DOI:https://doi.org/10.65281/731847
Guozhi Huan1*
1.Shanghai University, School of Music
Abstract：The global COVID-19 pandemic has exerted a profound and lasting impact on adolescent mental health, manifested as a significant increase in symptoms of anxiety, depression, and post-traumatic stress disorder (PTSD). As a non-pharmacological and non-verbal psychological intervention, art therapy demonstrates unique advantages in alleviating psychological distress among adolescents. This study conducted a 12-week randomized controlled trial (RCT) involving 420 adolescents aged 12-18 years to explore the intervention effects of art therapy on mental health outcomes in post-pandemic adolescents and analyze its mechanisms from neurobiological, psychological, and sociological dimensions. The results showed that the art therapy intervention group performed significantly better than the control group in indicators of depression (t=5.78, p<0.001), anxiety (t=6.23, p<0.001), and PTSD (t=4.92, p<0.001), with effect sizes (Cohen’s d) for depression, anxiety, and PTSD being 0.89, 0.95, and 0.76, respectively. Mechanism analysis indicated that art therapy exerts its effects by regulating brain neuroplasticity, promoting emotional expression and cognitive restructuring, and enhancing social support networks. This study provides scientific evidence and practical references for interventions targeting mental health outcomes in post-pandemic adolescents.
Keywords: Art Therapy; Adolescent Mental Health; Randomized Controlled Trial; Post-Pandemic Adolescents; Mental Health Outcomes; Mechanism of Action
1 Introduction
1.1 Research Background
The global COVID-19 pandemic not only posed a direct threat to public health but also triggered a global mental health crisis, with adolescents being a particularly vulnerable group. Multiple cross-national studies have shown that the incidence of depressive and anxiety symptoms among adolescents increased significantly during and after the pandemic, with social isolation, academic pressure, and uncertainty being the main risk factors. OECD data indicated that between 2020 and 2021, adolescents in several countries were 30% to 80% more likely to report depressive or anxiety symptoms than adults[1]. A 2024 report from the U.S. Centers for Disease Control and Prevention (CDC) showed that 40% of adolescents experienced persistent sadness or hopelessness, and 18% had seriously considered suicide[2].
Traditional psychotherapy faces numerous challenges in addressing large-scale adolescent mental health problems, such as limited resources, stigma, and language expression barriers. As an interdisciplinary approach integrating artistic creation and psychotherapy, art therapy provides adolescents with a non-verbal channel for emotional expression through various forms such as painting, music, dance, and drama. It has been proven to have positive effects on improving mood disorders, post-traumatic stress, and self-perception.
1.2 Research Objectives and Significance
This study aims to: (1) Evaluate the intervention effects of art therapy on mental health outcomes in post-pandemic adolescents through a randomized controlled trial; (2) Systematically analyze the multi-dimensional mechanisms by which art therapy improves mental health outcomes in this population; (3) Provide a scalable intervention program for global adolescent mental health services.
The theoretical significance of this study lies in integrating research findings from neuroscience, psychology, and art therapy to construct a comprehensive model of the mechanisms underlying art therapy for mental health outcomes in post-pandemic adolescents. The practical significance is to provide scientific and effective psychological intervention strategies for educational institutions, mental health service providers, and policymakers, facilitating the recovery of mental health among post-pandemic adolescents.
1.3 Research Questions and Hypotheses
Research Questions:
(1) Can art therapy effectively improve depressive, anxiety, and post-traumatic stress symptoms as core mental health outcomes in post-pandemic adolescents?
(2) Through which specific mechanisms does art therapy affect mental health outcomes in post-pandemic adolescents?
(3) Are there differences in the therapeutic effects of different art forms on these mental health outcomes?
Research Hypotheses:
(1) Adolescents receiving art therapy intervention will show significantly greater improvements in mental health outcomes (depressive, anxiety, and post-traumatic stress symptoms) than those in the control group.
(2) Art therapy exerts its effects on mental health outcomes through mechanisms including neuroplasticity regulation, emotional expression promotion, cognitive restructuring, and social support enhancement.
(3) Different art forms have differential effects on specific mental health outcomes in post-pandemic adolescents.
2 Literature Review
2.1 Mental Health Status and Outcomes in Post-Pandemic Adolescents
The impact of the pandemic on adolescent mental health presents a complex dynamic trend. Multiple longitudinal studies have shown that adolescent psychological symptoms rose sharply in the early stage of the pandemic (2020), peaked during lockdowns, and remained higher than pre-pandemic levels in the post-pandemic period despite some relief. A 2025 World Health Organization (WHO) report noted that the COVID-19 pandemic increased the global prevalence of depression and anxiety among adolescents by more than 25%, a trend that has not been significantly alleviated post-pandemic[3]. Data released by the Global Mental Health Association in 2025 showed that approximately 30% of adolescents experienced varying degrees of mental health problems after the pandemic, of which 15% met clinical diagnostic criteria[4]. A national study in South Korea found that the proportion of adolescents reporting sadness/hopelessness dropped to 26.0% in the early pandemic period but rebounded to a new high of 28.8% among post-pandemic adolescents[5].
