From depression to expression: Arts-based intervention in helping community-dwelling depressed elderly

Hong Kong is a developed society with the longest life expectancy in the world. According to the Census and Statistics Department, there were 2.14 million seniors aged 60 or above by mid-2022, accounting for more than a quarter (29.4%) of the total population. Research shows that about one in ten seniors suffers from depression, a major concern for local mental health issues.

Geriatric depression often brings detrimental consequences such as reduced cognitive ability, worsening treatment outcomes of medical disorders, and higher mortality among the elderly.

With the burgeoning aging population in Hong Kong and the outbreak of the COVID-19 pandemic, the number of elderly suffering from depressive symptoms in recent years has been increasing. Studies have found that elderly in Hong Kong have shown significantly more depressive symptoms than their counterparts from Taiwan and Guangzhou, yet local attention and support for those with mild to moderate depression are very limited.

A community project aiming to promote geriatric mental health using Expressive Arts-based Intervention (EABI) was launched between July 2017 and June 2021 by the Centre on Behavioral Health (CBH) of The University of Hong Kong. EABI is one of the non-pharmacological interventions with a growing popularity worldwide. It refers to a multimodal approach, which utilizes the creation process of different art forms (i.e., visual art, music, dance movement, drama and creative writing) to promote personal growth and healing.

Throughout the process of aging, changes in one's life and wellness could be an indescribable experience. EABI provides a non-verbal way for the elderly to express their thoughts and feelings. It also encourages them to use their imagination and creativity to break through the limits of aging. With the emphasis on aesthetic appreciation, they could also learn to appreciate each other's beauty and strengths. All these elements could help enhance the physical, psychosocial and spiritual well-being, as well as the overall quality of life of the elderly.

To tackle the increasing cases of geriatric depression and maximize the number of beneficiaries, CBH organized a number of public educational talks to raise public awareness of geriatric depression and encouraged the public to reach out to those in need.

The team also designed an EABI protocol for the elderly, which consisted of eight 90-minute sessions. The contents of the protocol were delivered to the frontline workers of local elderly centers through a "train-the-trainer" approach to enhance their knowledge and skills in using EABI to support the elderly in need.

The training was delivered by two registered expressive arts therapists. It was a three-day program with a total of 18 contact hours. The training began with an introduction of the prevalence and concerns of geriatric depression, as well as the principles of EABI, followed by experiential learning of all the art-making processes designed for the elderly according to the EABI protocol.

Facilitation skills and concerns about conducting EABI with the elderly were illustrated. After the training, the frontline workers could become the project's ambassadors and were required to conduct two EABI groups at the organizations they served to support the elderly with mild to moderate depressive symptoms. CBH also provided individual follow-up to the elderly who needed intensive psychosocial support services upon referral from the ambassadors.

Over the past four years, the project conducted six public educational talks, seven professional training sessions, 283 EABI groups, 692 individual follow-up sessions and four art exhibitions, benefitting over 2,207 elderly, 260 professionals and 37,561 community members.

The research team of CBH conducted an evaluation study on 1) the effectiveness of EABI in relieving the elderly's depressive symptoms, as well as improving their quality of life, perceived social support, and spiritual well-being; and 2) the training effectiveness in enhancing the ambassadors' altruism level in applying EABI in their work settings.

The participating elderly had to complete a questionnaire before and after the EABI, while the ambassadors needed to complete a questionnaire before and after the training, as well as upon the completion of the EABI. Some of the elderly and ambassadors were also invited to attend a focus group interview upon program completion to share their experiences with the research team.

The team successfully recruited a total of 1,089 elderly and 260 ambassadors to participate in the study. The findings are as follows:

1. The quantitative findings showed:

(i) There were significant improvements in depressive symptoms, overall quality of life and spiritual well-being among the elderly after participating in the EABI. There was also a significant increase in the average quantity and satisfaction score of social support.

(ii) Ambassadors' altruistic attitude and self-efficacy to apply EABI in their work settings increased significantly after the training.

2. The focus group interviews revealed:

(i) The physical, psychosocial and spiritual well-beings of the elderly were improved. The music and dance activities in the EABI provided them with an opportunity to exercise their bodies, which helped enhance the connection between their body and brain. The art-making process was fun and relaxing, so the elderly could develop a sense of accomplishment and express their stories and feelings more easily. It helped soothe their unpleasant feelings. The group also offered them a chance to discover the joy of participating in community activities, which in turn strengthened their connection with others and enhanced their motivation to participate in other activities in the future.

(ii) The training program helped enhance the ambassadors' knowledge of EABI, enrich their existing skills, and improve their ability to empathize with the elderly.

Overall, the findings of this study confirmed the effectiveness of the EABI in alleviating the elderly's depressive symptoms and improving their quality of life, perceived social support and spiritual well-being. Professor Rainbow Ho, Director of CBH, hopes that this project will become a seed for EABI to be more widely accepted and applied to the holistic care of the elderly.

Provided by The University of Hong Kong