studies
published between 1997 and 2009 (here) The studies involved a wide variety of disorders
including Alzheimers disease, schizophrenia, developmental disabilities, and Downs
syndrome. Amazingly, all 28 of the studies reported that interacting with therapy animals
produced beneficial results. More recently, neuroscientist Lori Marino, the executive
director of the Kimmela Center for Animal Advocacy, found that 26 of 28 AAT studies
published between 2005 and 2011 reported positive outcomes in patients undergoing
animal therapy (here).
Now The Bad News: Big Problem #1
These results sound great. But are they too good to be true? Unfortunately, when it comes
to animal assisted therapy studies, two problems loom large.
The first is that most of the clinical trials on the effectiveness of animal assisted therapy
are so methodologically flawed that their conclusions cannot be trusted. Therapies
involving horses are a good example. In a recent article in the Journal of Clinical
Psychology, investigators lead by Michael Anestis of the University of Southern
Mississippi analyzed all of the published clinical trials on equine assisted therapy. They
379
found that in 12 of the 14 studies the sample sizes were too small to produce reliable
results, and 8 of the studies also lacked no-treatment control groups. In only one of the
trials were subjects randomly assigned to treatment conditions, and none of them
controlled for the effects of simply being exposed to a new experience or
for unconsciousbias on the part of the researchers. Based on these problems,
Anestis' teamrecommended that that equine therapy be put on hold until well-designed
studies demonstrate its effectiveness.
Lori Marino found that nearly all of the 28 AAT studies she examined were seriously
flawed. She says there is little evidence that the improvements seen in animal therapy
studies are due to the presence of the animal, as opposed to, say, interacting with the
animal's sympathetic handler. Dr. Anna Chur-Hansen and her colleagues found that poor
research methods have compromised the validity of clinical trials on the impact of animal
visitations on hospitalized children (here). And Japanese researchers found that all of the
randomized clinical trials on AAT conducted to date are so methodologically flawed that
they do not meet the accepted minimum standards for inclusion in meta-analyses
(here). (Note: Meta-analysis is a statistical tool that allows combining the results of
different studies.)
Animal-Assisted Therapy Research Deficiencies
Among the most common flaws in AAT studies are:
-Lack of a non-treatment control group.
-Insufficient numbers of subjects.
-No controls for effects of novel experiences (e.g., swimming with dolphins).
-No written manual spelling out the treatment procedures (important for standardization
and replication).
380
-No use of blind observations to control for unconscious bias on the part of the
researchers.
-Reliance on self-reports rather than objective measures.
-Lack of long-term follow-up studies.
-Putting a positive spin on negative results (e.g., While interacting with the therapy dogs
did not actually decrease the patients symptoms, the participants reported that they
enjoyed interacting with the animals.).
-Cherry picking (only presenting the results for variables that worked)
Big Problem #2: The File Drawer Effect
A second major problem with the scientific literature on animal assisted therapy is the
file drawer effect. This is the tendency for experiments that find positive results to be
published while experiments in which treatments do not work are rarely published. As a
result, in many areas of science, published findings are heavily biased toward positive
results. This is not a trivial issue. A recent study by the Food and Drug Administration
found that 91% of published clinical trials on the effectiveness
of antidepressant drugsreported positive results. However, when the results of non-
published trials were included in the analysis, antidepressants were found to be effective
in only 51% of the studies.
This bias toward the publication of only positive results also slants the AAT efficacy
literature. Take a study conducted by the psychologist Dr. Alisa Greenwald. For her
doctoral dissertation, Greenwald investigated the impact of a therapeutic horseback riding
program on 81 boys with emotion problems ranging from depression to ADHD to PTSD.
She found that participation in equine assisted therapy had no impact on the
childrens self-esteem or frustration tolerance. Indeed, children who were highly attached
to the therapy horses had higher levels of depression and anxiety. But the study was never
published.
381
For a systematic demonstration of the file drawer effect in the AAT literature, I turned to
a 2007 study by Julie Nimer and Brad Lundahl of the University of Utah (here). They
conducted a meta-analysis of 49 AAT studies, including 12 unpublished doctoral
dissertations. For each study, they calculated the effect size of participating in animal
assisted therapy. (I wont go into the details of how effect sizes are calculated. You just
need to know that .20 is considered a minor effect of the experimental treatment, .50 is
medium sized, and .80 is viewed as a large effect.) Using their results, I calculated the
average effect sizes of
ARTICLE CONTINUES AFTER ADVERTISEMENT
Source:
the unpublished and the published AAT studies. The results are shown in this graph. The
average effect size for the published studies was a healthy .53. On the other hand, the
average effect size in the unpublished studies was a much more anemic .28, about half as
large as in the published clinical trials. (An effect size of this magnitude means that if 100
people were to get animal assisted therapy, roughly 9 of them will be better off for the
experience while the other 91 would have done just as well by staying home and hanging
out on Facebook.)
382
The Hype versus the Evidence
Alan Beck, the Director of the Center for the Human-Animal Bond at Purdue University,
is a pioneering researcher who helped establish the field of anthrozoology. In 1984, along
with his colleague Aaron Katcher, he published the first review of studies on AAT. In that
paper, Beck and Katcher warned about the sorry state of research purporting to
demonstrate the effectiveness of animals as therapists. They argued that investigators
needed to carefully separate the feel-good temporary recreational benefits of interacting
with animals from the long-term clinical benefits of AAT. And they were particularly
concerned that too many enthusiastic investigators were asking How can I demonstrate
the therapeutic effect of pets? rather than the more appropriate question, Do pets have a
therapeutic effect?
Unfortunately, despite the media hype and 30 years of research on therapy dogs, dolphins
and horses, Beck and Katchers warning is nearly as true today as it was in 1984.
However, things are improving on the research front. In 2008, the Waltham Center for
Pet Nutrition and the Eunice Kennedy Shriver National Institute of Child Health and
Human Development initiated a grant program which has provided over 9 million dollars
for research related to human-animal relationships. Already these funds have begun to
pay off in terms of better AAT studies. (See, for example, this study by Maggie O'Haire
and her colleagues on the impact of Guinea pigs on the social behaviors of kids with
autism.)
But the truth is that we still don't know the answer to Lori Marinos question How
important is the animal in animal assisted therapy?
* * * *
Some important articles on the effectiveness of AAT.
Anestis, M. D., Anestis, J. C., Zawilinski, L. L., Hopkins, T. A., & Lilienfeld, S. O.
(2014). Equine related treatments for mental disorders lack empirical support: A
383
systematic review of empirical investigations. Journal of Clinical Psychology,70, (12),
1115-1132.
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assisted-therapy-really-work
Animal-Assisted Intervention for trauma: a systematic

literature review
Marguerite E. O'Haire,* Nomie A. Gurin, and Alison C. Kirkham
Abstract
Introduction
384
The inclusion of animals in psychological treatment is not new, nor is it uncommon. The
first reported occurrence is estimated to be the late eighteenth century, when animals
were incorporated into mental health institutions to increase socialization among patients
(Serpell, 2006). Today, a number of programs in the United States report involving
animals in their services in some capacity. One of the most commonly targeted
populations for these services is individuals who have experienced trauma, including
those with posttraumatic stress disorder (PTSD; Tedeschi et al., 2010). Yet despite the
popularity of positive media surrounding these programs, it is unclear whether empirical
data supports their practice. The purpose of this review is to systematically collect and
critically assess current research on Animal-Assisted Intervention (AAI) for trauma,
including PTSD.
AAI is broadly defined as any intervention that includes an animal as part of the process
(Kruger and Serpell, 2010). It encompasses targeted therapeutic interventions with
animals (Animal-Assisted Therapy), less structured enrichment activities with animals
(Animal-Assisted Activities), and the provision of trained animals to assist with daily life
activities (Service or Assistance Animals). The use of AAI has been related to promising
outcomes in a number of populations, including increased social interaction among
children with autism spectrum disorder (O'Haire, 2013), increased social behaviors and
reduced agitation and aggression among persons with dementia (Filan and Llewellyn-
Jones, 2006; Bernabei et al., 2013), reduction in symptoms among patients with
depression (Souter and Miller, 2007), and increased emotional well-being such as
reduced anxiety and fear (Nimer and Lundahl, 2007). It is purported to provide value for
trauma in similar ways.
PTSD is an anxiety disorder that is characterized by symptoms related to intrusion,
avoidance, negative alterations in cognition and mood, and alterations in arousal and
reactivity (American Psychiatric Association, 2000). It is estimated to affect
approximately 7.8% of the US population (Kessler et al., 1995) and can lead to
substantial work and social impairments (e.g., Hidalgo and Davidson, 2000). It is a
difficult disorder to treat, with dropout and non-response rates up to 50% in studies of
empirically-supported treatments (Schottenbauer et al., 2008). One of the most well-
established treatments in research, exposure therapy, is not commonly undertaken by
therapists due to its perceived level of difficulty and discomfort to patients (e.g., Becker
et al., 2004). Discovering and evaluating alternative and complementary therapies has
been deemed imperative (Cukor et al., 2009; Bomyea and Lang, 2012).
Anecdotal evidence suggests that animals may provide unique elements to address
several PTSD symptoms. With respect to intrusion, the presence of an animal is
purported to act as a comforting reminder that danger is no longer present (Yount et
al., 2013) and to act as a secure base for mindful experiences in the present (Parish-
Plass, 2008). Individuals with PTSD often experience emotional numbing, yet the
presence of an animal has been reported to elicit positive emotions and warmth (e.g.,
Marr et al., 2000; O'Haire et al., 2013). Animals have also been demonstrated as social
facilitators that can connect people (e.g., McNicholas and Collis, 2000; Wood et
al., 2005) and reduce loneliness (e.g., Banks and Banks, 2002), which may assist
individuals with PTSD to break out of isolation and connect to the humans around them.
One of the most challenging aspects of PTSD tends to be hyperarousal. The presence of
385
an animal has been linked to secretion of oxytocin (Beetz et al., 2012b) and reductions in
anxious arousal (e.g., Barker et al., 2003), which may be a particularly salient feature for
individuals who have experienced trauma. Yet despite the theoretical promise of AAI and
its popularization through anecdotal media, there has been no comprehensive review of
its empirical research base for trauma.
The purpose of this review is to surpass anecdotal accounts by presenting a
comprehensive overview of empirical research on AAI for trauma. The goal is to
systematically identify, summarize, and evaluate any existing empirical studies of AAI
for trauma in order to document currently researched AAI practices and their reported
findings, as well as to provide directions for further, more rigorous research. The specific
aims are to: (a) describe the characteristics of AAI for trauma, (b) evaluate the state of the
evidence base, and (c) summarize the reported outcomes of AAI for trauma.
Methods
Protocol
The preferred reporting items for systematic reviews and meta-analyses (PRISMA)
guidelines were consulted to perform this systematic review (Liberati et al., 2009; Moher
et al., 2009). The study procedures were defined a priori in a study protocol that specified
the search strategy, inclusion and exclusion criteria, and data extraction items.
Eligibility criteria
The following inclusion criteria were used to select relevant articles for review: (a)
publication in English in a peer-reviewed journal or thesis, (b) collection of original,
empirical data on outcomes from AAI, which was defined as any intervention that
intentionally incorporated a live animal, and (c) reporting of summative results for
participants who have experienced trauma, including PTSD.
Search procedure
Studies were identified by searching the following electronic databases from their
inception date through October 2014: ERIC (1966-Present), Medline (1950-
Present), ProQuest (1971-Present), PsycARTICLES (1987-Present), PsycINFO (1806-
Present), and Scopus (1960-Present). To increase coverage, two additional databases were
included: HABRI Central (Human-Animal Bond Research Initiative), a specialized
human-animal interaction research database, and PILOTS (Published International
Literature on Traumatic Stress), a specialized PTSD research database maintained by the
National Center for PTSD of the Department of Veteran Affairs. Search terms for all
databases included at least one identifier for trauma and at least one identifier for AAI in
the article title, abstract, and/or keywords. Identifiers for trauma included PTSD OR
trauma*, where the asterisk indicates any word variation including the base trauma.
Identifiers for AAI included a comprehensive list of 38 search terms used in a previous
systematic review of AAI for autism spectrum disorder, detailed in Table
Table11 (O'Haire, 2013). To reduce overestimation of effects due to potential publication
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bias, theses were included in addition to peer-reviewed journal articles. For all articles
meeting the inclusion criteria, reference lists were screened for possible additions.
Table 1
List of terms to identify Animal-Assisted Intervention (AAI) in database search.
Data extraction and evaluation

Information was extracted from each included study to achieve the three aims of this
systematic review. To achieve the first aimdescribe key characteristics of the AAIs
data items included AAI terminology, animals, setting, interventionist, format, activities,
and duration. To achieve the second aimevaluate study methodology and risk of bias
data items included sample size, participant characteristics (including age, gender, and
PTSD diagnosis), study design, comparison condition, and assessment measures
(including type, standardized instruments, and raters/informants). To achieve the third
aimsummarize study outcomesdata items included the results of each study, which
were subsequently organized by the most commonly reported outcomes. Additional data
items were extracted for study identification and exploratory purposes, including first
author, publication year, country of corresponding author, and journal name.
To compare effect sizes across studies, we calculated Cohen's d for all studies which
reported means and standard deviations. We used two different formulas based on study
design. For within-participant designs, effect size was calculated by dividing the
difference of the means by the average standard deviation of both repeated measures
(Lakens, 2013).
dwithin=MdiffSD1+SD22
(1)
For between-participants designs, effect size was calculated using the recommended
formula for pre-post-control group designs using the pooled pre-test standard deviation
(Morris, 2007).
dbetween=cp[(Mpost,TMpre,T)(Mpost,CMpre,C)SDpre]
(2)
Where, the pooled standard deviation is defined as:
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SDpre=(nT1)SD2pre,T+(nc1)SD2pre,CnT+nC2
(3)
and
cp=134(nT+nc2)1
(4)
Results
Study selection
The initial literature search resulted in 453 citations. A flow diagram of the study
selection process is presented in Figure Figure1.1. The final sample included 10 studies
(2.2% of the total initial pool) that met the inclusion criteria of empirically evaluating
AAI for trauma. Six studies were published in peer-reviewed journals and four were
theses. Publication dates ranged from 2004 to 2014, with the majority of studies (9 of 10)
being published within the last 4 years, since 2011.
Figure 1
Flow chart of study selection process. HAI, human animal interaction; AAI, animal-
assisted intervention; PTSD, posttraumatic stress disorder.
Despite the limitation to English-language articles only, there was an international
representation of researchers. Among the peer-reviewed journal articles, countries of
corresponding authors included the USA (2 studies), Spain, Germany, Israel, and
Australia (1 study each). The articles were primarily published in child or family studies
journals (4 studies), in addition to psychology and alternative medicine (1 study each).
The final sample of articles included studies with a range of designs, participant age
groups, intervention types, and outcome measures. Due to heterogeneity across studies,
the results of this review focus on descriptive and qualitative synthesis rather than meta-
analysis.
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Characteristics of AAI for trauma
To achieve the first aimto describe the characteristics of AAI for traumathe key
features of AAI in the 10 studies were extracted and are summarized in Table Table22.
Table 2
Overview of Animal-Assisted Intervention (AAI) characteristics.
Terminology
The terminology used to identify AAI varied depending on the type of animal
participating in the study. Seven different terms were used across the 10 studies, with
animal-assisted therapy occurring the most frequently (n = 4). Other terms included
equine-facilitated therapy (n = 1), natural horsemanship (n = 1) and psychiatric
service dogs (n = 1). One study incorporated two different terms, using both dog-
assisted therapy and canine-assisted therapy in different instances. A final study did
not include a specific term to denote AAI other than reporting the presence of a dog.
Animals and settings

The majority of studies included dogs as the participating species (n = 5), while other
studies focused on horses (n = 3), or a combination of dogs, horses, and other farm
animals (n = 2). All horse-based interventions took place at a riding facility. The dog-
based interventions occurred in a variety of settings, including treatment centers (n = 2), a
school (n = 1), a laboratory (n = 1), and the participant's home (n = 1).
In the studies that included information about the participating animals' background (n =
9), four studies classified the animal as a therapy dog or service dog that had
received prior training (Dietz et al., 2012; Murrow, 2013; Lass-Hennemann et al., 2014;
Newton, 2014). Two of these studies specified the therapy dog training organization. One
received certification from Therapy Dogs International (Murrow, 2013) and the other was
trained at Therapiehundezentrum Saar (Lass-Hennemann et al., 2014). In the remaining
studies (n = 5), the animals were reported to have had prior socialization with humans,
but no specified training.
Interventionists and format

All but two of the studies (n = 8) included specified interventionists who facilitated the
AAI sessions. Over half of these studies included an interventionist who had previous
experience or training in AAI (n = 5); however, the specifics of their background are not
389
mentioned. At least one therapist, psychologist, or social worker was present for most of
the studies (n = 6), and was often accompanied by an animal professional, including a
dog handler (n = 2), riding instructor (n = 1), or veterinarian (n = 1). In the remaining two
studies, one involved a service dog so it did not require an interventionist and the other
included the researcher as the study facilitator in a laboratory setting.
The format of the AAIs included individual sessions, group sessions, and a combination
of both forms. The individual format used a triangle approach with the participant, the
interventionist(s), and the animal (n = 3). The group and mixed formats included varying
numbers of participants in each group, with only two of four studies reporting group size
(range: 610).
Activities
The activities and role of the interventionist were inconsistently described with varying
levels of detail. No studies reported the use of a published, manualized protocol. Most
reported the procedures undertaken within the text of the publication; however, none
provide enough detail to allow for replication. Three studies reported having a
predetermined theme for each session. Among the activities described, two main
variation factors were identified: the animal species, and whether or not the intervention
animal was used as a metaphor for the child's relationship with his or her usual social
partners.
Variation in activity based on animal species may have been due to the nature of indoor
vs. outdoor animals. Dogs were the only species included in traditional, clinic-based
therapy sessions, whereas horses and farm animals tended to be part of more active
engagement outdoors. Three of five studies with dogs integrated them into classical
therapy sessions, which included both dog-focused activities such as training as well as
talking to the dog about personal traumatic experiences (Hamama et al., 2011; Dietz et
al., 2012; Murrow, 2013). Only one study evaluated the effect of different components of
the AAI, comparing the effect of the mere presence of the dog vs. the integration of the
dog through stories told from the animal's perspective (Dietz et al., 2012). The effects of
the dog were generally enhanced by telling a therapeutic story about the dog, which may
be attributed to giving the dog a role and integrated purpose in the therapy session, rather
than being a mere entity in the room.
In the three studies involving horses as the sole animal, only one included horse riding
(McCullough, 2011), while the other two used ground-based activities, reported as basic
horsemanship and natural horsemanship. Examples of ground-based activities
included grooming, observing horse behavior, and using body language to direct the
horse around the pen. One study also provided education about horse biology and
behavior without the horses present.
The two interventions on farm settings incorporated a variety of farm animals in addition
to horses and dogs, such as cats, sheep, pigs, chickens, opossums, and llamas. The
activities in these programs were not standardized and varied greatly. In one study,
participants were given free time to interact with the animals and engage in various
activities, such as dog training or gardening (Woolley, 2004). In the other study,
390
participants chose one animal at the beginning of the program to interact preferentially
with throughout the program (Balluerka et al., 2014). Neither study reported which
animals were most often selected, nor the frequency or duration of interacting with
different species.
Among the 10 studies, two did not report the activities undertaken due to the nature of the
intervention. The first was based in a laboratory setting, where the AAI consisted of the
simple presence or absence of a dog. The second involved the provision of service dogs
in the participants' homes. Across the eight remaining studies, seven used human-animal
interaction as a metaphor for the participant's relationship with his or her usual social
partners. This type of metaphor was incorporated into all AAIs with horses, both AAIs on
farm settings, and two AAIs with dogs (Hamama et al., 2011; Murrow, 2013).
Duration
Eight studies applied programs with ongoing sessions. These AAIs lasted from 1 to 12
weeks. Most reported an exact duration; however, if only a range was reported, we used
the midpoint of the range in descriptive calculations. The average duration of AAI was
7.8 weeks (range: 112, SD = 3.5) with 11.6 sessions (range: 434, SD = 9.0), each
lasting 115.4 min (range: 17.52 40, SD = 74.3). The duration of AAI in the remaining
two studies included a laboratory-based study with a single, 20-min session, and
interviews about service dogs, who had lived with participants for at least 1 year.
Methodological evaluation
To achieve the second aim, to evaluate study methodology and risk of bias, key
characteristics of the methods were extracted and summarized with respect to each
study's sample size and characteristics, study design (Table (Table3),3), and assessment
type (Table (Table44).
Table 3
Summary of participants, study design, and outcomes.
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Table 4
Assessment measures.
Sample size and characteristics

Sample sizes ranged from 1 to 153 participants, with half of the studies (n = 5) having a
relatively small sample size of 11 participants. For studies with more than one
participant, the percentage of males ranged from 0 to 83%, with males making up 20.2%
(74 of 366 participants) of the total sample across the 10 studies.
Three studies were conducted with adults (n = 87), and seven studies concentrated on
children and adolescents (n = 279). Of the three adult studies, only one reported
participant age and it was a case study with only one participant and horses (Nevins et
al., 2013). The other two studies specified instead that the participants were students with
dogs (N = 80; Lass-Hennemann et al., 2014) or veterans with service dogs (N = 6;
Newton, 2014). All studies on children and adolescents reported the age range of their
participants; however only five reported the mean age or enough information to calculate
it, and only two reported the standard deviation or enough information to calculate it.
Using the information provided, the mean age of child and adolescent participants was
12.3 years (range: 418, SD = 1.93).
Diagnosis
Participants were exposed to a range of traumas. Two of three studies with adults
included war veterans with a prior community diagnosis of PTSD (Nevins et al., 2013;
Newton, 2014). One was a case study with one veteran and horses (Nevins et al., 2013)
and the other was a small study with six participants with service dogs (Newton, 2014).
The third adult study was a laboratory-based, experimental study with dogs, in which
healthy participants were exposed to traumatic video content (Lass-Hennemann et
al., 2014).
The seven studies on children and adolescents focused on family violence. None of these
studies included participants with a prior diagnosis of PTSD. Most included a
combination of physical abuse, sexual abuse, and/or unspecified trauma. Only one study
focused on a specific type of abuse, including dogs in school for 30 children who had
experienced sexual abuse (Kemp et al., 2013).
A subset of participants in one dog study experienced no trauma (Hamama et al., 2011). It
compared a treatment group of nine children with teacher-reported trauma who
participated in AAI to a control group of nine children without teacher-reported trauma
who did not participate in AAI. This unequal comparison was further complicated by the
fact that a subset of participants in each condition did not qualify for PTSD on the PTSD
Checklist for Children (PCL-C; 2 of 9 in treatment group; 6 of 9 in control group). Given
the high proportion of children without PTSD in the control group, and the fact that the
study did not report separate results for the three individuals who had experienced
trauma, the results from the control group in this study were not included in the final
review.
392
Study design
Half of the studies included a comparison condition (n = 5), while the others looked only
at the treatment condition, using a pre-post design (n = 4) or retrospective interviews (n =
1). The comparison conditions included one study with a within-participant, waitlist to
treatment (AB) design and four studies with between-participants comparisons against a
waitlist with treatment as usual or the AAI procedure without an animal. Only one of the
between-participants studies used random assignment to condition, conducting data
collection a laboratory setting with dogs (Lass-Hennemann et al., 2014). Only one study
included a follow-up assessment; it was a case study of one veteran and horses with
measures at 2, 4, 6, and 12 weeks post-AAI (Nevins et al., 2013).
Assessment type
Surveys were the most frequent means of assessment (n = 9; Table Table4).4). Responses
were predominantly self-report, but also included reports from parents and a treatment
facility staff member. In addition to surveys, one study included behavioral observations
of nine participants during therapy sessions, counting how many times they approached
the therapy dog (Murrow, 2013). Another study assessed the physiological arousal of 80
female participants, measuring their blood pressure, heart rate and cortisol level when
with a dog, stuffed dog, person, or nothing (Lass-Hennemann et al., 2014). One study
was based on qualitative interviews alone, evaluating six veterans with service dogs
(Newton, 2014). No studies incorporated blinded observational measures of participant
outcomes.
Outcomes of AAI for PTSD