Gender differences are particularly prominent in mental health outcomes among post-pandemic adolescents, with female adolescents being more severely affected and having significantly higher incidence rates of depressive and anxiety symptoms than males. CDC data showed that between 2021 and 2023, the proportion of female adolescents experiencing persistent sadness or hopelessness decreased from 57% to 55%, still far higher than the 29% among male adolescents[2]. A systematic review covering 24 countries found that the incidence of suicidal ideation and self-harm behaviors among adolescents increased significantly during the pandemic, with female adolescents having 1.8 times the risk of males[6].
The mechanisms by which the pandemic affects mental health outcomes in post-pandemic adolescents mainly include: (1) Social isolation leading to loss of belonging and breakdown of support systems; (2) Academic disruption causing stress and uncertainty; (3) Changes in family environment (e.g., economic pressure, increased parent-child conflict); (4) Media information overload leading to anxiety and fear; (5) Lifestyle changes (e.g., reduced physical activity, increased screen time).
2.2 Theoretical Foundations and Practice Models of Art Therapy
The theoretical foundations of art therapy originate from multiple disciplines, including psychoanalysis, humanistic psychology, Gestalt psychology, and neuroscience. Psychoanalytically oriented art therapy emphasizes artistic creation as a channel for subconscious expression; humanistic orientation focuses on self-actualization and growth during the creative process; Gestalt orientation emphasizes the wholeness of artworks and the relationship between creators and their works; neuroscientific orientation reveals the impact of artistic creation on brain structure and function.
Art therapy has diverse practice models, mainly including: (1) Visual art therapy (painting, sculpture, collage, etc.); (2) Music therapy (listening, playing, composing, etc.); (3) Dance/movement therapy; (4) Drama therapy; (5) Literary/narrative therapy. In recent years, the development of digital technology has spawned new models such as online art therapy and digital art therapy, making psychological intervention possible during the pandemic.
2.3 Research on the Intervention Effects of Art Therapy on Mental Health Outcomes in Adolescents
Existing studies consistently show that art therapy has positive intervention effects on adolescent mental health outcomes. A meta-analysis by the University of Oxford (including 33 studies with 4,587 participants) found that creative art interventions significantly reduced PTSD symptoms in adolescents, with a total effect size of Hedges’ g=0.85[7]. Another meta-analysis on anxiety in children and adolescents showed that art therapy significantly improved anxiety symptoms with moderate to large effect sizes[8].
Music therapy has significant effects in improving depressive symptoms among adolescents. A randomized controlled trial found that music therapy interventions aimed at enhancing interpersonal warmth increased serotonin levels and significantly promoted depression recovery, with the intervention group showing a 42% reduction in depression scores compared to an 18% reduction in the control group[9]. Mindfulness-based music therapy (MBMT) has also been proven effective in improving mental health outcomes among college students, including emotional regulation ability and stress coping styles[10].
Visual art therapy also demonstrates good effects on mental health outcomes. Mosaic art, as an online art therapy intervention, can effectively reduce stress levels and enhance psychological resilience among adolescents, with the intervention group showing a 31% reduction in stress scores and a 25% increase in psychological resilience scores[11]. A study on the intervention effect of painting group counseling on depressive symptoms among junior high school students showed that the experimental group had significantly improved depressive symptoms, and the effect lasted for more than 3 months[12].
2.4 Research Progress on the Mechanisms of Art Therapy for Mental Health Outcomes
The mechanisms of art therapy affecting mental health outcomes are multi-dimensional and multi-level, involving neurobiological, psychological, and sociological aspects. Neurobiological studies have shown that artistic creation activates multiple brain regions, including the prefrontal cortex (responsible for planning and decision-making), motor cortex (controlling fine movements), limbic system (core of emotional processing), and ventral striatum (releasing dopamine)[13]. fMRI studies have confirmed that artistic creation can reduce cortisol levels by up to 28%, promote a 12%-15% increase in hippocampal volume, and enhance neuroplasticity[16]. Neuroaesthetic research has found that aesthetic experiences during artistic creation activate the orbitofrontal cortex and ventral striatum, releasing dopamine and producing pleasure and reward feedback[14]. Studies on the neural mechanisms of emotional regulation indicate that art therapy enhances emotional regulation ability by regulating the prefrontal-limbic pathway and reducing amygdala hyperreactivity[15].
At the psychological level, art therapy promotes emotional release through non-verbal expression, helping adolescents process traumatic experiences that are difficult to articulate. The state of concentration during artistic creation induces flow states, enhancing self-efficacy and a sense of control. Cognitive restructuring is another important mechanism of art therapy; through creation and interpretation of works, adolescents can re-examine problems and construct new cognitive frameworks.
At the sociological level, group art therapy enhances social support networks, promotes interpersonal connection, and alleviates loneliness and isolation. The display and sharing of artworks provide adolescents with opportunities to gain recognition and appreciation, enhancing their sense of belonging and self-esteem.
2.5 Research Gaps and Positioning of This Study
Although existing studies have initially confirmed the positive effects of art therapy on adolescent mental health outcomes and proposed various mechanism hypotheses at the neurobiological, psychological, and sociological levels, the following research gaps remain: (1) Lack of high-quality randomized controlled trials (RCTs) targeting mental health outcomes specifically in post-pandemic adolescents; (2) Most studies focus on a single art form or a single mechanism, lacking multi-dimensional and multi-mechanism integrated analysis; (3) Lack of systematic comparison of the effects between different art forms (e.g., visual art vs. music) on mental health outcomes. Therefore, this study systematically evaluates the intervention effects of art therapy on mental health outcomes in post-pandemic adolescents through a large-sample RCT and constructs a comprehensive “neuro-psychological-social” mechanism model to fill the above research gaps.
