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. 2023 May 5:1–13. Online ahead of print. doi: 10.1007/s12144-023-04536-x

Effects of the original zentangle method on older adults with depressive symptoms a randomized waitlist-controlled trial

Henri Chun-Yiu Chan 1, Herman Hay-Ming Lo 2,✉
PMCID: PMC10161183  PMID: 37359601

Abstract

Objectives: Depressive symptoms are common among older adults and many of them did not seek for professional help. Although Zentangle has been widely implemented in service centers for older adults in many societies, very limited empirical study has been conducted on the effects of this method. This study aims to evaluate the effects of Zentangle on community-dwelling older adults with depressive symptoms. Methods: A randomised waitlist-controlled trial of Zentangle was conducted. Forty-six community-dwelling older adults with mild to moderate depression were recruited and randomly assigned to a six session Zentangle group or a waitlist control group. The effects were examined by comparing the participants who received a six-week Zentangle intervention with those in the waitlist control group. Patient Health Questionnaire (PHQ-9), Self-compassion Scale – Short form (SCS-SF) and other mental health outcomes were assessed at baseline, post-intervention and six-week follow-up. Results: Repeated measure ANOVA revealed significant Time x Group effects for depression (F (2, 88) = 21.29, p < .001) and self-compassion (F (2, 88) = 18.50, p < .001) with a large net effect size. Six-week follow-up indicated that such improvements were sustained. Conclusion: This study provides preliminary support that the Zentangle programme is an effective alternative treatment approach for older adults with mild to moderate depression. The original Zentangle method can reduce depressive symptoms and cultivate self-compassion. Further research is necessary to expand our understanding of the underlying mechanisms of how the original Zentangle method works. Trial registration: ISRCTN66410347.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12144-023-04536-x.

Keywords: Late-life Depression, Self-compassion, Older adults, Zentangle, Randomised Waitlist Controlled Trial

Introduction

Managing depression in older adults

Depression is one of the world’s most common health issues, by which more than 264 million people are affected (World Health Organization, 2021). Late-life depression is associated with functional and cognitive disability and poor outcomes of physical illnesses (Rodda et al., 2011; Wilkinson et al., 2018).

Antidepressant medications are considered the first-line treatment for people suffering from major depression (Barry et al., 2012; National Health Service, 2019; National Institute of Aging, 2017). For older adults, however, low response rates or side effects of antidepressants have often been reported (Kok et al., 2012; Tham et al., 2016). Rates of non-adherence to antidepressants among older adults with depression are also high, ranging from 29 to 40% (Sirey et al., 2017). Many older adults perceive depression as a normal part of aging and believe that depression would pass with time by self-management, without the need for interventions (Nair et al., 2020). Psychotherapy is also recommended for older adults with depression, especially for those with mild to moderate depression (Kok & Reynolds, 2017). In a systematic review of community-based treatment for late-life depression, Frederick et al. (2007) showed that the effectiveness of group psychotherapy for late-life depression was mixed and recommended that a multifaceted approach that includes antidepressant medications and psychotherapy be used to ensure the effectiveness of treatment for depression. A meta-analysis conducted by Cuijpers et al. (2014) concluded that psychological intervention is generally effective in managing late-life depression and the effect of psychotherapy for older adults is similar to those for adults in general (Cuijpers, 2017).

Some interventions involving behavior activation targeting to promote pleasant activities and social activities such as doing exercises and investing time in personal hobbies have been found to be effective (Cuijpers et al., 2014). Pleasant activities have been determined to be a significant predictor of depression in a survey of older adults with minor or major depressive symptoms in the community in Hong Kong (Wong et al., 2018; Glass et al., 2006) also found that social engagement, including social activities, pleasant activities and leisure, was negatively associated with depressive symptoms. Increasing engagement in pleasant activities, including social activities or leisure, which can reduce loneliness, can be used as an intervention for late-life depression. Group therapy based on a creative approach may also be appealing to older adults with depression.

Some barriers to psychotherapy are culturally specific. For example, a study identified a number of factors, such as lack of information, lack of faith in treatment, self-reliance strategies or denial of suffering from depression, as the predominant barriers to psychotherapy among African-American older adults, which is consistent with their cultural beliefs and values (Conner et al., 2010). Concerning depression in the Chinese cultural context, emotional non-expression is a characteristic of the pragmatic Chinese mindset. Chinese individuals with this mindset often exhibit a low level of individuality and place importance on maintaining stability and harmony with others. Emotion regulation is important to maintain relational harmony and status hierarchies (Bond, 1993; Leung & Singh, 1998). The non-expression of emotions may be identified as cultural defence mechanisms, as they protect the individual against intrapsychic anxiety for disrupting interpersonal harmony and stability (Chung, 2006; Sun, 2013). Ryder and Chentsova-Dutton (2012) found that Chinese people with depression reported a higher level of suppressed emotions. Compared with Western counterparts, Chinese people with depression tend to report somatic complaints and are reluctant to report emotional distress (Dere et al., 2013). Therefore, an alternative approach that allows less direct expression of emotions and experiences may be favorable to older adults from such a pragmatic cultural background.