To achieve the third aim of this review, we synthesized the study outcomes. Although the
designs and assessments of the 10 studies were varied, key outcomes were identified and
categorized according to the number of studies in which they were reported. Table
Table55 reports effect sizes and mean percent change from before to after AAI for the
most commonly reported outcomes in quantitative studies.
Table 5
Percent change and effect size of most commonly reported outcomes in quantitative
studies.
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Depression
The most commonly reported outcome from AAI for trauma was a reduction in
depression symptoms in six out of 10 studies. Four different instruments were used to
assess depression, including Beck's Depression Inventory (BDI), the Children's
Depression Inventory (CDI), the Short Center for Epidemiologic Studies Depression
Scale (SCESD), and the Trauma Symptom Checklist for Children (TSCC). One study
also included qualitative self-report. Outcomes included reduced depression following
AAI, compared to before the AAI (n = 5) and after the comparison condition (n = 2). One
study found reduced depression from before to after individual AAI sessions with farm
animals for 21 participants (51% mean change, Woolley, 2004). However, changes over
the course of the program compared to baseline were only evidenced after the last session
(47% mean change) but not before the last session (+1% mean change). Thus, in this
study the changes appear to be short-term, whereas a case-study on a war veteran with
horses found lasting changes at 12 weeks post-AAI (44% mean change, Nevins et
al., 2013). Taken together, there was variability in the timing magnitude of changes, with
the mean percent change from before to after AAI ranging from 19 to 72%. Effect
sizes ranged from small to large.
PTSD symptoms
The second most commonly reported outcome from AAI for trauma was a reduction in
PTSD symptoms in five out of 10 studies. Three different instruments were used to assess
PTSD symptoms, including the Children's Revised Impact of Event Scale (CRIES), the
PTSD ChecklistCivilian Version (PCL-C), and the Trauma Symptom Checklist for
Children (TSCC). Outcomes included reduced PTSD symptoms following AAI,
compared to before the AAI in five studies. These changes were significant compared to
the comparison condition in one study of 30 participants with horses (Kemp et al., 2013)
but not in another study of 153 participants with dogs (Dietz et al., 2012). These two
studies also examined dissociation as a separate symptom using the TSCC and both found
significant decreases in dissociation symptoms following AAI, compared to before the
AAI and after the comparison condition. There was a high variability in the magnitude of
changes, with the mean percent change from before to after AAI ranging from 13 to
80% across the five studies. Effect sizes ranged from small to large.
Anxiety
Another common finding was reduced anxiety in four studies. Three different survey
instruments were used to assess anxiety, including the State-Trait Anxiety Inventory
(STAI), the Trauma Symptom Checklist for Children (TSCC), and Beck's Anxiety
Inventory (BAI). Outcomes in two studies included reduced anxiety following AAI,
compared to before the AAI and to the comparison condition (Dietz et al., 2012; Kemp et
al., 2013). In a study on AAI with farm animals, results showed a short-term effect on
anxiety from before to after individual AAI sessions (27% mean change,
Woolley, 2004). However, changes over the course of the program compared to baseline
were only evidenced after the last session (21% mean change) but not before the last
session (+12% mean change). The final study showed that 80 healthy, female participants
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reported feeling less anxious watching a traumatic video with a dog or a person,
compared to a stuffed dog or alone. However, physiological measures (i.e., cortisol, heart
rate and blood pressure) showed no differences based on condition (Lass-Hennemann et
al., 2014). The mean percent change in anxiety from before to after AAI ranged from
21% to 65% across the four studies. Effect sizes ranged from small to large.
Social outcomes
A variety of outcomes were relevant to participants' social environment and social
competencies. Among these, one study with farm animals reported a 20% increase (d =
0.50) in attachment security in 21 adolescents from before to after AAI as measured by
the Cartes: Modles individuels de Relation (CaMiR) questionnaire (Balluerka et
al., 2014), and one with dogs reported non-significant improvements in social-emotional
competencies from before to after AAI in nine children (+8%, d = 0.40) as measured by
the Devereux Student Strength Assessment (Murrow, 2013). Qualitative reports from six
veteran service dog recipients indicated an increase in involvement with helping others
and feelings of social support after receiving their service dogs. Conversely, they also
acknowledged that owning a service dog can bring social difficulties, such as being
denied access to public places or lack of respect for the dog as a working animal
(Newton, 2014).
Sleep
Two studies assessed outcomes related to sleep. One war veteran participating in a case-
study reported a lasting increase in nightly sleep duration that continued for 3 months
after the AAI program (Nevins et al., 2013). Another study with six war veterans reported
drops in the frequency of nightmares when living with service dogs (Newton, 2014).
Child functioning
Two studies specifically addressed areas of child functioning. One study reported a 63%
reduction in problem behaviors among 30 children and adolescents following AAI with
horses, compared to before AAI (d = 2.26) as measured by the Child Behavior Checklist
(Kemp et al., 2013). Another study of therapy sessions with a dog reported increases in
global scores of behavioral functioning from before to after AAI as measured by staff on
the Youth Outcome Questionnaire to measure treatment progress (+15% mean
change, d = 0.41), but not in the aggregated scores of the 11 participants on the Youth
Self-Report to measure problem behaviors (Woolley, 2004).
Quality of life
A final group of findings addressed constructs related to quality of life. A war veteran
case study reported increases in satisfaction with quality of life (+180% change) and
decreases in dissatisfaction with quality of life (93% change) from before to after AAI
with horses (Nevins et al., 2013). Outcomes related to self-efficacy included significant
improvements in coping with stressful life events during AAI with dogs (+7% mean
395
change, d = 0.14; Hamama et al., 2011) and increased resilience-focused behaviors and
processes in the case-study with a war veteran and horses (35% increase; Nevins et
al., 2013). Qualitative interview data indicated reduced fear of public spaces and less use
of psychotropic medications in six war veterans with service dogs (Newton, 2014). In the
laboratory-based study, dogs helped reduce a subjective drop in negative affect after the
participants had watched the traumatic video, but there was no increase in positive affect
(Lass-Hennemann et al., 2014). Other studies with dogs reported reductions in anger
(41% mean change, d = 0.68; Dietz et al., 2012) and increases in well-being (+10%
mean change, d = 0.24; Hamama et al., 2011) from before to after AAI.
Discussion
We conducted a systematic review to synthesize the empirical literature on AAI for
individuals who have experienced trauma, including PTSD. The exhaustive search
procedure resulted in 10 studies, including six peer-reviewed journal articles and four
theses. There has been a recent growth in the number of studies on AAI for trauma, with
all but one study published in the last 5 years. Results support short-term, subjective
benefits of AAI for trauma, including reduced depression, PTSD symptoms, and anxiety.
Effect sizes ranged from small to large. Intervention procedures and research designs
varied greatly, evidencing the preliminary nature of research in this area. The field of
research is international and interdisciplinary, with a global range of corresponding
author countries and diverse journal disciplines. The broad range of outlets highlights the
need for systematically collecting and synthesizing the literature in one place, which was
the purpose of this review. Each study was reviewed to achieve three key aims: (a)
describe the characteristics of AAI for trauma, (b) evaluate the state of the evidence base
to provide recommendations for further research, and (c) summarize the reported
outcomes of AAI for trauma.
Characteristics of AAI for trauma

To achieve the first aim of the review, several elements of AAI were examined in each
study, including terminology, animals, setting, interventionist, format, activities, and
duration. Across the 10 studies reviewed, five different terms were used to identify AAI,
with animal-assisted therapy being the most common term used in four studies. The
field of human-animal interaction has experienced a push to unify terminology. The core
terminology are undisputed; however, the organizational structure of the terms has been
met with some dispute regarding whether Animal-Assisted Activities is a sub-category of
Animal-Assisted Intervention or its own separate entity. Based on our review of the
literature, we recommend the continued use of the term Animal-Assisted Therapy to
signify individualized, goal-directed treatment, Animal-Assisted Education for
individualized, goal-directed education, Animal-Assisted Activities for unstructured,
enrichment activities, and Service Animals for trained animals living in the home and
with individuals throughout their daily life (Kruger and Serpell, 2010; IAHAIO, 2013).
The inconsistency in terminology across the reviewed studies may be a function of the
diverse and nascent nature of the field. Given the diversity of reviewed programs, we
recommend that future studies follow a consistent taxonomy with the spectrum term AAI
and its sub-categories. Consistent terminology will enable more cohesive and productive
396
research as well as better community understanding of the definition and function of AAI,
which will influence both practice and policy.
Despite inconsistent terminology, all studies were consistent in that they each presented
an animal for individuals who had experienced trauma. The most common animal species
were dogs and horses, with a small subset of studies also including a range of farm
animals. The settings with dogs were more variable than those with horses or farm
animals, which were limited to outdoor farms and riding centers. Interventionists
included personnel with a range of backgrounds in both human-focused (e.g.,
psychologist, social worker) and animal-focused (e.g., veterinarian, animal-handler)
domains. Limited information regarding specific AAI training for interventionists was
provided. We recommend that future studies provide specific details about both animal
and interventionist background, training, and experience with AAI.
The level of detail regarding AAI procedures was often insufficient to enable replication.
From the information provided, protocols varied widely, even across studies with the
same species. Formats included both individual- and group-based intervention. The
duration of weekly AAI programs ranged from 1 to 12 weeks, with contact time ranging
from 20 min to 36 h over the course of the AAI program. No studies used fidelity
checklists to assess treatment integrity. Only one study experimentally evaluated a
procedural component of the intervention. Findings revealed that positive outcomes were
greater when dogs were meaningfully incorporated into child and adolescent group
therapy through stories, compared to when they were simply present in the room without
story integration (Dietz et al., 2012). No study used a published treatment manual, which
is a critical component of establishing evidence-based interventions (Foa et al., 1997).
Replicable protocols are recommended to enable evaluation of generalizability in
research and consistent implementation in community practice (Cukor et al., 2009).
Given the procedural variability across studies, it appears that AAI for trauma is at
present not well defined and in need of technique refinement and protocol
standardization.
Assessing AAI for trauma

To achieve the second aim of the reviewto evaluate the state of the evidence basewe
reviewed the methodology of the included studies. There was a wide variability across
the studies with respect to sample size and characteristics, study design, and assessments.
Sample sizes ranged from a case study design with one participant to a larger study with
153 participants. Participants included children, adolescents, and adults. Not all studies
reported descriptive statistics regarding participant age, which should be more carefully
reported in further research.
The type of trauma varied across studies, with the most common type being child abuse.
Despite a growing number of AAI programs targeting military veterans, only two studies
included this population; one was a case study and the other was an unpublished thesis. It
appears that there is a gap in the empirical literature on the effects of animals for
veterans. Given the broad range of trauma types, it would be valuable for further research
to investigate and develop treatments that are best adapted to specific experiences. For
example, factors that may influence AAI format and outcomes could include the timing
397
of the trauma (e.g., recent vs. distant past), the age group of participants during treatment
and during trauma (e.g., child vs. adult), and the cause of the trauma (e.g., war, physical
assault, sexual abuse, or witnessing violence). Given predominantly small sample sizes in
existing studies, it is not possible to explore individual differences to determine the
characteristics of people who benefit from AAI. In the future, larger studies can be used
to distinguish the profiles of individuals who are most likely to benefit from AAI. This
will enable efficient and effective allocation of AAI services.
The trajectory of research to establish specialized AAI programs for trauma is in its very
early stages. The current body of research consists predominantly of small, pre-post
studies. These types of studies are recommended as the first step in PTSD treatment
research, as a means of documenting feasibility, safety, and potential treatment benefits
(Rosenberg et al., 2011). Although the existing studies' successes imply feasibility and
safety, they do not directly address or report on these outcomes. Further studies should
specifically assess and report outcomes for feasibility and safety, in addition to treatment
benefits. This stage is generally followed by the development of standardized, manual
procedures with fidelity checklists and subsequent randomized clinical trials. However,
we recognize that the steps to develop evidence-based, complementary, and integrative
treatments are often not linear and there may be concurrent pursuit of multiple research
goals related to the development and evaluation of AAI for trauma (National Center for
Complementary and Alternative Medicine, 2011).
One noteworthy area of consideration for further research is the selection of an
appropriate control condition. Half of the included studies had no control condition. The
other half predominantly used a standard of care control. The standard of care control
condition is essential to establish whether there is any effect of AAI, above and beyond
current practices or treatment as usual. These designs are important to establish whether
or how AAI can add value to existing approaches. Yet while findings from these studies
can attribute outcomes to the AAI program as a whole, they do not necessarily evidence
any specific role of the animal. If effectiveness trials continue to demonstrate benefits
from AAI, follow up studies may begin to compare AAI to a placebo or sham treatment
to disentangle the effects of the animal from potential effects due to novelty, expectancy
biases, or extraneous treatment components. The challenge in AAI research will be to
identify suitable attention controls to isolate these factors.
Outcomes of AAI for trauma

Although the reviewed studies are diverse and limited, all reported positive outcomes of
AAI for individuals who have experienced trauma. It is important to interpret these
outcomes as preliminary, given the low level of methodological rigor in many of the
studies. The most common finding was reduced depression following AAI. This outcome
is consistent with prior research indicating that AAI can reduce depression among
individuals in nursing homes and psychiatric hospitals (Souter and Miller, 2007).
Reductions in depression may be related to positive perceptions of animals. Indeed the
simple presence of an animal has been related to increased instances of smiling and
laughing among children (O'Haire et al., 2013) as well as positive social engagement
among adults (Hunt et al., 1992; Wood et al., 2005).
398
The second most commonly reported outcome was reduced PTSD symptom severity. It is
unclear whether there are specific symptoms that were targeted in AAI protocols, or
whether there are specific symptoms that were most amenable to change from AAI.
Reductions in depression may be related to changes in the PTSD symptom of negative
alterations in cognition and mood. Another symptom, alterations in arousal and reactivity,
may be interrelated with the finding of reduced anxiety following AAI. Previous research
has documented an anxiety-reducing effect of animals in many studies (e.g., Shiloh et
al., 2003). The reduction in arousal may be due to the comforting soft contact of stroking
an animal (Beetz et al., 2012a) or to the centering ability of animals to act as a positive
external focus of attention (Gullone, 2000). Exploring the mechanisms of change during
AAI offers a complex and open area for ongoing investigation. It will likely require
careful manipulation of a set number of interaction variables, such as physical contact,
attentional focus, and situational demands.
The duration of positive outcomes was only examined in a case study of one war veteran
with horses (Nevins et al., 2013). Follow-up measures in this study indicated lasting
benefits; however, another study of AAI sessions for 21 adolescents showed positive
benefits only during sessions with the farm animals, but not following a week-long
period without the animals (Woolley, 2004). Further research should focus specific
attention on the nature and timing of positive outcomes, as well as the duration required
to achieve them.
It would also be informative to document differential outcomes based on the type of
interaction and activity with each animal. For example, the largest study reviewed (N =
153 children and adolescents) demonstrated that AAI with dogs resulted in greater
positive outcomes if the dog was incorporated into the therapy setting by telling stories
from the dog's perspective, rather than simply being present during sessions (Dietz et
al., 2012). In the development of effective AAI manuals, it may be fortuitous to test
variable treatment components such as AAI activities or animal species. Example
variables might include the format of treatment (e.g., group vs. individual), type of
contact (e.g., stroking a dog vs. watching a dog), or type of activity (e.g., mounted horse
riding vs. un-mounted activities such as grooming). These evaluative processes are
critical in the early stages of intervention development and piloting, particularly for
complex interventions with multiple components (Craig et al., 2008).
Finally, it is notable that no outcomes were reported related to animal welfare. We
hypothesize that a high level of animal welfare is necessary to achieve positive outcomes
from AAI. It is important to document the standard of care required and provided to
enable consistent replication as well as to highlight animal care as an important
component of a successful and ethical AAI program.
Risk of bias and future directions

The assessments in the reviewed research were predominantly self-report. This is a
critical format to capture individual perceptions related to depression, anxiety, and quality
of life following trauma. Further studies should corroborate self-reported findings with
measures that have a lower risk of bias, such as blinded behavioral observation or
physiological assessment. For example, in addition to asking a person about nightmares
399
and sleep quality, it would also be informative to track sleep patterns and arousal via
telemetric monitoring devices that can be worn comfortably at night. Advances in
technology will enable high-quality, comprehensive assessments from multiple angles to
address core PTSD symptoms in addition to comorbid disorders and overall functioning.
Critics of new intervention research may suggest that positive findings are due to a
publication bias or file drawer problem, whereby negative or non-significant positive
findings are filed away rather than published. To address this possibility, we included
both published and unpublished work in our review. Positive outcomes were reported in
both categories. However, the effect sizes in published studies were larger than those in
unpublished studies. Given the preponderance of methodological weaknesses in the
unpublished theses, it is unclear whether the lack of publication is due to study design or
findings. What is clear is that the field of research is in a nascent stage, and further
inquiry over time will be necessary to truly elucidate a potential publication bias.
Another form of potential bias is researcher expectancy bias. This may be particularly
salient for studies in which the researchers designed and conducted the study in addition
to providing the intervention. For example, study authors in some cases included an
animal handler or other AAI personnel. Independence between the research team and the
service providers may lend more credibility to study findings. Once a larger number of
quantitative studies have been conducted, it will also be possible to use more
sophisticated techniques to evaluate internal and external risk of biases, such as p-curves
(Simonsohn et al., 2014) or funnel plots (Egger et al., 1997).
Conclusion
There has been a recent growth in the number of studies examining AAI for trauma.
Results have been predominantly positive, showing short-term improvements in
depression, PTSD symptoms, and anxiety. A review of the methodology indicates that
research in this area is in its very early stages. Given the preliminary nature of the data,
we conclude that at present AAI shows promise as a complementary technique, but
should not be enlisted as the first line of primary treatment for trauma. Further research is
needed to better understand the nature of outcomes for different types of trauma, to
directly evaluate feasibility and compliance, to manualize evidence-based AAI treatment
protocols, and to evaluate generalizable outcomes in larger community samples.
Author contributions
MO conceptualized and designed the project, obtained funding for the review, conducted
the literature research, analyzed and interpreted data, and participated in the writing of
the manuscript. NG analyzed and interpreted data, provided summaries of reviewed
articles, conducted statistical analysis, and participated in the writing of the manuscript.
AK conducted literature research, analyzed data, and participated in the writing of the
manuscript. All authors contributed to and have approved the final manuscript.
400
Acknowledgments
Funding for this study was provided by the Human-Animal Bond Research Initiative
(HABRI) Foundation Grant D15HA-031. The HABRI Foundation had no role in the
study design, collection, analysis or interpretation of the data, writing the manuscript, or
the decision to submit the paper for publication.
Notes
This paper was supported by the following grant(s):
Human-Animal Bond Research Initiative (HABRI) Foundation D15HA-031.
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The Benefit of Pets and Animal-Assisted Therapy to the Health

of Older Individuals
E. Paul Cherniack 1 , 2 , * and Ariella R. Cherniack 3
Abstract
1. Introduction
Two-thirds of all US households [1, 2] and close to half of elderly individuals own pets
[3]. Investigations involving pets and other animals attempting to improve the health of
older individuals have involved many species, including dogs, cats, and manufactured
simulations of animals [4]. In this paper, the evidence for the impact of animals on the
health of the elderly is assessed. Given the small number of published manuscripts, a
systematic review was not attempted. Rather, the studies considered were obtained by
performing a PubMed search using terms including pets, elderly, and animal-assisted.
Additional articles were obtained from the reference lists of the original articles found.
2. Potential Benefits of Animals
2.1. Effects on Mental Health

The most frequently studied use of animals with elderly participants has been to alleviate
manifestations of cognitive disorders, such as agitation [5]. All of the studies were
unblinded, not all were controlled, but most, though not all, showed small but statistically
significant improvements in behavioral symptom scores in the animal-assisted
interventions.
One trial, the sole study that used a bird, uniquely noted that animals conferred
psychological benefits to cognitively unimpaired older individuals; 144 persons without
cognitive impairment in nursing homes in Italy were exposed to either a canary, a plant,
or neither of the two [6]. The individuals assigned to care for a canary or plant were
provided with care instructions and participated in a three-month intervention, the details
of which were not specified in the paper. Subjects who cared for the bird had significantly
better scores at the end of the intervention on subscales of psychological symptoms in the
Brief Symptom Inventory and LEIPAD-II-Short Version, which subjects in the other two
groups did not.
405
Other investigations explored the effects of animals on demented elderly individuals
(see Table 1). A dementia unit for US veterans piloted the use of a pet dog to elicit for
socialization. Twelve demented patients exhibited a significant larger number of social
behaviors, such as smiling or speaking in the presence of the dog, implying that animals
might create benefit apart from any effect on cognition [7].
Table 1
Studies on use of animals in dementia.
Another uncontrolled trial suggested that animals could help alleviate problematic
behaviors in demented individuals. This trial enrolled elderly residents of two US nursing
homes who had MMSE scores of 15 or below who were treated with animal-assisted
therapy [8]. The participants, in a recreational room for one hour a day, met with a dog
and its trainer. They could engage in a variety of activities including feeding, petting,
grooming the animal, socializing with the trainer, and discussing pets the subjects
previously owned. Subjects achieved a mean 25 percent, significantly better scores on the
CMAI index of behavioral disturbance after the intervention.
Two further studies, in addition, piloted the efficacy of animal-assisted therapy on
cognition and mood in cognitively impaired older persons. Twenty-five moderately
demented residents of a nursing home were divided into two groups [9]. In the
intervention group (mean Folstein Mini-Mental (MMSE) score 15.3, mean fifteen-
question Geriatric Depression Scale (GDS) score 5.9), the subjects experienced a weekly
hour and a half activity for 60 days in which they interacted with trained pet therapy
dogs. The participants either walked, played with, petted, or held the animals under the
supervision of a trainer. In the control group (mean MMSE score 18.3, mean GDS score
7.4, which was not significantly different than in the intervention group) the subjects
watched the animals enter the nursing home but did not interact with them.
Unfortunately, after the intervention, both groups increased their MMSE and lowered
their GDS scores, but the changes in both groups between pre- and postintervention
values were not significant. A second small study examined four moderately to severely
demented residents of a nursing home who were videotaped for behavioral responses
prior to and during an animal therapy session with a dog [10]. The residents displayed
significantly fewer signs of agitation and more social behaviors during animal therapy.
An additional trial uniquely explored the possibility that animals might confer physical
benefits to older persons with dementia and, furthermore, used fish, which did require the
subjects to handle the animals. In this study, demented individuals in several nursing
homes successfully gained weight after fish tanks were installed [11]. Sixty-two older
persons who resided in the dementia units of three different nursing homes containing
406
tanks in recreational and dining rooms that allowed a twenty 30 20inch viewing area
with background lighting to compensate for potential resident visual impairment were
compared with another group of residents who had a scenic ocean picture added to
similar rooms. Residents in each of the homes had different exposure times to either the
fish tanks or the pictures. When the data from the subjects who were exposed to the fish
tanks was pooled together, there was a mean 1.65lbweight gain between three months
before the tanks and four months after the tanks were placed (P < .000) but no gain in the
control group.
Animals might provide other benefits to demented individuals, such as improving their
ability to socialize, as suggested in several trials. In one study, which was not blinded, 33
individuals who lived in a nursing home were exposed to animals during 41.1 hours of
animal-assisted therapy and 33.8 hours of recreational therapy without animals [12].
Long conversations between alert participants were more likely to occur in therapy
groups when animals were present, but brief conversations were more likely when
animals were absent. In another trial, a videotape captured the social interactions between
36 nursing home residents in ninety-minute occupational therapy sessions with or without
a dog present [13]. Residents were more likely to have verbal interactions with the dog in
the session. In a third investigation, thirteen demented residents were exposed to a plush
mechanical toy dog that could sit up and wag its tail, or a robotic dog that could respond
to seventy-five commands [14]. Subjects responded to both objects, similarly, by talking
to it or clapping their hands when it moved.
Nurses have written their personal, qualitative observations that animals relieve
loneliness and boredom, foster social interaction, and add variety to the lives of such
persons, indirectly suggesting other possible advantages to human interactions with
animals not thus far documented in clinical trials [5, 15]. In one survey, the nursing staff
of an intermediate care unit delineated their perceptions of cat mascots, animals that
spend the day in the unit [16]. There was no formal regulation of the interaction between
the cats and the patients, nor any formal measures of the interaction. However, the nurses
did state their opinions that the cats increased patient interactivity with their other people
and their environment, and that the patients enjoyed their presence.
Pets may also positively influence the behavior of demented elderly owners. In one
comparison survey, demented pet owners were less likely to exhibit verbal aggression but
were otherwise similar to non-pet owners in likelihood of vegetative, hyperactive, or
psychotic behaviors [17].
Thus far however, none of these studies on the use of animals in demented subjects have
suggested a mechanism for how animals might alter the behavior of such individuals.
One might speculate that animals might create a distraction to inhibit disruptive behavior
or serve as a surrogate for human interaction to learn or practice social behavior.
Several investigations have also piloted the use of animals in the treatment of depression
with mixed results. One small trial showed even a brief intervention conferred some
benefit. Thirty-five individuals who were about to receive electroconvulsive therapy
(ECT) spent 15 minutes with a dog and animal trainer or the same period of time reading
magazines before ECT treatment sessions [18]. All subjects had both types of
407
pretreatment every other day. Individuals reported lower levels of fear about the
upcoming ECT rated on visual analogue scales when they had sessions with the dog. In a
similar trial, forty-two depressed patients spent time waiting for ECT in rooms with or
without aquariums. The presence of aquariums did not influence the pretreatment anxiety,
fear, or depressive symptoms the patients experienced [19].
Animal-assisted therapy has been considered in the treatment of depression in
institutionalized individuals in a number of studies. In one investigation, twenty-eight
residents of an Italian nursing home had three-hour treatment sessions once a week for a
month and a half with a cat or no change in their usual routine [20]. A nurse supervised
individuals in a therapy room, who could pick up or play with the cat. The individuals
who interacted with a cat did not have any significant difference in Geriatric Depression
Screen score, or cognition as measured by MMSE, but did have sixteen-point lower
systolic blood pressure (P = 0.05) and five-point lower diastolic blood pressure (P =
0.05) than subjects who were not exposed to the cat. In an additional survey, subjective
rankings of pet attachment were actually associated with higher ratings of depressive
symptoms in older individuals living in rural areas [21]. In another trial of 68 nursing
home residents in Australia, individuals who visited a dog reported less fatigue, tension,
confusion, and depression [22]. Cancer patients undergoing chemotherapy were divided
into two groups, one of which had a weekly hour-long session of therapy with a dog and
one of which did not [23]. Those patients at sessions at which a dog was present rated
their symptoms of depression and anxiety half as severe as those who did not. Taken
together, these studies imply a rather modest benefit at best for animals in depressed
individuals.
A meta-analysis was conducted of five studies of the use of animal-assisted activities
therapy in the treatment of depression in institutionalized subjects [24]. None of the five
studies whose data was pooled for the meta-analysis was ever published in a scientific
journal; four were printed in doctoral dissertations and the fifth was published in a book
chapter almost thirty years ago. The meta-analysis concluded that such therapy could
alleviate depressive symptoms with a medium effect size. Neither the meta-analysis nor
the previously referenced manuscripts commented on possible mechanisms of an effect.
Other studies have examined if pets might assist the treatment of individuals with
schizophrenia. Two investigations suggested that animals could improve social behaviors
in elderly schizophrenics. Twenty schizophrenics, at least sixty-five years old, had three-
hour visit every week for a year with a dog or cat and a therapist [25]. The subjects were
taught to ambulate with the animals on a leash, bathe, feed, or groom them. A control
group had a weekly news discussion session simultaneously with the animal therapy
group. Schizophrenics exposed to animals had significantly improved mean scores on
social functioning as part of the Social-Adaptive Functioning Evaluation scale which
members of the control group did not. There were no differences between groups on
survey instruments describing the subjects' impulse control or self-care.
In another investigation, 21 schizophrenic inpatients were divided into an intervention
and control group [26]. Both had 45-minute meetings twice weekly with a psychologist
for a total of 25 sessions. In the intervention group, a therapy dog and handler
participated. The dog was the focus of interventions tailored to improved communication,
408
social skills, and cognitive rehabilitation. The control group had similar sessions, except
without the dog. Subjects in the intervention group had significantly better scores on the
social contact score in of the Living Skills Profile and total score on the Positive and
Negative Symptoms Score scale.
Not all investigations noted that schizophrenics derive benefit from animals. Fifty-eight
older psychiatric inpatients in one trial were randomized to spend five sessions of either
an hour a day with either pet therapy or an exercise group [27]. There was no difference
in a forty-question psychiatric symptom score between groups. In addition to the trials of
animal therapy in older persons with mental illness, qualitative research comprising focus
groups of individuals recovering from acute episodes of psychiatric disease has outlined
what subjects perceive to be benefits of pet ownership, such as companionship and a
reinforced sense of self-worth [28]. However, subjects sometimes were troubled by their
pet care responsibilities and grieved over the loss of pets.
Furthermore, several studies have implied that animals offer psychological or social
benefits to the elderly independent of disease state. In one investigation, the effects of
animals on the degree of loneliness of long-term care residents were assessed using a
survey instrument [29]. Thirty-five people who lived in a nursing home had an
experience in which, for two and a half months, they interacted with several animals
including dogs, cats, and rabbits for two hours each [30]. They scored significantly higher
on the Patient Social Behavior Score during and after the intervention. In another study,
forty-five residents of three facilities were divided into those who received thirty-minute
animal-assisted therapy once a week for a month and a half, the same therapy three times
a week, or not at all. Residents who received any animal therapy scored significantly
lower on the UCLA Loneliness Scale than those who did not. In a case series, a robotic
dog improved the loneliness scores on one assessment instrument of five medically ill
elderly persons [31]. In a qualitative survey, dog owners over age of 70 in Austria stated
that dogs provided companionship and a sense of purpose [32]. However, finally, in few
cases, animal-assisted therapy has even been utilized to provide subjective benefit to
critically ill patients in intensive care units [33].
2.2. Effects on Physical Health