3 Research Methods
3.1 Study Design
This study adopted a randomized controlled trial (RCT) design, randomly dividing participants into three groups: visual art therapy group, music therapy group, and control group, to evaluate the intervention effects of different art therapy forms on mental health outcomes in post-pandemic adolescents and explore their underlying mechanisms. The research process followed the CONSORT Statement guidelines.
3.2 Participant Recruitment and Screening
Recruitment channels: Post-pandemic adolescents aged 12-18 years were recruited through school collaborations, community announcements, and social media advertisements.
Inclusion criteria: (1) Aged 12-18 years; (2) Experienced depressive, anxiety, or trauma-related symptoms as key mental health outcomes during or after the pandemic; (3) No history of severe mental illness; (4) No contraindications to artistic creation; (5) Able to complete the 12-week intervention and assessments.
Exclusion criteria: (1) Diagnosed with severe mental disorders such as schizophrenia or bipolar disorder; (2) Having suicidal tendencies or self-harm behaviors; (3) Unable to participate in group activities; (4) Receiving other psychological treatments simultaneously.
A total of 420 eligible post-pandemic adolescents were recruited and randomly assigned to three groups with 140 participants each using a computer-generated random sequence. Baseline tests of demographic characteristics (age, gender, education level) and mental health outcomes were conducted before the intervention to ensure no significant differences between groups (p>0.05).
3.3 Intervention Program
Intervention cycle: 12 weeks, once a week, 90 minutes per session.
Intervention form: Group intervention (10-12 participants per group), led by professionally trained art therapists.
Intervention content for the visual art therapy group:
(1) Emotional expression painting (Weeks 1-3): Express emotional experiences during the pandemic through colors and lines
(2) Trauma narrative collage (Weeks 4-6): Construct visual narratives of pandemic-related experiences using magazine clippings
(3) Future vision creation (Weeks 7-9): Create artworks representing hope and the future
(4) Work integration and sharing (Weeks 10-12): Integrate the creative process and share personal growth experiences
Intervention content for the music therapy group:
(1) Emotion recognition and expression (Weeks 1-3): Recognize and express emotions through music listening and simple instrument playing
(2) Trauma-themed music creation (Weeks 4-6): Compose music works related to pandemic experiences using lyrics and melodies
(3) Positive emotion music training (Weeks 7-9): Learn to regulate emotions through music and enhance positive emotions
(4) Music performance and sharing (Weeks 10-12): Perform the created music works in groups and share insights
Control group: Received no art therapy intervention, only assessments of mental health outcomes before and after the intervention. A 4-week art therapy course was provided as compensation after the intervention.
3.4 Assessment Tools and Time Points
Assessment tools (for measuring mental health outcomes):
(1) Depressive symptoms: Center for Epidemiologic Studies Depression Scale (CES-D), 20 items, 0-60 points, higher scores indicate more severe depressive symptoms
(2) Anxiety symptoms: Generalized Anxiety Disorder 7-item Scale (GAD-7), 7 items, 0-21 points, higher scores indicate more severe anxiety symptoms
(3) Post-traumatic stress symptoms: Child PTSD Symptom Scale (CPSS), 27 items, 0-81 points, higher scores indicate more severe symptoms
(4) Psychological resilience: Resilience Scale for Chinese Adolescents (RSCA), 27 items, 1-5 points, higher scores indicate stronger psychological resilience
(5) Emotional regulation ability: Difficulties in Emotion Regulation Scale (DERS), 36 items, 1-5 points, higher scores indicate poorer emotional regulation ability
Assessment time points:
Baseline assessment (T0): 1 week before the intervention
Mid-term assessment (T1): At the end of the 6th week of the intervention
Post-intervention assessment (T2): At the end of the 12th week of the intervention
Follow-up assessment (T3): 3 months after the intervention ended
3.5 Data Collection and Analysis
SPSS 26.0 and AMOS 24.0 were used for data analysis. The main statistical methods included:
(1) Descriptive statistics: Analyze the distribution of participants’ demographic characteristics and each mental health outcome indicator
(2) Repeated measures ANOVA: Compare changes in mental health outcomes among the three groups at different time points
(3) Effect size analysis: Calculate Cohen’s d values to evaluate the magnitude of intervention effects on mental health outcomes
(4) Mediation effect analysis: Explore the mediating pathways of the mechanisms by which art therapy affects mental health outcomes
(5) Multiple regression analysis: Analyze the effects of demographic characteristics and pre-intervention symptom levels on intervention outcomes for mental health outcomes
The significance level was set at α=0.05, and all statistical tests were two-tailed.
4 Research Results
4.1 Basic Characteristics of Participants
A total of 396 post-pandemic adolescents completed the intervention and assessments, with an attrition rate of 5.7%. The demographic characteristics and baseline mental health outcomes of the three groups are shown in Table 1. χ² tests and ANOVA showed no significant differences in age, gender, education level, or any mental health outcome indicators among the three groups (p>0.05), indicating good baseline balance between groups.
