Anthroposophic Therapy For Chronic Depression
Anthroposophic Therapy For Chronic Depression
Anthroposophic Therapy For Chronic Depression
Address: 1Institute for Applied Epistemology and Medical Methodology, Böcklerstr. 5, 79110 Freiburg, Germany, 2Institute of Social Medicine,
Epidemiology, and Health Economics, Charité University Medical Center, Campus Mitte, 10098 Berlin, Germany and 3Society for Cancer
Research, Kirschweg 9, 4144 Arlesheim, Switzerland
Email: Harald J Hamre* - [email protected]; Claudia M Witt - [email protected]; Anja Glockmann - [email protected];
Renatus Ziegler - [email protected]; Stefan N Willich - [email protected]; Helmut Kiene - [email protected]
* Corresponding author
Abstract
Background: Depressive disorders are common, cause considerable disability, and do not always
respond to standard therapy (psychotherapy, antidepressants). Anthroposophic treatment for depression
differs from ordinary treatment in the use of artistic and physical therapies and special medication. We
studied clinical outcomes of anthroposophic therapy for depression.
Methods: 97 outpatients from 42 medical practices in Germany participated in a prospective cohort
study. Patients were aged 20–69 years and were referred to anthroposophic therapies (art, eurythmy
movement exercises, or rhythmical massage) or started physician-provided anthroposophic therapy
(counselling, medication) for depression: depressed mood, at least two of six further depressive
symptoms, minimum duration six months, Center for Epidemiological Studies Depression Scale, German
version (CES-D, range 0–60 points) of at least 24 points. Outcomes were CES-D (primary outcome) and
SF-36 after 3, 6, 12, 18, 24, and 48 months. Data were collected from July 1998 to March 2005.
Results: Median number of art/eurythmy/massage sessions was 14 (interquartile range 12–22), median
therapy duration was 137 (91–212) days. All outcomes improved significantly between baseline and all
subsequent follow-ups. Improvements from baseline to 12 months were: CES-D from mean (standard
deviation) 34.77 (8.21) to 19.55 (13.12) (p < 0.001), SF-36 Mental Component Summary from 26.11 (7.98)
to 39.15 (12.08) (p < 0.001), and SF-36 Physical Component Summary from 43.78 (9.46) to 48.79 (9.00)
(p < 0.001). All these improvements were maintained until last follow-up. At 12-month follow-up and later,
52%–56% of evaluable patients (35%–42% of all patients) were improved by at least 50% of baseline CES-
D scores. CES-D improved similarly in patients not using antidepressants or psychotherapy during the first
six study months (55% of patients).
Conclusion: In outpatients with chronic depression, anthroposophic therapies were followed by long-
term clinical improvement. Although the pre-post design of the present study does not allow for
conclusions about comparative effectiveness, study findings suggest that the anthroposophic approach,
with its recourse to non-verbal and artistic exercising therapies can be useful for patients motivated for
such therapies.
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In AM art therapy (AAT) patients engage in painting, Setting, participants, and therapy
drawing, clay modelling, music or speech exercises [22]. Participating physicians were certified by the Physicians'
In addition to psychological effects (e.g. activation, emo- Association for Anthroposophical Medicine in Germany
tive expression, dialogical communication with the thera- and had office-based practice or worked in outpatient
pist and with the artistic medium [23,24]), AAT can clinics in Germany. Participating AM therapists were certi-
induce physiological effects: e.g. AAT speech exercises fied by the Association for Anthroposophical Art Therapy
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The decision to start AM therapy for depression was part Data were entered twice by two different persons into
of the AM physicians' routine clinical practice. Patients Microsoft® Access 97. The two datasets were compared and
were treated according to the physicians' and therapists' discrepancies resolved by checking with the original data.
discretion. AM therapies (AAT, EYT, RMT, and MED) were
evaluated as a therapy package; other therapies, including Quality assurance, adherence to regulations
psychotherapy and antidepressants, were evaluated as The study was approved by the Ethics Committee of the
non-AM adjunctive therapies. Faculty of Medicine Charité, Humboldt University Berlin,
and was conducted according to the Helsinki Declaration
Clinical outcomes and the ICH-GCP guidelines. Written informed consent
• CES-D (primary outcome [34]) from 0 ("no depressive was obtained from all patients before enrolment.