Numerous studies have recorded evidence of the effects of animals on the physical health
of elderly individuals. Several have attempted to quantify physiological benefits of the
presence of animals on the effects of stress (see Table 2). One study exposed hypertensive
pet owners to the stress of solving an arithmetic problem and making a speech [34]. The
investigators instructed half of the subjects to acquire a pet, and the total subject
population was restudied after six months. Those who owned a pet had significantly
lower increases in systolic and diastolic blood pressure in response to the stressor than
those who did not. In an additional investigation, the presence of a dog in the room
alleviated an increase in blood pressure in response to the stress of public speech [35].
Eleven community-dwelling older individuals with hypertension, mean age 81.3, were
asked to speak in the presence or absence of a dog while blood pressure was being
recorded. Participants who spoke in the presence of a dog had a significantly lower
diastolic blood pressure (mean difference = 12.8mmHg, P = 0.006) than in the absence
409
of the dog. Another 10 healthy dog owners of a canine achieved a significant systolic and
diastolic blood pressure reduction and subjective measures of anxiety after performing a
stressful task whether their own dog or not was used [36]. There was a greater
improvement of outcome measures when the subject's own dog was used, which lasted
up to an hour. Finally, in a small case series of community-dwelling elderly individuals
aged 65 to 91, one group of participants received a weekly visit from a nurse with a dog
for a month, while one group had visits without the dog [37]. Those who were in contact
with the dog had a significantly lower mean systolic and diastolic blood pressure than
those who did not (mean decrease 8mmHg systolic and 4mmHg diastolic, P < .01
difference in the intervention group from baseline). Taken together, these investigations
imply ameliorating effect of pet ownership on the physiologic effects of stress.
Table 2
Studies on the use of animals on blood pressure.
Epidemiologic studies suggest pet owners may acquire physical benefits, such as
improved blood pressure and greater physical activity. Among 5741 individuals in
Australia, those who possessed pets had a significantly lower resting systolic blood
pressure, a mean 5mg/dL lesser cholesterol, and 84mg/dL triglyceride levels which were
statistically significant [38]. In another survey of 1179 elderly persons (mean age 70), pet
owners had comparatively reduced systolic mean arteriolar and pulse pressure, and lesser
risk of hypertension (O.R. = 0.62) [39].
Other investigations imply that dog walking encourages individuals to take part in
physical activity (see Table 3). In another study, dog owners in Canada (not exclusively
elderly, but including participants up to age 80) were more likely to visit multiuse or
walk-through parks than individuals who did not possess dogs [40]. An investigation of
5902 individuals in the US noted a positive relationship between dog walking and
amount of total walking time [41]. Dog owners were more likely to walk at least 150
minutes a week (O.R. 1.69; 95% CI 1.131.59) and were more likely to involve
themselves in any physical activity during leisure time (O.R. 1.69; 95% CI 1.332.15).
Dog walking was also associated with likelihood of walking in 608 Washington state
residents (P < .01) [42]. A recent analysis of a cohort of 545 Scottish participants, all at
least 65 years old, dog owners were more likely to report themselves at the highest level
of physical activity than those not possessing dogs [43]. Among 3,075 elderly individuals
(aged 7082) in Memphis and Pittsburgh, dog owners were twice as likely but non-dog
owners half as likely to take part in physical activity compared to people who did not
own pets [44].
410
Table 3
Studies on the use of animals on physical activity.
Dog walking may encourage participants to take part in other beneficial physical
activities and to preserve their functionality. In the largest survey to date, the California
Health Interview Survey, comprising more than 55,000 individuals, dog owners more
commonly walked as a leisure time activity than those who did not own a pet (O.R. 1.6;
95% CI 1.51.8) but were less likely to walk for transportation (O.R. 0.91; 95% CI .
85.99) [45]. In an epidemiological survey of more than one thousand elderly persons at
least 65 years old in Canada, the loss of ability to perform activities of daily living of
persons who did not own pets progressed at a greater rate than for pet owners [46]. In a
Japanese survey of 5283 adults up to age of 79, dog owners were 1.54 times more likely
to obtained recommended amounts of physical activity [47]. Among 127 elderly persons
in Colorado, those possessing pets ambulated longer distances (P < .05) and had lower
triglycerides (P < .01) than those without animals [48].
However, dog ownership may not be enough to guarantee greater physical activity. In one
Australian study, owners of large dogs spent more time walking than those who owned
small dogs, and dog ownership per se was not associated with greater probability of
obtained recommended activity levels [49]. While none of the manuscripts considering
the effect of dog walking on physical activity specifically considered mechanism, one
might speculate that, rationally, the need to walk a dog might create a need to walk more,
and that increased physical activity might be more associated with the pet's needs than
those of their owners.
Pet ownership may confer additional benefits to patients with cardiovascular disease
(see Table 4). Participants in a treatment trial of antiarrhythmia drugs who owned dogs
were less likely to die over a year than others, including those who owned other types of
animals [50]. Patients owning pets who were released from a coronary care unit were
significantly more likely to survive after one year [51]. Individuals who had sustained a
myocardial infarction in the past year and walked their dogs for fifteen minutes three
times daily improved their exercise capacity on stationary bicycles (P < .05) [52]. Further
analysis of a trial in which 460 pet owners were implanted with a defibrillator (mean age
= 61) revealed that possession of pets rendered participants less likely to die (P = 0.036)
in the following 2.8 years [53]. In another survey, seventy-six persons with congestive
heart failure were divided into three groups, one of whom visited a dog for 12 minutes,
one of whom visited a person for 12 minutes, and one of whom did not receive either
[54]. Those who were exposed to the dog had a lower systolic pulmonary artery or
capillary wedge pressures, and reduced serum epinephrine concentrations. Sixty-nine in-
patients with congestive heart failure participated in an ambulation training program in
411
which they walked with a dog and a trainer [55]. When matched with a historical
sample of congestive heart failure patients, subjects who walked with a dog walked
twice as far as the historical sample (mean 230.07 steps/day versus 120.2 steps/day, P <
.0001). Not all studies imply that pets are beneficial for cardiovascular disease; in one
follow-up study of patients admitted to a unit for acute coronary syndrome those
owning a pet were more prone to death or rehospitalizations a year later [56].
Nevertheless, given the preponderance of the evidence, the American Heart Association
has released a statement acknowledging the relationship and causality of pet ownership in
the attenuation of cardiovascular disease risk [57].
Table 4
Studies on the use of animals in cardiovascular disease.
3. Harms of Animals
While the use of pets and animal therapy might confer several potential health benefits to
older persons, harms also exist. Pet owners fall and sustain fractures as a result of their
animals. The US Center for Disease Control and Prevention noted that there were 86,629
falls a year attributed to dogs and cats, with a mean injury rate of 29.7 per 100.000
persons a year from 2001 to 2006 [58]. Older persons above 75 had the highest injury
rates (68.8 for those 6574, and 70.6 for those 75 and older), twice as high as those
between 35 and 44 (28.6). A case series from Australia also reported 16 fractures to
elderly individuals who were at least aged 65 [59]. Most of the injured were women, and
individuals commonly tripped over the pets or fell while bending down to feed them. The
pets were most commonly dogs and cats, but they also included birds, a goat, and a
donkey.
Other harms may be present, as well. Pets can be expensive, time-consuming, and
complex to care for. The average lifetime cost of an average-sized dog can be $10,000
and a cat $8,000 [1]. The pets need adequate food, housing, hygiene, and veterinary care
[60]. Elderly persons may, because of physical or cognitive limitation, be less able to
provide such care than younger persons. In addition, the pets might damage an elderly
person's property, although there are no reports in the published medical literature. Pets
that are not safeguarded properly by their owners might also be a threat to other people
and to the environment. The pets could potentially injure others, harm their property, or
create fear or mistrust. The animals might damage the environment (e.g., destroying
animals and plants, creating waste).
Institutionalized elderly may also be less able to interact appropriately with animals. One
qualitative report of the reactions of staff to an institutional cat mascot stated that
412
residents placed the cat in garbage and toilet and nearly ran over its tail with wheelchairs
[16].
Animals have the potential to cause human infection and trauma. Concern about human
infections caused by pets has been mentioned as a possible adverse consequence to pet
ownership in the elderly [61]. Greater than 200 different zoonotic infections exist [62];
however their exact incidence in the elderly who own pets or participate in animal-
assisted treatments has not been documented and remains unknown. Similarly, there may
be traumatic injury from animal bites or scratches, but similarly, how frequently this
takes place as well as the impact of any events is uncertain. The aforementioned report of
an institutional cat mascot mentioned that a cat scratched a patient but did not give
further details as to this or other human injuries [16].
Pets might also cause psychological harm. Humans can become very attached to their
pets, and when they lose them, they may undergo grief reactions similar to those with loss
of other people [32, 60]. The results of any investigations of such losses on human health
in the elderly have not been published.
4. Future Directions and Conclusions

Preliminary studies have suggested the potential benefits of animals on the physical and
psychological health in humans. Despite over four decades of research, these studies
remain preliminary. They are compounded by methodologic problems including small
sample size and lack of adequate controls and blinding. A review of animal research more
than a decade ago outlined barriers [63] that still need to be overcome, including access
of animals to subjects in institutional settings, fear of zoonotic diseases, lack of
standardized survey instruments, and recruitment of animal handlers. There have yet to
be blinded animal investigations.
In addition, the potential influence of the differences in demographic characteristics of
human subjects (e.g., differences in education, ethnicity, and income) remains uncertain.
In one study, elderly Latino pet owners, mean age 66, responded to a survey of their
attitudes toward their dogs and health [64]. Two-thirds considered the dogs to be their
best friends and reason for getting up in the morning and their health to be better
than most people, and seventy-five percent deemed their health excellent. Future
investigations can clarify such influences.
Thus far, studies on the effects of animals on both mental and physical health have
reported modest benefits. Trials of animal-assisted therapy demonstrated improvements
in behavioral symptom scores in small numbers of subjects of limited duration.
Investigations on the influence of animals on physical health, particularly
epidemiological studies, that imply that the presence of animals can reduce
cardiovascular risk, are more robust methodologically, but prospective trials
demonstrating clinical benefit still need to be performed. New uses of animals may be
piloted in the future. For example, in one preliminary report, a dog was trained to detect
human melanomas by smell [65]. The use of animals as pets and in therapy may also
have harms, but their incidence is rare, and these hazards have been even less well
documented than the benefits. There has been no formal determination if whether these
413
benefits outweigh the costs of feeding and caring, which are listed for comparison
in Table 5. However, many reports describe participants' subjective positive feelings
towards animals. These positive subjective feelings that people have toward animals
together with growing evidence of a potential role in the treatment of cardiovascular
disease may motivate their continued use of therapy and ownership.
Table 5
Potential benefits and risks of animals in the elderly.
Conflict of Interests
The authors declare that there is no conflict of interests regarding the publication of this
paper.
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Another Breed of Service Animals: STARS

Study Findings about Pet Ownership and
Recovery from Serious Mental Illness
Jennifer P. Wisdom, PhD, MPH, Goal Auzeen Saedi, BA, and Carla A. Green, PhD,
MPH
The publisher's final edited version of this article is available at Am J Orthopsychiatry
See other articles in PMC that cite the published article.
Abstract
While the notion of dog as mans best friend has been commonplace for more than 150
years, the dogs potential for satisfying specific psychological needs first emerged more
than 40 years ago. Child psychologist Boris Levinson (1962) used dogs as co-therapists
and advocated using animals in therapeutic settings. Since then, animals have been used
effectively in therapeutic environments and across various age groups (e.g., Banks &
Banks, 2002; Martin & Farnum, 2002). While animal-assisted therapy can be beneficial,
pets outside of a structured therapy setting also provide physical (Friedmann & Thomas,
1995; Allen, Blascovich, & Mendes, 2002) and psychological benefits (Jennings,
1997; Wood, Giles-Corti, & Bulsara, 2005) and can lead to decreased health expenditures
(Headey, 2003; Siegel, 1990; Headey, 1999). The means by which pets influence mental
health have not been adequately addressed, however. We present reports from individuals
with severe mental illness about the influence of pets on their recovery process. Recovery
from serious mental illness is an approach to mental illness that emphasizes the
restoration of self-esteem and identity and attaining meaningful roles in society beyond
merely relief from symptoms (U.S. Department of Health and Human Services, 1999).
Serious Mental Illness

Serious mental illnesses can negatively affect social, educational, and occupational
functioning, while limiting social networks and increasing loneliness (American
Psychiatric Association, 2000). Although serious mental illnesses have been viewed as
chronic and deteriorating disorders, recent work on recovery (Warner, 1994; Harding,
Zubin & Strauss, 1992; DeSisto et al., 1995) has found that up to 70% of people with
schizophrenia either make a complete recovery (return to pre-illness functioning) or
demonstrate social recovery (economic and residential independence and low social
disruption). Several models of recovery from serious mental illness are emerging
(e.g., Davidson & Strauss, 1995; Green, 2004; Spaniol, Wewiorski, Gagne & Anthony,
419
2002). For example, Greens (2004) model emphasizes the role of such factors as
personal development, learning, healing, and adaptation as key to recovery. Reducing
social isolation can also be an important part of the recovery process, and understanding
mechanisms for reducing isolation and improving quality of life could help facilitate
recovery. Pet ownership has been identified as one such method of reaching these goals
(e.g., Hennings, 1999).
Pets and Health

Several studies have demonstrated stress reduction resulting from owning and exposure
to pets (Allen, 2003; Allen, Blascovich, & Mendes, 2002; Allen, Shykoff & Izzo, 2001).
Improved quality of life, increased social interactions, and improved health outcomes are
also associated with pet ownership (McCabe, Baun, Speich, & Agrawal, 2002; Wood,
Giles-Corti, & Bulsara, 2005; Headey, 1999). Pet owners have lower blood pressure and
heart rate levels than non-owners, lower blood pressure increases following stress-
inducing tasks, and quicker post-stressful-task recovery times (Allen et al., 2002; Allen et
al., 2001). Blood pressure readings taken after stress tasks suggest that in comparison to
spouses, pets provide a more calming effect (Allen, 2003). The presence of pet dogs has
also been shown to reduce perceptions of psychological threat during stressful situations
(Allen, Blascovich, Tomaka, & Kelsey, 1991) and to relieve stress among women (Allen
et al., 1991) and the elderly (Siegel, 1990).
Pets are associated with improved social interactions and quality of life, particularly
among institutionalized populations such as nursing home residents (McCabe et al.,
2002; Motomura, Yagi, & Ohyama, 2004). For example, Kaiser, Spence, McGavin,
Struble and Keilman (2002) found that among elderly nursing home residents, visits from
pets provided as much benefit as from young, upbeat volunteers with no obligation to
visit. Domestic animals can also aid social interaction (Wood, Giles-Corti, & Bulsara,
2005), be effective in therapy programs (Martin & Farnum, 2002), and reduce loneliness
(Banks & Banks, 2002; Jennings 1997). Further, pet ownership is associated with greater
civic engagement and social capital because pet owners interact more with neighbors,
other pet owners, and the community at large (Wood et al., 2005).
Pets have been identified as influencing other health outcomes as well. Animal-assisted
therapy may positively influence the mental state of dementia patients (Motomura, Yagi,
& Ohyama, 2004) and resident dogs decrease disruptive behavior in this population
(McCabe, Baun, Speich, & Agrawal, 2002). Among individuals who experienced an
acute myocardial infarction, dog owner mortality was significantly lower than that of
non-owners (Friedmann & Thomas, 1995). Jennings (1997) noted that pets increase
physical fitness and decrease anxiety. Pets have also been found to decrease the need for
medical service use among both elderly and general populations (Siegel, 1990; Headey,
1999).
Service animals provide assistance with specific disabilities (e.g., guide dogs for the
blind) and are different from pets, although they provide some similar benefits, such as
companionship (Valentine, Kiddoo & LaFleur, 1993). Several authors have also
suggested that pet-facilitated therapy may be beneficial for people with specific mental
health problems (e.g., Cusack, 1988). In particular, Post-traumatic Stress Disorder has
420
been identified as amenable to pet-related interventions, because pets may help alleviate
some of the anxiety and fear that these individuals experience (Altschuler, 1999).
Similarly, Hennings (1999) suggested that pets may enhance other mental health
treatments and provide structure, support, and love for patients with serious mental
illness.
The Current Study

Positive effects of pets include reduced stress reactions, anxiety and perceptions of threat,
and improved social interaction and mood. Based on this evidence, pets may plausibly
benefit people whose mental health problems are accompanied by such difficulties as
anxiety and mood disturbances. These benefits, however, have been explored only in
small, controlled studies, and have not been assessed within larger, naturalistic
populations of individuals. Furthermore, many existing pet studies have significant
limitations. Some studies have focused on an exclusive species of pet (i.e., cats), while
others have not included the special needs of those with severe mental illness or have
focused on specific populations, such as nursing home residents. The role pets may play
in recovery of individuals with mental illnesses has not been explored in a large,
naturalistic study. The present study addresses this gap in the literature, qualitatively
analyzing consumers perceptions of the roles pets played in their process of recovering
from serious mental illness.
Methods
Setting
The setting for this study was Kaiser Permanente Northwest (KPNW), a non-profit
prepaid, group model, integrated health plan serving about 480,000 members in
northwest Oregon and southwest Washington State. KPNW provides comprehensive
outpatient and inpatient medical, mental health, and addiction treatment to its members.
Study Design
Data are from STARS (the Study of Transitions & Recovery Strategies), a mixed-
methods, exploratory, longitudinal study of recovery among individuals with serious
mental health problems (schizophrenia, schizoaffective disorder, bipolar disorder, or
affective psychosis). Additional information on the study is available in Green et al.
(2008) and Young, Green and Estroff (2008). Four in-depth interviews explored mental
health history and various personal experiences affecting mental health and recovery.
Two initial interviews were conducted at the start of the study, totaling about 4 hours;
additional interviews of 60-90 minutes were conducted at 12 and 24 months. At each
wave of interviews, participants also completed paper-and-pencil questionnaires that
included questions about pet ownership and pet importance. Results presented here were
derived from the questionnaires and from analyses of all interview-generated text
discussing pets. At the initial interviews, we asked if participants had a pet that depended
on them, and at each follow-up interview, we asked about changes in pet status. No
participants reported having a service animal. Most participants reported being primary
421
caretakers or co-caretakers of their pets. Participants were also offered the opportunity, at
the initial interview, to take photos of things they found helped or hindered their recovery.
At the second interview we reviewed photos with participants and asked them to explain
the importance of each one; many photos included pets as subjects, and this text was
included in analyses.
The study was approved and monitored by KPNWs Institutional Review Board and
Research Subjects Protection Office. All study participants provided informed consent
prior to participation.
Participant Identification, Inclusion and Exclusion Criteria, and Recruitment

Participants were identified through health plan records. Inclusion criteria were as
follows: having a diagnosis (for a minimum of 12 months) of schizophrenia,
schizoaffective disorder, bipolar disorder, or affective psychosis; at least 12 months of
health plan membership prior to study enrollment; age 16 years or older; and plans to stay
in the local area for at least 12 months. To prevent problems with ability to provide
informed consent, respond to interview questions or complete paper-and-pencil
questionnaires, we excluded those with diagnoses of dementia, mental retardation, or
organic brain syndrome. We also excluded those whose mental health clinician felt they
were unable to participate.
We extracted a pool of potential participants (N = 1827), and prepared recruitment letters
in batches to be signed by the principal investigator and the members mental health
clinician or primary care provider (the latter only when we found no specialty mental
health visits). We asked 213 providers to sign letters for members they believed were able
to participate in the study. Clinicians screened out 15.8% (n = 286) of potential
participants as unable to participate; 15 clinicians (representing n = 17 potential
participants) did not return letters. The remaining potential participants (n = 1524) were
stratified on diagnosis (mood vs. schizophrenia spectrum) and gender and were randomly
sampled within these groups to balance the sample.
We mailed recruitment letters in small batches over a 10-month period and telephoned
people who did not respond to the letter. We surpassed our recruitment goal (n = 170)
after attempting to recruit 418 individuals from the recruitment pool. Of 418 attempts, we
contacted 350 individuals, had 127 refusals, and determined that 22 individuals were not
eligible. Overall, we enrolled 44% (n = 184) of the 418 people we attempted to recruit
and 46% of those who were eligible. Of these, 3 did not complete both initial interviews,
and 4 were excluded because study staff determined that medical record diagnoses had
been in error. Data from these latter 4 individuals were not included in analyses.
Participants
Study participants were 177 KPNW members, 93 women (52.2%) and 85 men (47.8%)
with schizophrenia, schizoaffective disorder, bipolar disorder, or affective psychoses. The
average age of participants at the initial interview was 48.8 (SD = 14.8) years and ranged
from 16 years to 84 years. Additional descriptive information, including more about
422
clinical problems, can be found in Green et al. (2008) and Young, Green and Estroff
(2008).
Quantitative Data Collection and Analysis

