Every individual is entitled to a life of dignity. The World Health Organization and United Nations Human Rights Council ensures that all citizens should have access to essential requirements for survival [1]. Destitution is a more comprehensive deprivation rather than insufficient income or consumption, and depends upon the context [2]. A destitute woman can be defined as a female individual who experiences a deficiency in the necessary support and motivation from her immediate family, extended relatives, and occasionally even from the wider societal context, consequently resulting in an existence marked by various forms of adversity [3]. This may occur when a woman finds herself widowed or abandoned, or without any form of care. The term "destitute" when associated with a woman or widow refers to any female who does not have financial support or the individual is not receiving care from any family member or relative, including individuals who have been divorced [4]. Destitution has emerged as a significant consequence of family issues in the world [5]. Women consistently find themselves in vulnerable positions within fractured households. This occurrence is evident not only in economically disadvantaged families but also in affluent families. Research findings suggest that women predominantly seek refuge in destitute shelters involuntarily [6].   When a woman falls into destitution, she encounters numerous challenges and disadvantages in daily life. This often leads to feelings of loneliness, social exclusion, and vulnerability. Additionally, destitute women may become targets of various forms of abuse, violence, oppression, impoverishment, and other adversities [7]. Depressive symptoms present a significant social and economic challenge for healthcare systems worldwide [8]. Owing to the substantial number of individuals requiring assistance and the moral obligation to minimize distress, there is a requirement to introduce scalable mental health interventions to tackle this challenge [9,10]. Typically, pharmaceutical intervention is the primary option for alleviating key symptoms in mental disorders, but numerous antipsychotic medications are associated with diminished quality of life and side effects [11,12]. As a result, healthcare providers have shifted their focus towards complementary therapies, such as art therapy, to address patients' healthcare needs about 50 years ago [9].   “Art therapy, a non-pharmacological complementary and alternative therapy, has been implemented as a medical intervention that yields positive clinical outcomes [13–15]. Art therapy, as defined by the British Association of Art Therapists, is a form of psychotherapy that uses art as a primary mode of expression and communication” [16]. The primary objective of providing art therapy is to initiate the transformation and development of clients by utilizing creative media in a secure and accessible setting [16,17]. During the course of therapy, art therapists have the capacity to employ a variety of art medium such as visual art, painting, drawing, music, dance, drama, and writing [18]. Drawings and paintings, in particular, have long been acknowledged as integral components of the therapeutic journey within the realms of psychiatry and psychology specialties. By engaging in activities such as painting, drawing, and sculpting, destitute individuals can potentially find therapeutic benefits that enhance overall wellbeing [19]. Pharmacological intervention is typically prioritized in the management of mental illnesses to alleviate predominant symptoms, but it has side effect in long term treatments [20].   The relation between stress and depression among impoverished and non-impoverished women has been carried out, analyzing the implications of potential disparities in stress and depression levels [21]. The mental health conditions of women in various age groups according to literacy levels in relation to marital status showed that adequate financial assistance and social support to be provided with counseling, psychotherapy, behavior modification therapy [22]. Moreover, studies on the life and challenges faced by impoverished women are less. Therefore, by integrating expressive art therapy within a comprehensive framework, which can address emotional needs and socioeconomic challenges, effective mental health interventions can be created for underserved communities.   Aim of the Study This study aimed to evaluate the effectiveness of expressive art therapy on depression and quality of life among destitute women.