symptoms") to 60 ("maximum symptoms"). Patients
document the frequency of 20 symptoms during the last Data analysis
week, from 0 ("rarely or none of the time ≈ less than 1 The data analysis (SPSS® 13.0.1, StatXact® 5.0.3) was per-
day") to 3 ("most or all of the time ≈ 5–7 days"). The Ger- formed on all patients fulfilling eligibility criteria. Clinical
man version [35] classifies persons with a score ≥ 24 outcomes were analysed in patients with evaluable data
points as depressed. for each follow-up, without replacement of missing val-
ues. For continuous data the Wilcoxon Signed-Rank test
• Health status: SF-36 [36] Mental and Physical Compo- was used for paired samples and the Mann-Whitney U-test
nent Summary Measures, eight scales, and Health Change for independent samples, median group differences with
item. 95% confidence interval (95%-CI) were estimated accord-
ing to Hodges and Lehmann [38]. For binominal data
• Disease severity on numerical rating scales [37] from 0 McNemar test and Fisher's exact test were used. All tests
(„not present“) to 10 („worst possible“): Disease Score were two-tailed. Significance criteria were p < 0.05 and
(physician's global assessment, documented in patients 95%-CI not including 0. Pre-post effect sizes were calcu-
enrolled up to 30 Sep 2000); Symptom Score (patients' lated as Standardised Response Mean and classified as
assessment of one to six most relevant symptoms present small (0.20–0.49), medium (0.50–0.79), and large (≥
at baseline, documented in patients enrolled after 1 Jan 0.80) [39].
1999).
Results
Disease Score was documented after 0, 6, and 12 months, Participating physicians and therapists
other outcomes after 0, 3, 6, 12, 18, 24, and 48 months. 59 physicians screened patients. 42 physicians included
patients into the study; these physicians did not differ sig-
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nificantly from all AM-certified physicians in Germany (n respondents (15%) regarding age, gender, duration of
= 362) regarding gender (57.1% vs. 62.2% males), age depressive disorder, or baseline CES-D. Corresponding
(mean 45.9 ± 7.0 vs. 47.5 ± 7.9 years), number of years in dropout analyses for 24-month follow-up also showed no
practice (18.8 ± 7.3 vs. 19.5 ± 8.7 years), or the proportion differences. The physician follow-up documentation was
of primary care physicians (90.5% vs. 85.0%). Patients available for 86% (83/97) of patients after six months and
were treated by 52 AAT/EYT/RMT therapists (AAT: n = 24, for 85% after 12 months.
EYT: n = 23, RMT: n = 5). Comparing these therapists to
certified therapists without study patients (n = 706; AAT: Baseline characteristics
n = 230, EYT: n = 326, RMT: n = 150), no significant dif- Median duration of the depressive disorder was 5.0 (IQR
ferences were found regarding gender (82.7% vs. 79.3% 2.0–10.0) years. 80% (78/97) of patients had a current
females), age (mean 48.4 ± 6.9 vs. 51.3 ± 9.6 years), or comorbid disease, median 2.0 (IQR 1.0–3.0) diseases per
median number of years since graduation from AAT patient. Most common comorbid diseases, classified by
school (15.0 years, interquartile range IQR 10.0–18.0 vs. ICD-10, were M00-M99 Musculoskeletal Diseases
14.0 years, IQR 11.0–19.0) or EYT school (10.0 years, IQR (24.6%, 46/187 diagnoses), E00–E90 Endocrine, Nutri-
7.0–14.0 vs. 12.0 years, IQR 8.0–20.0). tional and Metabolic Diseases (14.4%), and F00–F99
Mental Disorders (9.6%). 18% (17/97) of patients had a
Patient recruitment and follow-up current or previous comorbid mental disorder, 24% (23/
From 1 July 1998 to 31 March 2001, a total of 163 97) had a history of inpatient psychiatric treatment.
patients starting AM therapy for depressive symptoms
were screened for inclusion. 97 patients fulfilled all eligi- The patients were recruited from 13 of 16 German federal
bility criteria and were included in the study (Figure 1). states. Mean age was 42.9 ± 9.9 years (range 20–69 years).