Participants completed surveys concurrently with each wave of interviews. The surveys
included demographic information (e.g., gender, age, household income) in addition to
questions about recent mental health symptoms, lifetime psychiatric hospitalizations,
social support, pet ownership and other topics. Questionnaire data were linked to health
plan records of diagnoses. To assess whether pet ownership was associated with
psychiatric symptoms, we used the Colorado Symptom Inventory (CSI) (Shern et al.,
1994). The CSI is a 14-item self-report measure of psychiatric symptom status for the
prior 30 days and produces an overall score that measures anxiety/depression,
psychoticism, and dangerousness to self/others. To assess differences in social support,
we used a single item from the Wisconsin Quality of Life Inventory. The item assesses
quality of social support for the prior four weeks on three levels (1) infrequent support
from family and friends or only when absolutely necessary, (2) receiving only moderate
support from family and friends, and (3) having good relationships with other and
receiving support from family and friends. Descriptive information from the
questionnaire and health plan records appears in Table 1.
Table 1
Characteristics of Pet Owners and Non-Owners
Interview Procedures and Qualitative Data Analysis

All interviews were semi-structured and audiotaped and were transcribed verbatim. Study
investigators and interviewers reviewed transcripts each week during data collection. This
ensured transcript accuracy and appropriate interviewing and was also used to develop
descriptive coding schemes. Interviews were coded using the software program Atlas.ti
(Muhr, 2004).
We used a grounded theory approach for data analysis (Strauss & Corbin, 1998) and, as
such, did not begin with explicit hypotheses to be tested. All data coded as pet-related
were analyzed via an iterative process. We developed a secondary, detailed coding
scheme, specific to relationships with pets, by reviewing all material assigned to codes
for pets and identifying themes and ideas present in the text. In the sections that follow,
we describe the most commonly discussed and important themes derived from these
interviews. Check coding was completed throughout the coding process to ensure coder
423
consistency; inconsistencies were discussed and resolved by the coding team, and code
definitions were revised to clarify code application when needed. We took several steps to
increase methodological rigor: (a) multiple researchers participated in data collection and
analysis to ensure multiple viewpoints and discussion of perceptions of data, (b) we
sought consensus on coder agreement to ensure more accurate coding, (c) we considered
rival explanations while analyzing data to facilitate trimming and validating the
theoretical scheme, and (d) we compared researcher and theoretical findings to validate
our findings (Boyatzis, 1998).
Results
Table 1 reports the characteristics of pet owners and non-owners in the sample. About
59% of participants reported having a pet. The study sample distributions for age and
gender, within diagnosis, did not differ from the study-eligible population of health plan
members, which, in turn, is a reasonable approximation of the metropolitan area general
population.
We found no differences between pet owners and non-owners for the following measures:
gender, age, social support, annual income, or self-reported social class. Pet owners
compared to non-owners were more likely to have a diagnosis of bipolar disorder or
affective psychosis than a schizophrenia-spectrum diagnosis, 2(1, n = 171) = 7.471, p = .
005, were more likely to have a co-occurring addiction t(169) = 2.06, p = .041, less
likely to be hospitalized F(1) = 4.27, p = .04, and more likely to live with others than
alone 2(1, N = 171) = 10.04, p = .001
Nearly 75% of pet owners reported that their pets were very important to them. Among
participants who did not have pets, 67% indicated that they would like to have a pet,
although 25% were prevented from doing so by their living situation and 23% were
prevented for other reasons. Species ranged from standard domestic cats and dogs, to
birds, chinchillas, chickens, horses, and guinea pigs.
Four major themes were extracted from participant interviews about how pets assisted in
their recovery from serious mental illness by (a) providing empathy and therapy; (b)
providing connections that could assist in redeveloping social avenues; (c) serving as
family in the absence of or in addition to human family members; and (d) supporting
participants self-efficacy and strengthening their sense of empowerment.
Theme 1: Empathy and Therapy

Social isolation, reduced social network size, and loneliness are common among
individuals with serious mental health problems, often constricting opportunities to
interact with others or to feel understood by others. For some in the sample, pets provided
a sense of being known and understood.
When I was depressed she would lay down on the bed next to me and put her paw across
me, and I didnt even have to tell her I was depressed, shed just sense it.
424
In sensing their owners depression or other symptoms, pets could make their owners feel
that someone empathized with their struggles. In fact, in some cases, pets were described
as therapeutic.
it sounds funny, but Ive had this dog for about 8 years now, shes 18 pounds, and shes
willful and demanding, and takes a lot of attention, and I think shes been therapeutic for
me.
Regardless of the pet species, participants felt that animals sense human emotions and
respond accordingly. They also were seen as giving more and expecting less than human
companionsas one participant put it, animal companions are unconditional love.
Theme 2: Connections
For some individuals with mental illness, the outside world may feel intimidating and
overwhelming. STARS participants indicated that their pets provided them with an
avenue for re-connecting with others and subsequently finding social support to assist
them in their recovery.
I think [having pets is] something that increases ones sanity, or ones connection with
the rest of the world, just by having another creature you have to care for, because they
do, even cats, seem to care for you, they seem to want closeness, jump on your lap,
wanting to be petted and that sort of thing.
While pets may enable some to feel more connected to the world at large, others found
them to be helpful in more intimate human interactions. One woman noted how her pet
helped her become more open to the possibility of meeting others.
When I moved here from [state], the first couple of years I really didnt date, or anything,
and then once I got my cat I started feeling more comfortable and open and wanting to
meet more people. She just opened me up somehow.
Isolation can become intense during some phases of life with mental health problems.
This participant noted that her pet helped her recover from drug and alcohol abuse that
had been exacerbated by loneliness.
I just had other interests, like a lot of times in Hawaii I was alone by myself, like I am
now, and Id just drink and use drugs to get through the lonelinessPets are pretty
therapeutic, they ease the loneliness a little bit, going out for walks
Some noted that very early on in life they used pets to help them overcome feelings of
isolation and loneliness, thereby setting up a lifelong pattern of valuing pets as critical to
their connection to the world. This participant spent time with horses.
I just lived in the stables. That was my life and that was where I felt safe.
One woman noted that after being admitted to a mental hospital at age 18, her only friend
was her dog.
425
I was working and I didnt have any friends. I would go shopping alone. I didnt have any
transportation. I just walked to the shopping center. It was a long walk. It was so
depressing. The only friend I had was my dog.
The means by which pets provided owners with a sense of connection across various life
stages ranged from struggles during high school and adolescence to moving to a new
locale. Yet despite these differences, it was apparent that in all of these cases, these pet
owners experienced a stronger sense of belonging and integration into mainstream
society. In some cases, pets served as companions, while in others they were a bridge to
interacting with other humans. The most explicit commonality across these examples was
ultimately an increased connection with others.
Theme 3: Pets as Family

For individuals recovering from serious mental illness, family may be a significant source
of support. Yet for some, family relationships can be absent or strained. Moreover,
individuals with mental illness may not feel comfortable having children. Participants
noted that their pets filled these roles, often functioning as family.
A lot, theyre like children for us, we thought wed never get that way, but they are.
Theyve taken the place of having a family. We do everything for them and they do
everything for us, and its really nice.
Theme 4: Self-Efficacy/Self-Worth
Participants also found that the control they were able to have over pets began to
empower them, even if in a small way.
Right now I just feel so consumed by the whole diabetes thing that Im not feeling like I
do have all that much control, but I only have control over the checkbook, and the yard,
and the dogs
One woman saw her recovery as assisted by her pets, whom she found particularly
helpful when feeling suicidal. The thought of her responsibility to her pets in part gave
her the will to keep living. Rather than feeling mere obligation toward her pets, she
realized that she contributed in an essential way to their continuing well-being.
They are something that is very important in my recovery and helping me not get too
depressed. Even when I was so depressed, I was kind of suicidal. I never got really bad,
but I was suicidal at one time. The thing that made me stop was wondering what the
rabbits would do. That was the first thing I thought of and I thought, oh yeah, I cant
leave because the rabbits need me. So they were playing a really big role in that.
Related to this notion of feeling responsible and in control, pet ownership also
strengthened feelings of self-esteem and self-efficacy. One participant reported:
My best quality is that I love animals and I take care of animals Other than that, I cant
think of anything real outstanding.
426
Another remarked that to aid recovery, consumers should be allowed to have pets to
develop a stronger sense of self and self-confidence. Participants suggested a variety of
outlets to achieve this, including interacting with animals.
In reflecting upon her experience throughout STARS, one participant listed the main
things that she needed to maintain her recovery. Her pet facilitated this process, as caring
for her dog enabled her to have a sense of responsibility. Successfully fulfilling ones
responsibilities enhances feelings of self-worth.
To have the support of my family, things I need, to have the hobbies I enjoy, and to have
my fluffy, white dog to have something to take care of, and job security. Those are the
main things I need for my recovery, so I can stay healthy and happy.
However, while pet ownership can enhance feelings of self-efficacy, in some cases,
caring for animals also made their owners feel overwhelmed and, in feeling out of
control, owners sometimes slipped into depression. While pets were not the only reason
for this, they could add to the equation.
I was trying to care for 3 cats of my own that I loved, stray cats in the neighborhood I
was feeding. I tried to spay the ones that appeared to be pregnant, and I was putting food
out twice a day, and I was just feeling overwhelmed, just overwhelmed and more and
more depressed, more a sense of failure, and finally it just got worse and worse and
worse.
Similarly, losing a pet could trigger depression just as it might in persons without mental
illness. Yet, some participants noted that they were eventually able to come to terms with
their loss and still derive joy from memories of times past with their pets.
I was very depressed by [pets] death. While she was getting worse, we had her home for
a while and I had to make myself be strong [] It was more after her death that I kind of
broke down, and just thinking about her would make me cry for a couple of weeks or
more. Gradually I got to the point where I knew that it was her time. The life that she had
and what she had given to me, I could always think of that. It always makes me happy.
Like all human beings who need reassurance and a sense of self-worth, those with severe
mental illnesses, likewise, need to feel a sense of empowerment. In some cases, pets
provided a way in which patients were able to exercise control, feel that they mattered,
and could make a difference in the life of another living thing. While caring for another
creature could become overwhelming on occasion, most cherished this time. Perhaps
most remarkably, one man reported regaining his will to live due to his sense of
responsibility to his pets.
Discussion
Many individuals with serious mental illness view their pet-related experiences as
contributing in important ways to their overall recovery. This research confirmed this
effect and also found differences between people with serious mental illness who own
pets and those who do not. For example, pet owners were more likely to have a co-
occurring addiction, to live with others, and to have fewer hospitalizations over their
427
lifetimes. Although we cannot determine causality in these relationships, these
associations call for further research. We did not, however, find differences in symptoms
or social support between pet owners and non-owners. It is possible that we were unable
to identify such differences because of small sample sizes, or because our symptom
measure covered a limited period (30 days) when effects on symptoms might become
apparent over longer periods. Our quantitative findings of no differences in social support
between pet owners and non-owners, in the context our qualitative findings, suggest that
pets may provide additional forms of support rather than substituting for human support.
The qualitative inquiry confirmed that pets serve several important roles for individuals
with serious mental illness: pets provide empathy and therapy, facilitate connections
that assist in redeveloping social avenues, serve as surrogates for family, and strengthen
a sense of empowerment.
This work provides new insights into how people come to view their pets as therapeutic.
STARS participants reported that pets both sense their emotions and respond in an
empathic and understanding way. Further, in fulfilling their responsibilities to care for
pets, individuals indicated that pets actively contribute to their sense of empowerment
and mastery. The role of pets in providing accessible forms of companionship, nonverbal
communication, and opportunities for responsibility has direct applicability to recovery
processes for individuals with serious mental illness.
Our findings are also consistent with previous research showing that pets facilitate
development of social relationships (Hart, 2000; Harker, Collis & McNicholas, 2000) and
can serve as surrogate family members (Cohen, 2002). Therefore, although individuals
who own pets are not employing service animals per se, it appears these animals can
serve a positive purpose in their owners lives. Since there is a strong literature on the
benefits of service animals, it would be useful to identify any differences between
participants who own a pet of their choosing compared to those who employ service
animals, as well as to describe whether effects of these animals on their owners are
different. Patient choice of animal to adopt as a pet, and the unstructured nature of owner-
pet interactions compared to more specifically delineated tasks of service animals, may
contribute to differences between the effects of pets and service animals.
Although most of the research addressing the role of pets in aiding people with mental
health problems has focused on benefits, we also found that the responsibility of caring
for pets, while often empowering, can sometimes exacerbate symptoms for already
stressed and vulnerable individuals. Thus, studies examining the effects of pets should
consider identifying factors that are associated with positive or negative outcomes among
individuals with serious mental health difficulties.
This study has several limitations. A primary limitation is that it is a comparison study in
which pet ownership was not randomized, so we cannot disentangle causality of whether
there is something different about individuals who choose to have pets from those who do
not choose to have pets, or whether the situation of actually owning a pet changes
individuals. Several individuals in this study who were non-pet owners reported wanting
a pet, suggesting the former explanation, but more research is needed on this topic.
Second, our sample was drawn from a single health plan in one geographic area, which
may limit its generalizability to individuals with other types of health insurance or in
428
different geographic areas. Since the themes the participants raised in this study are
consistent with findings from other studies on pet ownership, we anticipate adequate
generalizability.
Implications
The study findings have significant implications for mental health providers. Because pet
owners with mental health problems may not always volunteer information about their
pets, it may be important for clinicians to inquire about whether the client has a pet, and
to take pets into account when working with individuals as they make decisions that
might affect their ability to maintain their pets (e.g., hospitalizations, housing). When
taking patient histories, health professionals could ask about pets and their importance to
clients. Plans should be made to care for pets, perhaps in advance, to manage situations
during which consumers might become unable to care for their pets. Health care and
social agencies may also be able to make temporary or permanent pet placements when
needed (Cohen, 2002), easing clients concerns about their animals safety and well-
being. Finally, clinicians may want to consider suggesting interactions with pets or pet
ownership for individuals in the process of recovering from mental illnesses, particularly
those who are lonely or socially isolated and who desire pets. Clinicians should be aware,
however, that some individuals who desire pets and might benefit from them may need
help to address housing or other barriers to pet ownership. Mental health agencies that
own or operate housing for their clients could also address pet ownership as a policy
issue, rather than as an issue of protecting property, and could consider the beneficial
therapeutic affects of pet ownership. Agencies might also consider having facility pets for
those who do not feel they can assume the responsibility of full ownership but would
benefit from regular access to a pet.
Future studies should address temporal relations and causality between pet ownership and
recovery from serious mental illness. Addressing the association between having a pet
and health outcomes, including symptoms and quality of life would be beneficial. Pet
ownership promises as a low-cost adjunct to therapy that could substantially benefit
recovery.
Acknowledgement
This project was supported by grant MH62321 from the National Institute of Mental
Health.
Footnotes
Publisher's Disclaimer: The following manuscript is the final accepted manuscript. It
has not been subjected to the final copyediting, fact-checking, and proofreading required
for formal publication. It is not the definitive, publisher-authenticated version. The
American Psychological Association and its Council of Editors disclaim any
responsibility or liabilities for errors or omissions of this manuscript version, any version
derived from this manuscript by NIH, or other third parties. The published version is
available at www.apa.org/pubs/journals/ort.
429
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ownership-and-recovery-from-serious-mental-illness
The Truth About Animal-Assisted Therapy

By Brandi-Ann Uyemura
~ 5 min read
You know the impact your pet has on your life. But
can the same sense of healing, security and unconditional love that your furry friend
gives you be transferred in therapy? This is a question people like Amy McCullough,
M.A., and Cynthia Chandler, Ed.D., are answering with a definitive Yes.
The American Humane Association defines animal-assisted therapy (AAT) on their
website as:
a goal-directed intervention in which an animal is incorporated as an integral part of
the clinical health-care treatment process. AAT is delivered or directed by a professional
health or human service provider who demonstrates skill and expertise regarding the
clinical applications of human-animal interactions.
Here are four more facts you might not know about animal-assisted therapy :
432
1. They are not dependent on a specific theory. Animal-assisted therapy encompasses all
types of psychology theories from psychoanalytic to behavioral. Amy McCullough, who
is the American Humane Associations National Animal-Assisted Therapy Director,
explains that animal-assisted therapy is utilizing an animal as an adjunct to a therapeutic
process regardless of theory. In general, AAT becomes another tool in their tool kit for
the type of therapy they practice.
2. They are not service animals. Although often confused with service animals, there
are significant differences between them. Service animals, for example, are protected by
the American Disabilities Act, live with owners who have physical and emotional
disabilities and assist them solely with daily living. In contrast, therapy animals work
with professionals and clients.
3. They dont just include dogs and horses. While you will most likely hear about dogs
and horses, therapy animals run the gamut from llamas to dolphins.
4. They help individuals with a wide variety of causes and settings.Therapy animals
assist therapists in helping clients with a multitude of goals such as improving self-
esteem and developing social skills, as well as providing help for anxiety and post-
traumatic stress disorder (PTSD). They also work in a wide variety of clinical settings
from psychiatric hospitals to nursing homes.
Benefits of Animal-Assisted Therapy
Cynthia Chandler, Ed.D is a counseling professor at the University of North Texas, the
Center for Animal-Assisted Therapys founder and director and the author of Animal
Assisted Therapy in Counseling. She brought up a common question skeptics have when
considering the benefits of animal-assisted therapy: Well that sounds cute, but why I
would really want to bring my dog to work? Pet lovers will happily vouch for the
positive impact their pets have on their lives. But is there anything significantly beneficial
about involving animals in therapy?
McCullough seems to think so. In her nine years as a volunteer, shes worked with her
dog Bailey and a recreational therapist at an inpatient psychiatric hospital. While there,
shes witnessed an increase in patient participation in group therapy and changes in
patient behavior. She also found that practical skills such as hygiene and self-care,
specifically for patients with severe mental health issues, could be addressed more easily
and with less discomfort in Baileys presence. He (the therapist) would ask me sort of
what did Bailey have to do to be able to come in here today and so I would talk about
433
[grooming, nutrition and exercise] and he would use that as a jumping-off point to talk
about how thats important for all of the people in the room to think about.
Animal-assisted therapy can also help individuals develop social skills. AAT helps clients
realize behavioral cues practiced with a therapy animal can be use(d) beyond the 45
minutes that they are with the animal and apply this skill to other settings whether its
getting along with their peers or talking to their counselor.
The relationship between therapy animals and the therapist can also be a model for a
healthy relationship. For example, Chandler says that clients gain information about how
to form and maintain relationships and trust by watching how a therapist responds to the
animal and the animal responds to the therapist. The therapist and the therapy animal,
their interactions, their relationships serves as a good model for client that helps the client
feel safer in a session.
The presence of animals themselves is soothing and can more quickly build rapport
between therapist and client. In addition, therapy animals, especially horses and dogs,
have built-in survival skills. That makes them able to pick up social cues imperative to
human relationships. Therapists then can process that information and use it to help
clients see how their behavior affects others. And they can do this in an immediate way.
Chandler says, If they say or do something the animal doesnt like, the animal will just
go and react negatively immediately and if they do something the animal likes, the
animals going to react positively immediately. It gives them a chance to practice caring
skills and social skills with a being which is simpler to do that with than a human.
Does Animal-Assisted Therapy Really Work?
AAT began in the early 1990s and thus is a relatively new field. Since then, it has grown
in popularity, has gained wide acceptance and is evolving into mainstream psychology.
This is evident in the increasing number of universities such as the University of North
Texas that offer a graduate course in animal-assisted therapy.
Therapists and potential clients may wonder, however, what makes AAT more beneficial
than traditional talk therapy. Skeptics may question the lack of research to back up the
434
benefits of AAT. McCullough says, Theres a lot of anecdotal information and case
studies,
but theres really a need in this field for a broader long-term study. Her organization is
currently working on a multi-site study with AAT and pediatric oncology patients and
their families.
But though the research may be sparse, Chandler says the research is out there and has
been increasing since 2002. She cites one study, for example, that showed a significant
drop in stress hormones such as cortisol, adrenaline and aldosterone and an increase in
health inducing and social inducing hormones such as oxytocin, dopamine and
endorphins after 20 minutes with a therapy dog. Working with a therapy animal has also
resulted in behavioral improvement in children and a reduction in depression for elderly
with dementia. To her, the research speaks for itself. There is actually a psycho-
physiological, emotional and physical (component) to interacting with a therapy animal.
And the key that links all of these positive benefits comes down to oxytocin. In addition
to lowering blood pressure and heart rate, it is a powerful healing mechanism. Oxytocin
is one of the best, most powerful, wonderful, healthy social hormones we have and its
the one thats the most grossly affected in a positive way through human-animal
interaction. She says animal-assisted therapy is here to stay simply because the oxytocin
effect is undeniable.
Therapy animals have also returned the positive benefits of touch to counseling. Touch
has been understandably removed from therapy, especially with counseling youth, but at
a cost. Therapy animals also provide a purely nonjudgmental space for individuals to
work out their problems. Chandler says, Animals do not prejudge you. They dont know
that youve had a divorce. They dont know that youre dealing with sexual abuse.
Sometimes its petting an animal itself or their ability to teach us in the present moment
what we find too difficult to learn on our own. But its also the sheer presence of an
animal, their acceptance and admirable ability to express themselves without holding
anything back that makes animal-assisted therapy so powerful. McCullough says it best.
They accept you for the way you are flaws and all. They are so forgiving and they are
always happy to see you. Their behavior is just so consistent and so consistently happy
that I think its just comforting to people knowing that there is a being there that you can
always count to be happy to see you and not judge you for anything youve done.
435
If you are interested in seeking animal-assisted therapy, you can contact the American
Humane Association, the American Counseling Association or ask your veterinarian to
refer you to an animal-assisted therapist in your neighborhood.
Soucre:- https://psychcentral.com/lib/the-truth-about-animal-assisted-therapy/
Gardening And Mental Health
A Sidewalk Garden In Greater Portmore, St. Catherine, Jamaica W.I.
436
What Is the Evidence to Support the Use of Therapeutic
Gardens for the Elderly?
Mark B. Detweiler,1 Taral Sharma,2 Jonna G. Detweiler,3 Pamela F. Murphy,4 Sandra Lane,5 Jack
Carman,6 Amara S. Chudhary,2 Mary H. Halling,3 and Kye Y. Kim 7
Abstract
Go to:
INTRODUCTION
It is well known that the population around the world is aging at an unprecedented rate
and is an enduring global phenomenon, with profound implications for many facets of
human life. A 2010 report from the Population Division, Department of Economic and
Social Affairs of the United Nations predicts that the United States will experience major
increases of individuals 65 years old and older, from 13.3% at this time to a projected
20.1% in 20 years.1 However, the Republic of Korea will surpass the American aging
with one of the greatest increases in elderly populations in the world, from 11.5% in 2011
to almost one quarter (24%) of the population in 2031. The United Nations also predicts
that in 20 years a larger proportion of the Korean elderly (22.4%) will be very old, 80
years old or older. Clearly these nations need to prepare for the dramatic changes in
population demographics.
For some elderly, aging brings declines in cognition and function that may precipitate
losing independent living.2 In general, for those persons with advancing medical and
psychiatric problems, declining cognitive and functional changes may necessitate
entering assisted living or dementia residences.3 In either case, the role of health scientists
is to find the most supportive and pleasant environments during these latter chapters of
life. Economics will also play a major role in determining some of the most cost-effective
ways to humanely care for the elderly, as the proportions of working individuals will
greatly diminish in the future.
Constructing rehabilitation centers, assisted living or dementia residence gardens that
encourage autonomy and sensory stimulation is an economically sound, non-
pharmacological strategy for improving the quality of life for persons needing these types
of residences.4-7 Therapeutic gardens offer elderly residents the choice of leaving the
residential unit for a natural setting designed to promote exercise and stimulate all the
437
senses. Another aim of therapeutic gardens is to promote ambulation, positive
reminiscences, decreased stress and stabilized sleep wake cycles.8,9 As described in this
article, exposure to nature has been associated with reduction in pain, improvement in
attention and modulation of stress responses. In addition, some studies have reported that
having free access to an outdoor area may reduce some agitated behaviors, medications
and falls in dementia residents.
Horticulture has been used as a therapeutic modality since ancient times. However,
despite its long use in fields of physical therapy, psychiatric occupational and recreational
rehabilitation, there are few strong quantitative studies supporting the efficacy of garden
settings for therapy and rehabilitation.10 Nevertheless, there is an increasing body of
literature supporting the theoretical therapeutic mechanism of nature on attention, stress
and healing. We present some of the findings in the English literature that support
initiating research in the effectiveness of horticultural therapy in garden settings for
elderly individuals.
Go to:
HISTORY OF HORTICULTURE AS A THERAPEUTIC MODALITY