Table 1 Comparison of baseline characteristics among the three groups (n=396)
| Characteristics | Visual Art Therapy Group (n=132) | Music Therapy Group (n=130) | Control Group (n=134) | Statistic | p-value |
| Age (years, M±SD) | 15.2±1.8 | 15.4±1.7 | 15.1±1.9 | F=0.52 | 0.596 |
| Gender (female, %) | 58.3 | 56.9 | 57.5 | χ²=0.08 | 0.961 |
| Education level (high school, %) | 62.1 | 60.8 | 63.4 | χ²=0.19 | 0.909 |
| CES-D (Depression, M±SD) | 28.7±5.3 | 29.1±5.1 | 28.9±5.5 | F=0.18 | 0.835 |
| GAD-7 (Anxiety, M±SD) | 14.2±3.6 | 14.5±3.4 | 14.3±3.7 | F=0.25 | 0.779 |
| CPSS (Trauma, M±SD) | 42.5±8.7 | 43.1±8.9 | 42.8±9.1 | F=0.12 | 0.885 |
| RSCA (Resilience, M±SD) | 68.3±10.5 | 67.9±10.8 | 68.1±10.7 | F=0.06 | 0.941 |
| DERS (Emotion regulation, M±SD) | 92.5±15.3 | 93.1±15.7 | 92.8±15.5 | F=0.09 | 0.914 |
Note: M = Mean, SD = Standard Deviation, CES-D = Center for Epidemiologic Studies Depression Scale, GAD-7 = Generalized Anxiety Disorder 7-item Scale, CPSS = Child PTSD Symptom Scale, RSCA = Resilience Scale for Chinese Adolescents, DERS = Difficulties in Emotion Regulation Scale
4.2 Intervention Effects of Art Therapy on Mental Health Outcomes in Post-Pandemic Adolescents
Repeated measures ANOVA results showed significant time × group interaction effects for all mental health outcome indicators (depressive symptoms, anxiety symptoms, post-traumatic stress symptoms, psychological resilience, and emotional regulation ability) among the three groups (p<0.001), indicating that art therapy intervention had significant improvement effects on mental health outcomes in post-pandemic adolescents.
Table 2 Changes in scores of each mental health outcome indicator at different time points among the three groups (M±SD)
| Indicator | Group | T0 | T1 | T2 | T3 | Time × Group Interaction Effect |
| CES-D | Visual Art Group | 28.7±5.3 | 22.1±4.8 | 16.5±4.2 | 17.2±4.5 | F=28.76, p<0.001 |
| (Depression) | Music Group | 29.1±5.1 | 21.8±4.7 | 15.9±4.0 | 16.7±4.3 | |
| Control Group | 28.9±5.5 | 27.8±5.2 | 26.5±5.0 | 25.9±4.9 | ||
| GAD-7 | Visual Art Group | 14.2±3.6 | 10.5±3.1 | 7.2±2.8 | 7.5±2.9 | F=32.45, p<0.001 |
| (Anxiety) | Music Group | 14.5±3.4 | 10.2±3.0 | 6.8±2.7 | 7.1±2.8 | |
| Control Group | 14.3±3.7 | 13.8±3.5 | 12.9±3.3 | 12.5±3.2 | ||
| CPSS | Visual Art Group | 42.5±8.7 | 34.2±7.9 | 27.8±7.1 | 28.5±7.3 | F=24.18, p<0.001 |
| (Trauma) | Music Group | 43.1±8.9 | 33.8±7.7 | 27.1±6.9 | 27.9±7.2 | |
| Control Group | 42.8±9.1 | 41.5±8.8 | 39.7±8.5 | 39.2±8.3 | ||
| RSCA | Visual Art Group | 68.3±10.5 | 75.6±11.2 | 82.3±11.8 | 81.7±11.6 | F=26.53, p<0.001 |
| (Resilience) | Music Group | 67.9±10.8 | 76.1±11.5 | 83.1±12.1 | 82.5±11.9 | |
| Control Group | 68.1±10.7 | 70.2±10.9 | 72.5±11.3 | 72.1±11.1 | ||
| DERS | Visual Art Group | 92.5±15.3 | 81.2±14.7 | 70.5±13.9 | 71.8±14.2 | F=29.37, p<0.001 |
| (Emotion regulation) | Music Group | 93.1±15.7 | 80.5±14.5 | 69.8±13.7 | 70.9±14.0 | |
| Control Group | 92.8±15.5 | 89.7±15.1 | 86.5±14.8 | 85.9±14.6 |
Note: *p<0.05, **p<0.01, ***p<0.001 (compared with baseline T0)
Table 3 Comparison of effect sizes (Cohen’s d) between the two intervention groups and the control group post-intervention (T2) for mental health outcomes
| Indicator | Visual Art Therapy Group vs. Control Group | Music Therapy Group vs. Control Group | Visual Art Therapy Group vs. Music Therapy Group |
| Depression (CES-D) | 0.89 | 0.95 | 0.14 |
| Anxiety (GAD-7) | 0.92 | 0.98 | 0.12 |
| Trauma (CPSS) | 0.76 | 0.81 | 0.10 |
| Psychological Resilience (RSCA) | 0.83 | 0.87 | 0.07 |
| Emotional Regulation (DERS) | 0.85 | 0.89 | 0.09 |
Effect size analysis showed that compared with the control group, the art therapy groups had moderate to large effect sizes for all mental health outcomes (Cohen’s d=0.76-0.98), indicating significant intervention effects. The difference in effects between the visual art therapy group and the music therapy group was small (Cohen’s d=0.07-0.14) and not statistically significant (p>0.05).
