A Randomized Controlled Study on the Effectiveness of Painting Therapy Combined with Chai Hu Plus Long Bone Oyster Tang Plus Reduction in the Psychological Treatment of Depression in Adolescents Volume 52- Issue 2

Liu Zhenyi and Ye Cunchun*

• Yunnan Normal University, China

Received: July 18, 2023;   Published: August 14, 2023

*Corresponding author: Lara F Tutunji, Pharmacy Department, Faculty of pharmacy, Amman Arab University, Amman, Jordan

DOI: 10.26717/BJSTR.2023.52.008214

Abstract PDF

To examine the clinical value of using thematic drawing in the treatment of adolescent depression. Methods: Patients with adolescent depression who met the age profile and diagnostic characteristics between December 2021 and December 2022 were retrospectively included in the study and were divided into a control group (50 patients treated with paroxetine) and an experimental group (50 patients treated with thematic painting combined with the addition and subtraction of Chai Hu plus Long Bone Oyster Tang) by random sampling. clinical efficiency. The clinical effectiveness rate was 98% in the experimental group and 58% in the control group (p<0.000, x²=65.448); the HAMD depression scale score was 4.2 ± 2.19 in the experimental group and 15.02 ± 8.58 in the control group. In the treatment of adolescent depression, a combination of thematic painting treatment with Chai Hu plus Long Bone Oyster Tang plus reduction is recommended to effectively intervene in adolescent depression.

Keywords: Depression; Chai Hu plus Long Bone Oyster Tang Plus and Minus (CLMD); Painting Treatment; Adolescents; Randomized Controlled; Effect Study

As the economic situation continues to grow, people’s needs are also growing, and the satisfaction of material needs is no longer the only pursuit of people, they are gradually exploring deeper spiritual needs. The “China National Mental Health Development Report (2019-2020)” states that 24.6% of adolescents are depressed, with 7.4% of them being severely depressed, and the detection rate of depression among adolescents in 2020 will be 24.6%, with the detection rate of mild depression being 17.2%, higher than the 0.5% in 2009. 17.2%, 0.4 percentage points higher than in 2009. The rate of major depression was 7.4%, which was the same as in 2009. According to the results of an epidemiological survey of 1597 university students by Professors Du Zhaoyun and Wang Keqin, the prevalence of mild depression was 42.1% and that of major depression was 2.1%. Depression is gradually coming into the limelight, and depressive symptoms in adolescents are a matter of concern, and the search for new treatments is urgent. In China, most of the existing literature on the analysis of the causes of depression and treatment strategies for adolescents is based on the theoretical template of Western research, which will lead to a “Western approach” to the treatment strategies for adolescents’ depression, but research shows that the factors of depression in adolescents are strongly related to the social and cultural background of the country in which they live.

However, research has shown that there is a strong correlation between the onset of depression in adolescents and the social and cultural context of the country in which they live, and therefore most Western research on adolescent depression is only applicable to adolescents in their own country and is not fully applicable to the psycho logical factors of adolescents in China but is of reference value. In this paper, the author will analyse the causes of adolescent depression and find ways of treatment strategies from the perspective of traditional Chinese medicine, in order to solve the current problem of increasing detection rates of adolescent depression in China and will propose the use of Chinese medicinal food therapy as an adjunct to the treatment of adolescent depression. In the treatment of depression in adolescents, antidepressants such as escitalopram oxalate tablets, fluoxetine hydrochloride dispersible tablets and paroxetine hydrochloride are mainly used in the current clinical treatment of associated depression. Antidepressants can cause the following symptoms: autonomic nervous system disorders, weight gain, effects on liver function, endocrine system disorders and acute hypertension, etc. The main point is that the use of antidepressants cannot intervene in a timely manner to treat certain manifestations of the symptoms, but only by increasing or decreasing the dosage of medication.

The effectiveness of antidepressants is therefore long and not in line with the principles of evidence-based medicine. In response to these problems, Chinese scholars and medical experts have begun to use Chinese herbal medicine in the treatment of depression and related disorders in clinical practice this year and have compared its efficacy with that of Western antidepressant drugs. For example, Zhang Lu et al. demonstrated that Chai Hu plus Long Bone Oyster Tang has good antidepressant efficacy compared with Escitalopram Oxalate Tablets, Nie Wenyi et al. evaluated the efficacy and safety of Chai Hu plus Long Bone Oyster Tang in the treatment of tumour-related depression based on META analysis [1], and Wang Jianghuai concluded that Chai Hu plus Long Bone Oyster Tang plus reduction is more effective than Zhuangyao San plus reduction in the treatment of depression [2]. In recent years, research on the treatment of depression with Chai Hu and Long Bone and Oyster Tang (CLMD) has been intensifying, and the efficacy of the treatment and other factors have been increasingly emphasized.