Horticultural therapy is a relatively new discipline combining horticulture and
rehabilitation disciplines. It employs plants and gardening activities in therapeutic and
rehabilitation activities to improve human well being.11 Historically, the use of
horticulture to calm the senses dates as far back as 2000 BC in Mesopotamia. Around 500
BC, the Persians began creating gardens to please all of the senses by combining beauty,
fragrance, music (flowing water) and cooling temperatures.
In the USA, the therapeutic benefits of peaceful garden environments have been
understood since at least the 19th century. Dr. Benjamin Rush, considered to be the
"Father of American Psychiatry" in the United States, reported that garden settings held
curative benefits for people with mental illness.11 A professor of the Institute of Medicine
and Clinical Practice at the University of Pennsylvania known for his role in the
development of modern psychiatry, Dr. Rush published his book Medical Inquiries and
Observations Upon Diseases of the Mind in 1812. In it he stated that "digging in a
garden" was one of the activities that distinguished those male patients who recovered
from their mania from those that did not engage in garden activities.12 Based on these
observations, the hospital grounds included landscape-shaded paths through grassy
meadows. Gradually in the United States, agricultural and gardening activities were
included in both public and private psychiatric hospitals.
The use of horticulture to improve the care of veterans took a large step forward during
WWI. The enormous number of returning wounded veterans to US hospitals precipitated
the start of horticulture use in the clinical settings. Initially, horticulture was used for
occupational and recreational therapy as part of psychiatric rehabilitation. The Rusk
Institute of Rehabilitative Medicine, associated with New York University Medical
Center, was the first US medical center to add a greenhouse to its rehabilitation unit in
1959 for interdisciplinary diagnostic and rehabilitative therapy.13 In 1972 the Menninger
Foundation teamed with the Horticulture Department at Kansas State University to
438
provide training for undergraduate students in the mental health field. This would lead to
the first horticultural therapy curriculum in the US.
Go to:
CURRENT SCIENTIFIC UNDERSTANDINGS OF THE

EFFECTIVENESS OF HORTICULTURAL THERAPY FOR THE
ELDERLY
Horticultural therapy (HT) and exposure to gardens has been shown to have positive
benefits for the elderly. Indoor gardening has been reported to be effective for improving
sleep, agitation, and cognition in dementia patients. As a cognitive therapy, HT helps
clients learn new skills and regain lost skills. It is a restorative technique to improve
memory, attention, sense of responsibility and social interaction with few to no adverse
side effects. Moreover, HT has been found to reduce stress,14-17 to increase feelings of
calm and relaxation,18,19 to foster a sense of accomplishment20,21 and to improve self-
esteem.18,22-25 As a result of activities in a green setting, there was a significant
improvement in self-esteem in nine out of ten case studies.26 Randomized controlled
studies of larger sample size are needed to confirm treatment effect.27
While the literature supports the role of horticultural therapy in improving
attention28,29 and reducing stress,30-32 this knowledge has not resulted in many quantitative
studies about chronic pain, cardiac and post stroke rehabilitation. A few descriptive case
studies, often without control patients, to delineate the benefits of the restorative natural
setting over traditional rehabilitation settings, have been published about rehabilitation
patients in garden settings: cardiac;33 amputee;34,35 post stroke7,36-38 and chronic pain.39
The therapeutic garden

Since Homo sapiens evolved in a natural environment, an intrinsic physiologic and
psychological positive reaction to nature has developed that is involved in maintaining
the human being's homeostasis. Thus, an automatic and subconscious propensity to react
to nature in a positive manner is theorized.40 Orians41proposed that there is higher
attentional response to environmental cues such as trees and natural features associated
with landscapes providing sources of food and water.
Most importantly, therapeutic gardens should contain familiar elements that are typical of
the region and activities that elders may have participated in at previous stages of their
lifetime.
Therapeutic garden design focuses on increasing sensory stimulation by providing
assisted living or dementia residents access to the outdoor spaces on a daily basis.
Dementia facilities have elaborate structural and electronic devices to prevent residents
from eloping and to reduce the risk of injury or death.42 Therapeutic gardens provide
assisted living or dementia residents a safe environment for exercise, reflection and
passing time with other residents, friends or family members. They may also have
structured spaces that reduce disorientation.
439
To stimulate the senses, therapeutic gardens typically include a variety of plants to
promote visual, olfactory, and tactile stimulation and to attract birds and butterflies. Also,
trees may provide shade, color, seasonal variation, and sound when the leaves rustle in
the wind. Walking paths promote movement, encourage contact with plants (all nontoxic
and non-injurious), and lead the residents to protected areas for sitting and
socializing.43 For the dementia populations, the paths should be continuous with no dead
ends to encourage cardiovascular exercise. Vegetables and herbs can be planted to expand
visual and tactile experiences and help with improved eating. Some therapeutic gardens
include raised planters where the residents can use their hands or simple safe tools for
digging and other activities with supervision. Gardens should be designed to stimulate the
senses and to encourage older adults to spend time outside in nature. Horticultural
therapy may also be used to promote gardening interests both as pastimes and to
stimulate function and cognition.44 For climates with extended periods of inclement
weather, therapeutic gardens may have enclosed perimeter walkways with exits into the
garden. Large windows looking out into the garden allow the residents full view of the
garden in order to promote positive ideations and to remind them of the presence of the
garden.45
Reduction of pain
Therapeutic gardens in residences for the elderly may reduce pain perception. The
sensory stimulation of a natural setting has been proposed to reduce the consciousness of
unpleasant internal and external stimuli. In a randomized controlled study utilizing
murals of nature sights and tapes of nature sounds supplied to patients undergoing
bronchoscopy, pain, but not anxiety, was significantly reduced.46 It was suggested that
such non-intrusive interventions may reduce the need for pharmacologic analgesia while
the patient is undergoing painful, invasive procedures. The mechanism of this distraction
therapy was not identified.
With aging, the risk of needing rehabilitation for acute and chronic medical problems
such as cognitive decline, altered mental status, strokes, heart attacks, and surgical
procedures increases. Preliminary studies suggest post trauma and post surgical patients
have improved treatment outcomes secondary to greater exposure to natural settings.
Ulrich47 performed one of the classic studies on the positive effect of passive interaction
with garden settings to reduce pain. Post-cholecystectomy patients having a window with
a view of nature required fewer high potency analgesics and had shorter hospital stays
than patients with windows having a view of a brick wall.
Another measure of the strength of a passive interaction with nature involved the role of
sunlight in post cervical and lumbar surgery patients. Walch et al.48 found that patients in
high sunlight rooms had less perceived stress, utilized fewer analgesic medications and
had lower costs for pain medications. Also, there was a trend, although it was not
statistically significant (p=0.58), toward reduced perception of pain. In a third passive
interaction study, Park49 reported that having plants in the hospital room following
thyroidectomy, appendectomy and hemorrhoidectomy shortened patients' post operative
hospitalization, reduced analgesic use, and reduced pain, anxiety and fatigue when
compared to the control group that had no plants in their rooms.
440
Improvement in attention
Many patients in horticulture or rehabilitation therapy have attention deficits due to either
internal or external negative stimuli secondary to clinical entities such as pain, post-
stroke sequelae, head trauma, anxiety, depression or dementia. James50 hypothesized that
navigation of one's complex external environment is facilitated by two components of
attention, voluntary and involuntary. In his attention restoration theory (ART), voluntary
attention filters extraneous stimuli when an individual is attempting to concentrate on a
specific task. This voluntary attention undergoes fatigue with time and stress. On the
other hand, involuntary attention does not incur fatigue and is stimulated by colors,
motion, contrasts and the unusual sensory stimuli in garden settings. Consequently, in a
natural setting, engaging the involuntary attention may spare voluntary attention fatigue,
allowing a more prolonged and higher level of attention. The benefits of improving
attention in a garden setting when compared to attention in non-green or traditional
rehabilitation settings has been described.51-54 Elderly with mild cognitive impairment,
dementia, post stroke deficits, or chronic pain may have impaired executive control
function (ECF) secondary to cerebral and subcortical changes. Decreased ECF is often
accompanied by attention deficits.55-59 In such cases, conserving voluntary attention in
garden settings during activity or rehabilitation sessions may be advantageous and may
shorten outcome times when compared to results achieved in the traditional non-green
inpatient rehabilitation settings.7,28
Attention deficits may be barriers to cognitive60 and functional improvement following
brain injury.61 The benefit of therapeutic measures to improve alertness and sustained
attention for post stroke patients has been reported.62 Several studies support the ART
hypothesis as a component in attention restoration. Herzog et al.63 reported that the
perceived restorative effectiveness of natural settings was ranked higher than the
perceived restorative effectiveness of sports, entertainment centers and viewing urban
settings. Laumann et al.29 tested the hypothesis that exposure to nature stimuli improves
attention restoration. They reported that reduced autonomic arousal, when viewing a
video with nature scenes, resulted in subjects' improved attention and orienting task
performance. Using different screen sizes, De Kort et al.54 found that attention restoration
improved with a corresponding increased sense of immersion (increasing screen
dimensions) when viewing nature scenes. Improved performance on attention measures
was also reported for students looking out a window at natural scenes when compared to
students looking out a window at man-made landscapes.64
In a study of more active outdoor participation, Hartig et al.51 found a positive correlation
between outdoor walking and attention improvement. After 40 minutes of completing a
task requiring focused attention, subjects that walked in a wilderness park reported
improved mood and decreased errors in proof reading compared to subjects that followed
the tasks with a walk in an urban setting or sat in a windowless room listening to music or
reading magazines. In another study of attention restoration with pregnant women in their
third trimester, Stark52 demonstrated that spending two hours a week in nature activities
improved concentration and reduced errors. Using a similar protocol, Cimprich et
al.53 found that two hours of exposure to a natural environment per week improved
women's capacity to direct their attention 19 days after breast cancer surgery when
compared to controls.
441
The brain's physiological response to stress
The brain is the central organ in determining the best response to a level of danger, thus
initiating appropriate responses. Physiological and behavioral reactions to stress involve
bi-directional communication of the brain with multiple systems, including the endocrine,
cardiovascular and immune systems.65 A healthy response to acute stress that promotes
adaptation is termed allostatic stress. In contrast, a reaction that promotes a state of
chronic stress with negative structural remodeling of the hippocampus, amygdala and
prefrontal cortex is termed allosteric load.66
The fight or flight model of stress described by Hans Selye 67 begins by activation of the
hypothalamic-pituitary axis (HPA) and the sympathetic systems in addition to the limbic-
frontal neurocircuitry system of fear.68 Such a response is needed to survive and manage
threats such as a house fire or assault. Damage to the brain and body occurs when the
stress is chronic, resulting in dysregulation of neurobiologic stress mediators. Allostatic
load occurs when the mediators of stress are not turned off after the threat has ceased or
when they are not turned on in a manner to adequately manage an immediate threat.66
Damage to corticosterone receptors

For the elderly, the role of chronic stress on the aging brain is particularly important. Loss
of hippocampal cells with aging is normative in most cases; however the glucocorticoid
hypersecretion syndrome is not. It is suspected that the cytological degeneration of
amyloid in the hippocampus and neocortex, including neurofibrillary tangles and neurotic
plaques,69 in addition to organ aging, combine to accelerate glucocorticoid
hypersecretion.70 Thus hippocampal damage from a combination of aging, AD and other
trauma appears to promote glucocorticoid hypersecretion as illustrated by elevated basal
cortisol and dexamethasone (DEX) resistance.70-73
Elevated cortisol levels appear to play an important role in memory74 and affective
disorders.66 Imaging studies with PET and fMRI of persons with recurrent depression
altered patterns of activity and decreased volume of the hippocampus, amygdala and
prefrontal regions.75-77 In major depression, the duration of the symptoms is a stronger
predictor of hippocampal volume loss on MRI than is age.76,78 Based on these and other
findings, it appears that prolonged stress with concurrent neurobiologic changes during
aging may accelerate the loss of function and cognition with the end result of an earlier
need of health care support due to a declining ability to live independently.57,58,79-81
Reduction in stress
The neurobiology and physiology of the stress response provide background for the
Overload and Arousal Theory of Ulrich and Parsons.14 They proposed that modern society
bombards the human central nervous system (CNS) with excessive noise, movement and
complex visual stimuli. These stressors eventually overload long-term neural and
endocrine dysfunction leading to functional and cognitive decline. It is thought that an
environment with the appropriate ratio between plant abundance and hardscape (man
made structures) may reduce the deleterious effects of man-made settings to the human
inhabitants. The ratio of nature and hardscape to foster a positive therapeutic result has
442
been debated.82 Current opinion is that this ratio needs to be greater than 70% lush garden
and less than 30% hardscape to have a clinical advantage.83 Such an environment that
includes pleasant smells, colors and shapes of the plants, in addition to less complex
visual stimuli, may reduce CNS arousal and reduce short and long term stress.
Appropriately designed garden settings may be ideal for experiencing stress
modulation30,32 and thus have an important therapeutic role for the elderly experiencing
the stresses of aging with comorbid medical and psychiatric problems.
Garden settings, both viewed and experienced actively, have already been associated with
stress reduction in other populations. Parsons et al.85 reported that after a mildly stressful
event, subjects viewing simulated drives through nature dominated environs had greater
stress reduction, as measured by blood pressure and electrodermal activity, than subjects
viewing simulated automobile drives through environs replete with man made hardscape.
In another study, subjects viewing pleasant rural scenes on the wall while using a
treadmill experienced greater blood pressure reduction than subjects viewing unpleasant
urban scenes.26,85 Ulrich et al.86 found that persons waiting to donate blood had more
reduced stress as measured by blood pressure and pulse rate when viewing nature scenes
on TV than did donors viewing urban scenes on TV, regular TV programming or no TV
programs. Viewing nature scenes not only lowers sympathetic arousal, it may alter EEG
activity. Nakamura and Fujii87 reported that viewing pictures of a natural hedge produced
a greater ratio of alpha to beta activity on EEG when compared to subjects viewing a
picture of a similarly shaped concrete wall.
In more active garden activities, Hartig et al.31 found that after undergoing tasks to
increase psychophysiological stress, a walk in a garden setting improved performance on
a test of attention when compared to group members who walked in an urban setting.
Restoration of blood pressure, emotion and attention were all more positively affected for
the nature group compared to the urban group. A recent study by Van Den Berg and
Custers17 also involved active participation within gardens. Gardeners whose stress levels
had first been deliberately elevated with a difficult task demonstrated significantly
lowered salivary cortisol levels and higher self-reported positive mood after 30 minutes
of light gardening activities as compared to those who engaged in indoor pleasant reading
after the stressful event. Although the relaxing reading did also reduce cortisol levels, this
reduction was less than with the gardening, and positive mood showed no increase with
the indoor activity. The authors suggest that gardening, as an involved and goal-directed
way of interacting with nature, can be valuable in promoting restoration from stress.
Thus, there are numerous studies demonstrating the effect of nature in decreasing
sympathetic response and stress. Multiple modalities have been used to measure stress
responses, including blood pressure, pulse rate, electrodermal activity, EEG activity,
salivary cortisol level and self-reported positive and negative moods. These studies
demonstrate the need for more research to determine if there will be a quantitative
difference in stress reduction as measured by sympathetic and endocrine responses when
the elderly engage in active and passive garden activities compared to similar activities
performed in non-garden environments.
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443
BENEFITS FOR RESIDENTS WITH DEMENTIA
The prevalence of dementia is estimated to be from three to 11% in community dwellings
of elderly older than 65 years of age and up to 47% in long-term care residents.88,89 In one
study, 67% of patients admitted to a long-term care facility were diagnosed as having a
dementia syndrome.90 Age appropriate environmental strategies have been explored in the
attempt to reduce inappropriate behaviors in the elderly with cognitive impairment.
Studies with a broad spectrum of ages suggest that having a daily view of a natural
setting, or having access to gardens may promote healing and reduce tension.14,91 Kuo and
Sullivan92 reported that knowing there is a park or garden nearby or seeing and having
activities in a natural setting may reduce family aggression.
One of the important concepts to be considered in the design of residences for the elderly
is to not replicate the modern medical center appearance. The sterile modern medical
complex, often without the sight of or access to gardens or natural settings, may increase
resident anxiety and fear as evidenced by elevated vital signs.93 Anxiety and fear may
contribute to inappropriate behaviors, particularly for residents on long term care
units.94 Dementia unit residents may resent being confined to a locked environment and
may express this frustration through aggressive behavior.95,96 Cohen-Mansfield et
al.97 reported that 93% of nursing home residents had agitated behavior once or more
times per week during one shift, with a mean of 9.3 weekly reports of inappropriate
behaviors. The National Nursing Homes Survey reported that 30-50% of late stage
dementia patients exhibit inappropriate behavior.98 It has been suggested that
inappropriate behaviors reflect the failure of the environment to meet the needs of the
residents.99 As dementia patients have a limited capacity to communicate their needs and
thoughts, inappropriate behaviors may be interpreted as an index of anxiety and
depression.100
Entering a rehabilitation center, assisted living or dementia residence requires
adjustments that are usually not welcomed by the elderly. Most cognitively impaired
elderly making this transition have little possibility of returning to a more independent
environment.101 The more advanced demented elderly are often dependent on the
dementia residence staff for some or most of their activities of daily living (ADLs), and
they require being confined to a safe custodial environment with limited exposure to
natural settings.96 McMinn and Hinton96 reported that the mandatory indoor confinement
of dementia residents can result in increased verbal and physical agitation and increased
use of psychotropic medications. One design intervention to decrease inappropriate
behaviors is to increase opportunities for residents to leave the dementia unit to enjoy a
garden setting.
Several authors have explored the value of a therapeutic garden for dementia residences.
In the residential setting, Namazi and Johnson95 reported that having access to unlocked
doors leading into a garden might increase autonomy and quality of life. The autonomy of
choosing to exit from the residence may reduce the frequency of agitated behavior.
Mather, Nemecek, and Oliver102 reported that a therapeutic garden reduced the incidence
of inappropriate behaviors in a long-term dementia care facility in Canada. McMinn and
Hinton96 reported decreased inappropriate behaviors following 32 days of confinement of
dementia patients when access to an outdoor area was granted. Ellis44 found that light
444
exercise in a dementia therapeutic garden could reduce disruptive behaviors. In addition,
access to sunlight in the garden can naturally increase production of Vitamin D and help
balance a resident's circadian rhythms.103
Wander garden studies concerning agitation

Wander gardens are therapeutic gardens designed specifically for the safety and benefit of
residents with dementia. For example, all plants are edible, the garden is enclosed to
prevent residents from eloping and all paths lead the residents back to entrances. The
number of factors critical to understanding the role of wander gardens for dementia
patients is myriad.6 Namazi and Johnson95 stated that decreased inappropriate behaviors
expressed within 30 minutes of finding an unlocked door suggested that a sense of
freedom may improve the residents' quality of life. Having the option of leaving the
indoor residential area for a well designed garden may be useful in reducing agitation and
negative behaviors towards other residents and staff. Thus, the question arises: Is there a
positive interaction between dementia patients' ambulatory capacities and benefits from
the wander garden?
Several studies have suggested that being able to see trees and flowers reduces agitation
and aggression and promotes healing.7,96,102 In a prospective observational study, Detweiler
et al.48 investigated the effect on dementia resident behaviors by adding a wander garden
to an existing dementia facility. In this study, 34 male residents were observed for 12
months before and after opening the wander garden. Behaviors were assessed using the
Cohen-Mansfield Agitation Inventory Short Form (CMAI),104 incident reports, as needed
medications (PRNs), and surveys of staff and residents' family members. Results showed
that the final CMAI scores and number of PRN medications used were lower than
baseline values with a trend for residents who used the garden more often to have less
agitated behavior. Staff and family members felt that the wander garden decreased
inappropriate behaviors, and improved mood and quality of life of the dementia residents.
Retaining a habit of exercise to assist in supporting ambulatory capacity is an important
element in preventive health during aging.105 The consequences of visiting a wander
garden on monthly agitation levels of a group of elderly veterans diagnosed with
dementia was assessed utilizing a growth model within the framework of hierarchical
linear modeling.106 The focus was on differences in the ambulatory capacity of the
veterans using wheelchairs, merry walkers and those ambulating freely. A sample of 34
veterans residing in a locked ward in a dementia unit was observed for a baseline period
and for twelve months after a wander garden was opened in their facility. The findings
suggest that while visiting the wander garden helped lower agitation levels in all the
dementia patients there was a differential effect based on the patients' ability to walk
unassisted versus those in wheelchairs and merry walkers, with freely ambulatory
patients benefiting more.106
Reduction in falls and antipsychotic medications

In the expanding elderly population, over one third of the community dwellers older than
65 years of age will fall, with 50% of these elderly experiencing recurrent falls.107-109 For
the elderly in long-term care facilities, falls and fall-related injuries have been reported to
445
be three times higher than for community-dwelling older adults with a mean of 1.5 falls
per institutional bed year.110,111 Dementia is an independent risk factor for falls with an
increasing incidence as the disease progresses. The yearly estimates of fall prevalence
range from 30% in early dementia to 75% for institutionalized residents with advanced
dementia.112
Each year the medical costs climb despite the state of the economy.113 The total direct cost
of all fall injuries for people 65 and older is expected to increase from greater than $19
billion in 2000 to about $55 in 2020 in the USA.114,115 Excluding physician fees, the
average cost for a fall injury in persons aged 72 and older, was approximately
$19,440.116 While about 90% of falls do not require medical attention, approximately 10%
necessitate medical attention. Moreover, about 5% of the falls needing medical treatment
result in fracture.117,118 It is noteworthy that 95% of hip fractures in the elderly are caused
by falls. The mortality for hip fractures in nursing home residents is higher than for
community residents with hip fractures.119,120
A variety of medications can be employed to treat behavioral disturbances in the elderly
with and without dementia. In the residents with dementia, fall risk is often compounded
by the side effects of the routine medications employed to treat the comorbid medical
problems in addition to those medications prescribed for concurrent depression, agitation,
psychosis, anxiety and insomnia.121 The most common classes of medications to treat
agitation and behavioral problems in dementia include antipsychotics, antidepressants,
anxiolytics and hypnotics.122 Most of these medications contribute to increased fall risk in
the elderly.121 Of all medications, psychotropic medications have the highest risk of
increasing falls.123-125
There is sparse data regarding the influence of a garden on scheduled medication use and
fall risk for dementia unit residents. Risk factors for falls are extensive for the moderate
to severe dementia residents, with psychiatric medications one of the most prominent.
Detweiler et al.126 examined the complex interaction of falls and scheduled medications in
a garden. The questions investigated were whether a garden had a positive effect on fall
frequency and severity and whether it reduced the number and doses of scheduled
psychiatric medications used to treat dementia unit residents. The 28 residents
experienced about a 30% decrease for both the raw number of falls and fall severity
scores after the garden opened. The raw number of falls decreased 38.7% for the high
garden users compared to 7.9% for the infrequent garden users. There was a significantly
decreased need for high dose antipsychotics, whereas there was relatively no change in
primary antidepressant, hypnotic and anxiolytic use.126
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POSSIBLE LIMITATIONS OF GARDEN SETTINGS

The patient population most likely to experience negative experiences in garden settings
consists of the more advanced dementia patients. It has been reported that advanced
dementia residents who can see the natural setting but find the doors to the garden locked
may experience increased agitation.95 On the other hand, a survey of 65 staff members
from 10 nursing homes with indoor and outdoor plant activities reported a positive
446
psychological and social effect on the participating dementia residents. Of note, the
dementia unit staff reported that the residents ingested both soil and plants with a
preference for the more colorful plants and berries.127 The dementia wander garden, a
subspecialty of garden settings, requires all garden components to be edible, thus
excluding toxic plants and pesticides. Consequently, residents eating any garden setting
component should not have any serious side effects. It was reported that some staff
members responsible for managing the plants may consider resident actions of picking
flowers or moving or watering the plants outside of supervised activities as negative
resident actions.127 During the days when there is rain or snow and the garden doors are
open, residents may get wet, requiring a change of clothes. Also, there is a higher
probability of having wheelchairs and merry walkers slide off the paths to become stuck
in the adjacent mulch or grass after inclement weather.45 This may result in more work for
the nursing staff and be considered a barrier to garden use.
Finding new and improved answers to elderly health issues has increased the focus on the
ethical issues involved in the protection of elderly research subjects. This is particularly
relevant for the cognitively impaired, the mentally disabled and the critically ill.
Investigators should be aware of the special problems associated with research in the
older population and be prepared to deal with these before embarking on a research
project.128 Informed consent and proxy consent are important issues affecting the design,
approval and implementation of research on this diverse, vulnerable population of the
institutionalized elderly. As the majority of critically ill adults lack decision-making
capacity involving participation in research studies, how do Institutional Review Boards
(IRBs) define and weigh risks and benefits in considering research involving capacity and
proxy consent.129 Gong et al.130 examined how IRBs oversee research protocol safeguards
for incapacitated adults. They found that IRB practices on surrogate consent and other
safeguards to protect incapacitated adults in research varied, from studies including only
those patients as having decisional capacity to studies where no assessment of decisional
ability was even involved.131 If proxies are necessary for consent in a research protocol, to
what degree do the proxies' research decisions reflect what patients themselves would
decide.129 As geriatric research on therapeutic gardens moves forward, progress depends
on addressing the many variables in constructing, approving and conducting relevant and
ethical studies.
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CONCLUSIONS
Preliminary studies have reported the benefits of horticultural therapy and garden settings
in reduction of pain, improvement in attention, lessening of stress, modulation of
agitation, lowering of PRN medications and antipsychotics and reduction of falls. These
benefits are important factors in improving the quality of life and possibly reducing costs
for long-term, assisted living and dementia unit residents. Most of the existing studies of
garden settings have utilized views of nature or indoor plants with sparse studies
employing therapeutic gardens and rehabilitation greenhouses. Despite the long history of
horticultural therapy in various clinical settings, to the best of our knowledge there are no
controlled clinical trials demonstrating the positive or negative effects of the passive or
447
active rehabilitation of the elderly in garden settings. The quantitative analysis of the
benefits of garden settings for older individuals is long overdue. Initiating studies
regarding the use of therapeutic gardens and/or therapeutic greenhouses may increase the
evidence to sustain or refute the benefits of garden settings for persons with similar late
life and rehabilitation needs. It would seem that there is a pressing need for scholarly
innovative studies investigating this treatment modality for our aging population.
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Articles from Psychiatry Investigation are provided here courtesy of Korean Neuropsychiatric
Association
Therapeutic landscapes and healing gardens: A review of

