رقص/حرکت درمانی (D / MT) برای افسردگی: بررسی حوزه

Depression affects 121 million people worldwide (WHO, 2010). The socio-economic repercussions of depression are putting an enormous strain on UK and US governmental health budgets. Regarding treatment interventions, D/MT and other arts therapies are widely practiced around the world as a treatment of choice for depression. Research evidence suggests that exercise has positive effects on mood. Similarly, it has been argued that dance has a positive social-cultural influence on a person's wellbeing. However there are no systematic reviews that support the effectiveness of D/MT for people with a diagnosis of depression. It is therefore important to map the field of existing research studies of D/MT for depression. In this paper a scoping review is presented that engaged with an extensive search to best answer the question: is there good quality research evidence available regarding the effectiveness of D/MT and related fields for the treatment of depression? A search strategy was developed to locate publications from electronic databases, websites, arts therapies organizations and associations using specified criteria for including and excluding studies. All studies meeting the inclusion criteria were then evaluated for their quality, using broad criteria of quality such as type of methodology followed, number of participants, relevance of interventions and specific comparisons made and outcome measures. A total of nine studies were found. Six studies followed a randomized controlled trial design, and three adopted a non randomized design. At least one study met most criteria of quality. We concluded that there was a need to undertake a full systematic review of the literature and to follow a Cochrane Review protocol and procedures

It is often difficult for arts therapists, including dance/movement therapists, who are not in direct contact with academic institutions, to keep up to date with research evidence. As a result, practitioners often become disconnected from recent developments, while relying upon theoretical frameworks and their own and others’ experience to inform their work. In recent years, however, dance/movement therapists, along with the other arts therapists, have been encouraged to shift towards a more cyclical process of practice which on the one hand still remains well-informed by theory and experience but on the other also draws upon research findings (Karkou, 2009). This way research becomes an integral part of practice informing clinical decisions throughout the therapeutic process. Thorough evaluation of the therapeutic work and generation of research evidence based on practice are also part of this cycle, aiming to develop improved services. Ultimately this approach to practice highlights the value of research and makes it more tangible to the working clinician. The framework for clinical practice that incorporates scientific research evidence is known as Evidence-Based Practice (EBP) (Leach, 2006, Mason et al., 2002 and Melnyk and Fineout-Overholt, 2005). EBP requires a shift away from the traditional paradigm of clinical practice grounded solely in intuition, clinical experience, and psychological rationale (Leach, 2006, Mason et al., 2002 and Melnyk and Fineout-Overholt, 2005). Clinical expertise is seen as important in combination with best scientific evidence, patient values and preferences, and clinical circumstances. In Dance/Movement Therapy (D/MT) in particular, Meekums (2010) argues that practitioners have at times tended to be misinformed and consequently demonize the EBP paradigm. She suggests that there is a need for dance/movement therapists to embrace research evidence including quantitative experimental studies while not losing sight of the particular strengths offered through embodied knowledge. Our intention through this scoping review is to offer this integration with respect to one particular area of evidence, namely D/MT for depression. In order to support the shift towards EBP, it is important that good quality research evidence becomes available to practitioners. Systematic reviews and/or meta-analyses that report on and evaluate research studies are often regarded as important sources of research evidence in a particular area of clinical practice. However, there are not enough systematic reviews and/or meta-analyses available to guide practitioners. Working with depression in D/MT is one such area; while this is a common diagnosis for a number of clients seen by dance/movement therapists, there is still a marked absence of either systematic reviews or meta-analyses on the topic. This article, therefore, attempts to address the gap in the literature by reporting on a scoping review of published and unpublished research studies pertaining to the effectiveness of D/MT in the treatment of depression. The scoping review was an initial, step in order to determine whether we could undertake a systematic Cochrane Review on the topic. Systematic reviews aim to collate all empirical evidence relating to a