CRITICALLY APPRAISED PAPER (CAP)

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1 CRITICALLY APPRAISED PAPER (CAP) Pinniger, R., Brown, R. F., Thorsteinsson, E. B., & McKinley, P. (2012). Argentine tango dance compared to mindfulness meditation and a waiting-list control: A randomised trial for treating depression. Complementary Therapies in Medicine, 20(6), CLINICAL BOTTOM LINE Psychological stress, anxiety, and depression may significantly affect an individual s quality of life and lead to decreased engagement in meaningful occupations and levels of independence. Unfortunately, many individuals are reluctant to seek conventional psychiatric treatment or be labeled as mentally ill. As a result, they avoid traditional treatments and do not receive the critical help that they need. However, these patients may be more receptive to nontraditional treatments. Thus, it is important for therapists to be aware of different therapy modalities to treat depression. In this study, a Level I randomized controlled trial was used to evaluate tango dance as an alternative treatment to alleviate stress, anxiety, and depression. This treatment was compared with a mindfulness meditation group as well as a waitlist control group. The tango dance group and mindfulness meditation group met for 1.5 hours per week for 6 weeks. Each session was graded and introduced a new aspect of either mindfulness or tango dance. The findings indicate that mindfulness meditation and tango dance could be effective complementary therapies for the treatment of depression or stress. Furthermore, the tango dance program was associated with increased levels of mindfulness and decreased levels of psychological stress. Thus, the authors postulated that tango is a possible cost-effective and practical alternative to traditional psychiatric treatment for depression. Occupational therapists see their patients holistically and create individualized treatment plans according to the needs of the patient. As occupational therapists become more prominent in the field of mental health, it is important to expand the repertoire of mental health treatments and consider all alternative therapies that may be beneficial for different patients with mental health needs. Tango dance may be an appealing, cost-effective, and evidence-based intervention for occupational therapists to recommend for patients who have depression. 1

2 RESEARCH OBJECTIVE(S) Determine whether tango dancing is as effective as mindfulness meditation in reducing symptoms of psychological stress, anxiety, and depression and in promoting well-being DESIGN TYPE AND LEVEL OF EVIDENCE Level I: Randomized controlled trial PARTICIPANT SELECTION How were participants recruited and selected to participate? Advertisements were used to recruit participants with self-reported stress, anxiety, or depression. These advertisements were placed in local newspapers, medical centers, and technical colleges in the Sydney metropolitan area and displayed on two websites ( and Respondents were 97 individuals who had self-reported stress, anxiety, depression, or a combination thereof, as assessed by the Depression Anxiety Stress Scale. Participants were randomized to the tango intervention, mindfulness intervention, or waitlist control group. Out of the 97 individuals who answered the advertisement, 66 completed the randomized controlled trial. Inclusion criteria: Age 18 years or older Self-reported psychological distress Exclusion criteria: Pregnancy Walking or balance problems PARTICIPANT CHARACTERISTICS N= 66 #/ % Male: 6/(9.1%) #/ % Female: 60/(90.9%) Ethnicity: Not reported Disease/disability diagnosis: Self-reported stress, anxiety, or depression, as assessed by the Depression, Anxiety, and Stress 2

3 Scale INTERVENTION AND CONTROL GROUPS Group 1: Control group Brief description of the intervention How many participants in the group? Where did the intervention take place? The waitlist control group did not receive meditation or tango dance classes. They were mailed the pretest survey at the beginning of the study. The same survey was sent 6 weeks later, at posttest. Thirty-one participants were allocated to the control group, and 29 completed the program. Not applicable Who delivered? How often? For how long? Not applicable Not applicable 6 weeks Group 2: Mindfulness meditation group Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? The mindfulness meditation group went to meditation classes based on mindfulness exercises. At the start of class, participants were asked to relax and leave the world behind, so they could pay full attention. Instructors emphasized enjoying the experiences rather than achieving a certain outcome (10 minutes). This was followed by a warm-up period (10 minutes) and then the 1-hour class. Meditation sessions focused on breathing, the mindfulness of eating, body scanning, walking meditation, and music meditation. At the end, participants were asked to sign the sign-out sheet and share their experiences or ask questions if they wished (10 minutes). Thirty-three participants were allocated to the mindfulness meditation group, and 16 completed the program. The intervention took place at a venue in Surry Hills, Sydney, called The Kirk. An experienced, registered instructor volunteered to develop a special mindfulness program based on John Kabat-Zinn s mindfulness-based stress reduction. Participants met once weekly for a 1.5-hour session. The participants met 6 times over 6 weeks. Group 3: Tango dance group 3

4 Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? The tango dance group went to tango classes based on the Argentinean close-embrace tradition. At the start of class, participants were asked to relax and leave the world behind, so they could pay full attention. Instructors emphasized enjoying the experiences rather than achieving a certain outcome (10 minutes). This was followed by a warm-up period (10 minutes) and then the 1- hour class. Tango dance sessions focused on the consciousness of walking, awareness of one s own and one s partner s body, resistance and transference of weight, and close embrace. At the end, participants were asked to sign the sign-out sheet and share their experiences or ask questions if they wished (10 minutes). Thirty-three participants were allocated to the tango dance group, and 21 completed the program. The intervention took place at a venue in Surry Hills, Sydney, called The Kirk. An experienced, registered instructor volunteered to develop a special tango program and led the tango classes. In addition, trained tango helpers also volunteered their time to help with the intervention. Participants met once weekly for a 1.5-hour session. The participants met 6 times over 6 weeks. INTERVENTION BIASES Contamination: NR Explanation: The frequency of exercise was measured for all participants, and it was found that 62.1% exercised at least once a week and 22.7% exercised at least once a day. Therefore, there is the possibility of contamination bias, because participants in the waitlist control group and mindfulness meditation group might have participated in their own physical activity or exercising outside of the study. Co-intervention: YES NR Timing of intervention: YES NO Explanation: The researchers did not go into detail about whether any of the participants in the study received medication or therapy for their stress, anxiety, or depression. Explanation: Timing was sufficient for all three groups. 4