The original Zentangle Method

The Zentangle method, established in 2004, is an easy-to-learn, relaxing, and fun way to create beautiful images by drawing structured patterns (Roberts & Thomas, 2012, 2019). It emphasizes the “relaxed focus” aspect that aims to promote calmness and awareness (Roberts & Thomas, 2019). Zentangle was introduced as a practice to induce mindfulness. People who have drawn using the Zentangle method have described that their experience with the method was similar to their experience with mindfulness practices (Malchiodi, 2014; Roberts & Thomas, 2012). Compared with other visual art forms, Zentangle requires individuals to have an intention to not plan out their work and instead draw with no expectations or planned goals (Krahula, 2012). Participants need to pay attention to the instructions given by the facilitator or follow the steps to draw; this allows them to focus on every deliberate stroke, as they do not need to follow any plans. The Zentangle intervention may be conducted in an individual format, a group format or a guided self-help format.

Although Zentangle has been widely implemented in some countries, both in the general and clinical populations, studies of its outcomes are limited. Chung et al. (2022) conducted a pilot randomized controlled trial among adults and found that the level of anxiety was decreased and level of self-compassion increased among those participants who had more than eighty minutes Zentangle practice per day. Hesterman and McAuliffe (2017) conducted an ethnographic case study to examine the educational benefits of Zentangle for young children and showed its positive effects on children’s fine motor skills and language experience. Masika et al. (2020) conducted a mixed-methods pilot randomized controlled trial to investigate the efficacy of Zentangle in treating community-dwelling older adults with mild cognitive impairment (mean age = 72.7 years) in Tanzania. The experimental group (n = 21) was administered a 6-week intervention of Zentangle, whereas the control group (n = 18) was provided usual health education. The Zentangle group demonstrated significant improvement in depressed mood after the intervention, compared with the control group. However, the maintenance effect of the intervention was not evaluated, and the sample was limited to older adults with cognitive impairment living in rural areas. Chen et al. (2016) conducted a randomized controlled trial to investigate the efficacy of Zentangle in treating anxiety symptoms of patients with schizophrenia in Taiwan. The experimental group (n = 22) was administered an 8-week intervention of Zentangle, whereas the waitlist control group (n = 22) was provided occupational training. The Zentangle group showed significant improvement in self-esteem and anxiety in social interactions after the intervention, compared with the waitlist control group. Chang (2016) conducted an online survey and based on 106 respondents who practice Zentangle regularly, positive changes in their self-worth and emotion regulation were reported.

Gilbert (2007) provided a model of threat and problematic innate defenses and suggested self-compassion as the key to treating depression (Gilbert, 2007; Gilbert & Simos, 2022). In the current study, this model is used to elucidate the possible mechanism underlying the effects of Zentangle. According to Gilbert (2007), depression is a stress-coping defense mechanism involving the toning up of threat sensitivities and the toning down of positive emotions, which manifests in the face of thwarted goals and social and role conflicts. When the stress-coping defenses are successfully enacted and coping is successful with adjustment, mood changes are mild or transitory. When stress activation continues and physiological dysfunction increases, depression is likely to happen. The abilities to feel socially connected, content and calm are also toned down in this state. Psychological interventions aim to restimulate these abilities and thereby regulate the threat and drive systems.

Self-compassion involves being open to and moved by one’s own suffering, experiencing feelings of caring and kindness toward oneself, taking an understanding, non-judgmental attitude toward one’s inadequacies and failures, and recognizing that one’s own experience is part of the common human experience (Neff, 2003, 2021; Neff & Germer, 2013). An increasing amount of research on the relationship between self-compassion and depression has emerged in recent years. A meta-analysis showed that lower levels of self-compassion were a significant predictor of depressive, anxiety and stress symptoms (MacBeth & Gumley, 2012; Hughes et al., 2021) conducted a systematic review and found that self-compassion is inversely associated with the level of depression and anxiety among people with physical chronic illness. Two other meta-analyses found that an increase in self-compassion had a positive effect on mental health outcomes, such as depression, anxiety and well-being (Kirby et al., 2017), and that self-compassion interventions had a moderate yet significant effect on stress, depression and anxiety (Ferrari et al., 2019).

Objectives of the study

As mentioned, alternative psychological intervention to support older adults with depression should be promoted. Recently, Zentangle as a unique intervention approach that requires less emotional expression and promotes self-compassion has been applied in community services for older adults to promote mental wellness and applied as a group intervention (Liu et al., 2022). However, little is known about the effects of the Zentangle intervention on older adults with late-life depression. Thus, the aims of this study were to evaluate whether the Zentangle intervention affects depression and self-compassion among older adults with depression and whether it has maintenance effects on depression and self-compassion at the 6-week follow-up after the intervention. This study used a waitlist control design to evaluate the abovementioned effects of a 6-week Zentangle intervention. It was hypothesized that compared with the waitlist control group, the intervention group would show greater improvements in depressive symptoms, levels of self-compassion, and other mental health outcomes at post-intervention. It was also hypothesized that a maintenance effect would be observed on depression, self-compassion, and related mental health outcomes in the intervention group at the 6-week follow-up.