Chinese literature in relation to the studies in western
countries
Shan Jiang
Abstract
The paper deciphers the Chinese literature to English speaking scholars and bridges the
gap between China and the western countries on the topics of therapeutic landscapes and
healing gardens. Three parts of contents are included in the paper. Firstly, four schools of
theories explaining how and why nature can heal, are introduced based on the studies in
western countries with the examination of terminology used. In the second part, 71
455
publications in Chinese are systematically reviewed, with 19 significant studies analyzed
in details, including focus areas, the research method, and major findings. In the final
part, Chinese studies are evaluated in relation to the theories in western countries.
Keywords
Therapeutic landscapes;
Healing garden;
Literature review;
China;
Western countries
1. Introduction
There have been accumulated research interests on the therapeutic effects of nature since
1970s in western countries. Research evidences have explained how and why natural
views and landscape sceneries ease peoples pressure and change their mood from various
perspectives, including medical geography (Gesler, 2003), environmental psychology
(Kaplan and Kaplan, 1989; Kaplan, 1992; Ulrich, 1984 ; Ulrich, 19991999), ecological
psychology (Wang and Li, 2012 ; Moore and Cosco, 20102010), and horticultural
therapy (Detweiler et al., 2012 ; Sderback et al., 2004). The once disappeared
courtyards in hospitals revives in the early 1990s accompanied by the increasing research
interest of therapeutic landscapes/healing gardens in the United States. Researches on this
topic in western countries have a great impact on China.
Aiming to decipher the Chinese literature to English speaking scholars and bridge the gap
between China and the western countries on the topics of therapeutic landscapes and
healing gardens, three parts of contents are included in the paper. Firstly, four schools of
theories explaining how and why nature can heal are introduced based on the studies
from western countries, with the examination of terminology used. In the second part, 71
publications in Chinese are systematically reviewed, with 19 significant studies analyzed
in details, including focus areas, the research method, and major findings. In the final
part, Chinese studies are evaluated in relation to the theories and studies in western
countries.
2. Theories and terminology of therapeutic landscapes and healing

gardens in the western countries
There has been a long tradition to view nature as healer in different cultures. Garden
for the ill first appears in Europe during the Middle ages, with monastic hospitals
providing enclosed vegetation gardens with an earnest wish for the spiritual
transformation of patients (Gerlach-Spriggs et al., 1998). The therapeutic effects of nature
to improve patients recovery has been, for the first time, precisely written and published
by Florence Nightingale in Notes on Nursing in 1860. She believes that visual
connections to nature, such as natural scenes through window and bedside flowers, aid
the recovery of patients ( Nightingale, 1863).
456
Since the 1970s there have been continuous empirical studies in western countries
indicating that natural environments have therapeutic effects. For instance, Olds
(1985) examines the therapeutic effects of nature by interviewing focus groups in a
coherent workshop for several years, and concludes that places with natural features can
heal peoples emotional depression. Francis and Cooper Marcus (1991) conducted similar
interviews and found out that people went to natural environment for self-help under
stressed or depressed conditions. As a result, several schools with different bodies of
knowledge emerged, establishing a relationship between landscape and health to explore
the healing mechanisms of nature (Table 1). In the following text, the author discusses
four major schools based on the studies in western societies, including: medical
geography, environmental psychological, salutogenic environment and the ecological
approach, and horticultural therapy.
Table 1.
Therapeutic landscapes and healing gardens: four schools of theories in western
studies.
School Terminology Theories Representatives
1 Medical Therapeutic Sense of place; four Gesler (2003)
geography landscape dimensions of
therapeutic
landscapes: natural
environment, built
environment,
symbolic environment
and social
environment
2 Environmental Restorative Attention-Restoration Kaplan and Kaplan

psychology environment Theory (ART); four (1989); Kaplan
features as restorative (1992); Kaplan and
environment: being Berman (2010)
away, extent,
fascination, and action
and compatibility
Therapeutic Esthetic-Affective Cooper-Marcus and
landscapes Theory (AAT); Barnes (1999); Cooper-
and healing psycho-evolution Marcus and Sachs
garden theories; three features (2013); Ulrich, 1984 ;
of healing gardens: Ulrich,
relief from physical 19991999; Ulrich, et al.
symptoms, illness or (1991); Ulrich and
trauma; stress Parsons (1992).
reduction for
individuals dealing
with emotionally
and/or physically
457
School Terminology Theories Representatives
stressful experiences;
and an improvement
in the overall sense of
well-being
3 Ecological Salutogenic Theories of Heft (1999,

psychology environment and environmental 2010); Grahn et al.
therapeutic affordances; (2010); Grahn and
landscape ecological psychology Stigsdotter (2003).
4 Horticultural Healing garden Theory of flow Sderback et al.

Therapy and therapeutic experience; sensory (2004); Detweiler, et al.
garden stimulation theories (2012).
Table options
2.1. Medical geography

In view of explaining the healing effects of nature, a significant amount of research come
from cultural geography leading to the development of the medical geography school.
The concept of therapeutic landscape is first introduced by medical geographers, to
define places with natural or historic features for the maintenance of health and well
being (Velarde et al., 2007). The term therapeutic landscape has traditionally been used
to describe landscapes with enduring reputation for achieving physical, mental and
spiritual healing (Gesler, 2003 ; Verderber, 1986). This term has also been linked to
sense of place, leading to four dimensions of therapeutic landscape including: natural
environment, built environment, symbolic environment and social environment (Gesler,
2003). Branched from environmental psychology, two streams of theories have explained
the therapeutic effects of nature with discussions as followed.
2.2. Environmental psychology

2.2.1. Attention-Recreation Theory and the restorative environment
Kaplan and Kaplan starts the research of restorative environment, which describes the
types of environments that help people recover from mental fatigue (Kaplan, 1992 ;
Vries, 20102010). According to their Attention-Restoration Theory (ART), people
process surrounding information through two kinds of attention: directed attention and
fascination or involuntary attention (Kaplan, 1992 ; Kaplan and Berman, 2010). Directed
attention is employed in tasks such as problem solving. Directed attention fatigue is a
type of temporary symptom of the brains that makes people feel distractible, impatient,
forgetful, or cranky, and hence result in a decline of working efficiency (ibid.). Recovery
of directed attention is enhanced best in restorative environments where fascination
system is used. Additionally, nature encompasses four features as a restorative
environment: being away, extent, fascination, and action and compatibility; hence
458
performs well in mental fatigue recovery (ibid.). The following paragraphs introduce
another stream of theories in the framework of environmental psychology.
2.2.2. Psycho-evolution theories and healing gardens

Another stream of research reveals that environmental stressors (e.g., crowding, noise)
can elicit substantial stress in people, while visual access to nature shows effects on stress
recovery (Ulrich et al., 1991 ; Ulrich and Parsons, 1992). Psycho-evolution theories
consider that the natures therapeutic effect is a matter of unconscious processes and
affects located in the oldest, emotion-driven parts of the brain that inform people when to
relax (Grahn et al., 20102010 ; Velarde et al., 2007). Backed up by these theories, a
significant quasi-experimental study conducted by Ulrich (1984) concludes that patients
get recovered more quickly when looking out of a window with natural scenes. Ulrich
(1999) and Cooper-Marcus and Barnes, 1995 ; Cooper-Marcus and Barnes, 1999 refer
the term healing garden to gardens or landscape settings as variety of garden
features that have in common a consistent tendency to foster restoration from stress and
have other positive influences on patients, visitors, and staff or caregivers. They also
present that a healing garden has either one or a mixture of the three following processes:
relief from physical symptoms, illness or trauma; stress reduction and increased levels of
comfort for individuals dealing with emotionally and/or physically tiring experiences;
and an improvement in the overall sense of well-being (Cooper-Marcus and Barnes,
1999). Moving forward, the term healing garden has been widely recognized, referring
to green outdoor spaces in healthcare facilities that provide a chance of stress relief for
patients, staff and families (Eckerling, 1996; Gharipour and Zimring, 2005; Lau and
Yang, 2009 ; Szczygiel and Hewitt, 2000).
2.3. Salutogenic environments and the ecological approach

Landscape architects and psychologists also believe that green urban open spaces
improve quality of everyday life by providing salubrious environments and perceived
visual esthetics to the public. Frederick Law Olmsted, who is internationally renowned as
the founder of modern landscape architecture in America, practices dynamically towards
healthful environments and landscape designs for the improvement of public health,
defined as salubrious landscape (Szczygiel and Hewitt, 2000). He stated that an
environment containing vegetation or other nature employs the mind without fatigue and
yet experiences it gives the effect of refreshing rest and reinvigoration to the whole
(health) system (Olmsted, 1865). Olmsteds ideas about the healthful, therapeutic nature
in cities is still a major influence today on urban park system and community green open
spaces (Ulrich and Parson, 1992).
Since the 1970s, perceptual psychologists, represented by J.J. Gibson, suggests an
environment-behavior model identifying that the environment affords certain behaviors
(Kleiber et al., 2011 ; Greeno, 1994). The model no longer considers viewers as
receptors of meaningless environmental stimulations; conversely, they emphasize on the
dynamic and reciprocal relationship between perceiver and what the environment affords
that is, environmental affordances (Heft, 20102010 ; Gibson, 1979). This approach of
perceptual research is known as ecological approach. In this framework, researchers
believe that environmental affordance in landscape plays a key role in alleviating the so-
459
called lifestyle-related symptoms (e.g., burnt out disease, stress-related pain), by
stimulating physical activity, facilitating social contacts and social cohesion among
residents (Vries, 2010), and encouraging meaningful communications among children
and the environment (Moore and Cosco, 2010). Theories and applications related to
salutogenic environment in a manner of ecological psychology have been elaborated
in Innovative Approaches to Researching Landscape and Health: Open Space: People
Space 2 edited by Thompson, Aspinall and Bell (2010).
2.4. Horticultural therapy school

The horticultural therapy school believes that working in a garden is particularly obvious,
meaningful, and enjoyable, hence therapeutic (Stigsdotter and Grahn, 2002). Leisure
theories back up their research in the way that adults feel rewarded during gardening
activities and may go through flow experiences with feelings of well-being, total
commitment, and forgetfulness of time and self (Czikszentmihalyi, 1990). Horticultural
therapy scientists usually refer to healing gardens or therapeutic gardens as settings
that provide places for gardening activities and encourage physical movements, such as
therapeutic walking (Detweiler et al., 2012). In recent decades in the United States, some
healing gardens focus on the design of sensory stimulation and accommodation of
horticultural activities. This approach has been proven beneficial for the patients with
dementia or post-traumatic stress symptoms(Detweiler et al., 2012 ; Stigsdotter and
Grahn, 2002).
To broaden the views of research, this paper refers to therapeutic landscapes as general
public open spaces that improve peoples physical, mental/ spiritual/ emotional, and
social well being. Additionally, the term healing garden is referred to gardens and
natural settings in healthcare facilities that support users stress reduction and enhance
patients recovery. Following the author systematically reviews Chinese literature in
realm of therapeutic landscapes/healing gardens. Research topics, research methods and
major findings are discussed.
3. Systematic literature review of therapeutic landscapes/healing

gardens in China
In view of understanding the current philosophies of therapeutic landscapes/healing
gardens in China, this part systematically reviews 71 publications in Chinese language
using the search engine of CNKI databaseChina Knowledge Resource Integrated
Database, which records academic publications and outstanding dissertations with
English abstract and keywords since 1979. Research methods and results of the literature
review are discussed in the following section.
3.1. Keywords and search combinations

Keywords and search combinations are set up for the literature search after the discussion
with experts (shown in Figure 1). A systematic review strategy is developed including
three procedures: (1) literature search using the keywords and combinations; (2) analysis
of the inner connections among the search results, amount of citations and influence
factors of the literatures; (3) analysis of the significant studies. 71 Studies written by
Chinese scholars are analyzed, including 33 peer-reviewed articles, 2 books and 36
460
dissertations. The analysis of citations and influences of the 71 research studies are
shown in the next section.
Figure 1.
Flow chart of systematic literature review.
Figure options
3.2. Analysis of 71 studies written by Chinese scholars

In Figure 2, horizontal axis represents the reviewed publications from the year 2000 to
2012. Publications are clustered by year and classified by source type. The black
histogram above the horizontal axis represents the times being cited of the particular
publication according to the record of CNKI. The gray histogram below the horizontal
axis represents the influence factor of the journal where the particular article is published
according to the record of CNKI.
461
Figure 2.
Analysis of 71 studies written by Chinese scholars.
Figure options
This figure shows that intrinsic research interests in realm of therapeutic landscapes starts
from the study of horticultural therapy (Li, 2000a ; Li, 2000b).The application of
salubrious plantings in garden design emerges from the understanding of traditional
Chinese medicine (Zhao, 2001 ; Chen, 2004). In 2009, the most influential Chinese
journal in the realm of landscape architectureChinese Landscape Architectureedits a
special issue of therapeutic landscapes/healing gardens in which research topics and
theories in the western countries are generally introduced to Chinese scholars.
According to Figure 3, the 71 reviewed studies generally fall into 9 categories of topics,
including: general introduction of therapeutic landscapes/healing gardens (22/71);
hospital exterior environments (24/71); therapeutic urban parks (3/71); therapeutic
environments especially for children (3/71); horticultural therapy (5/71); hospital planting
design (4/71); application of traditional Chinese medicine in therapeutic landscapes
(5/71); evidence-based design (1/71) and post occupancy evaluation of healing gardens
(2/7). Two among the 71 studies are unclassified; an article introduces Zen and Japanese
meditation garden (Zhang et al., 2010), and a thesis talks about landscape design of post-
disaster trauma center on basis of Wenchuan earthquake (Ma, 2010). Among all the
categories, therapeutic landscapes/healing gardens and hospital exterior environmental
study have gained the most research interests. Inter-connections of the 71 studies are
illustrated in a circular literature map (shown in Figure 3). All the studies are arranged
along a circle. Each line represents that the connected two studies are closely related.
462
Connections are identified according to the citation and bibliography in the end of each
study. The top 19 studies with the most connections are selected for the further analysis,
as discussed in the following section.
Figure 3.
Inter-relationship among 71 studies written by Chinese scholars.
Figure options
3.3. Detailed analysis of the 19 studies

Among the 19 studies there are 2 empirical studies, and 9 case studies. 13 Sources
discuss design recommendations for therapeutic environments informed by the authors
literature researches but not based on empirical evidences. 7 sources report that healing
garden design should combine Yin and Yang and five elements (i.e., metal, wood,
water, fire and soil) from the theories of traditional Chinese medicine. 5 studies focus on
the appropriate application of medicinal plants in the design of therapeutic landscapes. 1
introduces evidence-based approach as the major research method in this realm, and 1
463
study talks about the evaluation issue that a grading standard from the professional
opinions excluding users experience and satisfaction is suggested (shown in Table 2).
Table 2.
Detailed Analysis of 19 selected Chinese Studies.
Design
No Source Author(s) Research recommendatio
. type and year Focus area method Major findings n
1 Article Li, 2000a ; Horticultural Case study: Three benefits China should
Li, 2000b therapy and University of of horticultural combine
design of healing Hyogo (Awaji therapy: traditional
gardens for Campus) spiritual, social Chinese medicine
gardening Horticultural and physical into its own
activities Therapeutic aspects; horticultural
Garden, Awaji procedures of therapy program
Island, Japan horticultural and healing
therapy: pre- garden design
evaluation, set
the therapeutic
goal,
implementation,
key steps of the
program, post-
program
evaluation
2 Article Zhao, R. Nature has Literature Treatment

(2001) therapeutic research using natural
effects; resources can
treatments of heal illness;
traditional viewing natural
Chinese scenes helps to
medicine reduce stress
integrated into
therapeutic
landscape design
3 Article Chen, L. Therapeutic Literature People- Make medicinal

(2004) landscapes and research centered plants the
planting design; design fundamental plant
the application of principles in the whole
medicinal plants based on the planting
public behavior community; using
psychology; the a large amount of
application of plants to form
medicinal visual comfort
plants can heal ability; fitness
and improve equipment can be
well-being placed near to the
medicinal planting
community
4 Master Cui, Y. Hospital exterior Survey to Garden is a key Healing gardens

thesis (2004) environments; patients at component of should focus on
464
Design
related theories hospitals in hospital healing planting design;
and design Beijing, environment; multi-dimensional
recommendation Nanjing and therapeutic design of green
s Zhengzhou, landscape open spaces in
China Case settings help hospital
study of 3 users relief environment;
hospitals in stress, enhance visual
USA and 2 recovery from connections from
hospitals in illness and inward to outdoor
China change mood natural
environment is
essential to
patients
5 Master Tian, S. Hospital exterior Case study of Five types of Design for
thesis (2005) environments; multiple hospital exterior different users
related theories hospitals open spaces needs.
and design inside and are classified, Accessibility,
recommendation outside China including: traffic visibility,
s space, adaptability for
gathering multi-use,
space, esthetic
relaxation attractiveness,
space, viewing and borrowed
space and roof landscapes for
garden the patients and
families; private
gardens should
be designed for
caregivers
6 Article Han, X., et Hospital exterior Case study of Employing Hospital

al. (2006) environment and multiple sustainable courtyards should
healing gardens; hospitals garden design be designed
design inside and strategies; according to
recommendation outside China visual users needs;
s connections to Healing gardens
healing should be
gardens can esthetic,
facilitate patient accessible and
recovery visible. Proper
selection of
plants, organized
paths, water
elements of
landscape
design, and the
selection of art
work with positive
meanings
465
Design
7 Article Niu, Z. and Horticultural Literature People- Properly use of
Xu, F. therapy and research centered different
(2006) healing gardens; design landscape
integration of principles; elements, such
traditional landscape as water,
Chinese medical design medicinal plants
into healing according to and sunlight;
garden design five elements design of
in traditional topography and
Chinese paths to
medicine; encourage
design using therapeutic
knowledge of exercise.
environmental
psychology
8 Article Xiu, M. and Influence of Quasi- Horticultural

Li, S. horticultural experiment: Therapy
(2006) therapy activities Self-report program can
on the physical and help the elderly
and mental measurement people
health of the of blood ameliorate
elderly pressure cardiovascular
(n=40) system
residences at degradation,
Holly Nursing change the
Home, Beijing mood positively
and improve
the sense of
well-being
9 Master Yao, C. Hospital exterior Case study of Features of Buffer zone near
thesis (2006) environments; 1 hospital in hospital the entrance;
related theories Beijing, China outdoor interior-exterior
and design and 2 environment visual
recommendation hospitals in include: privacy,connections;
s Shenyang, sense of accessibility to
China territory, and the garden;
recognizability. spatial design
Healing encouraging
gardens should physical activities;
be designed for high accessibility
various of the healing
activities and garden and
needs of barrier-free
different user design.
groups Application of
medicinal plants
10 Master Wang, Z. Healing garden Literature Healing garden Organized traffic

Thesis (2007) design; design research should fulfill and clear spatial
466
Design
principles and various needs layout, plants and
special needs for of patients, water are
children and the visitors and important design
elderly patients staff. The elements;
garden should comfortable
be visible and seats, paths with
contain diverse smooth materials
spaces. Cold and wide enough
color, quiet for wheels,
environment positive art works;
with fragrance surveillance
of plants can space near
enhance childrens
recovery playground
11 Master Ying, J. Urban Case study: Green open Design different

thesis (2007) therapeutic open The Elizabeth spaces are types of spaces
spaces for & Nova beneficial to the for privacy and
peoples physical Evans patients health social
and mental Restorative outcomes. communication; a
health; healing Garden, Healing large amount of
gardens design Cleve- land, gardens should plants in the
OH be designed garden provides a
according to sense of amenity;
varied needs of the use of
patients, medicinal plants
visitors and assists patients
caregivers recovery
according to the
five elements in
traditional
Chinese medicine
12 Article Li, S. and A review of the Literature The research

Zhang, W. methodologies research trend in this
(2009) employed in realm in China:
horticultural urban green
therapy spaces and the
worldwide; public health,
Introduction of plant and its
horticultural contribution to
therapy in USA, human well-
European being through
countries, Japan the five sensory
and China stimuli,
horticultural
activities and its
effect to mental
and physical
symptoms
467
Design
13 Article Yang, H., et Application of Case study of Theories Design to keep
al. (2009) traditional a healing influencing the the balance
Chinese theories garden design of between body
in healing garden designed by healing and mind, people
design. the author for gardens and nature, Yin
Comparison of a professor include: sense and Yang; five
design guidelines with minor of control, elements and
between China depression social support, landscape
and the West and insomnia natural elements should
distractions, be closely related
physical in design
movement and
exercise.
Differences of
design
guidelines
between China
and the West:
design
philosophy,
people-nature
relationship,
concept, and
the application
of traditional
Chinese
medicine
14 Article Zhang, W., Nature has Case study: Primary goal of Healing garden
et al. (2009) therapeutic Buehler healing garden design should
effects. Enabling is stress relief; emphasize
Evidence-based Garden, features of sensory
design as Chicago, MI; healing garden environment:
primary William T. include: clarity, green visual
methodology of Bacon access, scenery, sound of
healing garden Sensory gathering birds and water,
research and Garden, spaces, aroma from
design; common Chicago, MI private/intimate plants to
features of spaces, people- stimulate the
healing gardens nature sense of smell,
and design connections. design
recommendation Three encouraging
s approaches people to touch
through which plants and water,
healing art works with
gardens positive
promote people meanings; design
s well-being: should combine
natural horticultural
environment therapy and learn
facilitating from traditional
physiological Chinese medicine
468
Design
process,
sensory
perception and
psychological
stimuli and
activities for
physical fitness
15 Article Jiang, Y. Introduction to 2 Case study: Design of

(2009) cases of healing Healing healing
gardens in United garden of the gardens should
States Oregon Burn also focus on
Center at special needs
Legacy for
Emanuel disadvantaged
Hospital, population
Portland, OR;
healing
garden of
Good
Samaritan
Regional
Medical
Center,
Phoenix, AZ
16 Article Zhang, J., et Introduction of Literature Well-designed The application of

al. (2010) Taoism culture research ecological Taoism theories
and the environment including: a
application of can contribute balance of
Taoism theories to peoples person-nature
in healing garden physical and relationship,
design psychological forms of the
health. Taoist space should
health follow both
preservation stillness and
culture provides movement, and
great Yin and Yang.
inspiration to Selection of
healing garden medicinal plants
design based on the five
elements theory
17 Article Lei, Y., et A brief review of Case study: Four stages of Healing garden
al. (2011) history and Joel healing garden design should
current research Schnaper design: forming learn from
status of healing Memorial stage, rudiment traditional
garden in Garden, New period, silent Chinese medicine
western and York, NY; The period, and design in
eastern countries Elizabeth & development humanist
Nova Evans period; Western approaches
469
Design
Restorative country has
Garden, implemented
Cleveland, theories to
OH healing garden
design practice,
while it is still
theoretical
research period
in China on this
topic
18 Article Wang, X. Intention and Literature Therapeutic

and Li, J. extension of the research landscapes
(2012) meanings of include healing
therapeutic gardens,
landscapes and rehabilitation
terminology gardens,
discrimination meditation
gardens and
memorial
gardens. A
healing garden
is usually the
place where
horticultural
therapy
activities
happen
19 Article Li, Q. and Development of Post- Qualitative