In this study, we will try to use a combination of pictorial therapy and Chai Hu plus Long Bone and Oyster Soup plus reduction to treat depression in adolescents. This formula is composed of Chai Hu, Lead Dan, Dragon Bone, Ginseng, Oyster, Poria, Radix Panax, Cinnamomum, Rhubarb, Scutellaria, Ginger and Jujube, and can be adjusted according to changes in symptoms. The source of Chinese medicine treatment can be traced back to Sun Simiao’s “Thousand Gold Essentials”, which states that “A doctor must first understand the source of the disease and know what it is, and then treat it with food, and if the food treatment is not cured, then order the medicine. The first thing you need to do is to know the source of the disease and know what it is, and then treat it with food. If one can use food to pacify disease and release emotions to dispel illness, one can be considered a good worker.” Sun Simiao also proposed that “the essence of tranquillity must be fed”, emphasizing the role of medicine and food therapy. Depression in adolescents can be classified as a disease of the emotions. Traditional Chinese medicine believes that when people’s emotions such as happiness, anger, sadness, happiness, thought, sadness and shock are too persistent or suddenly strong, it will lead to the body’s tolerance and damage, so it is also called the seven emotions that hurt the disease.

Secondly, it is dual in nature, as depression is both a cause and a clinical manifestation, as pointed out in Jing Yue Quan Shu (The Complete Book of Emotions): “Where the five qi cause depression, all diseases are present, so the disease is depressed. It is difficult to detect and determine the pathogenesis of the disease. Therefore, in addition to the traditional Chinese medicine treatment, Chinese medicine is also used to regulate and supplement the treatment of emotional disorders. Secondly, drawing therapy is a kind of handwriting therapy, which uses artistic techniques and symbolic means to enter the inner world to explore the subconscious desires, thoughts, emotions and other symptoms, to read the inner world of the helper without his conscious obstruction, to transform his thoughts and behaviour, and to solve psychological and behavioural problems; drawing therapy for the psychological trauma and problems of the helper is the result of years of clinical experience. We explore the psychopathological clues, traumas, emotional desires and the physical and psychological characteristics that flow from the paintings of the helpers to better predict their future behaviour. According to the theme of this study, the feasibility of drawing therapy in the clinical field was studied, because drawing therapy originated from abroad, so the development trend of drawing therapy abroad and the practical application of drawing therapy in China were combined and analyzed in order to achieve the purpose of integrating drawing therapy into adolescent depression.

The British Association of Art Therapists describes painting therapy as a process of externalising unexpressed thoughts, emotions, desires and somatic symptoms through the medium of painting and shaping with the help of an art therapist, using the indicators of the visual mind table to diagnose and treat them through the use of symbolic art and the use of objects as metaphors for the externalisation of unrelated objects. Drawing also has its origins in the psychological development of the child, which is in fact a process of human reenactment. It is the most relevant art therapy for students in psychotherapy, especially for younger children. It is suitable for emotional expression, symbolic expression and alternative satisfaction, and can also reflect the child’s psychological problems or deficiencies, and explore the study of their physical illnesses, for example, a child with a bad abdomen will exaggerate the abdomen, or a child who is dissatisfied with his father’s severity is likely to draw a Drawing therapy can be carried out with children as young as two years old, and the younger the child, the more realistic the expression and the less disguised it is, so it is easiest to interpret the drawings of young children. Later, painting therapists began to study the interpretation of different creative or psychological traits and to develop indicators and analytical frameworks.

In the early 20th century, with the arrival of psychoanalysis, psychopathologists showed a keen interest in the pictorial symbolism and improvisation of psychiatric artists (such as Van Gogh), began to study their artworks and gradually developed pictorial psychotherapy. The American psychologists Cuk and Hammer began to study the room-tree-person technique. Sing began to use drawing in trauma therapy, using it with children who had experienced domestic violence, parental divorce and sexual abuse, allowing them to express and communicate their feelings, repair trauma and deal with psychological problems with significant results. The main aspects of drawing therapy currently applied in counselling are as follows:

1. The Macchio Drawing Test: which assumes that the expression of the self-portrait can clearly reflect his personality traits Generally speaking, the visitor is asked to draw a person about himself according to his subjective view and identification of himself, that is, a self-portrait, a self-portrait of the whole body, and to analyse his gender characteristics, mental activity characteristics, through a visual mental image chart. The visual mind-sheet is used to analyse his or her gender, mental activity, personality and physical characteristics.