specific research question, using explicit, systematic, and pre-determined methods in order to minimize bias and generate reliable findings (Higgins & Green, 2011). This kind of research activity is often given priority as evidence (Eccels, Freemantle, & Mason, 2001). As a result, systematic reviews, with or without meta-analyses, are highly respected by establishments such as governmental bodies and national health systems. Some of the most respected systematic reviews are undertaken by the Cochrane Collaboration. A Cochrane Review is a systematic review that not only offers a summary of reliable evidence of the benefits and risk of health care, but does this through a very clearly defined process and clearly defined criteria. For a review to be called a Cochrane Review it needs to be part of the ‘parent database’ (Cochrane Collaboration, 2012, p. 1) and to be linked with the Cochrane Collaboration from the beginning to the end of this process. In all cases and as a first step towards a systematic review, it is common for researchers to undertake a scoping review. The purpose of a scoping review is to establish the breadth of the field, key concepts and types of evidence, and what outcome measures might be relevant; in effect, to ‘map’ it (Arksey & O’Malley, 2005). For the scoping review reported in this article, our intention has been to map the field of D/MT for depression. Why depression? The World Health Organization (WHO, 2010) reports that depression affects about 121 million people worldwide and is predicted to become in 2020 the second most disabling illness in the world after ischemic heart disease. In the UK, national figures indicate a similarly large impact of depression on the general population. According to the 2000 Psychiatric Morbidity Report among adults living in private households, 8–12% of the population is diagnosed with depression at some point in their lives (Office of National Statistics, 2000). The National Institute of Mental Health (NIMH, 2010) in the US state that 9.5% of the population, which is approximately one in ten American adults, suffers from depression. Scott and Dickey (2003), in their research on the global burden of depression, suggest of those who suffer major depressive disorders 20% will have symptoms that persist beyond two years of the initial diagnosis and treatment. Whichever estimates are accepted, depression clearly represents a significant burden to families and to society; it has a negative impact on quality of life, and can lead to suicide. For example, more than 90% of Americans who take their own lives have an undiagnosed mental health disorder or a continual depressive disorder (NIMH, 2005 and Scott and Dickey, 2003), Often depression goes undiagnosed; hence the real scale of the problem is probably much larger than that identified by national statistics. Departments of Health in the UK and US acknowledge that only a few sufferers receive treatment. For example, the USA Department of Health and Human Services (2011) reports that only one in five adult sufferers receive adequate treatment in accordance to guidelines set by the American Psychiatric Association (APA) (2012); even fewer receive treatment amongst ethnic minority groups (Arean, 2011)). In the UK, The Depression Report by The Centre for Economic Performance's Mental Health Policy Group (2006) claims that two in six people who do not receive treatment could be “cured at a cost of 750 pounds” (p. 4). The focus of the report is one of economic cost and reduction of Incapacity benefits. It suggests that depression is the biggest social problem and number one cause of unemployment affecting 40% of people claiming Incapacity benefits in the UK (The Center for Economic Performance's Mental Health Policy Group, 2006). Major depression is a feature of 22% of Americans who classify themselves as unable to work and 10% of those who are already unemployed (Centers for Disease Control and Prevention, CDC, 2010). The cost of depression, the loss of productivity and medical expenses is $83 billion in the USA (Leahy, 2010) in comparison to the £12 billion a year for the UK Government (The Center for Economic Performance's Mental Health Policy Group, 2006), an enormous cost to the government but perhaps an even greater cost to the individual who on average decrease their lifetime earning potential by 35% due to undiagnosed and untreated depression (Leahy, 2010). Between 1991 and 2002 in the UK alone, prescriptions per head for anti-depressants increased by £310 million (Medical News Today, 2005). In the USA the overall costs for outpatient treatment of depression increased from $10 billion in 1997 to $125 billion in 2007 (Zorumski & Rubin, 2011), a point which illustrates the sheer expense of the pharmaceutical management of medication. Zorumski and Rubin (2011) state that there is potential to curb the costs if physicians were to prescribe less inexpensive and more generic anti-depressants and consider other evidenced-based psychotherapies rather than be concerned with prescription privileges. The