Cultural Arts for Reducing Depressive Symptoms and Age-related Self-stigma in Older People: a Randomised Waitlist Controlled Trial
Phase: NA
Conditions: Depressive Symptoms, Ageism, Older Adults, Psychosocial Intervention, Art
Sponsor: The Hong Kong Polytechnic University

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Cultural Arts for Reducing Depressive Symptoms and Age-related Self-stigma in Older 
People: A Randomised Waitlist Controlled Trial  
 
Tianyin Liu, Ph.D 
Department of Applied Social Sciences 
The Hong Kong Polytechnic University 
 
Document date: June 1st, 2024 
 
 
 
 

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Background 
Depression is a common chronic condition in old age; however, it is, to a large extent, under-
recognized and under-treated. In Hong Kong, it is estimated that approximately 1 in 10 older people 
has clinically significant depression (Sun et al., 2012), and it is associated with suffering, functional 
impairment, and diminished health-related quality of life in older adults (Unützer et al., 2000). 
Research shows that stigmatizing belief is an important barrier to seeking help from mental health 
services (Barney et al., 2006), and some study suggests that self-stigma may be more strongly 
linked to the perception of barriers to mental health care than perceived public stigma (Arnaez et 
al., 2019). Self-stigma obstructs help seeking and recovery from mental illness, and has been 
widely researched in severe mental illness, adult and adolescent population. However, self-stigma 
has rarely been studied in older persons living with depression in Chinese community, who may 
face tripled the harm from internalized ageism, stigma about depression, and Chinese culture about 
face; and intervention aimed at reducing self-stigma is very scarce.  
Self-Stigma: Depression, Ageism, and Lose “Face” 
Stigma, according to Goffman (Goffman, 2009), is predominately a social construct that associates 
an tribute with a stereotype. Self-stigma comprises mainly three steps: awareness of the stereotype, 
agreement with it, and applying it to one self. Once self-stigma is formed, the person may embody 
the negative stereotype, often unconsciously, in his/her behaviour and functioning, leading to more 
social isolation and hopelessness (Levy, 2009). 
It is common for older people with depression to develop self-stigma. For instance, in 
Europe, self-stigma occurs among approximately 1 in 5 people with bipolar or depression (Brohan 
et al, 2011). Some common self-stigmatising beliefs about depression include that the person is 
responsible for his/her own situation, he/she is weak, unable to recover, and undesirable to be 
around (Barney et al., 2009). The most common coping strategies with the stigma include 
avoidance, withdrawal, and secrecy. It was reported that among mental health patients in Hong 
Kong, regardless of age, the most frequently reported coping method was maintaining secrecy 
about the illness (Chung & Wong, 2004). Depressed older adults may also suffer from ageist beliefs. 
Ageism centres around the stereotypes of older people as burdensome and useless (Ayalon & 
Tesch-Römer, 2018), and older persons are discriminated against in employment, health care, and 

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other domains. When older persons internalize ageist beliefs, they can begin to believe and behave 
as though they are no longer independent, healthy, and vibrant human beings (Levy, 2009).  
In addition, depressed older adults in Hong Kong may face unique moral experiences tied 
to stigma. Yang et al. proposed a dimension of moral experience, or what is most at stake for people 
in a local social world, to stigma (Yang et al., 2007). In Chinese culture that values “face”, there 
are moral-somatic (where values are linked to physical experience) and moral-emotional (values 
are linked to emotional states) dimensions to stigma. To elaborate, “face” represents one’s moral 
status in the local community, an individual may “have” and “receive” face for individual 
achievement, “give” face to respected others, or “lose” face for socially undesirable conditions 
associated with them, and the physical sensation of “losing face” is inseparable from the emotion 
of humiliation. Seeking professional mental health is often times associated with “losing face” 
(Yang, 2007). The interplay between these three types of plausible self-stigma in older adults with 
depression in Hong Kong may add extra barriers to their help seeking behaviours, and have 
pervasive negative impact on recovery. 
 