2. House-Tree-Human Test: Visitors are asked to draw a combined picture of a house, a tree and a person on the same sheet of paper. The house reflects the social and interpersonal relationships, personality traits, psychological defence mechanisms and emotional characteristics of the person seeking help, his or her psychic world and the dwelling place of the soul, as well as the imaginary and repressed reactions of the person seeking help. The tree is able to reflect the life experience of the person seeking help and the basic overview of personality development and traumatic processes, the state of the spiritual world and psychological energy, the relationship with and influence of parents in early life, the physical health of family members and even the emotional flow and gastrointestinal function of the person seeking help, among other things, the mental outlook of the person. It is not only through the person’s inner world, self-image, physical characteristics and physical illnesses that one can reflect, but it is also possible to understand his or her way of going and social activities.

3. Mandala Painting Test: Using Jungian mandala painting emphasizes the protection of the self through painting, the cohesive and integrative function, and the use of mandalas to express inner intentions and emotions.

4. Climber’s Drawing Test: A self-efficacy test that describes the climber’s problem-solving skills and attitudes.

In terms of the application of drawing therapy in China, it is mainly used in the field of education for university students. According to (Cui Yingying, et al. [3]) “Art therapy has made great progress and development in China’s education industry. Expressive arts therapy has good prospects for development in mental health education and group counselling for university students” [3,4] As time goes by, drawing therapy is not limited to the use of mental health education for university students, but is also used in the field of special education. The study by (Lee SL, et al. [4]) concluded that art therapy can be used effectively as a precursor therapy for special education children with good therapeutic outcomes [4], and with the advent of the internet, drawing therapy has also been used in the field of virtual therapy. It can be used in a variety of ways However, a review of the literature reveals that there is a major problem with interventions for depressed people in China: although the literature points to the use of psychological interventions (but without clear methods and techniques) or the use of cognitive therapy there is little focus on the psychoanalytic field. Drawing therapy, with its strict interpretation criteria and effective diagnosis of the present state of mind, can be used to diagnose and intervene in the subsequent treatment, and is therefore complemented by medication, with the aim of increasing the cure rate of depression and reducing the use of psychotropic drugs in order to be responsible for the physical development of the adolescent [5-10].

Objects and Methods

The subjects of this study were selected using a case-retrospective approach, and 100 patients who had been diagnosed with moderate or higher depression by a professional psychiatrist from the psychology department of Wenshan Prefecture Hospital in Yunnan Province according to the DISM-V criteria will be used as the study subjects.

Research Tools

Questionnaire Method: The HAMD depression scale was used for this study, and the screening criteria, using the total score of the 24-item version of the HAMD scale as the screening criteria: a total score of 9-20 was recorded as a low-scoring subject, and a total score greater than 20 was recorded as a high-scoring subject. 100 adolescents were collected for this study, and there were no statistical differences in age (x² =12.79, P=0.>0.05) and gender (x² =8.96, P=0. & gt;0.05) were not statistically different.

Experimental Design

In this experiment, two groups will be set up, the observation group and the experimental group, and separate pre-test and posttest experiments will be conducted to control variables and reduce errors.

Setting up Groupings and their Criteria: Observation group: 50 patients diagnosed with moderate depression or above by a specialist psychiatrist, 25 girls and 25 boys, aged 14-18 years, were divided into the observation group, which was treated with paroxetine supplemented with emotional support as prescribed by the doctor. The Experimental group was Divided: 50 patients diagnosed by a professional psychiatrist as moderately depressed or above were divided into the experimental group, 25 girls and 25 boys, aged 14-18 years old. The grouping was based on: firstly, the 100 participants were grouped so that they met the criteria of 50 male and 50 female; secondly, the male and female groups were randomly grouped again to form two groups of 25 male and 25 female; finally, the two groups were combined to form an observation group of 25 female and 25 male; the experimental group was the same as above. 100 participants all met the diagnostic criteria of HAMD as moderate or above depression [11-15].

Experimental Setup and its Steps: The experiment was divided into two phases: the first was a pre-test phase in which all group members were identified as moderately depressed or above using the HAMD score; after 3 months and 3 phases of intervention, the second phase was conducted again using the HAMD score, and finally a twoby- two comparison was conducted using a t-test of independence to classify the high and low groups according to the HAMD score and to find the cure. Efficacy rate

Outcome Indicators: The HAMD score was divided into X as low and X as asymptomatic, and finally the number of asymptomatic people was used as the cure rate criterion.