London Center of Economic Performance's Mental Health Policy Group (2006) proposes a new nationwide therapy service to be put in place to counter-balance the billions of pounds lost through inactivity. The loss, when compared to the £0.6 billion it would cost to provide an effective therapy service in the UK, surely justifies the importance of therapeutic interventions for depression. The argument that remains is that a therapy service is only justified if it is effective enough in making people feel better, and enabling them back to work. In terms of UK health policy, the last decade has seen an expansion of psychological treatments for common mental health problems. The general consensus according to both English and Scottish governments is that attitudes towards mental health, especially depression, should be less about reaction and more about prevention (The Department of Health, 2008 and The Scottish Government, 2008). Governmental targets emphasize an approach towards mental health based on a social model which recognizes that healthy mental capacity is shaped by social, cultural and economic environments. In contrast, in the USA there does not appear to be a single governmental incentive, mainly due to the complex infrastructure of the health care system; many different providers, treatment settings and payment mechanisms (Sundararman, 2009). Legislation under discussion focuses heavily upon practical issues related to mental health such as access in rural areas, co-ordination between providers, comprehensive health insurance cover and better evaluation measures of the quality of mental health care (Sundararman, 2009). Research conducted through the NIMH (2010) is largely focused on the connectivity of neuronal and biochemical processes in the brain that explains the symptoms and behavior of depression. As a result, it appears that US treatment has a more medical focus in comparison to the social focus in the UK and is thus much more interested in the development of pharmaceuticals and the adherence and continuous use of anti-depressants (NIMH, 2010). In the UK, the shift away from a model of treatment heavily reliant on medication and towards a more holistic approach indicates the need for evidence relating to a range of psychological therapies. English targets, which initially prioritized Cognitive Behavioral Therapy (CBT) as the main intervention, nevertheless enshrine the intention of including the wider range of therapies approved by UK-based treatment decision bodies (National Institute of Clinical Excellence, NICE, 2009; Scottish Intercollegiate Guidelines Network, SIGN, 2010). A review of the evidence relating to D/MT for depression is thus timely. Dance/Movement Therapy (D/MT) and depression: the evidence so far D/MT is widely practiced around the world, often with people who are suffering from depression, whether or not depression is diagnosed. There are no systematic reviews on the effectiveness of D/MT for depression. There is, however, a relatively large body of knowledge that relate to exercise and the effects of exercise on mood. Furthermore, overviews of the effects of exercise on depression can be found as early as 1988. In a meta-analysis by Craft and Landers (1988) movement was seen as having beneficial effects on depressive symptoms. More recently, a range of publications have reported on the effectiveness of exercise on depression. However, the validity of their conclusions has been hampered by methodological problems and lack of follow up studies (Dimeo et al., 2001, Lawlor and Hopker, 2001 and Sjosten and Kivela, 2005). Mead, Movely, and Campbell (2008), in their study to determine the effectiveness of exercise as a treatment for depression, call for more robust research that describes the type, frequency and intensity of the form of exercise used in the trial. Bradshaw, Lovell, and Hams (2005) insist that specific client groups within specific settings should be defined in all systematic reviews. For example, particular attention needs to be paid to levels and etiology of depression for older age groups. Physical problems and isolation are particular risk factors for the development of depressive symptoms in people aged between 60 and 74 (Kerse et al., 2008, Sjosten and Kivela, 2005 and Williams and Tappen, 2007). Furthermore, evidence suggests that exercise can lead to short-term mood improvement (Dimeo et al., 2001, Sjosten and Kivela, 2005 and Williams and Tappen, 2007), but there is no evidence of significant long-term effects. There is a need for long-term studies of the effects of exercise on depression, involving larger groups (Dimeo et al., 2001, Kerse et al., 2008, Lawlor and Hopker, 2001, Mead et al., 2008, Sjosten and Kivela, 2005 and Williams and Tappen, 2007). If exercise programs can be assumed to improve strength, endurance, and body mechanics and possibly alter mood states, dance may have all of these effects but also has the potential pleasure from creating dance movement and the added dimension of social interaction. A growing body of