Study design and Participants A quasi-experimental research design was implemented to evaluate the effectiveness of expressive art therapy in improving quality of life and decreasing depression levels in destitute individuals with depression. This study was approved by the Institutional Ethics Committee of Saveetha Medical College and Hospital (No 001/11/2023/IEC/SMCH dated 21/11/2023). Permission was taken from the authorities of the destitute homes Udavum Karangal, Thiruverkadu (Thiruverkadu, Tamil Nadu, India) and Karunai Illam (Maduravoyil, Tamil Nadu, India). Ten participants were chosen for both “control and experimental groups.” The women were of the age of 20 to 60 years were included. Those who were bed ridden and with serious medical complications were excluded. Participants were introduced to the study objectives and all 10 female individuals were enrolled in the research subsequent to obtaining appropriate consent.   Tools The Zung Depression Rating Scale was used to assess the depression levels [23,24]. Depression refers to the psychological and physiological imbalance that leads to a state of physical, emotional, or mental exhaustion in individuals residing in destitute homes. The WHOQOL-BREF is a short version of the WHOQOL-100, which is a 26-item questionnaire was used to assess the quality of life of destitute women [25]. The domains were physical health, social relations, and the environment.   Art Therapy Expressive art therapy was conducted over a 12-week period, with weekly sessions lasting approximately 40 minutes. The intervention followed a four-session cycle: Session 1 involved introduction, orientation, and assessment of depression. Session 2 included art therapy using the House-Tree-Person drawing to explore emotions, thoughts, self-concept, and creativity. In Session 3, certified therapeutic music designed for depression was used for music therapy. Session 4 involved dance therapy through a one-mile music-guided walk incorporating simple movements such as marching, side steps, toe taps, and sidekicks for 15 minutes. These four sessions were rotated weekly as part of the expressive art therapy cycle and implemented consistently across the 12-week intervention period.   Statistics Data on sociodemographic variables were expressed as a frequency table. As the sample size was small, frequencies were analyzed using Fisher’s exact test. “The data on comparison of “control and experimental groups” on depression and quality of life (QOL) are represented as mean + SEM and analyzed by two-way repeated measures analysis of variance (RM ANOVA) for one factor repetition, and Bonferroni ‘t’ test for post hoc multiple comparisons. Factor A is ascribed to groups (between group comparison – “control and experimental”), Factor B is ascribed to tests (within group comparison i.e., repetition factor – “pre-test” and “post-test”) and the group X test interaction. A probability of 0.05 and less was considered as statistically significant. Sigma Plot 14.5 version (Systat Software Inc., San Jose, USA) was used for statistical analysis.”

Socio-Demographic Variables Table 1 presents the frequency distribution of sociodemographic variables for both groups. In the control group, 20% of participants were aged <40 years and 80% were >41 years, compared to 40% and 60% in the experimental group (P = 0.628). Regarding education, 10% of the control group had primary education and 90% had middle school or above, while in the experimental group, 40% had primary education and 60% had higher education (P = 0.303).   Marital status showed that 40% of the control group were single and 60% married, while in the experimental group, 10% were single and 90% married (P = 0.303). Concerning number of children, 80% of the control group and 50% of the experimental group had no children, while 20% and 50%, respectively, had 1–3 children.   Employment status revealed that 80% of the control group were employed and 20% unemployed, compared to 50% employment in the experimental group (P = 0.350). Regarding duration of stay, 40% of the control group and 60% of the experimental group had stayed less than 5 years; 60% and 40%, respectively, had stayed more than 5 years.   Past psychiatric illness was absent in 80% of participants in both groups. Reasons for stay showed that 90% of the control group cited family abandonment, while 60% of the experimental group were destitute. Only one participant in the experimental group had family contact; none in the control group did. All experimental group participants received family visits, while only 50% in the control group were visited.   Table 1: Socio-demographic variables of control and experimental groups for homogeneity S.No. Variable Category Con Exp Statistics 1 Age < 40 years 2 4 P = 0.628 > 41 years 8 6 2 Education Primary school 1 4 P = 0.303 Middle school and above 9 6 3 Marital status Single 4 1 P = 0.303 Married 6 9 4 Number of children No child 8 5 P = 0.350 1 to 3 children 2 5 5 Employment status No employment 2 5 P = 0.350 Employed 8 5 6 Duration of stay < 5 years 4 6 P = 0.656 > 5 years 6 4 7 Past psychiatric illness No 8 8 P = 1.0 Yes 2 2 8 Reason for stay in destitute home Family abandonment 9 4 P = 0.057 Destitute 1 6 9 Contact with family members No 10 9 P = 1.0 Yes 0 1 10 Visit of family members No 5 10 P = 0.033 Yes 5 0 n = 10 each, the ‘P’ value is by Fisher’s exact test   Depression and quality of life The mean and standard errors for depression and quality of life are listed in Table 2. In the experimental group, the mean depression score decreased from 61.6±1.3 at pre-test to 58.0±4.4 at post-test, reflecting a 5.8% reduction. In contrast, the control group’s depression score increased from comparison between experimental and control groups showed a statistically significant difference (P=0.008), suggesting that the intervention was effective in reducing depression levels.   