Method

Sample size

A priori power analysis computed the sample size by controlling the statistical power (Faul et al., 2007). With reference to other similar research on RCTs in mindfulness practice (Azam et al., 2015; Friis et al., 2016; Jang et al., 2016; Moss et al., 2015), an estimated effect size f of 0.2 was set for changes of the primary outcome. On the basis of a one-sided type I error of 5% and 80% power to detect statistically significant differences (Noordzij et al., 2010) between the intervention group and waitlist control groups (ANOVA; 2 (Groups) x 3 (Time) repeated measures, within-between interaction), a total of 42 older adults (i.e. 21 in the intervention group and 21 in the waitlist control group) were needed in total, as calculated by the statistical software G-Power 3.1.9.2. Assuming an attrition rate of 10%, the total number of participants was expected to be 46 older adults. In the recruitment process, the participants were randomly assigned to the intervention group and the waitlist control group.

Participants

Participants were openly recruited or referred by social workers in two elderly community centers in Hong Kong. Fifty-eight participants over the age of 60 who applied for the Zentangle program from July to September 2019 were recruited for this study. Screening interviews were conducted to assess the participants’ eligibility through Patient Health Questionnaire-9 (PHQ-9) and assess the risk of participating the study. The inclusion criteria were as follows: (a) older adults living in the community, (b) aged 60 or above, (c) scoring 5 or above in the PHQ-9 and (d) having no formal psychiatric diagnosis of any mental health illness other than major depression. The exclusion criteria were as follows: a) severe depression (with a PHQ-9 score greater than 24; b) current suicidality; c) with previous suicide attempts. Excluded participants were follow-up by clinical social workers in the service unit.

Twelve participants were excluded from the study because their PHQ-9 score for depression did not meet the cut-off point (n = 8) or they were not interested in participating in the study (n = 4). Forty-six participants (24 from one center and 22 from another) were randomly assigned to the intervention or the waitlist control group. The randomisation sequence was created by Microsoft Excel using random block sizes of 2 and was administered by an independent collaborator who had no knowledge of the applicants and was not involved in the program implementation. The CONSORT flowchart of participant recruitment and intervention implementation in this randomized waitlist-controlled trial is provided in Fig. 1 (Hoffmann et al., 2014; Schulz et al., 2010).

Fig. 1.

Fig. 1

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CONSORT Diagram of the Process for this Randomised Waitlist Controlled trial

Procedure

The participants in the intervention group attended the Zentangle program during the study period. A number of measurement tools were adopted to evaluate and compare the outcomes between the intervention and waitlist control groups. Data collection was done before the intervention (baseline) (T0), immediately after the intervention (post-intervention; T1) and in a follow-up 6 weeks after completing the intervention (T2). This method yielded a between-group comparison condition. For ethical reasons, the same six-session Zentangle program was arranged for the waitlist control group after the study period.

The intervention consisted of six weekly sessions, each lasting 1.5 h once a week over the course of 6 weeks and involving 8–10 participants. A six-session intervention was developed based on the original Zentangle method (Roberts & Thomas, 2012, 2016, 2019) and the protocol was developed by the first author. The protocol was further revised after review by two certified Zentangle teachers (CZTs), each with 2 years of experience in teaching Zentangle to older adults. Pilot testing of the intervention protocol was done in three elderly community centers. Each session of the Zentangle program focused on a specific topic to cultivate the participants’ self-compassion and promote calmness through learning different drawing techniques and patterns. The theme and content of each session are summarized in Table 1.

Table 1.

Session plan of the Zentangle program

Session Theme Content
1

Self-awareness

and self-kindness

• Introduction, basic technique, principles and the eight steps in the original Zentangle method

• Draw in a mindful way: be sensitive and attentive

• Experience self-kindness and mindfulness

• Grid patterns: Keeko, Florz and Hollibaugh

• Round patterns: Printemps and Crescent Moon
2 Acceptance and non-judgmental attitude

• Expand techniques in the original Zentangle method

• Bring attention and awareness to self and others

• Experience self-acceptance and avoid self-criticism

• Grid patterns: Beelight, Cubine and Bales

• Texturing patterns: Nzeppel, Purk and Spoken
3 Acceptance and non-judgmental attitude

• Expand techniques in the Zentangle method

• Bring attention and awareness to self and others

• Experience self-acceptance and avoid self-criticism

• Organic patterns: Flux and Indy-rella
4 Distress tolerance

• Advanced techniques in the Zentangle method

• Respond to self-criticism with warmth

• Experience common humanity

• Blossoming patterns: Rumpus, Vitruvius and Flux
5 Distress tolerance

• Advanced techniques in the Zentangle method

• Respond to self-criticism with warmth

• Experience common humanity

• Geometric patterns: DooDah and ING

• Triangular patterns: Hemp, Munchin and Tripoli
6 Interconnectedness

• Recapture the main theme of the group

• Experience self-kindness, common humanity versus isolation

• Care for well-being: Find your soothing pattern

• Collective mosaics using Zentangle

• Grid pattern: Well

• Blossoming patterns: Poke leaf and Verdigogh

• Triangular patterns: Hemp and Munchin
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Two CZTs with a bachelor’s degree or above in social work and 3–5 years of experience in providing the Zentangle intervention for older adults with depression including the first author were the instructors to conduct the intervention. Both CZTs completed a 4-day certification program provided by Rick Roberts and Maria Thomas, the founders of Zentangle Inc. (Zentangle Inc, 2020).