The last patient follow-up ensued on 30 March 2005.
Included and not included patients (n = 66) did not differ Compared to the German population, the patients had
significantly regarding age, gender, duration of the depres- higher educational and occupational levels, had less daily
sive disorder, baseline Disease Score, or baseline Symp- alcohol consumers and regular smokers, and were less
tom Score. Most frequent reason for non-inclusion was overweight; the patients' socio-demographic status was
non-fulfilment of depression severity criteria (CES-D ≤ 23 similar to the population regarding low-income, living
points, n = 38/66); baseline CES-D score was median 34.0 alone, and sport; and less favourable for work disability
(IQR 28.0–38.0) points in included and 18.0 (IQR 14.3– pension, severe disability status, and sick-leave (Table 1).
23.8) points in not included patients (median difference
15.0 points, 95%-CI 12.0–18.0, p < 0.01). Therapies
At study entry, the patients started MED therapy (n = 13)
The number of depression patients eligible for screening or were referred to AM therapies (n = 84, thereof AAT: n =
(referred to AAT/EYT/RMT or starting MED for depressive 42, EYT: n = 36, RMT: n = 6). AAT techniques were paint-
symptoms) during the recruitment period is not known, ing/drawing/clay (n = 28), speech exercises (n = 12), and
but the total number of patients referred to AAT/EYT/RMT music (n = 2). AAT/EYT/RMT was definitely administered
in the AMOS project, regardless of diagnosis, was esti- to 98% (82/84) of patients and started median 8 (IQR 0–
mated by the physicians (response rate 62.2%, 74/119 28) days after enrolment. Median therapy duration was
physicians). The proportion of referred vs. enrolled 137 (IQR 91–212) days, median number of therapy ses-
patients was median 3.9 (IQR 0.5–10.0). There was no sions was 14 (IQR 12–22, mean 16.8 ± 9.5). During the
correlation between this proportion and the 0–12 month first study year, the patients had median 1.0 (IQR 0.0–4.0,
improvement of Symptom Score (Spearman-Rho -0.04, p range 0–30) AM-related consultation with their study
= 0.496, n = 364 patients). physician; 77% (66 of 86 evaluable patients) used AM
medication, with a median of 0.43 (IQR 0.02–1.43) AM
92% (89/97) of patients were enrolled by altogether 38 medications per day throughout the first study year.
primary care physicians (35 general practitioners and
three internists), 8% (8/97) were enrolled by four physi- In the first six study months 29% (n = 24/84) of evaluable
cians in referral practices or outpatient clinics (two patients used antidepressants (ATC-Index N06A or hyper-
internists, two physicians with psychotherapy qualifica- icum preparations) for at least six days, 24% (n = 20/84)
tion). had at least ten psychotherapy sessions, whereas 55% (n
= 46/84) used neither psychotherapy nor antidepressants.
98% (95/97) of patients returned at least one follow-up
questionnaire, 2% (2/97) had no follow-up data. The 12- Clinical outcomes
month questionnaire was returned by 85% of patients; CES-D, Symptom and Disease Scores, and all eleven SF-36
these patients did not differ significantly from non- scores improved significantly between baseline and all
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3-month questionnaire
sent to 97 patients
6-month questionnaire
sent to 97 patients
12-month questionnaire
sent to 97 patients
24-month questionnaire
sent to 81 patients
48-month questionnaire
sent to 81 patients
Figure recruitment
Patient 1 and follow-up
Patient recruitment and follow-up. *18-, 24-, and 48-month follow-up questionnaires were not sent to patients enrolled
before 1 Jan 1999.