Tang, X. quality evaluation occupancy evaluation
(2012) index system of evaluation index system of
healing garden healing
gardens is
established by
using level
analyzing
method
Table options
There are also 2 important translated studies which have great impact to Chinese studies.
One is Healing Garden in Hospitals originally written by Cooper-Marcus and translated
by Cooper-Marcus et al., 2009. In this article, a survey to 143 users of 4 hospitals in San
Francisco bay area is introduced. It has been stated that gardens in hospitals can reduce
users stress, enhance patients sense of control and then facilitate patients recovery.
Detailed recommendations of healing garden design are also suggested in the translated
article. Another article introducing case studies done by Cooper-Marcus and Barnes
(1999) is included in the detailed analysis (Jiang, 2009).Comparison of the research
philosophies, historical research on therapeutic landscapes/healing gardens, focus areas
and methodology is further analyzed in the third part of the paper.
470
4. Comparison of research status between China and western countries
4.1. Terminology
As Gerlach-Spriggs and Healy (2010) states, health care gardens are described by a
broad and vague collection of overlapping terms . Different terms are used from
various perspectives in both Chinese and western societies. In western studies, Medical
Dictionary defines therapeutic as including the healing powers of nature ( Hooper,
1839). Discussion of terminology issues can be retrieved from the first part of the paper
and Table 1.
In China, Jiang (2009)refers healing landscape to green spaces in healthcare
facilities, and Wang and Li (2012) refer healing landscape to landscape which has
therapeutic effect on physical and mental health. However, the most commonly used
definition by Chinese scholars is healing garden described by Eckerling (1996): healing
garden is a garden in a healing setting designed to make people feel better (Lei et al.,
2011 ; Li and Tang, 2012). Lei et al. (2011) have classified healing gardens into two
categories: (1) gardens in healthcare facilities which can improve the recovery process of
patients; (2) public parks for people suffering from life-style depression. Wang and Li
(2012) discriminates the meanings of the terms used in this realm and have stated that
healing gardens are usually the places where horticultural therapy activities happen.
While therapeutic landscapes consist of various natural settings with therapeutic effects,
including healing gardens, rehabilitation gardens, meditation gardens and memorial
gardens. Historical researches of therapeutic environments, especially gardens in hospital
environments, are comparatively different between China and the west, as discussed in
the following paragraph.
4.2. Historical research

One Chinese research briefly reviews the history of therapeutic environment in China
(Tian, 2005). BeiTian Yuan, built around the year 717 A.D., is the first public
hospice/hospital in ancient China. Temples located in the remoteness with wild natural
surroundings are the places where monks provide treatments and palliative care (ibid.).
Between the year1085 A.D. and 1145 A.D., the first public hospital is opened to
patients where green settings become essential in the form of courtyards. However, no
additional research is found on the history and development of therapeutic
landscapes/healing gardens.
Comparatively, there are already plenty of studies on history and development of
therapeutic landscapes/healing gardens in western countries. A chronologically based
historical introduction of healing gardens, from the Medieval, Renaissance, until the 19th
century, can be found from Restorative Gardens: The Healing Landscape ( Gerlach-
Spriggs et al., 1998). Architectural historian Hickman (2013) has systematically studied
hospital gardens in England since 1800. In addition, Ziff (2012) narratives the stories
behind the landscape design of asylums in Ohio after Civil War in the United States. In
the 20th century, Cooper-Marcus and Barnes (1999) clarifies that, from the year 1950 to
1990, the healing garden almost disappeared from hospitals in most western countries
because of the influence of the International Style and high-rise buildings which
dominates hospital designs. Empirical studies since the 1980s have revealed that nature
has positive influences on health outcomes, and the 1990s patient-centered care
471
movement triggers the revival of therapeutic landscapes and healing gardens (ibid.).
There are also several differences between Chinese studies and the western studies
regarding the research focus and theories, discussed in the following paragraphs.
4.3. Research focus and methods

In China, studies on horticultural therapy and the design of facilities accommodating
horticultural activities have gained most interest. Topics on hospital exterior
environments stably gain interest from the year 2007, and the topic of healing garden
becomes popular since the year 2010. There had also been a few number of Chinese
scholars who talked about therapeutic landscapes/healing gardens for unique user groups,
such as children and the elderly people.
Methods used in Chinese studies are mainly literature research and case study; very few
of them conduct empirical studies or controlled trails. As mentioned in the first part of the
article, the western literature encompasses 40 years study on theories and mechanism of
the therapeutic effects of nature, some of which have been proven by scientific evidences
(Ulrich et al., 1991 ; Vincent, 2009); post-occupancy evaluation is also an effective way
to summarize design guidelines (Cooper-Marcus and Barnes, 1999). Western studies in
this realm are rather highly specialized with topics covering various user groups (i.e.,
childrens hospital gardens, gardens for the veterans, gardens for the old people, gardens
of crisis shelters, etc.), various disease (i.e., gardens for dementia patients, gardens for
cancer patients, gardens for visual impaired patients, gardens for mental and behavioral
health facilities, and hospice gardens etc.), and various activities (i.e., gardens for
rehabilitation, gardens for horticulture therapy and public open spaces with restorative
features) (Cooper-Marcus and Barnes, 1999 ; Cooper-Marcus and Sachs, 2013).
Currently, for the research of healing gardens in western societies, evidence-based
approach has become a dominating method. Learnt from evidence-based medicine,
design guidelines of healing gardens should be proven by empirical studies; a systematic
evaluation of the actual therapeutic effects of the setting may also be included (Cooper-
Marcus and Sachs, 2013).
4.4. Theories
Theories discussed in the Chinese literature are mainly from the realm of horticultural
therapy and traditional Chinese medicine. Among the 19 detailed analyzed studies, 7
studies mention using theories from traditional Chinese medicine in the healing garden
design. Planting design with medicinal vegetation is also important in Chinese culture,
which can be seen in 5 studies. There have been well established theoretical frameworks
in western countries in this realm (see the four major schools of theories discussed in the
first part), by contrast, Chinese studies are relatively segmented. There is a significant
gap in Chinese literature that theoretically, scholars suggest using traditional Chinese
medicine theories in healing garden design. However, when talking about the application
of theories, most of the studies learn from western cases and employ design guidelines
suggested by western scholars. There is a need to integrate traditional theories from
Chinese culture into the western frameworks and work in a multiculturalist approach.
5. Conclusions
472
To understand the research status in both China and western countries, also to
discriminate the terms used in the realm of therapeutic landscapes/healing, terminology
has been comparatively examined; research topics, research methods and related theories
are also examined. It has been found that in both cultures, the term therapeutic
landscapes is referred to green public spaces which are beneficial to peoples physical,
mental and social health, by providing spaces for therapeutic activities and
contemplation, relieving pressures and encouraging social communications. Studies of
healing gardens in healthcare facilities aim to improve the quality of hospital
environment and reduce stress accompanied by the stressful hospitalization experience.
Also, the appearance of healing gardens and natural settings in hospitals can enhance the
sense of well being for caregivers in such high-pressure work places. Results of the
analysis have shown that research of therapeutic landscapes/healing gardens in China are
being heavily influenced by horticultural therapy. Meanwhile, Chinese researches focus
on the application of medicinal plants and traditional Chinese medicine theories in
healing garden design. However, the body of knowledge has not been well formed in
Chinese context and empirical tests to the design recommendations are needed in the
future.
Acknowledgement
Thanks Deborah Franqui, Ph.D. candidate at Clemson University, for reviewing the draft
manuscript.
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Peer review under responsibility of Southeast University.
Source:- http://www.sciencedirect.com/science/article/pii/S2095263513000836
Healing & Therapy

Studies in health care settings show a link between nature and healing. Nature contact
may serve to supplement or augment medical treatment and therapy. Both passive
exposure to landscapes and more active interactions with nature provide mental and
physiological benefits that contribute to healing and therapy.
Fast Facts
485

Hospital patients with plants in their room display less fatigue and pain, shorter
hospitalization, less anxiety, and higher hospital and room satisfaction.5

Patients with chronic musculoskeletal pain who participated in a 4-week
horticultural therapy program experienced an increase in mental and physical
health as well as an improved ability to cope with chronic pain.21

A study of children with Attention Deficit Disorder who played in windowless
indoor settings had significantly more severe symptoms than those who played in
grassy, outdoor spaces.24

Patients with clinical depression who participated in routine therapeutic gardening
activities experienced a reduction of severity of depression, and increased
attentional capacity, benefits that lasted up to three months after the program
ended.32

Gardening may be a preventative measure to help reduce the onset of dementia49;
gardening on a daily basis was found to reduce risk factors for dementia by 36%.50

Dementia patients who have access to gardens are less likely to display aggression
or experience injuries41 as well as improved sleep patterns, balanced hormones,
and decreased agitation.101

Studies have shown that participating in activities and/or interacting with natural
environments can ameliorate and help stave off attentional fatigue both before and
after breast cancer treatment or surgery.33

Ever more studies confirm the relationship between neighborhood open space and
physical activity.94 A study calculated a $2,200 reduction in average annual
healthcare charges per adult for those who had been sedentary, but became
active.99
Contents:
> Nature in Hospitals * Nature in the Room * Healing Gardens and Therapeutic Horticulture >
Horticulture Therapy > Mental Health, Function and Therapy * Children and Attention Deficit *
Depression * Cancer Patients * Psychiatric Patients * Dementia * Elder Care > Physical Health &
Therapy * Obesity and Active Living * Stress * Disabilities and Elder Care > Recovery, Resilience
and Rehabilitation * Crisis Recovery and Resilience * Military Service and Stress Disorders * Prisons
and Jails > Nature & the Healthcare Industry * Prescriptions for Parks & Trails * Insurance >
References *
cite: Wolf, K.L., S. Krueger, and K. Flora. 2014. Healing and Therapy - A Literature
Review. In: Green Cities: Good Health (www.greenhealth.washington.edu). School of
Environmental and Forest Resources, College of the Environment, University of
Washington.
Nature in Hospitals
In Europe the first hospitals were in monastic communities, where gardens played an
essential role in the healing process.1 As medical science and technologies have
progressed the more indirect connections between nature and the healing process are
486
often overlooked.1 Recent research suggests that access to natural features at a care
facility aids healing and recovery from a variety of physical and mental ailments.
Nature in the Room
Exposure to plants, natural views and nature imagery plays a positive role in recovery
and pain management inside care facilities. An early study by environmental psychologist
Dr. Roger Ulrich revealed that gallbladder surgery patients recovered faster and used
fewer strong pain medications when their room window faced a natural view rather than a
brick wall.2 The patients had, on average, a one-day shorter hospitalization and fewer
negative comments from nursing staff.2
A more recent study suggests views of natural surroundings may benefit male and female
patients differently. Men with obstructed views of nature demonstrated a decline in
mental health, while women with obstructed views appeared to have a greater decline in
physical health.3
Regardless of the view, windows in hospital rooms also allow for the potential benefits of
natural sunlight. Spinal surgery patients exposed to bright, naturally-sunlit hospital rooms
experienced significantly less stress, and used less pain-killing medication (thus reducing
costs of care) compared to similar patients who were not exposed to intense sunlight.4
Why might simply viewing nature ease pain and encourage healing? New insights from
neuroscience suggest that nature experiences are positive distractions that help a person
to refocus their attention. Increased focus on other inputs increases pain thresholds and
tolerance, leading to improved coping and healing strategies.10,11,12
Healing Gardens and Therapeutic Horticulture
Acting on research findings, healthcare facilities such as hospitals, nursing homes, and
rehabilitation centers have begun to install healing gardens for patients, visitors and staff.
In addition to contributing to the healing and therapy process, gardens are intended to
help address the mental stress, information overload, and emotional distress that visitors
may experience when assisting a loved one in a healthcare facility.13,14Gardens may also
serve as restorative environments for healthcare employees.15,16
Studies inform garden design by evaluating how specific pathways, plantings, and other
features influence levels of interaction with the garden, duration of stay, and therapeutic
benefits. Hospitals and care facilities may design healing gardens for a target population
and purpose, such as Alzheimer's patients or children with physical
disabilities.16Observations of patients undergoing treatment for stress-related diseases
suggests that gardens are most beneficial when they provide distinct areas for passive
reflection and emotional recovery, as well as social interaction, physical activity, and
sensory stimulation.17
487
A survey of visitors to four hospital gardens found that respondents most commonly
mentioned multiple nature elements of gardens - trees, greenery, flowers, and water - as
having positive benefits on their moods.18 A study of a pediatric hospitals healing
gardens demonstrated that having play features, pathways, and shading encouraged
higher levels of physical activity for visitors and children. Meanwhile staff preferred
garden areas that provided visual and auditory privacy.15 Other studies support the need
for distinct garden spaces for staff - spaces where they can enjoy breaks without
encountering visitors and patients.14
Horticulture Therapy
Providing gardens and other natural settings for the general purpose of facilitating healing
and wellbeing is known as therapeutic horticulture, including the examples provided
above. Horticultural therapy is the use of prescribed nature activity or experience by a
trained professional to aid recovery from specific mental or physical ailments.
Therapeutic treatment can take place in healthcare facilities or in community settings.
Horticultural therapists engage their patients in gardening activities as individuals or in
group settings. They guide activities that provide physical exercise or therapy, social
interaction, or cognitive development to meet clinically defined goals.19
A systematic review of over 240 scientific studies found reliable evidence to support
horticultural therapy as an intervention for a variety of conditions, from cerebral palsy to
schizophrenia.20 In one study patients with chronic musculoskeletal pain who participated
in a 4-week horticultural therapy program experienced an increase in mental and physical
health, as well as an improved ability to cope with chronic pain.21
After just one horticultural therapy session, patients recovering from cardiac surgery
experienced marked improvement in their mood, and stress reduction.22 Beyond treating
acute health conditions, research shows that horticultural therapy can also benefit
individuals trying to overcome emotional or physical trauma. In one study adults with
diagnosed depression participated in a therapeutic horticulture program and showed
significant beneficial change in mental health aspects of anxiety, mood, and depression.23
Mental Health, Function, and Therapy

Children and Attention Deficit
Over 2 million children in the U.S. have been diagnosed with attention-
deficit/hyperactivity disorders (ADHD). Such a child has reduced attention capacity,
which can have detrimental effects on social, cognitive, and psychological growth.
Studies at the University of Illinois have tested nature-based activity and ADHD
outcomes. In the first study parents judged that attention deficit symptoms were more
manageable after doing activities in green settings than after activities in other settings
(Table 1). Also, the greener a child's play area, the less severe his or her attention deficit
symptoms; children who played in windowless indoor settings had significantly more
severe symptoms than those who played in grassy, outdoor spaces (with or without trees).
488
Though the greenness of a childs home was unrelated to their ADD severity, more green
in their play setting was related to better outcomes.24
In a follow up study green outdoor activities reduced symptoms significantly more than
did either built outdoor activities or indoor activities.25 A third study found that children
with ADHD concentrated better after a walk in the park than after a downtown walk or a
neighborhood walk. Exposure to ordinary natural settings in the course of common after-
school and weekend activities may be widely effective in reducing attention deficit
symptoms in children. Green time may be an important supplement to traditional
medicinal and behavioral treatments.26
Depression
Depression, like stress, occurs at any age and can be ameliorated through improving
social connections (to decrease the feeling of isolation) and exercise,27both of which are
encouraged by the presence of nearby green outdoor spaces. A multi-study review found
that those who exercise in natural environments reported greater enjoyment and
satisfaction and declared a greater intent to repeat the activity at a later date. Compared to
being indoors, exercising in natural environments was associated with more positive
mental states, such as greater feelings of revitalization and positive engagement,
decreases in tension, confusion, anger, and depression, and increased energy.28
Exposure to natural light, in particular morning light, appears to be effective in treating

patients with seasonal affective disorder (SAD).31Outdoor walks are one way to access
natural lighting.
Studies investigating major depression disorder (MDD) have shown that an exercise
program can be just as effective as antidepressants in reducing depression among
patients,29 and that a 50-minute walk in a natural area (compared to a built setting) may
increase memory span and elevate moods.30 Patients with clinical depression who
participated in therapeutic gardening activities for 3 months experienced a reduction in
severity of depression and increased attentional capacity that lasted up to three months
after the conclusion of the program.32
489
Mental Stress and Cancer Patients
Clinical reports note a loss of concentration and increased distractibility in patients

undergoing cancer treatment, including those with breast cancer.33 There is a correlation
between cognitive function and cancer diagnosis. A decreased ability to direct attention
may begin before treatment actually starts. Treatment planning following diagnosis can
be mentally demanding and stressful, leading to attentional fatigue.33
Participating in activities and/or interacting with natural environments have been found to
ameliorate and help stave off the attentional fatigue both before and after breast cancer
treatment or surgery.33 A qualitative study compared the meaning of gardening in daily
life for those with and without cancer and found that - though dependent on past
gardening experiences, individual interests, and current circumstances - gardening can be
used as a potential coping strategy for stressful life experiences.34
Further, nature may have a preventative effect on cancer generation and development.
Studies of people doing 'forest bathing' trips in Japan show an increase in natural killer
cell activity, the number of beneficial cells, and the release of anticancer proteins.35
Psychiatric Patients
Studies investigating the effects of nature and gardening on psychiatric patients display a
range of results, from general mood improvement to specific illness. For example,
horticultural therapy was effective in decreasing the levels of anxiety, depression, and
stress among participants diagnosed with psychiatric illness.36 In another study placing
flowering plants in a ward increased socializing and food consumption in severely
withdrawn schizophrenic patients.37
The smells, colors, and handling of soil by patients during horticulture activities may be
particularly important and can improve life satisfaction, well-being, and self-concept in
mentally ill patients.38
Finally, when comparing intensive therapy patients in rooms with translucent windows to
ones without windows, those patients with windows had less sleep disturbance, improved
memory and orientation, as well as fewer hallucinations and delusions, providing more
normalcy and connection to the outside world.39
Dementia
Dementia patients experience multiple disorders, including memory impairment,

intellectual decline, temporal and spatial disorientation, impaired ability to communicate
and make logical decisions, and decreased tolerance to high and moderate levels of
stimulation. Dementia care poses a financial burden on society on par with cancer and
heart disease, with the total annual cost of care in the U.S. estimated to be $157 to $215
billion (in 2010).40
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Recent studies report that, in both adult day settings and nursing homes for those with
dementia, there are positive correlations of well-being and enhanced competence
following passive and active interaction with nature. Dementia patients are sensitive to
environments and natural surroundings can provide prosthetic support to compensate for
limited cognitive capabilities.41 Studies note decreased aggression, improved
socialization, and increased social competencies, as the natural environment provides
cues of what is comfortably familiar due to reminiscence and nostalgia.42 Additionally,
outdoor nature-based activity contributes to improved sleep patterns, balanced hormones,
and decreased agitation in dementia patients (Figure 1).43,44
Figure 1: Garden usage is associated with reduced agitation in dementia patients

(CMAI is a measure of agitation)
Overall quality of life measures for dementia patients, their family members, and staff
appear to improve at long-term care facilities with therapeutic gardens.45 Access to
gardens has been shown to reduce incidents of dangerous behavior and aggression for
dementia patients (Figure 2).41 Gardens can also evoke memories that reconnect patients
to the real world.46 Additionally, residents with high use of wander gardens have a
decreased use of high-dosage anti-psychotic medications.47Gardening activities may help
improve mobility and dexterity, confidence and social skills in dementia and stroke
patients.48 Finally, gardening can be used as a preventative measure to help reduce the
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onset of dementia49; gardening on a daily basis was found to reduce risk factors for
dementia by 36%.50
Figure 2: Comparison of behavioral incidents with dementia patients in institutions

based on garden access (over a one year period)
Design for dementia care is important; there is a distinct association between measures of
health and how spaces are designed.51 A space needs to promote functionality and well-
being, but also be safely open and free.52,51 Recommended design features for outdoor
spaces for dementia patients include: looped pathways; tree groves or sites to act as
landmarks for orientation; non-toxic plants; even, well-lit paths with handrails; seating
areas with the illusion of privacy; and low key fragrances and color to soothe, rather than
negatively stimulate.41
Elder Care
Some of the earliest research about nearby nature and human benefits focused on benefits
to the elderly. Studies continue as most industrialized nations have aging populations, and
face increased need for providing care as people get older. The University of Helsinki
summarized the potential mental, emotional, and social benefits experienced when the
elderly participate in gardening and horticulture (Table 2).48
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Physical Health & Therapy
Obesity and Active Living
The CDC reports that more than one-third of U.S. adults (35.7%) are obese, and the
estimated annual medical cost of obesity in the U.S. was $147 billion in 2008 U.S.
dollars. Obesity leads to increased risk of chronic diseases, such as asthma, Type II
diabetes, cardiovascular disease, some cancers, osteoarthritis, and can effect body image,
social stigmatization and discrimination, which can lead to depression.53
One lifestyle change that can help with weight control is routine physical activity,
sometimes termed active living. Studies found that the creation or improvement of a park
or open space was shown to lead to a 25.6% increase in nearby residents exercising three
or more days a week54 and a 48.4% increase in frequency of physical activity.55 Also, park
access increases aerobic capacity by 5.1%, reduces body fat, improves flexibility, and
increases perceived energy.55 Aerobic exercise in a natural environment may lead to
greater gains in lowering blood pressure, stress, and depression compared with exercise
in non-green urban settings.56,57
Stress
People experience stress at all ages, however it is especially prominent later in life due to
physical, psychological, and social changes that include chronic disease, disability, loss
493
of loved ones, and fixed incomes.58Stress can affect peoples perceptions of their well-
being, causing them to have diminished mental health.58 Physical activity has also been
linked to improved mental health and stress coping.59 Studies have connected park use to
decreased stress levels and improved moods. In one study participants showed fewer
stress symptoms the longer they stayed in the park.60
Simply viewing nature can help. Following a stressful activity, young adults sitting in a
room with a views of trees showed reduced blood pressure and feelings of stress
compared to those in a viewless room.61Lab and clinical investigations have found that
within five minutes of viewing a nature setting positive changes in blood pressure, heart
activity, muscle tension, and brain electrical activity occur.62,63
A study of brain activity, using alpha rhythms as a measure, showed that participants
were most awake and relaxed while looking at plants with flowers, rather than empty
pots.64 In a companion study EEG (electrical brain activity) indicated more relaxation
when viewing greenery compared to looking at a concrete structure.65
Disabilities and Elder Care
Horticultural therapy can increase self-esteem, making people with learning disabilities
consider themselves more desirable and confident than before.66 Much of the research of
green effects on mobility, dexterity, and disabilities focuses on the elderly. Preliminary
studies have reported the benefits of horticultural therapy and garden settings in reduction
of pain, improvement in attention, lessening of stress, modulation of agitation, lowering
of as needed medications, antipsychotics and reduction of falls.67
Outdoors gardening or activities improves exposure to sunlight, which can increase bone
density, due to increased vitamin D absorption,68 as well as improves circadian rhythms
and sleep cycles.69 Gardening activity can also help increase bone mineral density70 as
well as improve musculoskeletal function.71
Recovery, Resilience, and Rehabilitation

Crisis Recovery and Resilience
Efforts to recover and rebuild often follow soon after a major disaster or crisis, at both
personal and community levels. Nature can have a rehabilitating effect on individuals. A
study of people recovering from significant personal crises found that experiences in
nature had a powerful positive influence on recovery.72 Individuals place positive
symbolic value on trees and natural landscapes after a catastrophe;73familiar, green,
restorative places can ease trauma and discomfort.74
Historically, gardening was an expression of the will to be resistant and resilient during
World War I, as gardens were created by soldiers in battle trenches. The book, Defiant
Gardens,75 describes how people created gardens within the extreme conditions of World
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War II: Jews in Warsaw ghettos, prisoners of war, and Japanese-Americans in internment
camps.
The act of working together as a community to build something and help it grow can
improve attitudes and social ties, heal and create new memories, and provide an outlet for
grief.76 The Sunflower Project in New York City, an interim, living memorial before the
official 9/11 memorial could be constructed, was a movement to memorialize the loss of
loved ones through planting and nurturing new life.77
Community greening can encourage diversity and facilitate reconciliation between ethnic
and social groups, such as programs where Jews and Palestinians plant trees together in
Israel.78 Additionally, community greening can address economic and environmental
damage following events like tsunamis and hurricanes, by providing food and restoring
the landscape.78 Gardening can also aid in the resettlement process as it has been shown
to help asylum seekers and refugee families cope with the trauma of relocating and
acclimating to a new environment,79 especially as gardening can provide the opportunity
to restore cultural traditions and familiar foods.
Military Service and Stress Disorders
Those that have been or are in the military may experience emotional and psychological
trauma in addition to physical injuries. While little conclusive research that has been done
to date, nature shows promise as a therapy and treatment.
A study of veterans who participated in multi-day, group-based outdoor recreation

outings with the Sierra Club reported significant increases in well-being, social
functioning and life outlook, particularly for those veterans who had reported severe on-
going health problems.80 Veterans suffering from chronic post-traumatic stress disorder
who participated in a 12-month weekly sailing program experienced a reduction in
symptoms and improvements in daily functioning, hope, and perceived control over their
illness.81 Veterans who participated in an Outward Bound recreation program, compared
to more traditional therapy sessions, had inconclusive quantitative results, but showed
increased enthusiasm for the program, trust of the treatment staff, and improved feelings
of self-control of behavior and depression as well as physical abilities.82
While most nature therapy programs for veterans are conducted in places outside cities,
nearby nature may also provide benefit. A study of veterans participating in a community
gardening program reported that they gained a sense of purpose; had something to look
forward to; felt relaxed, secure and safe; learned new skills; and were able to share new
knowledge and skills with others.83
Prisons and Jails
Drawing from a small set of studies about gardening projects within prisons, nature may
be a tool for rehabilitation. Inmates have shown enhanced self-esteem and sense of
accomplishment,84as well as decreased hostility and a feeling of experiencing
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success.85 Female inmates who participated in a Master Gardener program reported
higher self-esteem and life satisfaction, particularly those who previously abused drugs or
alcohol.86
The benefits of these programs may extend to life after release. Participants in the
GreenHouse Program, a horticulture program at Rikers Island Prison (New York), had a
recidivism rate (number of released criminals that commit another offense and return to
prison) of 25%, compared to the overall recidivism rate of 65%.87 The Sustainable
Prisons Project (based in Washington State) facilitates conservation science research
within prisons. Offenders raise endangered frogs and butterflies, propagate native plants
for prairie restoration, assist with beekeeping to learn about bee colony collapse, and
participate in research. While the programs benefits have not been empirically assessed,
informal evaluations of the program suggest that inmates become motivated learners.88
Studies of youth offenders offer hope for behavioral improvements. Studies show that
youth offenders involved in horticulture training learn about responsibility, social skills,
problem solving, and better decision-making.89 Researchers concluded that such a
program can be a tool to improve social bonding, and be effective in causing attitude
changes and increasing perceptions of self-image, pride, and ability to
succeed.90Similarly, a study of a gardening program at a juvenile detention facility found
improved social skills, increased self-esteem, anxiety reduction, increased patience, and
an improved ability to delay gratification.91
Nature & the Healthcare Industry