Effectiveness of Previous Intervention Programmes 
With growing awareness of the impact of mental illness self-stigma, there is arisen interest in 
interventions aiming to combat self-stigma. However, the results so far are inconclusive. A critical 
review reported that eight out of the 14 studies that met their inclusion criteria revealed significant 
improvement in self-stigma outcome (Mittal et al., 2012). It also summarized two main approaches 
of intervention: one, interventions that attempt to alter the stigmatizing beliefs; and two, 
interventions that enhance skills for coping with self-stigma through improvements in self-esteem, 
empowerment (Mittal et al., 2012). The latter coincides with the “why try” model, suggesting 
empowerment as the mediator, and it is also gaining traction among experts than the former. A 
more recent study systematically reviewed five randomized controlled trials, despite the 
heterogeneity of these interventions, they had some elements in common: all of them included 
elements of psychoeducation and either Cognitive Behavioural Therapy (CBT) techniques or 
methods aimed at helping participants to develop a personally helpful identity (Büchter & Messer, 
2017). However, despite that individual studies reported some effectiveness, the systematic review 
concluded the effectiveness of the interventions for self-stigma uncertain because previous studies 
lacked statistical power, used questionable outcome measures, and had a high risk of bias (Büchter 

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& Messer, 2017). Furthermore, these programmes are all targeted at severe mental illness, and few 
stem from a theoretical background to examine the effect of empowerment on self-stigma in 
depressed older adults.  
 
Community-based Cultural Art Programmes  
Community-based cultural arts differ from Art Therapy; while the latter often uses art as a tool for 
expression and to build up a psychotherapeutic relationship between clients and certified therapists in one-
on-one or small-scale formats (American Art Therapy Association, 2012), the former uses art as a platform to 
provide a social and creative outlets or activity schemes for promoting wellness (Castora-Binkley et al., 2010). 
Artwork consists of a process and a product, and the beneficial effects of creating art are not dependent 
on a person’s skill or talents; some argue it is reliant on the creative process (Patterson et al., 2011), 
some think that the product has more importance because of its interpretive value (Ahmed & 
Siddiqi, 2006). However, in the field of non-pharmacological interventions utilizing arts, 
rigorously designed and evaluated intervention studies are scarce.  
 
Empowerment through Arts: Process & Product 
Wreford defined empowerment as the development of self-efficacy (Bandura, 2000), the belief that 
an individual has about his or her capacity to execute behaviours necessary to produce specific 
performance attainments. Community-based art programmes have the potential to empower the 
participants, which is supported by empirical data. A UK study evaluating the impact of 
participatory art projects for people with mental health needs found that arts participation increased 
levels of empowerment and had the potential to impact mental health and social inclusion (Hacking 
et al., 2008). However, the mechanism of empowerment was not discussed in detail.  
We hypothesize that for older adults living with depression who might internalize ageist 
beliefs such as being useless and worthless, or stereotypes of depression as weak and undesirable 
to be around, both the creative process of art making and the final art product may act as 
empowering agencies. In the process of appreciating and creating art, the participants will be 
exposed to new things and acquire new skills. One unique feature of community-based cultural arts 
is its relative ease of creating a “no fail” environment since there is no right or wrong in art, and 
participants can feel safer to try and gain confidence in the creative process. The final product, as 
a tangible manifestation of the creative process, can be perceived by not only the participants 

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themselves but also the friends and families of the participants and also the general public. 
Therefore, for older adults who may have lost their productive roles, self-efficacy in learning and 
creating new things and social recognition of their creation may empower them to have reduced 
self-stigma.  
Preliminary findings 
We co-developed a cultural art programme with older adults and professionals and tested its 
feasibility and preliminary effects (Liu et al., 2023). The findings revealed that culturally 
appropriate participatory arts groups can effectively promote empowerment in older people, and a 
definitive trial is needed to reveal its effectiveness. 
Research plan and methodology 
Design  
This study is a two-arm randomized waitlist controlled trial. The trial will compare older adults at 
risk for depression joining the cultural arts programme (experimental), versus those who receive 
treatment as usual (waitlist control) in local NGOs. A statistician who is not involved in any part 
of the study will independently randomise participants by using a predetermined random table 
generated by Microsoft Excel. Those numbers will not be decoded until the intervention group is 
assigned. The allocation is known to the interventionists, and concealed to the participants. Data 
will be collected at two-time points: baseline (T0) and completion of the 9-session intervention 
(T1). 
Study Sample 
Fifty participants will be recruited through community outreach and open referrals from local 
NGOs. The inclusion criteria are: (a) aged 60 years or above; (b) at risk for depression, i.e., Patient 
Health Questionnaire (PHQ-9) score under 10 (Kroenke et al., 2001); (c) having at least one risk 
factor of depression, including frequent loneliness, lack of social interaction, lack of 
meaningful/enjoyable activities, chronic pain, more than four chronic diseases, or bereavement. 
The exclusion criteria were: (a) known history of autism, intellectual disability, schizophrenia-
spectrum disorder, bipolar disorder, Parkinson’s disease, or dementia; (b) illiterate; (c) physically 
frail; or (d) significant suicidal risk. 