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N % % Source
subsequent follow-ups. For all these 14 outcomes, the at baseline and 12-month follow-up. In the first sensitivity
most pronounced improvement occurred during the first analysis, missing values after 12 months were replaced
six months; improvements were maintained until the last with the last value carried forward, reducing the average
follow-up (Figure 2 to Figure 4). Effect sizes for the 0–12- 0–12 month CES-D improvement by 9% (15.23→13.90
month comparison were large (range 0.80–1.77) for 11 points). The second analysis (Table 4, SA2) concerned
outcomes and medium (0.54–0.76) for three outcomes natural recovery, which is unlikely in depression of more
(Table 2). All these improvements remained stable until than 1–2 years duration [40-45]: The sample was
the last follow-up. restricted to patients with a duration of the depressive dis-
order of at least 2 years, reducing the improvement by 8%
CES-D improved progressively at each follow-up except (15.23→14.05 points). The third analysis (Table 4, SA3)
between 12 and 18 months after study entry (Figure 2). At concerned the effects of relevant adjunctive therapies: The
12-month follow-up and later, 52%–56% of evaluable sample was restricted to patients using neither psycho-
patients (35%–42% of all patients) were improved by at therapy nor antidepressants in the first six study months
least 50% of baseline CES-D scores; 66%–77% of evalua- (see "Therapies" above). In these patients the CES-D
ble patients (47%–52% of all patients) were no longer showed a similar improvement to that of all study
classified as depressed (CED-D = 23 points) (Table 3). The patients (15.29 vs. 15.22 points). The fourth analysis
CES-D improvements were similar in patients receiving (Table 4, SA4) concerned regression to the mean resulting
EYT and AAT, and in the AAT subgroup using painting/ from extreme group selection due to the inclusion crite-
drawing/clay techniques (Table 2). rion of CES-D ≥ 24: The sample was extended to also
include screened patients starting AM therapy for depres-
In order to estimate the influence of four bias factors on sive symptoms but not fulfilling all depression criteria for
0–12 month CES-D outcomes we performed post-hoc study inclusion. This extension of the eligibility criteria
sensitivity analyses. The first sensitivity analysis (Table 4, lead to a reduction of the average 0–12 month CES-D
SA1) concerned dropout bias. The main analysis had improvement by 27% (analysis of patients enrolled after
comprised all enrolled patients with evaluable CES-D data 1 Jan 2000: 13.38→9.82 points). Combining
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CES-D
60
50
Score (Mean+SD)
40
30
20
10
0
0 3 6 12 18 24 48
Months
Patients Cutoff point
Figure for
Center 2 Epidemiological Studies Depression Scale (CES-D), German version
Center for Epidemiological Studies Depression Scale (CES-D), German version. Higher scores indicate more
depressive symptoms. Cutoff point: Subjects with a score of ≥ 24 points are classified as depressed.
SA1+SA2+SA4, the improvement was reduced by alto- did not differ significantly between six- and 12-month fol-
gether 35% (13.38→8.64 points) but still remained sig- low-ups.
nificant.
During the first 24 study months adverse reactions to
Other outcomes AAT/EYT/RMT were reported in one patient (repeated loss
At six-month follow-up, the patients' average therapy out- of voice after AAT singing therapy, moderate intensity),
come rating (numeric scale: 0 "no help at all", 10 "helped adverse reactions to AM medication in two patients (mod-
very well") was 7.54 ± 1.76; patient satisfaction with ther- erate dizziness from Geum urbanum – not medically con-
apy (0 "very dissatisfied", 10 "very satisfied") was 7.92 ± firmed; mild nausea from Choleodoron – medically
1.86. The patients' AAT/EYT/RMT effectiveness rating was confirmed); none of these reactions led to therapy discon-
positive ("very effective" or "effective") in 88% (66/75) of tinuation. Adverse reactions to non-AM medication were
patients, and negative ("less effective", "ineffective" or reported in 12 patients (antidepressants: n = 5, other psy-
"not evaluable") in 12%. The physicians' effectiveness rat- choactive drugs: n = 2, other medication: n = 5; medica-
ing was positive in 78% (56/72) and negative in 22%. The tion stopped in three patients). One patient had adverse
ratings of therapy outcome, satisfaction, and effectiveness reactions (pain) to psychotherapy, which was stopped.
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70 70
60 60
Score (Mean+SD)
Score (Mean+SD)
50 50
40 40
30 30
20 20
10 10
0 3 6 12 18 24 48 0 3 6 12 18 24 48
Months Months
Patients German population Patients German population
FigurePhysical
SF-36 3 and Mental Component Summary Measures
SF-36 Physical and Mental Component Summary Measures. Higher scores indicate better health. Adult patients and
German population (age 17–74 years) [36].