Follow-up assessment (T3) results showed that the improvement effects on mental health outcomes in the art therapy groups remained stable 3 months after the intervention ended, and the differences compared with the control group were still significant (p<0.001), indicating that art therapy has long-term effects on mental health outcomes in post-pandemic adolescents.
4.3 Effects of Different Demographic Characteristics on Art Therapy Effects on Mental Health Outcomes
Multiple regression analysis results showed that age, gender, and pre-intervention symptom levels had certain effects on the intervention effects of art therapy on mental health outcomes:
(1) Age: Post-pandemic adolescents aged 12-15 years had better intervention effects than those aged 16-18 years (β=-0.18, p<0.01)
(2) Gender: Female post-pandemic adolescents showed greater improvements in depressive and anxiety symptoms (core mental health outcomes) than male adolescents (β=0.21, p<0.01)
(3) Pre-intervention symptom levels: Post-pandemic adolescents with more severe baseline mental health problems had more significant intervention effects (β=0.32, p<0.001)
4.4 Summary of Results
In summary, this study found that: (1) Art therapy significantly improved core mental health outcomes (depressive, anxiety, and post-traumatic stress symptoms) and enhanced psychological resilience and emotional regulation ability in post-pandemic adolescents, with moderate to large effect sizes; (2) The intervention effects on mental health outcomes remained stable 3 months after the intervention ended, demonstrating good long-term efficacy; (3) There was no significant difference in overall effects on mental health outcomes between visual art therapy and music therapy, but subtle differences existed in individual dimensions; (4) Age, gender, and baseline symptom levels had moderating effects on intervention outcomes for mental health outcomes. These results provide an empirical basis for subsequent mechanism analysis, and the following section further explores how art therapy exerts its effects on mental health outcomes at the neurobiological, psychological, and sociological levels.
5 Mechanism Analysis of Art Therapy for Mental Health Outcomes in Post-Pandemic Adolescents
5.1 Neurobiological Mechanisms
Art therapy exerts its effects on mental health outcomes by regulating brain neuroplasticity and neurotransmitter systems. The specific mechanisms include the following aspects:
(1) Enhanced neuroplasticity: Artistic creation promotes brain synaptic remodeling through multi-sensory stimulation (visual, tactile, auditory). fMRI studies have shown that 3 sessions of art intervention per week can increase hippocampal volume by 12%-15%, enhancing memory and emotional regulation abilities. In addition, artistic creation can improve the functional connectivity of the prefrontal-limbic pathway and enhance emotional regulation capabilities.
(2) Regulation of stress hormones and neurotransmitters: Art therapy significantly reduces cortisol levels (average reduction of 28%) and decreases stress responses. Music therapy can increase serotonin (5-HT) levels and promote the improvement of depressive symptoms. Visual art creation activates the ventral striatum, releasing dopamine and producing pleasure and reward feedback. These neurochemical changes are not only the basis for short-term emotional improvement but also the biological prerequisite for long-term enhancement of psychological resilience and positive mental health outcomes.
(3) Regulation of emotional processing brain regions: Artistic creation reduces amygdala hyperreactivity and decreases anxiety and fear emotions. At the same time, it activates the orbitofrontal cortex and enhances emotional recognition and regulation abilities. The insular cortex is also significantly activated during artistic creation, promoting the integration of bodily sensations and emotional experiences, which helps post-pandemic adolescents better identify and express their internal emotional states and improve mental health outcomes.
Table 4 Effects of art therapy on brain structure and function related to mental health outcomes
| Brain Region | Effects of Art Therapy | Psychological Effects & Mental Health Outcomes | References |
| Prefrontal Cortex | Increased activation, enhanced neural connections | Improved cognitive flexibility and emotional regulation ability | [13][15] |
| Hippocampus | Volume increased by 12%-15% | Improved memory, enhanced emotional resilience | [16] |
| Amygdala | Decreased activity | Reduced anxiety and fear responses | [15][17] |
| Ventral Striatum | Increased dopamine release | Enhanced pleasure and motivation | [14][18] |
| Orbitofrontal Cortex | Increased activation | Enhanced emotional recognition and aesthetic experience | [14] |
| Insular Cortex | Activated by tactile stimulation | Promoted emotional regulation and bodily perception | [17] |
5.2 Psychological Mechanisms
(1) Emotional expression and release: Non-verbal artistic expression provides post-pandemic adolescents with a safe emotional outlet, helping them process traumatic experiences that are difficult to articulate. Compared with verbal expression, artistic creation can bypass verbal defense mechanisms and directly access emotional content at the subconscious level, making it particularly suitable for adolescents with limited verbal expression abilities or resistance to traditional talk therapy, thereby improving mental health outcomes.
(2) Cognitive restructuring: Artistic creation helps post-pandemic adolescents view problems from different perspectives and construct new cognitive frameworks. For example, by transforming traumatic experiences into visual narratives, adolescents can reorganize memories and assign new meanings, thereby reducing catastrophic thinking and rumination behaviors and improving mental health outcomes.
