Effectiveness of using calligraphic activity to treat people with schizophrenia: a randomized controlled trial in Southern Taiwan

Wen-Yi Huang, Hector W H Tsang, Shu-Mei Wang, Yu-Chen Huang, Yi-Chun Chen, Chih-Heng Cheng, Chih-Yin Chen, Jung-Sheng Chen, Yen-Ling Chang, Ru-Yi Huang, Chung-Ying Lin, Marc N Potenza, Amir H Pakpour, Wen-Yi Huang, Hector W H Tsang, Shu-Mei Wang, Yu-Chen Huang, Yi-Chun Chen, Chih-Heng Cheng, Chih-Yin Chen, Jung-Sheng Chen, Yen-Ling Chang, Ru-Yi Huang, Chung-Ying Lin, Marc N Potenza, Amir H Pakpour

Abstract

Background: Prior research has shown preliminary evidence that calligraphy activity improves various body functions and decreases severity of psychotic symptoms in individuals with schizophrenia. However, major limitations of earlier studies include small and heterogeneous samples. The current large-scale randomized controlled trial examined effects of calligraphy activity on cognition (including attention), emotions, psychotic symptoms, quality of life, and mood in people with schizophrenia.

Methods: One-hundred-and-fifty patients with schizophrenia were randomly allocated to the treatment group (receiving calligraphy activity) or the control group (receiving general activity), both of which lasted for 24 weeks (70 minutes per session; one session per week). Assessments were conducted at pretest, posttest, and three-month follow-up. The Montreal Cognitive Assessment, Chu's Attention Test, Depression, Anxiety, and Stress Scale, Positive and Negative Syndrome Scale, World Health Questionnaire on the Quality of Life-Brief Form, and Visual Analogue Scale were used.

Results: Improved cognition and attention were found in both groups, although no group effects were shown. The treatment group appeared to show lower severity of positive symptoms at follow-up than posttest, whereas the control group appeared to show the opposite pattern. Improved mood was found in the treatment group.

Conclusion: This study provides evidence regarding effects of calligraphy activity on increasing cognition and potentially decreasing severity of positive symptoms in patients with schizophrenia. Calligraphy activity can be incorporated in clinical occupational therapy and may be provided to supplement medication treatment.

Trial registration: ClinicalTrials.gov NCT03882619; https://ichgcp.net/clinical-trials-registry/NCT03882619.

Keywords: attention; calligraphy; mental health; quality of life; schizophrenia; symptom.

Conflict of interest statement

Conflict of interest statement: All the authors declare that there is no conflict of interest. Dr. Potenza has consulted for Opiant Therapeutics, Game Day Data, the Addiction Policy Forum, Opiant, AXA and Idorsia Pharmaceuticals; has received research support from Mohegan Sun Casino, the Connecticut Council on Problem Gambling and the National Center for Responsible Gaming; has participated in surveys, mailings or telephone consultations related to drug addiction, impulse-control disorders or other health topics; has consulted for and/or advised gambling and legal entities on issues related to impulse-control/addictive disorders; has provided clinical care in a problem gambling services program; has performed grant reviews for research-funding agencies; has edited journals and journal sections; has given academic lectures in grand rounds, CME events and other clinical or scientific venues; and has generated books or book chapters for publishers of mental health texts. The other authors report no disclosures.

© The Author(s), 2022.

Figures

Figure 1.
Figure 1.
Study CONSORT flowchart.
Figure 2.
Figure 2.
Simple effects of calligraphy on positive symptoms. TAU, treatment as usual.
Figure 3.
Figure 3.
Improvement in mood in the calligraphy group during the 24 weeks of calligraphy activity. (a) Before participating in the calligraphy activity. (b) After completing the calligraphy activity. X-axis is the intervention period by week; Y-axis is the mood Visual Analogue Scale (scaling from 1 to 10).