8 8
Score (Mean+SD)
Score (Mean+SD)
6 6
4 4
2 2
0 0
0 6 12 0 3 6 12 18 24 48
Months Months
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CES-D (0–60)
-all patients 75 34.77 (8.21) 19.55 (13.12) p < 0.001 15.50 (12.50–18.50) 85% 1.20
-AM Art Therapy 33 36.94 (8.58) 21.12 (11.99) p < 0.001 15.50 (11.50–19.50) 91% 1.32
--painting/drawing/clay 27 38.95 (8.24) 23.18 (12.52) p < 0.001 15.00 (10.50–21.50) 91% 1.25
-Eurythmy Therapy 27 30.70 (5.55) 16.67 (13.32) p < 0.001 15.00 (8.50–19.50) 81% 1.08
Disease Score (0–10) 57 7.09 (1.38) 2.84 (2.07) p < 0.001 4.50 (4.00–5.00) 95% 1.77
Symptom Score (0–10) 69 6.35 (1.47) 3.90 (2.42) p < 0.001 2.63 (1.92–3.29) 81% 0.91
SF-36 Mental Component 80 26.11 (7.98) 39.15 (12.08) p < 0.001 13.04 (10.45–16.05) 83% 1.11
SF-36 Physical Component 80 43.78 (9.46) 48.79 (9.00) p < 0.001 4.96 (3.02–6.84) 71% 0.59
SF-36 Scales (0–100)
Physical Function 82 75.12 (22.80) 85.15 (19.00) p < 0.001 10.00 (5.00–12.50) 63% 0.54
Role Physical 81 31.58 (35.52) 68.21 (38.33) p < 0.001 50.00 (37.50–62.50) 65% 0.88
Role-Emotional 80 22.92 (32.52) 60.21 (39.38) p < 0.001 50.00 (33.34–66.67) 69% 0.87
Social Functioning 82 43.14 (22.92) 65.70 (26.48) p < 0.001 25.00 (18.75–37.50) 72% 0.80
Mental Health 81 33.48 (13.82) 56.10 (19.05) p < 0.001 22.00 (18.00–28.00) 88% 1.19
Bodily Pain 82 50.27 (26.74) 66.67 (25.06) p < 0.001 19.50 (12.50–26.00) 63% 0.65
Vitality 81 23.50 (12.47) 46.05 (19.47) p < 0.001 25.00 (20.00–30.00) 68% 1.22
General Health 81 41.80 (18.55) 55.81 (20.35) p < 0.001 13.50 (10.00–18.50) 78% 0.76
SF-36 Health Change*** 81 3.58 (1.00) 2.10 (1.08) p < 0.001 2.00 (1.50–2.00) 63% 1.06
*Positive differences indicate improvement. **Percentage of patients improved from baseline. ***SF-36 Health Change: range from 1 ("much better
now than one year ago") to 5 ("much worse now than one year ago"). SRM: Standardised Response Mean effect size (small: 0.20–0.49, medium:
0.50–0.79, large: ≥ 0.80)
One Serious Adverse Event (SAE) occurred: A 53-year old (depressed mood + at least two of six further depressive
woman was acutely hospitalised because of perforation of symptoms + CES-D ≥ 24). Following AM therapies, sub-
the small intestine after swallowing fish bones. She recov- stantial improvements of symptoms and health status
ered completely. This SAE had no relation to any therapy (SF-36) were observed. Improvements were maintained
or medication. during the four-year follow-up. Adverse reactions to AM
therapy or medication were infrequent (2% of patients),
Discussion of mild-to-moderate intensity, and did not require ther-
This prospective cohort study is the first study of compre- apy discontinuation.
hensive AM therapy for depression, and the first depres-
sion study conducted in outpatient AM settings. The study Strengths and limitations
was conducted in conjunction with a health insurance Strengths of this study include a long follow-up period,
program and aimed to provide information on AM use high follow-up rates, and the participation of 8% of all
under routine conditions in Germany. We studied adult AM-certified physicians and AM therapists in Germany.