Measures

Depression. The PHQ-9 is a 9-item self-report instrument with comparable sensitivity and specificity in screening people with major depressive disorder (Kroenke & Spitzer, 2002). It includes the nine essential criteria for the diagnosis of depression from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association, 2013). All items are scored on a 4-point scale ranging from 0 (not at all) to 3 (nearly every day). The total PHQ-9 scores range from 0 to 27, with higher scores indicating a greater severity of depressive symptoms. The internal consistency of the PHQ-9 in this study was good (Cronbach’s α = 0.83).

Self-compassion. The Self-compassion Scale – Short Form (SCS-SF) (Raes et al., 2011) is a 12-item self-report instrument with a six-factor structure that assesses the following components of self-compassion: self-soothing tendency including self-kindness, common humanity and mindfulness, and self-defeating tendency, including self-judgment, isolation and over-identification. All items are scored on a 5-point scale from 1 (almost never) to 5 (almost always) based on the extent to which each statement reflects how an individual has usually treated themselves during difficult times. Higher scores indicate greater self-compassion. In this study, internal consistency was good for both the total score (α = 0.86) and the subscales (self-soothing tendency, α = 0.79; self-defeating tendency, α = 0.84).

Positive and Negative Affect. The Positive and Negative Affect Schedule (PANAS; Watson et al., 1988) was used to measure the level of positive and negative affect. This self-report instrument consists of two scales: the positive and negative affect scales. These scales contain 10 positive emotion adjectives and 10 negative emotion adjectives, respectively, to indicate the respondents’ perception of experiencing each emotion within the past week. Each adjective is scored on a 5-point scale from 1 (not at all) to 5 (extremely). The total scores for positive affect and negative affect are obtained by summing up the scores on the relevant items. Higher scores indicate more positive or negative affect. The internal consistency of the positive and negative affect scales in this study was good (α = 0.81 and 0.85, respectively).

Data Analysis

All analyses were carried out according to the intention-to-treat principle. Any missing values of the participants were imputed by the multiple imputation method, a simulation-based statistical technique for handling missing data (Jakobsen et al., 2017; Skoog et al., 2015).

Outcomes of the study are analyzed the data using a mixed model with a repeated measures design to account for the variance in random intercepts between participants. Effects of the group (between intervention and control), time (across T0, T1, and T2), and their interaction on all psychological outcomes were examined. The model used t statistics to further compare the means between timepoints within groups and the timepoint differences between groups, providing more insights into the intervention effectiveness. Please note that the comparison between timepoints was based on subtracting a latter timepoint from a former timepoint. For example, a positive value between T0 and T1 indicates that the value in T0 is larger than that in T1 with a downward trend, and vice versa. Cohen’s d were interpreted as small (d = 0.2), medium (d = 0.5) and large (d = 0.8) effects based on the benchmarks suggested by Cohen (1988) (Lakens, 2013). All analyses were performed on jamovi using the GAMLj module.

Results

Table 2 summarizes the demographic characteristics of the participants. The study sample was predominantly female (89.1%). The mean age was 72.9 years (SD = 5.6) in the intervention group and 73.7 years (SD = 7.35) in the waitlist control group, indicating no significant between-group difference in age (t (44) = − 0.406, p = .686). No significant between-group differences were observed in any of the other demographic variables, including sex, living arrangement, history of psychiatric diagnoses and consumption of psychiatric medications (all ps > 0.5).

Table 2.

Demographics of Participants for the Study (Intention-to-treat)

Intervention
(N = 23)		 Control
(N = 23)
N % N % t (44) x 2 p
Sex -- 0.224 0.636
Male 3 13.0 2 8.7
Female 20 87.0 21 91.3
Age − 0.406 -- 0.687
Mean 72.9 73.7
 S.D. (5.6) (7.35)
Living arrangement -- − 0.882 0.643
Living alone 8 34.8 7 30.4
Living with spouse 7 30.4 10 43.5
Living with family 8 34.8 6 26.1
Psychiatric diagnoses (depression) -- 0.890 0.345
Yes 9 36.8 6 26.1
No 14 63.2 17 73.9
Psychiatric medication -- 2.681 0.101
Yes 9 36.8 4 17.4
No 14 63.2 19 82.6
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Depressive symptoms

Changes in depressive symptoms revealed large time, F(2, 88) = 21.285, d = 1.391, p < .001, and interaction effects, F(2, 88) = 21.285, d = 1.391, p < .001, but not the group effect (see Table 3). Underlying the large interaction effect was the strong time effect within the intervention group, in which there were lower depressive symptoms in T0 than in T1 (B = 2.83, SE = 0.33, 95% CI [2.17, 3.49]) and T2 (B = 2.43, SE = 0.33, 95% CI [1.78, 3.09]) respectively. The effect in the intervention group persisted from T1 and T2 (B = -0.39, SE = 0.33, 95% CI [-1.05, 0.27]).