References

    1. Kao HSR. Shufa: Chinese calligraphic handwriting (CCH) for health and behavioural therapy. Int J Psychol 2006; 41: 282–286.
    1. Kao H, Sr, Zhu L, Chao AA, et al.. Calligraphy and meditation for stress reduction: an experimental comparison. Psychol Res Behav Manag 2014; 7: 47–52.
    1. Chan SC, Chan CC, Derbie AY, et al.. Chinese calligraphy writing for augmenting attentional control and working memory of older adults at risk of mild cognitive impairment: a randomized controlled trial. J Alzheimers Dis 2017; 58: 735–746.
    1. Kwok TC, Bai X, Kao HS, et al.. Cognitive effects of calligraphy therapy for older people: a randomized controlled trial in Hong Kong. Clin Interv Aging 2011; 6: 269–273.
    1. Yang XL, Li HH, Hong MH, et al.. The effects of Chinese calligraphy handwriting and relaxation training in Chinese Nasopharyngeal Carcinoma patients: a randomized controlled trial. Int J Nurs Stud 2010; 47: 550–559.
    1. Chu KY, Huang CY, Ouyang WC. Does Chinese calligraphy therapy reduce neuropsychiatric symptoms: a systematic review and meta-analysis. BMC Psychiatry 2018; 18: 62.
    1. Lin C-Y, Chang C-C, Wu T-H, et al.. Dynamic changes of self-stigma, quality of life, somatic complaints, and depression among people with schizophrenia: a pilot study applying kernel smoothers. Stigma Health 2016; 1: 29–43.
    1. Solís-Vivanco R, Rangel-Hassey F, León-Ortiz P, et al.. Cognitive impairment in never-medicated individuals on the schizophrenia spectrum. JAMA Psychiatry 2020; 77: 543–545.
    1. Tripathi A, Kar SK, Shukla R. Cognitive deficits in schizophrenia: understanding the biological correlates and remediation strategies. Clin Psychopharmacol Neurosci 2018; 16: 7–17.
    1. Fond G, Korchia T, Sunhary De, Verville PL, et al.. Major depression, sleep, hostility and body mass index are associated with impaired quality of life in schizophrenia. Results from the FACE-SZ cohort. J Affect Disord 2020; 274: 617–623.
    1. Su C-T, Ng H-S, Yang A-L, et al.. Psychometric evaluation of the Short Form 36 Health Survey (SF-36) and the World Health Organization Quality of Life Scale Brief Version (WHOQOL-BREF) for patients with schizophrenia. Psychol Assess 2014; 26: 980–989.
    1. Vrbova K, Prasko J, Ociskova M, et al.. Quality of life, self-stigma, and hope in schizophrenia spectrum disorders: a cross-sectional study. Neuropsychiatr Dis Treat 2017; 13: 567–576.
    1. Xu M, Kao HS, Zhang M, et al.. Cognitive-neural effects of brush writing of Chinese characters: cortical excitation of theta rhythm. Evid Based Complement Alternat Med 2013; 2013: 975190.
    1. Zhu Z, Wang R, Kao HS, et al.. Effect of calligraphy training on hyperarousal symptoms for childhood survivors of the 2008 China earthquakes. Neuropsychiatr Dis Treat 2014; 10: 977–985.
    1. Teare MD, Dimairo M, Shephard N, et al.. Sample size requirements to estimate key design parameters from external pilot randomised controlled trials: a simulation study. Trials 2014; 15: 264.
    1. Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. Sydney, NSW, Australia: Psychology Foundation, 1995.
    1. Wang K, Shi HS, Geng FL, et al.. Cross-cultural validation of the Depression Anxiety Stress Scale-21 in China. Psychol Assess 2016; 28: e88–e100.
    1. Chu TF. A study of the relationship between vocational placement and attention of schizophrenia patients. J Taiwan Occup Ther Res Pract 2001; 19: 24–32.
    1. Lee P, Liu CH, Lin HY, et al.. Test-retest reliability and minimal detectable change of Chu’s Attention Test in persons with chronic schizophrenia. Taiwanese J Psychiatry 2014; 28: 46–54.
    1. Cheng JJ, Ho H, Chang CJ, et al.. Positive and Negative Syndrome Scale (PANSS): establishment and reliability study of a Mandarin Chinese language version. Chinese Psychiatry 1996; 10: 251–258.
    1. Nasreddine ZS, Phillips NA, Bédirian V, et al.. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005; 53: 695–699.
    1. Wu C, Dagg P, Molgat C. A pilot study to measure cognitive impairment in patients with severe schizophrenia with the Montreal Cognitive Assessment (MoCA). Schizophr Res 2014; 158: 151–155.