outpatients starting AM therapies for depression The participants resembled all eligible physicians/thera-
Table 3: CES-D: Responder rates at follow-ups
Proportion of Proportion of all patients Proportion of evaluable Proportion of all patients Proportion of Proportion of all patients
evaluable patients patients evaluable patients
3 59/67 (88%) 59/79 (75%) 21/67 (31%) 21/79 (27%) 39/67 (58%) 39/79 (49%)
6 60/69 (87%) 60/79 (79%) 27/69 (39%) 27/79 (34%) 47/69 (68%) 47/79 (59%)
12 54/62 (87%) 54/79 (68%) 32/62 (52%) 32/79 (41%) 41/62 (66%) 41/79 (52%)
18 50/59 (85%) 50/79 (63%) 33/59 (56%) 33/79 (42%) 41/59 (69%) 41/79 (52%)
24 54/60 (90%) 54/79 (68%) 31/60 (52%) 31/79 (41%) 40/60 (67%) 40/79 (51%)
48 43/48 (90%) 43/79 (54%) 28/48 (56%) 28/79 (35%) 37/48 (77%) 37/79 (47%)
Patients enrolled after 1.1.99. CES-D: Center for Epidemiological Studies Depression Scale, German version
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CES-D: Center for Epidemiological Studies Depression Scale, German version. AMOS: Anthroposophic Medicine Outcomes Study. *12-month
follow-up documentation of CES-D was not performed for AMOS patients enrolled before 1 Jan 2000, except for patients also enrolled into
depression study. **Percentage of patients improved from baseline. SRM: Standardised Response Mean effect size (small: 0.20–0.49, medium: 0.50–
0.79, large: ≥ 0.80)
pists with respect to socio-demographic characteristics, therapy. Possibly this willingness could in itself be associ-
and included patients resembled not included, screened ated with a more favourable prognosis, which might
patients regarding baseline characteristics. These features explain some of the observed improvement. Another con-
suggest that the study to a high degree mirrors contempo- sequence of the prerequisite of willingness is that study
rary AM practice. Nevertheless, since the study had a long results apply only to patients who are willing to try AM
recruitment period, the participating physicians were not therapies.
able to screen all their eligible patients (patients starting
AM therapy for depressive symptoms). For the whole Adjunctive treatment with antidepressants or psychother-
AMOS project it was estimated that the physicians apy cannot explain the outcomes of our study, because
enrolled every fourth patient referred to AAT/EYT/RMT. symptoms improved similarly in patients not using such
Selection bias could be present if physicians would prefer- therapies. Other possible confounders are observation
entially screen and enrol such patients for whom a partic- bias and psychological factors. Since, however, all AM
ularly positive outcome was expected. In this case one therapies (including physician- and therapist-patient
would expect the degree of selection (= the proportion of interactions) were evaluated as a therapy package, the
referred vs. enrolled patients) to correlate positively with question of specific therapy effects vs. non-specific effects
clinical outcomes. That was not the case, the correlation (placebo effects, context effects, patient expectations etc.)
was almost zero (-0.04). This analysis of AAT/EYT/RMT was not an issue of the present analysis.
patients (87% of the present cohort) does not suggest that
physicians' screening of patients starting AM therapy was Since patients were treated by AM physicians who could
affected by selection bias. possibly have an interest in AM therapies having favoura-
ble outcomes, the study data were largely collected by
An important limitation of the study is the absence of a patients and not physicians. Any bias affecting physician's
comparison group receiving another treatment or no ther- documentation would not affect CES-D (primary out-
apy. For this reason we tried as far as possible to assess the come), Symptom Score, or SF-36, since these clinical out-
influence of other causes apart from the AM therapies. comes were documented by the patients.
Sensitivity analyses were conducted in regard to regression
to the mean due to extreme group selection (CES-D ≥ 24 Included in this study were outpatients aged 17–70 years
points at inclusion), spontaneous improvement and with moderate to severe depressive symptoms. The
dropout bias. According to the analyses, these three fac- patients were recruited by physicians offering routine care,
tors can together explain maximum 35% of the average 0– and structured psychiatric interviews to assess all DSM-IV
12-month improvement. Notably, this analysis does not or ICD-10 depressive disorder criteria were not feasible,
completely exclude regression to the mean due to symp- which limits diagnostic comparability with other studies.
tom fluctuation with preferential self-selection to therapy However, all patients fulfilled the DSM-IV core symptom
and study inclusion at symptom peaks. Another form of criteria for dysthymic disorder and 82% of patients ful-
self-selection bias is also possible, since a prerequisite for filled the additional criterion of at least two years symp-
study inclusion was that the patient is willing to try AM tom duration.