Prescriptions for Parks & Trails
Ever more studies confirm the relationship between neighborhood open space and
physical activity.92 Even short doses of outdoor exercise in natural settings are shown to
improve mental health.93 Researchers have yet to define exact dosages and frequencies
for outdoor activity to address specific ailments. Yet, organizations and health care
providers now recognize the benefits of nature activity and some are working to develop
goal-oriented prescriptions for individual use of parks and trails.
For example, New Mexicos Prescription Trails program equips health care providers
with tools for motivating patients to use trails for walking and wheelchair use. Patients
receive individualized recommendations for duration and frequency of trail use based on
their physical condition.94The Golden Gate Parks Foundation launched a similar program,
encouraging health care providers to issue park prescriptions to establish and monitor
goals for outdoor activity as a preventative health measure for patients.95
Insurance
Traditionally, insurance reimbursements are spent on treatment of symptoms rather than

exercise or lifestyle interventions that could prevent the cause of disease. Not long ago
fewer than 14% of primary care providers regularly give any form of counseling on
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exercise.96 A 2003 study calculated a $2,200 annual reduction in average annual
healthcare charges per person for individuals who had been sedentary, but became
physically active (exercising three or more days a week).97
Insurance companies are recognizing the value of connecting customers to the benefits of
active lifestyles. SeeChange Health Insurance, for instance, reimburses state parks fees
for customers who visit parks in California and Colorado.98 Empirical analysis of such
programs are still forthcoming, but insurance companies may find that incentivizing
outdoor activity pays off for customers, communities, and insurers.99
Project support was provided by 1) the national Urban and Community Forestry
program of the USDA Forest Service, State and Private Forestry, and 2) the Pacific
Northwest Research Station, USDA Forest Service. Summary completed August 1, 2014.
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Source:- https://depts.washington.edu/hhwb/Thm_Healing.html
Research ArticleOpen Access
Comparison Of The Effects Of Individual

And Group Horticulture Interventions
Yuka Kotozaki*
Smart Ageing International Research Center, Institute of Development, Aging, and Cancer,
Tohoku University, Sendai, Japan
Corresponding Author:
505
Yuka Kotozaki
Smart Ageing International Research Center
Institute of Development, Aging and Cancer
Tohoku University, 4-1 Seiryo-machi, Aobaku
Sendai 980-8575, Japan
Tel: 81(0)227177988
Fax: 81(0)227177988
E-mail: kotoyuka@idac.tohoku.ac.jp
Received date: December 23, 2013; Accepted date: February 27, 2014; Published
date: March 1, 2014
Citation: Kotozaki Y (2014) Comparison of the Effects of Individual and Group
Horticulture Interventions. Health Care Current Reviews 2:120.
doi:10.4172/hccr.1000120
Copyright: 2014 Kotozaki Y. This is an open-access article distributed under the terms
of the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original author and source are
credited.
Visit for more related articles at Health Care : Current Reviews
Abstract
Abstract Chronic stress adversely affects the body, and stress and negative emotions
affect the development and progression of diseases. This study focuses on horticultural
therapy (HT) as a method of stress reduction. Although previous studies have reported
that HT has many benefits, the effects of HT in relation to differences in the intervention
style have not been investigated. The purpose of this study was to clarify whether there is
a difference in the effect due to the difference in intervention style in HT. The participants
were divided into three groups, a group intervention (GI group; n=15), an individual
intervention (II group; n=15), and a control group (C group; n=15). The GI and II groups
underwent four weeks of a horticultural intervention, whereas the C group was provided
with a gardening kit by an experimenter. The individuals in the C group cared for the
plants by themselves for 15 min per day for one month. The GI group showed significant
improvement in the WHO Quality of Life 26 (WHO-QOL26) subscore, the Emotional
Intelligence Scale (EQS) subscore, the General Health Questionnaire (GHQ) score, and
salivary cortisol level, as compared with the II group. These findings suggest that a group
HT intervention might be more effective than an individual intervention.
Keywords
Horticultural therapy; Group intervention; Individual intervention
Introduction
Many Japanese people lead stressful lives, as do many people in other parts of the world.
Previous studies suggest that the chronic stress adversely affects the body [1] and that
stress and negative emotions can affect the development and progression of diseases [2].
The reduction of stress is important for maintaining and enhancing health. In recent
506
years, methods of stress relief have been sought by many researchers. This study focuses
on horticultural therapy (HT).
HT is a method of psychological care for treating post-traumatic stress
disorder (PTSD) that was developed in the United States after World War II for the
psychological care and social rehabilitation of disabled soldiers and war veterans
showing PTSD symptoms [3]. HT interventions are led by professionals trained to
incorporate the use of plants and horticultural education into rehabilitation therapies [3].
It has been reported that participants begin to identify with plant growth, and regain
health and motivation. Through such experiences and their association with nature,
participants are thought to experience improvement [4]. HT has mainly been developed
for elderly adults and people with disabilities [5,6]. Previous studies have suggested that
HT and exposure to nature can have cognitive [7,8], psychological [3,9-12], social
[13,14], and physical benefits [10]. It has also been suggested that HT has a positive
effect on physiological factors, such as heart rate and salivary cortisol levels [15].
Previous studies have reported many therapeutic effects of HT in care and education
programs for disabled patients and the elderly [12,14,16-19]. However, the effects of HT
in relation to difference in the intervention style, such as group versus individual
interventions, have not previously been investigated.
The purpose of this study was to clarify whether there is a difference in the effect of HT
in relation to a difference in the style of the HT intervention, using psychological
measures and salivary cortisol level. We hypothesized that a group HT intervention may
produce better psychological effects than an individual intervention. Although the content
of the intervention was different from that used in previous studies, it has been reported
that group interventions may produce greater improvement than individual interventions
[20].
Participants
Forty-five healthy, right-handed university students or postgraduates (22 men and 23

women; age, 21.22 2.42 years) participated in this study. They had normal vision and
none had a history of neurological or psychiatric illness. Written informed consent was
obtained from each participant in accordance with the Declaration of Helsinki (1991).
Then, they were randomly allocated into group intervention (GI), individual intervention
(II), and control (C) groups. The study was approved by the Ethics Committee of Tohoku
University School of Medicine.
Procedure
Participants who were assigned to the GI and II groups participated in a horticultural

intervention in the laboratory at a specified date and time. Participants in the GI group
took the horticultural intervention in groups of five (total 3 groups). Before the start of
the intervention, all participants were assessed on the basis of some psychological
measures. The horticultural intervention was designed in collaboration with a
horticultural therapist and clinical psychologists. This intervention comprised a total of
four weekly sessions (60 min each) at a university lab and 15 min per day at participants'
homes. The sessions at the university lab comprised interactive lectures and practical
507
horticultural training. Participants attended four horticultural lessons, including topics
such as designing a garden planter, seeding, watering, weeding, and picking flowers.
They filled out a horticultural intervention session checklist after each session as self-
assessment. Participants took care of plants for 15 min per day at their convenience, using
horticulture kits provided by the experimenters, and recorded the completion of this task
daily on forms provided by the experimenters at the intervention sessions. The
participants submitted these forms to the experimenters at the weekly horticultural
intervention sessions. Participants who were assigned to the C group were provided with
a gardening kit by an experimenter; they cared for the plants by themselves for 15 min
per day for one month.
Psychological measures
We used Japanese versions of the following psychological measures.
Assessment of quality of life: The World Health Organization Quality of Life 26 (WHO-
QOL26) is a 26-item, self-report measure designed to assess quality of life [21]. Twenty-
four items measure the four domains of QOL: physical, psychological, social, and
environmental, and the other two items measure overall QOL and general health. The
score for each question ranges from 1 to 5, with higher scores reflecting higher QOL. The
present study used the Japanese version of the WHO-QOL26 [21].
Assessment of depressive symptoms: The Center for Epidemiologic Studies
Depressive Symptoms Scale (CES-D) is a 20- item, self-report measure designed to
assess depressive symptoms [22,23]. Scores for each item are summed to give a range of
total scores from 0 to 60. A higher score indicates a greater tendency toward depressive
symptoms. A score of 16 points or higher suggests the presence of clinical depressive
symptoms. The reliability and validity of the Japanese version of the CES-D have been
confirmed [23]. In the Japanese version, the cutoff value of 16 was also optimal, as
assessed by comparing the proportion of patients with CES-D scores of 16 points or
higher in a normal control group with that in a group of patients with mood disorders
[23].
Assessment of emotional intelligence: The Japanese version of the Emotional
Intelligence Scale (EQS) is a 65-item, self-report measure designed to assess emotionally
intelligent behavior, which provides an estimate of one's underlying emotional and social
intelligence [24-26]. The scale was developed and standardized for use with Japanese
subjects. A more detailed discussion of the psychometric properties of this instrument and
how it was developed is found in the Emotional Intelligence Scale technical manual [26].
The participant's responses render the following three composite scale scores (factors):
(a) Intrapersonal factor (comprising self-insight, self-motivation, and self-control), (b)
Interpersonal factor (comprising empathy, altruism, and interpersonal control), and (c)
Situation Management factor (comprising insight into and control of a situation). Each
composite scale score comprises three subscale scores. All three factors of the EQS have
been shown to be associated with better mental health, as measured by the General
Health Questionnaire (GHQ). The Situation Management factor has been shown to be
strongly associated with better mental health [24]. This result suggests that higher
emotional intelligence leads to better mental health [27].
508
Assessment of mental health: The GHQ is a 30-item selfreport measure designed to
assess mental health [28,29]. This scale includes six subscales: general illness,
somatic symptoms, sleep disturbance, social dysfunction, anxiety and
dysthymia, and suicidal depression. The questionnaire uses a four-point Likert scoring
method. The total score for the GHQ-30 is six or lower in 85% of healthy adults; in this
study, we used only the total score.
Assessment of mood state: The Profile of Mood States (POMS) is a 65-item self-report
measure designed to assess mood states [30,31]. It consists of the following six mood
state scales: tensionanxiety (TA), depressiondejection (D), angerhostility (AH),
fatigue (F), confusion (C), and vigor (V). The reliability and validity of the POMS have
been examined in the Japanese population [31].
Saliva sampling
We collected saliva samples from participants to measure their salivary cortisol levels.
Distressing psychological stimuli are associated with an increased cortisol level [32,33].
Considering the participants' circadian cortisol rhythms, we collected all saliva samples at
4:00 pm on weekdays, before and after the intervention. We selected 4:00 pm because
humans are less affected by circadian cortisol rhythms at this time of day [34].
Participants were asked to refrain from drinking, eating [35], and exercising [36] for two
hours before saliva sampling. This method was same as that in our previous studies
[32,37].
Measurement of salivary cortisol
To assess physiological stress, we employed the same technique to measure salivary
cortisol as described in a previous study [32,37]. Saliva samples were collected using the
Salivette apparatus (Sarstedt, Nmbrecht, Germany). Cortisol was measured in the
supernatant solutions, which were stored in airtight containers at -80C. We measured
salivary cortisol with a semi-microcolumn high-performance liquid chromatography
(HPLC) system (Shiseido, Tokyo).
Analytical methods
The psychological and salivary data were analyzed using the PASW statistical software
package (ver. 18 for Windows; SPSS Inc., Chicago, IL, USA). To examine the
psychological effects, a mixed design was used to compare the difference between the
three groups pre- and postintervention. Additionally, as our primary endpoint of interest
was the beneficial effect of intervention training, testretest changes were compared
between the intervention and control groups using onetailed tests (p<0.05), in the same
manner as in previous studies [32,37].
Results
Differences between three groups
The participants' demographic data are shown in Table 1; the ages of the three groups did
not differ significantly. Comparisons of the psychological changes pre- and post-
intervention are shown in Table 2. The GI group showed significant improvement,
relative to the C group, in the WHO-QOL26 Psychological score [F(2,42)=4.37, p<0.01],
509
the WHO-QOL26 Social score [F(2,42)=4.76, p<0.01], the EQS Interpersonal score
[F(2,42)=2.80, p<0.05], the EQS Empathy score [F(2,42)=4.38, p<0.01], and the EQS
Altruism score [F(2,42)=3.24, p<0.05]. Furthermore, the GI group showed a significant
decrease, relative to the C group, in the GHQ score [F(2,42)=2.66, p<0.05] and POMS
vigor score [F(2,42)=2.45, p<0.05]. Additionally, the GI group showed a significant
decrease in salivary cortisol level compared with the C group [F(2,42)=5.03, p<0.01].
The II group did not differ significantly from the C group.
GI group (N = 15) II group (N = 15) C group (N = 15)

Factor Mean SD Mean SD Mean SD
Age 20.53 2.45 21.60 1.54 21.53 3.00
One-way analysis of variance.
a
GI, group intervention; II, individual intervention; C, control; SD, standard deviation
Table 1: Demographic data of the participants
GI group II group C group

Pre Post Pre Post Pre
Measures Mean SD Mean SD Mean SD Mean SD Mean S
WHO-QOL26 3.23 0.53 2.93 0.58 3.23 0.4 3.01 0.69 3.07 0.
Physical QOL score
Psychological score 2.92 0.53 3.38 0.4 3.03 0.56 2.92 0.68 2.82 0.
Social score 3.18 0.89 3.75 0.8 3.53 0.75 3.58 0.65 3.4 0.
Environmental score 3.39 0.46 3.22 0.47 3.31 0.47 3.27 0.32 3.02 0.
Global score 3.24 0.56 3.35 0.45 3.32 0.49 3.3 0.42 3.17 0.
CES-D 13.53 10.32 7.67 3.64 9.53 5.28 8.87 6.67 14 11
EQS 46.6 11.87 49 13.52 54.67 11.88 56.93 12.5 42.4 7.
Intrapersonal
Self-awareness 12.07 3.65 12.73 4.06 15.47 4.93 16.33 4.55 11.33 3.
Self-motivation 14.13 5.3 14.8 5.35 17.47 4.5 17.93 4.28 13.2 2.
Self-control 20.4 4.52 21.47 6.6 21.73 6.32 22.67 6.11 17.87 4.
Interpersonal 41.87 12.8 46.8 11.1 44.4 13.73 42.67 7.54 47.8 12
Empathy 13.67 4.12 15.53 3.4 16.53 5.57 14.87 3.62 15.87 3.
Altruism 12.6 4.4 14.27 4.43 12.2 4.9 13.2 4.72 16.07 4.
Interpersonal relationship 15.6 6.7 17 5.77 15.67 6.95 14.6 3.52 15.87 6.
Situational 41.07 15.21 43.93 14.23 43.07 15.07 44 12.61 36.87 11
Situational awareness 18.53 6.65 19.13 5.78 18.4 8.64 19 6.11 17.07 4.
Leadership 10.27 5.19 12.07 5.24 10.67 5.19 11.33 4.84 8.53 4.
Flexibility 12.27 4.1 12.73 4.33 14 4.12 13.67 3.39 11.27 3.
510
GI group II group C group
Pre Post Pre Post Pre
Measures Mean SD Mean SD Mean SD Mean SD Mean S
GHQ score 6 3.34 3.2 2.81 6.07 3.88 4.33 3.5 4.73 2.
POMS TensionAnxiety 6.53 4.42 6.07 2.89 8.73 4.32 7.4 4.27 8.2 4.
Depression 5.87 5.58 2.73 2.55 6.4 4.03 4.87 3.85 5.67 6.
AngerHostility 4.07 3.35 4 3.89 4.93 4.11 5.07 4.13 5 4.
Vigor 8.87 3.52 10.47 3.72 8.73 4.42 9.93 3.9 9.73 4.
Fatigue 8.27 4.1 5.73 3.41 8.2 3.88 6.13 3.2 8.8 5
Confusion 7.2 3.38 6.33 2.5 6.6 2.87 5.87 3.2 6.47 4.
Total Mood Disturbance 23.07 19 14.4 13.68 26.13 15.25 19.4 15.78 24.4 22
Salivary cortisol level 3.96 0.96 2.15 0.79 4.54 3.21 3.97 1.74 3.97 1.
a
One-way analyses of covariance with prepost differences in psychological measures as
dependent variables and pre-intervention scores as covariates (one-tailed). GI, group
intervention; II, individual intervention; C, control; SD, standard deviation; WHO-QOL26,
World Health Organization Quality of Life 26; CES-D, Center for epidemiologic studies
depression scale; EQS, Emotional Intelligence Scale; GHQ, The General Health
Questionnaire; POMS, Profile of Mood States.
Table 2: Psychological measures pre- and post-intervention
Comparison of pre- and post-intervention scores in the GI and II groups
Comparisons of the psychological changes pre- and postintervention between the GI and
II groups are shown in Table 2. Relative to the II group, the GI group showed a
significantly higher post-intervention WHO-QOL26 Psychological score [F(1,28)=5.92,
p<0.05], WHO-QOL26 Social score [F(1,28)=3.97, p<0.05], EQS Interpersonal score
[F(1,28)=4.15, p<0.05], and EQS Empathy score [F(1,28)=7.97, p<0.005]. The GI group
also showed a significantly lower post-intervention GHQ score [F(1,28)=3.05, p<0.05]
than the II group. Additionally, the GI group exhibited a significantly lower salivary
cortisol level [F(1,28)=2.93, p<0.05] than the II group.
Discussion
The purpose of this study was to investigate whether there is a difference in the effects of
an HT intervention due to the difference in intervention style, using psychological
measures and salivary cortisol level. The study revealed that the GI group showed
improved psychological measures (WHO-QOL26, EQS, GHQ, and POMS) and salivary
cortisol levels post-intervention compared with the other two groups. Additionally, the GI
group was also showed improved psychological measures (WHO-QOL26, EQS, and
GHQ) and salivary cortisol levels post-intervention compared with the II group. These
results are consistent with our hypothesis that HT may be more effective by group
intervention compared with individual intervention.
The GI group showed improved WHO-QOL26 scores (psychological score and social
score) than the II and C groups, indicating that the group HT intervention increased
511
psychological and social QOL more than the individual intervention. Previous studies
have reported that HT improved QOL [11,37,38]. The raising of plants in a group is
thought to have brought new hope and stimulation to the participants, and this may have
led to greater improvement of their QOL (in particular, psychological and social aspects),
relative to an individual intervention, by synergy. The GI group showed improved EQS
scores (interpersonal, empathy, and altruism scores) relative to the II and C groups,
indicating that the group HT intervention increased interpersonal intelligence more than
the individual intervention. Previous studies have suggested that HT improves emotional
intelligence [39,40]. Conducting a multiple activity in a group is thought to have
developed a sense of community, interpersonal relationship, empathy, altruism, and so on.
These effects were reflected more in the EQS interpersonal factor score of participants in
the GI group than the II group. The GI group showed improved GHQ scores in
comparison with the other two groups, indicating that the group HT intervention
improved mental health more than the individual intervention. Many previous studies
have suggested that HT improves mental health [41-44]. Our results confirmed this
effect, and show that the mental health of the participants in the GI group had
significantly improved, relative to the II group, by the synergistic effect of interaction
with people and plants.
The GI group showed an improved POMS vigor score in comparison with the other two
groups. Additionally, the GI and II groups did not differ in the change from pre- to post-
intervention. POMS is a well-established tool for assessing mood state and current
emotional health. Previous studies suggest that various mood states are improved by HT
[19,45]. In the results of the present study, the vigor score had improved, as in previous
studies. Horticultural activity causes a positive change in life and mood. The results
suggest that the horticultural intervention elicits positive mood changes. The GI group
also showed improved salivary cortisol levels, in comparison with the other two groups,
indicating that HT reduced stress. The group HT intervention reduced salivary cortisol
levels more than the individual intervention. Previous studies suggest that HT reduced
salivary cortisol levels, and was an effective means of stress reduction [15,37,44]. The
group HT intervention is thought to have improved stress more than the individual
intervention, as reflected in the reduction of salivary cortisol levels.
Finally, this study raises some issues for future research. This was a preliminary
experiment, with a small number of participants. A possible future direction would be to
conduct the study with a larger number of participants and extend those findings.
In conclusion, this study suggests that it is easier to obtain many effects of HT with a
group intervention than with an individual intervention. The results of this preliminary
experiment will be reexamined in a future study.
Acknowledgements
The authors would like to thank the participants and all their colleagues at the Institute of
Development, Ageing and Cancer and the Tohoku University for their support. In
addition, the authors thank Ms. Kana Ohkiri, Ms. Shoko Tsuzuki, Ms. Rei Takamatsu,
and Ms. Mayu Fujita for assisting with psychological testing. The authors also appreciate
the contribution of Mrs. Taeko Shishido, a horticultural therapist who provided advice
during the preparation of the intervention program. This study was supported by a Grant-
512
in-Aid for Young Scientists (B) (KAKENHI 24730566) from the Ministry of Education,
Culture, Sports, and Science to Dr. Y.K.
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Closing Remarks
It is The View Of The Fletchers And Manakers Families That In Spite Of The Harsh
Economic Situation Which Jamaica, The United States and The Countries Of The
Region Face Much Better and Much More Can Be Done To Prevent Those With
Mental Health Challenges From Ending Up ON The Streets. That Is We Care!
517

Over Coming The Darkness, Advancing Community Based Health Care

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The Family Doctor, The Nurse & Community

Overcoming The Darkness Covering

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Dance as an Alternative Form of Exercise

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Assessment of cognitive function and depression

Metabolic syndrome (MS)

Exercise (n=26) Control (n=12) P-value *

Age (years) 68.19 (3.66) 68.16 (5.14) .986

Sex (n) Male 7 (26.9%) 2 (16.7%)

Female 19 (73.1%) 10 (83.3%)

Education (years) 6.23 (1.45) 4.66 (3.02) .112

BMI (kgm-2) 25.71 (2.87) 25.90 (2.38) .845

WC(cm) 94.43 (6.22) 92.95 (5.05) .481

Triglyceride (mgdl-1) 126.76 (54.41) 134.90 (50.0) .155

Glucose (mgdl-1) 102.00 (10.86) 96.55 (6.71) .504

HDL cholesterol (mgdl-1) 53.38 (14.20) 44.08 (7.57) .041

SBP (mmHg) 131.92 (11.73) 133.41 (7.68) .690

DBP (mmHg) 80.11 (6.95) 80.91 (5.83) .731

CERAD-K Verbal Fluency 13.46 (3.56) 11.66 (3.98) .173

Boston naming test 11.61 (2.15) 10.25 (2.95) .116

MMSE-KC 26.42 (2.10) 25.66 (2.77) .358

Word list learning 18.50 (4.10) 15.50 (5.10) .060

Constructional praxis 9.38 (1.57) 9.75 (1.05) .471

Word list recall 6.26 (1.90) 5.08 (1.78) .358

Word list recognition 9.19 (1.13) 8.41 (1.62) .096

Constructional recall 6.73 (2.79) 5.08 (2.19) .080

Trail making A 144.34 (125.08) 120.40 (80.38) .549

Trail making B 239.54 (87.63) 266.16 (65.71) .356

Total score 68.42 (9.75) 60.66 (13.25) .088

SGDS-K 3.88 (3.53) 5.16 (4.04) .327

* Statistical significance was tested using independent t-tests. or 2 test.

Exercise (n=26) Control (n=12)

Baseline Post Baseline Post

Baseline Post Baseline Post

Trail making A 144.34 71.61 120.40 94.51 .798

Baseline Post Baseline Post

Trail making B 239.54 218.03 266.16 252.67 .372

Triglyceride 126.76 120.21 134.90 (50.0) 124.78 .564

Glucose (mgdl-1) 102.00 110.17 96.55 (6.71) 107.00 .530

Baseline Post Baseline Post

SBP (mmHg) 131.92 123.41 133.41 (7.68) 130.71 .559

Statistical significance was tested using repeated measures analysis of covariance.

Disease: Improving Quality of Life

Dance therapy for individuals with Parkinsons disease: improving

Search terms including Parkinsons disease, dance, quality of life, exercise,

Keywords: exercise, music, QOL, mobility rehabilitation, intervention,

1 Due to the progressive worsening of PD-related symptoms, management and treatment

2 Non-motor manifestations of PD, specically declining emotional health and health-

4 Self-assessed health status has been demonstrated to be more powerful at predicting

The Parkinsons Disease Questionnaire (PDQ)-399 is a PD-specic measure of HRQOL

10 HRQOL is affected early in PD by multiple non-motor symptoms. 11 As the disease