Table 3.

Measures over time for the Zentangle program and waitlist control group

Outcome Time effect Control (n = 23) Intervention (n = 23) Group difference
F t d p F t d p F t d p
Depression Overall 0.000 - 0.000 1.000 42.570 - 1.968 < 0.001 0.819 0.905 0.273 0.370
T0 → T1 - 0.000 0.000 1.000 - 8.515 0.908 < 0.001 - 6.021 1.284 < 0.001
T0 → T2 - 0.000 0.000 1.000 - 7.336 0.782 < 0.001 - 5.187 1.106 < 0.001
T1 → T2 - 0.000 0.000 1.000 - -1.179 -0.126 0.242 - -0.834 -0.178 0.407
Self-compassion Overall 0.148 - 0.110 0.862 41.713 - 1.949 < 0.001 4.135 -2.034 0.613 0.048
T0 → T1 - -0.439 -0.047 0.661 - -8.349 -0.890 < 0.001 - -5.593 -1.192 < 0.001
T0 → T2 - -0.498 -0.053 0.620 - -7.382 -0.787 < 0.001 - -4.868 -1.038 < 0.001
T1 → T2 - -0.059 -0.006 0.953 - 0.967 0.103 0.336 - 0.725 0.155 0.470
Self-soothing Overall 0.585 - 0.230 0.559 50.318 - 2.137 < 0.001 7.234 -2.690 0.811 0.010
T0 → T1 - -0.912 -0.097 0.364 - -9.263 0.987 < 0.001 - -5.905 -1.259 < 0.001
T0 → T2 - -0.960 -0.102 0.340 - -7.967 -0.849 < 0.001 - -4.955 -1.056 < 0.001
T1 → T2 - -0.048 -0.005 0.962 - 1.296 0.138 0.198 - 0.950 0.203 0.345
Self-defeating Overall 0.022 - 0.000 0.979 13.212 - 1.096 < 0.001 1.303 1.142 0.344 0.260
T0 → T1 - -0.200 -0.021 0.842 - 4.594 0.490 < 0.001 - 3.390 0.723 0.001
T0 → T2 - -0.150 -0.016 0.881 - 4.294 0.458 < 0.001 - 3.143 0.670 0.002
T1 → T2 - 0.050 0.005 0.960 - -0.300 0.032 0.765 - -0.247 -0.053 0.805
Self-kindness Overall 0.552 - 0.220 0.578 25.241 - 1.516 < 0.001 2.789 -1.670 0.504 0.102
T0 → T1 - -1.001 -0.107 0.320 - -6.673 -0.711 < 0.001 - -4.011 0.000 < 0.001
T0 → T2 - -0.779 -0.083 0.438 - -5.450 -0.581 < 0.001 - -3.303 0.000 0.001
T1 → T2 - 0.222 0.024 0.824 - 1.223 0.130 0.224 - 0.708 0.000 0.481
Common humanity Overall 0.725 - 0.255 0.487 49.351 - 2.120 < 0.001 19.784 -4.449 1.341 < 0.001
T0 → T1 - -0.976 -0.104 0.332 - -8.664 -0.924 < 0.001 - -5.436 -1.159 < 0.001
T0 → T2 - -1.098 -0.117 0.275 - -8.542 -0.911 < 0.001 - -5.264 -1.122 < 0.001
T1 → T2 - -0.122 -0.013 0.903 - 0.122 0.013 0.903 - 0.173 0.037 0.863
Mindfulness Overall 0.135 - 0.110 0.874 35.324 - 1.791 < 0.001 1.727 -1.315 0.396 0.196
T0 → T1 - -0.260 -0.028 0.796 - -8.055 -0.859 < 0.001 - -5.512 -1.175 < 0.001
T0 → T2 - -0.520 -0.055 0.605 - -6.106 -0.651 < 0.001 - -3.950 -0.842 < 0.001
T1 → T2 - -0.260 -0.028 0.796 - 1.949 0.208 0.055 - 1.562 0.333 0.122
Self-judgment Overall 0.025 - 0.063 0.976 4.166 - 0.613 0.019 0.993 0.997 0.300 0.325
T0 → T1 - 0.222 0.024 0.825 - 2.553 0.272 0.012 - 1.649 0.351 0.103
T0 → T2 - 0.111 0.012 0.912 - 2.442 0.260 0.017 - 1.649 0.351 0.103
T1 → T2 - -0.111 -0.012 0.912 - -0.111 -0.012 0.912 - 0.000 0.000 1.000
Isolation Overall 0.166 - 0.127 0.847 14.572 - 1.152 < 0.001 0.845 0.919 0.277 0.363
T0 → T1 - -0.436 -0.046 0.664 - 5.010 0.534 < 0.001 - 3.850 0.821 < 0.001
T0 → T2 - 0.109 0.012 0.914 - 4.247 0.453 < 0.001 - 2.926 0.624 0.004
T1 → T2 - 0.545 0.058 0.587 - -0.762 -0.081 0.448 - -0.924 -0.197 0.358
Over-identification Overall 0.275 - 0.155 0.760 8.391 - 0.873 < 0.001 1.238 1.113 0.336 0.272
T0 → T1 - -0.295 -0.031 0.769 - 3.391 0.362 0.001 - 2.606 0.556 0.011
T0 → T2 - -0.737 -0.079 0.463 - 3.686 0.393 < 0.001 - 3.128 0.667 0.002
T1 → T2 - -0.442 -0.047 0.659 - 0.295 0.031 0.769 - 0.521 0.111 0.603
Positive affect Overall 1.186 - 0.327 0.310 36.067 - 1.809 < 0.001 18.144 -4.260 1.284 < 0.001
T0 → T1 - -1.503 -0.160 0.136 - -8.190 -0.873 < 0.001 - -4.728 -1.008 < 0.001
T0 → T2 - -0.460 -0.049 0.647 - -6.043 -0.644 < 0.001 - -3.948 -0.842 < 0.001
T1 → T2 - 1.043 0.111 0.300 - 2.147 0.229 0.035 - 0.781 0.166 0.437
Negative affect Overall 0.133 - 0.110 0.876 14.919 - 1.164 < 0.001 5.600 2.367 0.714 0.022
T0 → T1 - 0.088 0.009 0.930 - 4.617 0.492 < 0.001 - 3.202 0.683 0.002
T0 → T2 - 0.484 0.052 0.630 - 4.837 0.516 < 0.001 - 3.078 0.656 0.003
T1 → T2 - 0.396 0.042 0.693 - 0.220 0.023 0.826 - -0.124 -0.027 0.901
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Note. Although the standard deviations of depression differed across three time points in control group, their means were identical, so the p values were 1. The comparisons between timepoints were made by subtracting a latter timepoint from a former timepoint. Consequently, for example, a positive value from “T0 → T1” indicated a downward trend that T0 was larger than T1, whereas a negative value from “T0 → T1” indicated an upward trend that T0 was smaller than T1.