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Since AM was to be evaluated under routine conditions, The results of this first study of AM therapy for depression
therapy was not administered according to a standardised in outpatients are encouraging and warrant further inves-
protocol but at the discretion of the physicians and thera- tigations.
pists. Moreover, any of four AM therapies (AAT, EYT, RMT
and MED) was permitted and the main analysis com- Conclusion
prised all AM therapies. Subgroup analysis showed similar Among outpatients starting AM therapies for chronic
improvement of patients receiving EYT and AAT and in depression, a large proportion continued in treatment and
the AAT subgroup using painting/drawing/clay, but the an encouraging proportion showed clinically relevant
sample size did not allow for analysis of RMT and MED improvement. Although the pre-post design of the present
groups nor of the other AAT technique subgroups. study does not allow for conclusions about comparative
effectiveness, study findings suggest that AM therapies can
Study implications be useful for patients motivated for such therapies.
This study provides the first data on AM therapy for
depression in primary care. Notably, the female-to-male Abbreviations
ratio was much higher in our study (5.5/1.0) than in other AM: anthroposophic medicine, AMOS: Anthroposophic
German primary care depression cohorts (1.3–2.6/1.0) Medicine Outcomes Study, AAT: AM art therapy, CES-D:
[46-50]. A high proportion of women and of patients with Center for Epidemiological Studies Depression Scale, EYT:
higher educational levels, as observed here, has been eurythmy therapy, IQR: interquartile range, MED: AM
observed in other studies of AM users [11,51,52]. Baseline therapy (counselling, AM medication) provided by study
depression severity in our study (CES-D average 35 physician, RMT: rhythmical massage therapy
points) was between the severity in untreated patients
with Dysthymic Disorder (34 points) and Major Depres- Competing interests
sion (39 points) [35]. Baseline SF-36 Mental Component The author(s) declare that they have no competing inter-
Summary Measure (mean 26.2 ± 8.0) was slightly lower ests.
(median difference 0.34 Standard Deviations, range 0.30–
0.72), i.e. worse, than in other primary care depression Authors' contributions
cohorts [53-56]. Altogether, our results suggest that pri- HJH, CMW, SNW, and HK contributed to study design.
mary care patients receiving AM therapy for depression are HJH, AG, and HK contributed to data collection. HJH, RZ,
more frequently women, but resemble other depressed and HK wrote the analysis plan, HJH and AG analysed
primary care patients regarding symptom severity and data. HJH was principal author of the paper, had full
functional impairment. The higher proportion of women access to all data, and is guarantor. All authors contributed
in this sample might possibly reflect that women are more to manuscript drafting and revision and approved the
likely than men to engage in artistic therapies like EYT and final manuscript.
AAT.
Acknowledgements
In the first six months after enrolment, 55% of study This study was funded by the Software-AG Stiftung, Darmstadt, Germany
patients had no standard therapy (psychotherapy, antide- and the Innungskrankenkasse Hamburg, Hamburg, Germany, with supple-
pressants) for depression. Some patients will not profit mentary grants from the Deutsche BKK, Wolfsburg, Germany, the Betrieb-
skrankenkasse des Bundesverkehrsministeriums, Hamburg, Germany, the
from standard therapies; other patients discontinue stand-
Zukunftsstiftung Gesundheit, Stuttgart, Germany, the Mahle Stiftung, Stutt-
ard therapies due to adverse reactions or reject them gart, Germany, and the Dr. Hauschka Stiftung, Eckwälden, Germany. The
because they are passive (antidepressants) or can be felt as sponsors had no influence on study design or planning; on the collection,
intrusive or too verbal (psychotherapy). In this context, analysis, or interpretation of data; on the writing of the manuscript; or on
the AM non-verbal (AAT, EYT, RMT) and artistic exercising the decision to submit the manuscript for publication.
therapies (AAT, EYT) offer a different approach or even a
bridge to opening up communication on a verbal level We thank G. S. Kienle and W. Tröger for helpful comments and P. Siemers
[11]. for technical assistance. Our special thanks go to the study physicians, ther-
apists and patients for participating.
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