Experimental Hypothesis: Painting therapy combined with Chai Hu plus Long Bone Oyster Tang plus reduction is much more effective than paroxetine alone in the intervention of adolescent depression.

On the Content of Interventions at Different Levels of Painting

The following three stages of drawing therapy are specifically designed for patients with moderate depression and above. The aim is to enable patients to understand their overall mental health, to improve their sense of self-efficacy and ultimately to manage their emotions 1) Drawing Therapy with Regard to Overall Mental Health Level - Fanshuren Drawing Test

Unlike other psychological scales, for which there are specific real-life cases - with the Baiyin serial killer Gao Chengyong despite the large number of questionnaire-based psychological tests used by the authorities, the results of these questionnaire-based tests are shown to be normal due to the high level of vigilance and psychological defences of the prisoner, which also suggests that the validity of the questionnaires are tests is questionable. The results are questionable because of the presence of artifice and social approbation for people with some textual comprehension. Painting, however, is a projective test in which the subject is given unstructured stimulus situations in which he is free to express his responses in unrestricted situations, and his internal psychological characteristics are analysed by analysing the results of his responses to these stimuli; using unstructured tasks which allow for a wide variety of unrestricted responses from the subject. The test was developed by the American psychologist John Barker in collaboration with the South Swiss psychologist Koch and has since been refined.

2) Drawing Therapy on Self-Efficacy - Climber’s Drawing Test Different thematic painting therapies are used depending on the needs for real issues such as self-efficacy. 3) Drawing Therapy on Emotion Management - Mandala Drawing Test

Identify your negative emotions using the Mandala Drawing Test to actively seek out your positive emotions and learn to self-regulate and self-identify your emotions.

After the data was collated and collapsed, a total of 100 participants were included in the pre-test and post-test study, using spss22.0 and amos26.0. The results are shown in the table below.

Significance Tests and Clinical Effectiveness

(Table 1) shows that there was no difference between the scores of the experimental group and the control group on the Hamilton Depression Inventory before the intervention (p>0.05); after the intervention there was a highly significant difference between the scores of the experimental group and the control group on the Hamilton Depression Inventory, with an effect size of -1.728, a medium effect size. (Table 2) shows that there was a highly significant difference between the pretest and posttest scores on the Hamilton Depression Inventory in the control group (p<0.001), with an effect size of 2.844, a large effect size, and a highly significant difference between the pretest and posttest scores on the Hamilton Depression Inventory in the experimental group (p<0.001), with an effect size of 3.488, a large effect size (Table 3).

Table 1: Independent samples t-test between the pre-test of the control group and the experimental group, and the post-test of the control group and the experimental group on the HMAD depression scale scores.

Note: *denotes p<0.05; **denotes p<0.01; ***denotes p<0.001.

Table 2: Paired-samples t-test on Hamilton Depression Scale scores for the control group pre-post test and the experimental group prepost test.

Note: *denotes p<0.05; **denotes p<0.01; ***denotes p<0.001

Table 3: Clinical effectiveness.

Discussion of Results

Based on the statistical results in the three tables above, the expected hypothesis was met: that the clinical effectiveness of painting treatment combined with Chai Hu plus Long Bone Oyster Tang plus subtractive drug treatment for adolescent depression was significantly higher than that of clinical intervention with paroxetine alone for adolescent depression. Adolescents are in the special period of adolescence, when the development of their bodies and the growth and improvement of their functional systems are crucial, and the use of psychotropic substances during this period can lead to several problems. Firstly, during the initial period of psychotropic drug use, adolescents have the following clinical reactions:

1. Excessive Sedation: The specific manifestations in life are lethargy, drowsiness, sluggishness, difficulty in arousing attention, delayed thinking and behaviour, reduced initiative and lack of concern for the surroundings, most notably clozapine, chlorpromazine and olanzapine.

2. Persistence of depressive thoughts: Although there is a certain degree of suppressed state for some depressive states, their own depressive thoughts do not improve, showing depressed mood, lack of confidence and interest, and pessimism; common with chlorpromazine, haloperidol, endorphin, and trifluoperazine.

3. Psychomotor Excitement: Common in the early stages of treatment with piperazines (endorphine, etc.) and butylphenols, manifesting excitement, restlessness, agitation, hostility, impulsivity and aggression.

4. Disorders of Consciousness or Central Anticholinergic Syndrome: Manifests as disorientation, near-memory impairment verbal diffusion, delusions, hallucinations, stereotyped movements or impulsive behaviour.