Fig. 2.

Fig. 2

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Profile Plot

Further analysis was conducted to examine the changes in the severity level of depression. The PHQ-9 scores of all participants in both the intervention and waitlist control groups were categorized into levels of depression severity according to the cut-off point. At post-intervention and the 6-week follow-up, eight (34.8%) and six (26.1%) participants reported no depression, respectively. Two participants (8.7%) in the intervention group were categorized as having a moderate level of depression at baseline (T0), whereas no participants reported a moderate level of depression at post-intervention (T1) and the 6-week follow-up (T2).

To investigate the impact of the intervention, the Reliable Change Index (Jacobson & Truax, 1991) was computed by dividing the difference in scores between baseline (T0) and post-intervention (T1) by the standard error. Table 4.6 summarizes the number of participants who reported improvement, no change or increased depression severity after the intervention. The comparison of the measures between baseline (T0) and post-intervention (T1) showed that eight (34.8%) participants in the intervention group exhibited improvements in depression, while no participant reported worsened symptoms after completing the intervention. In the waitlist control group, one (4.3%) participant reported improvements in depression, while one (4.3%) reported worsened depressive symptoms. The chi-square analysis results confirmed that these differences were significant (x2 = 7.44, p = .03).

The level of clinical significance was further assessed based on the number of participants reporting a 50% reduction in their symptom scores at post-intervention (T1). Six (26.1%) participants in the intervention group, but only one (4.3%) participant in the waitlist control group, reported a 50% reduction in the depression scores. The chi-square analysis confirmed that these between-group differences were significant (x2 = 4.21, p = .04).

Self-compassion

Effects of time, F(2, 88) = 23.36, d = 1.46, p < .001, group, F(1, 44) = 4.14, d = 0.61, p = .048, and interaction, F(2, 88) = 18.50, d = 1.30, p < .001, were mostly large on improving general self-compassion. Similar to the interaction effect on depression, stronger self-compassion was observed in the intervention group from T0 to T1 (B = -1.03, SE = 0.12, 95% CI [-1.28, -0.79]) and T2 (B = -0.91, SE = 0.12, 95% CI [-1.16, -0.67]) respectively, and remained unchanged between T1 and T2 (B = 0.12, SE = 0.12, 95% CI [-0.13, 0.37]).