research literature exists concerning the socio-cultural communication encouraged by participating in dance which brings groups of people together in a ‘team spirit’. According to more current qualitative studies using dance as a parameter to assess well-being and psychological states in the older person, the focus is on the ritualistic or folkloric aspects of the dance (Belza et al., 2004 and Hui et al., 2008). Belza et al. (2004) for example, recruited 71 older adults through community agencies to participate in seven ethnic-specific focus groups: American Indian/Alaska Native, African American, Filipino, Chinese, Latino, Korean, and Vietnamese. Their results demonstrated that participants’ perception of improvement of depressive symptoms (e.g. fatigue, negative thoughts) was such to warrant the development of a country-specific folkloric dance program that aimed to enable older people to sustain independence and move away from isolation. D/MT and other arts therapies are used extensively in the treatment of depressive symptoms with client groups whose main diagnosis may be anxiety, obesity, medically unexplained conditions or behavioral difficulties (Brauninger, 2006, Karkou et al., 2010, Payne, 2009 and Meekums et al., 2012b). Yet there is limited quantitative evidence that supports their effectiveness of D/MT with people with a diagnosis of depression. It is possible that D/MT offers added value over both exercise treatments and dance classes in that it encompasses an embodied therapeutic relationship. Stiles, Barkham, Mellor-Clark, and Connell's (2007) study on the comparative effectiveness between different therapies (CBT, person centered therapy and psychodynamic psychotherapy), found that despite having non-equivalent theories and techniques, the outcomes were equivalent. They express this paradox as the ‘dodo bird verdict’ (Rosenzweig, 1936, cited in Luborsky et al., 2002, p. 2). This proposition is supported by Luborsky et al's (2002) review of meta-analyses; ‘Everybody has won and all must have prizes’ (taken from Lewis Carroll's Alice's Adventures in Wonderland). The dodo bird verdict suggests that a large part of the therapeutic effects of any psychotherapy is due to common factors and in particular the therapeutic relationship, regardless of the therapeutic framework of the therapist ( Stiles et al., 2007). In the context of arts therapies, qualitative research by Meekums (1999) suggests that one important factor in the therapeutic relationship is the client's sense of psychological safety, the presence of which acts like a catalyst for positive change while the absence of psychological safety acts like a malevolent presence, associated with deterioration in mental state. Despite this important finding, we have found no valid and reliable measures for the therapeutic relationship incorporating the client's sense of safety, other than in studies in family therapy ( Friedlander et al., 2006). Notwithstanding the evidence for common factors influencing psychotherapeutic outcome, there are a wealth of well-designed research studies concerning the effectiveness of CBT on depression. However, most of these studies do not compare CBT to other therapies but to waiting list controls. This may add a degree of bias to the results, since arguably any therapy is better than no therapy, provided that ‘common factors’ are met. It is perhaps not surprising, given the plethora of randomized controlled trials of CBT, that the potential value of D/MT has been overlooked. This is often associated with the degree to which D/MT is taken seriously enough to invest time and money on a substantial piece of research work. Furthermore, one could question the degree to which a randomized controlled trial, the golden standard of investigating medical treatments, is indeed the best possible research design for psychotherapeutic interventions. Unlike CBT, D/MT, as a form of humanistic or psychodynamically informed practice, does not follow a standardized mode of delivery and a fixed clinical protocol. In including a control group, there is a similar assumption that variables will be controlled and thus interventions will be compared without interference from other variables. The concept of randomization in itself can also be questioned; in regular D/MT clinical practice selection of members for a group requires careful consideration of group therapy criteria such as ‘best fit’, since this may offer the best prognosis. If this principle is not adhered to and instead people are randomly allocated to either D/MT or a control group, positive treatment outcomes can be jeopardized. It appears that either because prejudiced views of dance as ‘not serious’ remain or because randomized controlled trials (the gold standard of quantitative designs), are not seen as readily fitting D/MT practice, a ‘chicken and egg’ situation has developed: there is limited evidence of effectiveness which in turn leads to underfunding of research in this area (Karkou and Sanderson, 2006, Koch et al., 2007, Meekums, 2006 and Meekums, 2010).