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Interventions 
Participants in the experimental group will receive a nine-session (including an introductory and 
orientation session) cultural arts programme; the details of the programme are described in the 
protocol development paper (Liu et al., 2023). Participants in the control group will receive 
treatment as usual, which is their normal daily activities and usual mental health and health care 
available in NGO centers.  
 
Measurements 
The primary outcome measures are: 
1) Self-stigma:  
a. Stigma about Depression is accessed by the 16-item Self-Stigma of Depression 
Scale (SSDS) (Barney, Griffiths, Christensen, & Jorm, 2010), which comprises 
subscales of Shame, Self-Blame, Social Inadequacy, and Help-Seeking Inhibition. 
Questions begin with the stem “If I were depressed, I would …” and include items 
such as “feel inferior to others” (Shame), “think I should be able to cope with things” 
(Self-Blame), and “feel I couldn’t contribute much socially” (Social Inadequacy). 
Participants respond using a 5-point Likert scale of 1 (strongly disagree) to 5 
(strongly agree). 
b. Ageism beliefs are accessed by four questions modified from the Perceptions of 
Age Discrimination (PAD) (Sabik, 2015) to address internalized ageism. Items are 
rated on a scale of 1 (strongly disagree) to 5 (strongly agree) and included the 
statements “I consider myself a person who has been deprived of the opportunities 
that are available to others because of my age,” “I am excluded from many sectors 
of public life because of my age,” “After ending my working life, I am/will be 
considered to be worthless,” and “My achievements are not appreciated in our 
society because of my age.” 
2) Depression is assessed by the Patient Health Questionnaire (PHQ-9) (Kroenke et al., 2001). 
It is a 9-itme instrument that incorporates depression diagnostic criteria with other leading 
major depressive symptoms, and rates the frequency of the symptoms which factors into 
the scoring severity index. PHQ-9 scores of 5-9, 10-14, 15-19, 20 and above represent mild, 
moderate, moderately severe, and severe depression.   

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The secondary outcome measures are: 
1) Empowerment is measured by the self-empowerment subscale (4 items) from the Mental 
Health Recovery Measure (MHRM) (Young & Bullock, 2003). The MHRM scale has been 
validated in Hong Kong population (Ye et al., 2013). Items are rated on a 5-point scale 
ranging from 1, strongly disagree, to 5, strongly agree; higher scores indicate higher self-
reported level of self-empowerment. The four items are: “I believe in myself”, “I have 
control over my mental health problems”, “I am in control of my life”, and “I socialize and 
make friends”. 
2) Cognitive fusion is measured by the self-report Cognitive Fusion Questionnaire (CFQ) 
(Gillanders et al., 2014). It is a 7-item Likert-type scale ranging from 1 (never true) to 7 
(always true). Example items include: “My thoughts cause me distress or emotional pain” 
and “I tend to get very entangled in my thoughts.” Higher scores indicated higher levels 
of cognitive fusion in participants, ranging from 7 to 49. The scale was validated in 
Chinese, with good internal consistency (α = 0.92) and test-retest reliability (r = 0.67) 
(Zhang et al., 2014).  
 
The control variables are basic demographics: age, gender, marital status, education (years and 
highest attainment), work years, and number of chronic diseases. 
 
Data analysis 
We will generate descriptive statistics of the demographic and outcome variables at the baseline (T0). 
The independent sample t-test will be used to compare the means of continuous variables in the 
intervention and control groups; the chi-square test will be used to compare categorical variables; 
and Fisher exact test will be used for variables with low cell counts (n < 5). As observations at two 
time points are nested within individuals, changes in outcome measures will be assessed by a two-
level linear mixed model. R will be used for data analysis. Results will be reported according to the 
CONSORT statement for trials of non-pharmacological treatments. All results will be reported 
with the appropriate effect sizes, along with statistical significance and confidence intervals. 
 
 

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