These results generally mirrored those of the overall self-soothing, Ftime(2, 88) = 30.80, d = 1.67, p < .001, Fgroup(1, 44) = 7.23, d = 0.81, p = .010, Finteraction(2, 88) = 20.11, d = 1.35, p < .001, and self-defeating, Ftime(2, 88) = 6.09, d = 0.75, p = .003, Fgroup(1, 44) = 1.30, d = 0.34, p = .260, Finteraction(2, 88) = 7.14, d = 0.81, p = .001. The interaction effect consistently increased self-soothing and decreased self-defeating in the intervention group from T0 to T1 (Bsoothing = -1.40, SE = 0.15, 95% CI [-1.70, -1.10]; Bdefeating = 0.67, SE = 0.15, 95% CI [0.38, 0.96]) and T2 (Bsoothing = -1.20, SE = 0.15, 95% CI [-1.50, -0.90]; Bdefeating = 0.62, SE = 0.15, 95% CI [0.33, 0.91]) respectively. The effect on both persisted across T1 and T2 (Bsoothing = 0.20, SE = 0.15, 95% CI [-0.10, 0.50]; Bdefeating = -0.04, SE = 0.15, 95% CI [-0.33, 0.24]).

Positive affect

Effects of time, F(2, 88) = 24.40, d = 1.49, p < .001, group, F(1, 44) = 18.14, d = 1.28, p < .001, and interaction, F(2, 88) = 12.85, d = 1.08, p < .001, were large on promoting positive affect. Stronger positive affect was observed in the intervention group from T0 to T1 (B = -11.61, SE = 1.42, 95% CI [-14.43, -8.79]). Although the same applied between T0 and T2 (B = -8.57, SE = 1.42, 95% CI [-11.38, -5.75]), T2 had a lower level of positive affect than T1 (B = 3.04, SE = 1.42, 95% CI [0.23, 5.86]).

Negative affect

Large effects of time, F(2, 88) = 8.47, d = 0.88, p < .001, group, F(1, 44) = 5.60, d = 0.71, p = .022, and interaction, F(2, 88) = 6.58, d = 0.77, p = .002, showed effective reduction in negative affect. Lower negative affect was observed in the intervention group from T0 to T1 (B = 4.57, SE = 0.99, 95% CI [2.60, 6.53]) and T2 (B = 4.78, SE = 0.99, 95% CI [2.82, 6.75]) respectively, and remained unchanged between T1 and T2 (B = 0.22, SE = 0.99, 95% CI [-1.75, 2.18]).

Discussion

This study is one of the few empirical studies on the outcome of the original Zentangle method and, to the best of our knowledge, is the only study conducted in older adults with depression. The results from this trial provide evidence to support the use of the 6-week Zentangle program as a supplementary nonpharmacological approach to treat late-life depression of mild or moderate severity. The analyses of both the immediate intervention effects and maintenance effects revealed significant improvements in the participants’ depressive symptoms. Compared with the wait-list controlled group, participants from the intervention group showed significant larger improvement in depressive symptoms after the Zentangle program. The empirical findings of the present study support our hypothesis and the change in the PHQ-9 depression scores with a large effect size. These findings is consistent with the research findings of Masika et al. (2020), giving support to Zentangle as a supplementary treatment for older adults with depression. Besides, based on the criteria by Jacobson and Truax (1991), more than one-third of the participants reported reliable change after the Zentangle program and none of the them reported similar change in the wait-list control condition.

Furthermore, significant changes were found in the participants’ positive and negative affect from baseline to immediately after the intervention and to the 6-week follow-up. This finding suggests the efficacy of the Zentangle program in increasing positive affect and reducing negative affect among older adults with depression. The outcome is consistent with the Chung et al. (2022)’s findings that participation in Zentangle activity was associated with a decrease of negative affect. Moreover, participants perceived the Zentangle program as a pleasant activity, as it provided time and space for sharing and mutual appreciation among group members and with the instructor and thus enhanced social engagement. This outcome is consistent with the findings of Glass et al. (2006) and Wong et al. (2018) that participation in pleasant activities is associated with alleviation of depressive symptoms among older adults.

It is found that the Zentangle program could effectively improve self-compassion among older adults with depressive symptoms. This enhancement of self-compassion may be the possible mechanism underlying the effects of the original Zentangle method on older adults with depressive symptoms. This finding is consistent with the finding of Germer and Neff (2019) that self-compassion can be enhanced by different psychological interventions. Similarly, studies have shown that mindfulness-based interventions without explicit training on self-compassion can also promote self-compassion (Greenberg et al., 2018; James & Rimes, 2018; Taylor et al., 2014). The outcome is consistent with the findings of (Chung et al., 2022) that participation in Zentangle activity is associated with an increase in self-compassion.

This study provides strong evidence for the efficacy of the Zentangle program in improving self-soothing tendencies and reducing self-defeating tendencies. It is found a higher F ratio for the changes in self-soothing tendencies than for the changes in self-defeating tendencies, which implies that the effect of the Zentangle program on the changes in self-soothing tendencies is greater than that on the changes in self-defeating tendencies. A possible interpretation of these findings is that self-soothing tendencies confer psychological strength and resilience in times of adversity. In contrast, self-defeating tendencies are an indicator of psychological vulnerability. The concepts and perceptions of both the self-soothing (such as appreciating, comforting and calming oneself) and self-defeating (such as making no mistakes) tendencies were discussed by the instructor in the Zentangle program and during the drawing process. The Zentangle intervention appeared to inspire the participants into adopting a self-soothing tendency, although managing self-defeating tendencies was beyond the scope of this intervention.