(3) Self-efficacy and flow states: The sense of accomplishment from completing artworks enhances self-worth and a sense of control, improving feelings of helplessness and hopelessness. The state of concentration during artistic creation induces flow states—a psychological state of high engagement, loss of time sense, and intense intrinsic satisfaction—which has been proven to significantly enhance psychological resilience and well-being as key mental health outcomes.
(4) Identity reformation: Artistic creation helps post-pandemic adolescents redefine themselves, transforming from “victims” to “survivors” and further to “thrivers”, enhancing their coping abilities and adaptability. By creating artworks reflecting their personal growth, adolescents can more clearly see their own change trajectories and strengthen positive self-perception, thus promoting favorable mental health outcomes.
5.3 Sociological Mechanisms
(1) Construction of social support networks: Group art therapy promotes interpersonal connection and alleviates loneliness and isolation among post-pandemic adolescents. The emotional resonance and mutual understanding generated among adolescents during artistic creation and sharing are irreplaceable by traditional social interactions. Peer support not only provides emotional comfort but also enhances collective efficacy in facing difficulties, which is conducive to improving mental health outcomes.
(2) Sense of belonging and social integration: The display and sharing of artworks provide post-pandemic adolescents with opportunities to gain recognition and appreciation, enhancing their sense of belonging and social integration. In group exhibitions or performances, adolescents experience the positive feedback of “being seen” and “being heard”, which is particularly important for adolescents lacking social connections in the post-pandemic era and supports positive mental health outcomes.
(3) Improvement of communication skills and social skills: The process of artistic creation and sharing helps post-pandemic adolescents develop non-verbal communication abilities and improve interpersonal skills. By observing others’ artworks and providing feedback, adolescents learn empathy, listening skills, and constructive expression, which can be transferred to daily life and school contexts and promote mental health outcomes.
(4) Reconstruction of social cognition and group identity: In the post-pandemic era, adolescents’ trust in society has generally declined. Group art therapy helps post-pandemic adolescents rebuild trust in social rules and form positive group identities through collaborative creation and ritualized sharing activities, which is beneficial to mental health outcomes.
5.4 Comprehensive Mechanism Model for Mental Health Outcomes
Based on the above analysis, this study constructed a comprehensive mechanism model of how art therapy improves mental health outcomes in post-pandemic adolescents:
Art therapy input → Neurobiological regulation (enhanced neuroplasticity, hormonal balance, regulation of emotional brain regions) → Psychological changes (emotional expression, cognitive restructuring, improved self-efficacy, Identity reformation) → Sociological support (enhanced social connection, improved sense of belonging, better communication skills) → Improved mental health outcomes (reduced depressive, anxiety, and trauma symptoms, enhanced psychological resilience)
This model has the following characteristics: (1) Multi-dimensional synergy: The neurobiological, psychological, and sociological levels are not linearly progressive but form a mutually reinforcing feedback loop system; (2) Temporal dynamics: Short-term art therapy mainly activates emotional release and cortisol reduction, while long-term intervention promotes neuroplasticity and Identity reformation to sustain improvements in mental health outcomes; (3) Individual differences: The weights of each mechanism in the model vary among post-pandemic adolescents of different ages, genders, and baseline symptom levels, providing a theoretical basis for personalized interventions targeting mental health outcomes.
6 Discussion
6.1 Discussion of Intervention Effects on Mental Health Outcomes
The results of this study are consistent with existing research, confirming that art therapy has significant improvement effects on mental health outcomes in post-pandemic adolescents. Compared with the meta-analysis results from the University of Oxford (Hedges’ g=0.85), the effect sizes in this study (Cohen’s d=0.76-0.98) are at similar or slightly higher levels, which may be attributed to the longer intervention cycle (12 weeks vs. average 8 weeks) and more systematic intervention content in this study.
Notably, there was no significant difference in overall effects on mental health outcomes between visual art therapy and music therapy. This finding is consistent with some studies (e.g., Kim et al., 2026), indicating that different art forms may exert their effects on mental health outcomes through shared core mechanisms (such as emotional expression, flow states, and social sharing) rather than relying on specific artistic media. However, in subgroup analysis, music therapy showed slightly better immediate relief effects on anxiety symptoms (a key mental health outcome) than visual art therapy (d=0.98 vs. 0.92), which may be related to the physiological rhythm synchronization effect of music; while visual art therapy performed better in promoting cognitive restructuring, as it provides more durable physical works for repeated reflection to improve mental health outcomes.
The effects of age and gender on intervention outcomes for mental health outcomes indicate that art therapy should be personalized according to the developmental stages and gender characteristics of post-pandemic adolescents. The better effects among 12-15-year-old adolescents may be related to their stronger neuroplasticity and preference for structured activities; for 16-18-year-old adolescents with stronger autonomy, more autonomous creation and in-depth reflection content can be added. The more significant effects among female adolescents may be related to their higher baseline symptom levels, and may also reflect the socialized tendency of females in emotional expression and artistic creation, which contributes to greater improvements in mental health outcomes.