5 Site of intervention: YES NO NR Explanation: There was no site bias, because the site of intervention was consistent between both intervention groups. Both interventions, tango dance and mindfulness meditation, took place at a venue in Surry Hills, Sydney, called The Kirk. Use of different therapists to provide intervention: Explanation: Tom Jones, a clinical psychologist and meditation instructor, led the mindfulness meditation group. Jacqueline Simpson, a tango teacher who is experienced in Argentinean tango dancing, led the tango dance program. Nga Nguyen, Jean Weiner, Viet Nguyen, Ross Fairhurst, and Scott Ross, who are all trained in the Argentinean close-embrace tradition of tango dancing, assisted as leaders in the tango dance classes. Baseline equality: Explanation: Characteristics of the intervention and control groups were similar at baseline. MEASURES AND OUTCOMES Measure 1: Depression, Anxiety, and Stress Scale Name/type of measure used: What outcome is measured? Is the measure reliable (as reported in the article)? Is the measure valid (as reported in the article)? When is the measure used? Depression, Anxiety, and Stress Scale Measure 2: Rosenberg Self-Esteem Scale Self-reported emotional states of stress, anxiety, and depression Not Reported Not Reported At the beginning of the study and at the end of the study Name/type of measure used: Rosenberg Self-Esteem Scale What outcome is Negative and positive attitudes about oneself measured? Is the measure Not Reported reliable as reported in the article? Is the measure valid YES Not Reported 5

6 as reported in the article? When is the measure used? At the beginning of the study and at the end of the study Measure 3: Satisfaction With Life Scale Name/type of measure used: What outcome is measured? Is the measure reliable as reported in the article? Is the measure valid as reported in the article? When is the measure used? Satisfaction With Life Scale Individuals judgment of their contentment with life Not Reported YES Not Reported At the beginning of the study and at the end of the study Measure 4: Mindful Attention Awareness Scale Name/type of measure used: What outcome is measured? Is the measure reliable as reported in the article? Is the measure valid as reported in the article? When is the measure used? MEASUREMENT BIASES Mindful Attention Awareness Scale The frequency of mindful states in everyday life situations; distinguishes between people who practice mindfulness and those who do not Not Reported YES Not Reported At the beginning of the study and at the end of the study Were the evaluators blind to treatment status? YES NR Was there recall or memory bias? Explanation:. The study did not specify who gave out and collected the surveys or who conducted the statistical analysis of the data. Explanation: Recall or memory bias is possible with this pre- and posttest assessment, because the same survey was used for both. Participants might 6

7 have been influenced by their previous experience with the pretest when taking the posttest. Other measurement biases: None RESULTS List key findings based on study objectives: Depression levels were significantly reduced in the tango (effect size d = 0.50, p =.010) and meditation groups (effect size d = 0.54, p =.025), relative to the waitlist control group. Stress levels were significantly reduced only in the tango group (effect size d = 0.45, p =.022). Attending tango classes was a significant predictor for increased levels of mindfulness (p =.012). Was this study adequately powered (large enough to show a difference)? Explanation: To get power greater than 0.80 given an effect size of F = 0.4, α =.05, and three groups, the sample size needed to be greater than 63. This was exceeded, with a final sample of 66. Were the analysis methods appropriate? Explanation: This study had multiple outcome measures targeting different types of variables and appropriately used a one-way between-groups analysis of covariance and regression analysis test. Were statistics appropriately reported (in written or table format)? Explanation: Both table and written format were presented. Was participant dropout less than 20% in total sample and balanced between groups? YES NO Explanation: The dropout rate for the total sample was approximately 32%. The dropout rate for the control group was the least, at 6% (n = 2 of 31). The dropout rate for the tango dance group was 36% (n = 12 of 33). The dropout rate for the mindfulness meditation group was the most, at 52% (n = 17 of 33). What are the overall study limitations? Limitations of the study need to be considered. First, the sample size was relatively small. Second, most participants were well-educated women, so it may be difficult to generalize the results to the overall population. Third, information about clinical diagnoses or medications was not collected. Participants were admitted to the study on the basis of their own self-evaluations. Finally, a follow-up study was not conducted. Thus, it is uncertain whether the benefits gained continued beyond the cessation of the tango and meditation classes. 7

8 CONCLUSIONS State the authors conclusions related to the research objectives. Preliminary results suggest that tango dance is an innovative and promising approach and is comparable to mindfulness meditation in reducing levels of self-reported depression. Also, participating in the tango program was associated with increased levels of mindfulness and decreased levels of psychological stress. Thus, for depressed clients, tango is a positive, costeffective, and practical alternative to the traditional clinical focus on alleviating negative thoughts through therapy. However, further research is necessary to generalize the results to other populations and fully assess the potential benefits of tango dance for depression. This work is based on the evidence-based literature review completed by student Tracy Tang, OTS, and Jennifer McCorkle Kovacs, OTD, OTR/L, faculty advisor, University of Southern California. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998 by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, and M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: 8