For quality of life (QOL), the experimental group showed a substantial improvement, with scores rising from 56.5±1.1 at pre-test to 70.9±3.5 at post-test—an overall 25.5% increase, which was statistically significant (P < 0.001). The control group also showed improvement, from 60.8±1.7 to 70.7±2.7, a 16.3% increase. These findings indicate that while both groups improved in QOL, the experimental group achieved a greater and statistically significant gain, supporting the positive impact of expressive art therapy on emotional well-being and life satisfaction.   Table 2. Comparison of control and experimental groups on depression and quality of life (QOL) by two-way RM ANOVA with Bonferroni ‘t’ test S. No. Groups comparisons Test comparisons Depression Mean±SE QOL Mean±SE 1 Control pre-test 60.2±1.5 60.8±1.7 Experimental pre-test 61.6±1.3 56.5±1.1 Control post-test 63.8±1.6 70.7±2.7 Experimental post-test 58.0±4.4 70.9±3.5 2 Significance among groups (“Control and Experimental”) F = 2.994 F = 0.820 Significance among tests (“pre-test” and “post-test”) P = 0.101 P = 0.377 Significance in the interaction (groups X test) F = 0.857 F = 21.383 P < 0.001 3 Significance between “pre-test” (“Control and Experimental”) P = 0.367 F = 0.733 Significance between “post-test” (“Control and Experimental”) F = 5.100 P < 0.403 t = 1.240 4 Significance within Control (“pre-test” and “post-test”) P = 0.037 t = 0.365 P = 0.223 t = 0.0577 Significance within Experimental (“pre-test” and “post-test”) P = 0.717 t = 2.819 P = 0.954 t = 2.664 Values are mean + SE. P = 0.008 t = 2.251 P = 0.016 t = 3.875 n = 10 each in “control and experimental groups”. P = 0.037 t = 0.942 P < 0.001 P = 0.358  

Expressive Art Therapy has emerged as a promising intervention for addressing mental health issues, particularly depression, among vulnerable populations, such as destitute individuals. The socio-demographic variable data are shown in a frequency table and analyzed using Fisher’s exact test. The distribution of variables such as age, education, marital status, children, employment, duration of stay, psychiatric history, and reasons for being in a destitute home were analyzed. Differences between the “control and experimental groups” were tested, and p values were reported for each variable. The results indicated no significant differences between the two groups in terms of sociodemographic variables. For an unbiased study the socio-demographic variables should be uniform in “control and experimental groups”.   The results showed the mean scores for depression and quality of life. Two-way RM ANOVA did not show significance for depression scores but exhibited for quality of life. “Control group” showed increase in depression, while “experimental group” showed a decrease. QOL improved more in “experimental group.”   By incorporating these evidence-based practices, mental health professionals can provide destitute individuals with a well-rounded treatment plan targeting various facets of their psychological well-being [20], ultimately leading to more holistic and tailored support for this vulnerable population. Considering the unique cultural backgrounds and personal preferences of clients can significantly enhance the therapeutic process and foster a deeper sense of connection and understanding between the individual and mental health professional. While expressive art therapy has proven to be a valuable tool in addressing mental health issues, such as depression among vulnerable populations, it is essential to consider the cultural sensitivity and individual preferences of each client to ensure the effectiveness and inclusivity of the therapeutic approach. Some elements that play a role in the occurrence of destitution encompass economic deprivation, personality dysfunctions, sexual impairment, diverse manifestations of maladaptation, dynamics within the family unit, and encounters with sexual misconduct. Destitution has emerged as a significant consequence of familial challenges in the context of India. Women often find themselves disproportionately affected by disruptions in their family units.

The goal of this study is to explore the effect of expressive art therapy on improving the quality of life of destitute individuals with depression. This study suggests potential benefit, but requires confirmation in larger, randomized studies. An investigation into the participants' demographic characteristics was conducted, encompassing aspects such as age distribution, level of education, marital status, and presence of children. The “control group” displayed an increase in depressive symptoms compared to that of the “experimental group,” illustrating the positive impact of the intervention. Notably, the “control group” also exhibited a minimal rise in their quality of life in contrast to the “experimental group,” thereby underscoring the advantages associated with the intervention.   Limitations This study had several limitations. The small sample size and inclusion of only female participants from selected destitute homes limit the generalizability of the findings. The short duration of the intervention may not capture long-term effects. Additionally, reliance on self- reported measures for depression and quality of life introduces the possibility of response bias   Acknowledgement This study was approved by the Institutional Ethics Committee of Saveetha Medical College and Hospital (decision number: 001/11/2023/IEC/SMCH). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.   Conflicts of Interest We would like to thank the residents and volunteers in Udavum Karangal and Karunai Illam for supporting the study