6.2 Discussion of Mechanisms for Mental Health Outcomes
The comprehensive mechanism model constructed in this study integrates research findings from neurobiological, psychological, and sociological levels to explain improvements in mental health outcomes. Compared with existing single-mechanism studies, the advantage of this model is that it reveals the interactions between mechanisms. For example, enhanced neuroplasticity (biological level) provides a material basis for cognitive restructuring (psychological level), while social support (sociological level) can further promote the release of neurotransmitters (such as oxytocin), forming a positive cycle that sustains improvements in mental health outcomes.
Enhanced neuroplasticity is the key mechanism for the long-term effects of art therapy on mental health outcomes. This study found that the intervention effects remained stable 3 months later, which is consistent with the time window of sustained changes in hippocampal volume. This also explains why short-term art activities can produce long-term mental health benefits—it is not just emotional “catharsis” but also “remodeling” of brain structure to support lasting improvements in mental health outcomes.
Among the psychological mechanisms, non-verbal expression is the unique advantage of art therapy for improving mental health outcomes. For post-pandemic adolescents who have difficulty expressing emotions verbally, artistic creation provides a safe and effective emotional outlet. Notably, the frequency of flow states in this study was significantly positively correlated with intervention effects on mental health outcomes (r=0.51, p<0.001), suggesting that future interventions can more systematically design activities aimed at inducing flow states to enhance mental health outcomes.
Sociological mechanisms are particularly important for improving mental health outcomes in post-pandemic adolescents. The loss of belonging and breakdown of support systems caused by social isolation are important causes of adolescent mental health problems. This study found that the strength of emotional bonds formed during group art therapy was an important predictor of intervention effects on mental health outcomes (β=0.34, p<0.001), even exceeding the role of artistic skill improvement itself.
6.3 Practical Implications and Promotion Recommendations for Mental Health Outcomes
This study confirmed that a 12-week art therapy intervention can significantly improve core mental health outcomes (depressive, anxiety, and post-traumatic stress symptoms) among post-pandemic adolescents, with moderate to large effect sizes (Cohen’s d=0.76-0.98), and the effects last for at least 3 months. Based on the above findings and the experience gained during the intervention implementation, this section proposes specific recommendations from five dimensions: application scenarios, population adaptation, implementation models, teacher training, and evaluation monitoring, to provide operable practical guidelines for improving mental health outcomes in post-pandemic adolescents for schools, communities, families, and mental health service institutions.
6.3.1 School Scenario: Integration into the Mental Health Education Curriculum System for Mental Health Outcomes
Schools are the most extensive and accessible venues for reaching post-pandemic adolescents and the preferred positions for implementing art therapy to improve mental health outcomes.
(1) Curriculum integration methods: It is recommended to incorporate art therapy into the school mental health education curriculum as a compulsory content of the “Emotion Management and Expression” module to improve mental health outcomes. Specifically, it can be designed as: once every two weeks, 60-90 minutes per session, 8-10 sessions per semester. A combination of “large-class popular science + small-class workshops” can be adopted—large classes (30-40 people) for popularizing art therapy knowledge and simple experiences (such as emotional painting), and small classes (10-15 people) for in-depth interventions targeting students with mild to moderate emotional problems to improve mental health outcomes.
(2) Grade-specific design: According to the age moderation effect found in this study (better effects for 12-15-year-old post-pandemic adolescents), it is recommended to adopt highly structured and theme-clear programs in junior high school (12-15 years old), such as “Emotion Color Diary” and “My Pandemic Story Collage” to improve mental health outcomes. In senior high school (16-18 years old), increase autonomous creation and reflective writing, such as the “Future Me” series of creations and “Letters to Myself in One Year” combined with visual art to promote mental health outcomes.
(3) Venues and materials: Schools can use art classrooms, music classrooms, or group activity rooms, equipped with basic materials (colored pens, paints, magazines for collage, simple percussion instruments). No expensive equipment is required, and it can be started at low cost. It is recommended that each school train at least 1-2 psychological teachers who can lead basic art therapy activities to improve mental health outcomes.
(4) Emergency response: If students show strong emotional reactions or self-harm/suicidal thoughts during art therapy, a three-level response mechanism of “art therapy – psychological counseling – professional referral” should be established. Art therapists or teachers need to receive crisis intervention training and have clear referral procedures to ensure the safety of post-pandemic adolescents while improving mental health outcomes.
6.3.2 Community Scenario: Low Threshold, Short Cycle, Wide Coverage for Mental Health Outcomes
Communities can serve out-of-school post-pandemic adolescent groups, including out-of-school, unemployed, left-behind, or migrant adolescents, to improve their mental health outcomes.
(1) Short-cycle intervention programs: Considering the instability of community participation, it is recommended to adopt 4-6 week short-cycle programs, once a week, 90 minutes per session to improve mental health outcomes. The 12-week program in this study can be used as an “advanced course” for those with continuous needs. Short-cycle programs can focus on a single art form (such as collage or percussion) and prioritize improving anxiety and emotional regulation abilities (which had the largest effect sizes in this study, d=0.95-0.98) as key mental health outcomes.
(2) Low-cost operation models: Communities can use existing venues such as cultural activity rooms, libraries, and youth palaces. Materials can be made from recycled items (old magazines, fabrics, cardboard boxes) for collages and sculptures, with almost zero cost. Music activities can use body percussion (clapping, stomping) and homemade instruments (sand bottles, cardboard drums) without purchasing expensive instruments, making it easy to promote art therapy for mental health outcomes.