There is a blurring of consciousness, a state of foresight and confusion. It may be accompanied by rapid pulse, sweating, tremors, slurred speech, and dilated pupils. Secondly, with increased drug use, the adolescent’s extrapyramidal system, circulatory system, rhythmical system, digestive system, etc. are also affected to varying degrees. In some cases, the use of psychotropic drugs has led to drug resistance and dependence, and the inability to go about their day or sleep without psychotropic drugs or in insufficient doses are all symptoms of psychotropic drug use. The use of psychotropic drugs in the diet also leads to a certain extent to a cycle of psychogenic overeating and anorexia in adolescents, which over time will inevitably cause irreversible damage to the growth of adolescents, on the one hand through excessive obesity or restricted growth due to nutritional disorders, and on the other hand through the excessive depletion of various organs in the body, leading to complications such as nephritis and cardiac arrhythmia, which will do no good to the future development of adolescents. The use of psychotropic drugs can only alleviate, but not cure, the symptoms of depression in adolescents, and this leads to the use of psychotropic drugs aggravating the illness or even causing new illnesses.

A review of the literature on Chinese medicine and food reveals that there is little research on the psychological aspects of Chinese medicine and food, but that Chinese medicine and food can be of unexpected use in the treatment of psychological disorders.

For example, the naming of sleeping soup has the effect of a scientific psychological placebo, and let go of the discussion of its efficacy, as the patient has reached a state of extreme craving for stable sleep when he has not been able to get enough rest for a long time. The naming of Chinese remedies is clearly more in line with the patient’s inner needs, and the naming of the remedies is combined with suggestive therapy, which treats the body and regulates the nerves at the same time. Secondly, TCM food therapy takes into account both daily life and treatment, both form and spirit, and pays more attention to nourishing the spirit. The main ideas in the treatment of depression are summarised as situational nourishment of the spirit: clearing the mind, less thinking; pleasure and relaxation of the spirit: having give and take, less anxiety; and timely adjustment of the spirit: changing oneself, no worries, mainly expressing the central idea of mindfulness, self-pleasure, controlling one’s own needs and learning to adapt to emotions.

Finally, according to the principles of Chinese medicine and food treatment for depression, the therapist must be aware of the pathogenesis of the disease, grasp the main features of the physical and mental development of adolescents, treat both body and mind, use the heart medicine to cure the heart disease, separate emotions from the environment, and treat depression based on the treatment of physical symptoms, with the early stage addressing In the process of treatment, multiple parties should be involved: therapists, families, society and other aspects of support, multiple methods of treatment, and no strict boundaries between the Eastern and Western models for symptom improvement; moving the mind and nurturing the nature, paying attention to the personality characteristics of the patient and his or her psychological process at each stage of treatment; grasping the illness and being flexible in the treatment. The treatment is flexible in its approach to the patient’s illness; it captures the pathological mechanism and interrupts the vicious cycle of mind and body [16-20]. In this study, the clinical effectiveness rate and HAMD were used as indicators for the treatment of adolescent depression with the combination of Chai Hu plus Oyster Soup with Dragon Bone and Oyster. In terms of total clinical effectiveness, CLMD plus and minus painting treatment was superior to paroxetine alone in the treatment of adolescent depression; in terms of reduction of HAMD scores, Chai Hu plus Dragon Bone and Oyster Soup plus and minus painting treatment was superior to paroxetine alone as a Western psychiatric antidepressant.

The main limitations of this study are as follows: due to the nature of Chinese herbal formulas, both the subjects and the experimenter know the effects of the formulas and their scope of application, which makes it more difficult to use a blinded approach, and the fact that most of the psychotropic drugs currently used in the Western tradition for concomitant depression, such as paroxetine, have extremely strong side-effects, are ineffective, and fail to target the problem of the disease, for depression is less effective [21-25]. From the results of this study, it is clear that CLMD plus and minus is effective in the treatment of adolescent depression, and if combined with other interventions for depression will significantly increase the overall clinical effectiveness and improve the HAMD scores of the patients; it will also improve the quality of life of the depressed patients; and will reduce the side effects of western antidepressants. This requires that in future clinical practice, the use of Chai Hu plus Long Bone and Oyster Soup with addition and subtraction may be considered for the treatment of adolescent depression to improve the patient’s symptoms and physical quality, with the main aim of improving the quality of life of the patient and the clinical efficiency of the treatment. However, considering that there are still some shortcomings in the design and methodology of RCTs, it is suggested that researchers should use this as a research idea to provide more sample data and RCTs to prove the therapeutic effect of Chai Hu plus Long Bone and Oyster Tang Plus Decrease on depression in adolescents and extend it to other clinical practices [26-30].

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