    1. Tsai CF, Lee WJ, Wang SJ, et al.. Psychometrics of the Montreal Cognitive Assessment (MoCA) and its subscales: validation of the Taiwanese version of the MoCA and an item response theory analysis. Int Psychogeriatr 2012; 24: 651–658.
    1. World Health Organization. Development of the World Health Organization WHOQOL-BREF quality of life assessment. The WHOQOL Group. Psychol Med 1998; 28: 551–558.
    1. Yao G, Chung CW, Yu CF, et al.. Development and verification of validity and reliability of the WHOQOL-BREF Taiwan version. J Formos Med Assoc 2002; 101: 342–351.
    1. Lin C-Y, Hwang J-S, Wang W-C, et al.. Psychometric evaluation of the WHOQOL-BREF, Taiwan version, across five kinds of Taiwanese cancer survivors: Rasch analysis and confirmatory factor analysis. J Formos Med Assoc 2019; 118: 215–222.
    1. Liang K-Y, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika 1986; 73: 13–22.
    1. Tong J, Yu W, Fan X, et al.. Impact of group art therapy using traditional Chinese materials on self-efficacy and social function for individuals diagnosed with schizophrenia. Front Psychol 2021; 11: 571124.
    1. Cetin-Karayumak S, Di Biase MA, Chunga N, et al.. White matter abnormalities across the lifespan of schizophrenia: a harmonized multi-site diffusion MRI study. Mol Psychiatry 2020; 25: 3208–3219.
    1. Walder K, Bissett M, Molineux M, et al.. Understanding professional identity in occupational therapy: a scoping review. Scand J Occup Ther. Epub ahead of print 7 October 2021. DOI: 10.1080/11038128.2021.1974548.
    1. Alimoradi Z, Lin C-Y, Pakpour AH. Coronavirus disease-19 vaccine inequity and gross domestic product. Asian J Soc Health Behav 2021; 4: 129–130.
    1. Chen I-H, Chen C-Y, Pakpour AH, et al.. Problematic internet-related behaviors mediate the associations between levels of internet engagement and distress among schoolchildren during COVID-19 lockdown: a longitudinal structural equation modeling study. J Behav Addict 2021; 10: 135–148.
    1. Chen I-H, Chen C-Y, Liu C-H, et al.. Internet addiction and psychological distress among Chinese schoolchildren before and during the COVID-19 outbreak: a latent class analysis. J Behav Addict 2021; 10: 731–746.
    1. Chen I-H, Chen C-Y, Zhao K-Y, et al.. Psychometric evaluation of fear of COVID-19 Scale (FCV-19S) among Chinese primary and middle schoolteachers, and their students. Curr Psychol. Epub ahead of print 5 January 2022. DOI: 10.1007/s12144-021-02471-3.
    1. Chen C-Y, Chen I-H, O’Brien KS, et al.. Psychological distress and internet-related behaviors between schoolchildren with and without overweight during the COVID-19 outbreak. Int J Obes 2021; 45: 677–686.
    1. Chang K-C, Strong C, Pakpour AH, et al.. Factors related to preventive COVID-19 infection behaviors among people with mental illness. J Formos Med Assoc 2020; 119: 1772–1780.
    1. Hasannia E, Mohammadzadeh F, Tavakolizadeh M, et al.. Assessment of the anxiety level and trust in information resources among Iranian health-care workers during the pandemic of coronavirus disease 2019. Asian J Soc Health Behav 2021; 4: 163–168.
    1. Olashore AA, Akanni OO, Fela-Thomas AL, et al.. The psychological impact of COVID-19 on health-care workers in African Countries: a systematic review. Asian J Soc Health Behav 2021; 4: 85–97.
    1. Patil ST, Datar MC, Shetty JV, et al.. ‘Psychological consequences and coping strategies of patients undergoing treatment for COVID-19 at a tertiary care hospital’: a qualitative study. Asian J Soc Health Behav 2021; 4: 62–68.
    1. Pramukti I, Strong C, Sitthimongkol Y, et al.. Anxiety and suicidal thoughts during COVID-19 pandemic: a cross-country comparison among Indonesian, Taiwanese, and Thai university students. J Med Internet Res 2020; 22: e24487.
    1. Rajabimajd N, Alimoradi Z, Griffiths MD. Impact of COVID-19-related fear and anxiety on job attributes: a systematic review. Asian J Soc Health Behav 2021; 4: 51–55.
    1. Yao G, Wu C-H. Similarities and differences among the Taiwan, China, and Hong-Kong versions of the WHOQOL questionnaire. Soc Indic Res 2009; 91: 79–98.

Source: PubMed

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