During the drawing process, the instructor would also remind the participants to focus on their drawing, pay attention to the pattern they were drawing and concentrate on the sensation and feeling of each stroke. These actions are similar to those intended to refocus and alter one’s attention in self-compassion training. It echoed with the scoping review conducted by Gao et al. (2023), which found that self-compassion is a protective factor for late-life depression and it moderates the loneliness effect on depression. Self-compassion is correlated with reduced perfectionism, rumination and fear of failure (Neff, 2003a; Neff, Hsieh & Dejitterat, 2005). Meanwhile, Zentangle also promotes participants’ understanding of the concepts of “no mistakes”, “no perfect leaf” and “noticing the present moment” (Roberts & Thomas, 2012, 2016).

Our study showed that the Zentangle method is a feasible supplementary intervention to treat late-life depression. This method aims at promoting a non-judgmental attitude and mindfulness through drawing, which may be suitable for older adults with depression who prefer not expressing themselves to avoid social comparison or due to fear of judgment from others. Mental health practitioners in community health care can use the Zentangle method as a supplementary treatment, along with psychotherapy or pharmacological treatment, for mild or moderate late-life depression. The Zentangle method for older adults with depressive symptoms can also be conducted in therapeutic groups. The 6-week intervention tested in this study would also be easy to replicate in community centers for older adults. Along with face-to-face group sessions, home assignments could be prescribed to enable participants to cultivate a habit of drawing Zentangle as a self-help pleasant leisure activity.

Mindfulness-based program and Zentangle program share some similarities: First, these practices can promote stress reduction. Individuals have reported a decrease in stress after practicing both mindfulness-based program and Zentangle program (Masika et al., 2020). Second, both intervention involve a training in attention focus that would be helpful to reduce the ruminations that is common found among people experiencing major depression. A present focus attention can develop acceptance and non-judgmental attitudes that would be helpful to reduce depressive symptoms arising from loss and related memories (Wilson & Gregory, 2018). As for the difference between the two approaches, Zentangle combines mindfulness with art that can increase people’s acceptance and awareness through new visual senses (Jang et al., 2016; Newland & Bettencourt, 2020), while mindfulness-based program may provide visual, body-state, and acoustic experiences that can promote holistic-intuitive mind processing (Teasadale, 2022). Although social interactions were limited during the pandemic, there were some Zentangle activities conducted by NGOs through online platform to promote mental wellness under the pandemic in Hong Kong (Li et al., 2020). Further research direction may explore the differential approaches of mindfulness-based program and Zentangle method in reducing emotional distress and depressive symptoms for individuals.

Limitations

The first limitation of this study is that the sample was small, without formal diagnosis of major depression, mostly comprised women (89.04%) and recruited entirely through community centers for older adults in Hong Kong. Further studies using larger samples of older adults with formal diagnosis of major depressive disorder are warranted to verify our findings. Furthermore, in this study, outcomes were only evaluated using self-report measures. Future studies should consider multiple assessments including diagnostic interviews to assess outcomes.

The second limitation is that the follow-up period in this study was only 6 weeks, which is relatively short. Therefore, the maintenance effects should be verified in studies with longer follow-up periods, such as 6 months or 1 year, which will help to generate evidence of the long-term effects of the Zentangle program.

The third limitation is that the study had a waitlist control design, and therefore, no intervention was provided to the waitlist control group during the study period. The social gathering effect in the intervention group could not be eliminated. Future studies are recommended to include an active control group, such as a psychoeducational group, a social gathering group or other types of social support interventions to control for the social gathering effect.

Based on our initial sample estimation, a larger and adequate sample would be recruited to investigate the outcome of Zentangle program and to include mediational analysis of self-compassion for this study. Unfortunately, due to the COVID-19 pandemic, the research team could only recruit a small sample, as other community centers were shut down for face-to face services and collaborators were withdrawn from participation in this study. Further research efforts are warranted to investigate the outcome of Zentangle program with an adequate sample size and to explore the mechanism underlying the effects of the Zentangle program and the role of self-compassion in treating late-life depression. Specifically, a more detailed investigation of how the Zentangle program reactivates the self-soothing tendencies and reduces rumination, worry and self-criticism is recommended (Berking & Whitley, 2014; Gratz & Roemer, 2008).

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1 (25.1KB, docx)

Declarations

Ethical approval

All procedures performed in our study were approved by the Human Subjects Ethics Sub-committee at the Hong Kong Polytechnic University (Reference number: HSEARS20190806001) and in accordance with the ethical standards of the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

All participants received an explanation of the experimental processes before the study began and provided written informed consent.

Conflict of interest

The authors declare no competing interests.

Trial registration

ISRCTN, ISRCTN66410347, Registered 5 April 2021 – Retrospectively registered.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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