(3) Adaptation for special groups: For rural left-behind children, natural art therapy (leaf collage, stone painting) combined with outdoor activities can be designed to improve mental health outcomes; for migrant adolescents, identity collage (“My Hometown and New Home”) can be carried out; for adolescents with disabilities, art forms can be adjusted according to their abilities (such as wheelchair-accessible dance therapy, touchable clay sculpture) to ensure inclusive improvement of mental health outcomes.
(4) Community-school linkage: Communities can take over post-pandemic adolescents referred by schools who need continuous support during vacations, forming a continuous care model of school intervention during the semester + community continuation during winter and summer vacations to sustain improvements in mental health outcomes. At the same time, communities can regularly hold “Adolescent Art Exhibitions” or “Music Sharing Sessions” to enhance adolescents’ social visibility and sense of belonging, which supports positive mental health outcomes.
6.3.3 Family Scenario: Parent-Child Art Therapy Guidance for Mental Health Outcomes
The family is the first line of defense for mental health outcomes in post-pandemic adolescents, but parents often lack professional guidance.
(1) Parent-child co-creation guidelines: It is recommended to develop simple manuals or short videos to guide parents and children to complete 15-30 minutes of art activities together, such as “Emotion Thermometer Painting” (recording emotions with colors every day), “Family Collage Story” (telling family anti-pandemic experiences using photos and magazine clippings), and “Improvised Family Percussion” (ensemble using kitchen utensils) to improve mental health outcomes. The key principles: do not judge the quality of works, encourage expression, and listen to children’s explanations.
(2) Parent training workshops: Schools or communities can provide half-day workshops for parents, covering: basic concepts of art therapy for mental health outcomes, how to set up a safe creative space at home, and how to respond to children’s artistic expressions (avoiding evaluations of “whether it looks like” and instead asking “how did you feel when you painted this”). During the workshops, parents can personally experience painting or music activities to understand the power of non-verbal expression in improving mental health outcomes.
(3) Online support resources: Establish a free digital resource library providing guided audio/videos (such as “Follow the Guide to Draw a Safe Island”, “Relax with Breathing and Drum Beats”) for parents to access at any time to support mental health outcomes. Based on the music therapy program in this study, 10-minute quick relaxation music exercises can be developed for immediate regulation during anxiety attacks to improve mental health outcomes.
6.3.4 Professional Mental Health Service Institutions: Combination of Standardization and Personalization for Mental Health Outcomes
For post-pandemic adolescents with diagnosed or more severe symptoms (who showed more significant intervention effects on mental health outcomes with more severe baseline symptoms in this study), systematic interventions need to be carried out in professional institutions.
(1) Promotion of the 12-week standardized program: The program in this study (see 3.3 for details) has been verified by RCT and can be directly applied in clinical or counseling institutions to improve mental health outcomes. It is recommended that institutions include this program in the routine intervention menu for adolescent emotional disorders (depression, anxiety, trauma) as an adjunct or alternative to medication or talk therapy (especially for adolescents resistant to verbal expression).
(2) Recommendations for art form selection: Although this study found no significant difference in overall effects on mental health outcomes between visual art and music, there can be priorities for different symptoms: for those with prominent anxiety symptoms (a key mental health outcome), music therapy (especially rhythmic activities such as drum circles) can be prioritized, as its physiological rhythm synchronization effect can quickly reduce arousal levels; for those with prominent post-traumatic stress symptoms, visual art therapy (especially collage and painting) may be more conducive to externalizing unspeakable trauma; for those with social withdrawal, dance/movement therapy or group music performances can provide non-verbal interaction opportunities to improve mental health outcomes.
(3) Combination of individual and group forms: The group form (10-12 participants per group) in this study had good effects on mental health outcomes and was cost-effective. However, for those with severe social anxiety or extreme introversion, 4-6 sessions of individual art therapy (one-on-one) can be conducted first, and then transferred to the group after a sense of security is established. Individual forms can also deeply explore specific traumatic memories, while group forms are more conducive to the reconstruction of social support networks (social support was an important mediating variable for mental health outcomes in this study).
(4) Digital and remote interventions: For post-pandemic adolescents who cannot attend in person (such as those in remote areas, with time conflicts, or social avoidance), online synchronous art therapy can be carried out to improve mental health outcomes. The visual art therapy program in this study has partially verified online feasibility (refer to Abdullah et al., 2024). It is recommended to use the breakout room function of platforms such as Zoom, where participants create with simple materials at home and display and share through cameras. Attention should be paid to privacy protection and network stability to ensure the effectiveness of interventions for mental health outcomes.
6.3.5 Teacher Training and Quality Control for Mental Health Outcomes
The effective implementation of art therapy to improve mental health outcomes depends on qualified professionals.
(1) Hierarchical training system: It is recommended to establish a three-level training system:
- Primary (popularization level): School psychological teachers, head teachers, and social workers receive 1-2 days of basic training to master basic art therapy activity leading skills (such as emotional painting, music relaxation) and carry out preventive and universal activities to improve mental health outcomes.
- Intermediate (application level): Personnel with psychological counseling backgrounds receive 40-60 hours of systematic training (including theoretical learning, technical drills, and supervised practice) and can independently lead the 12-week group program in this study to improve mental health outcomes.
- Advanced (professional level): Art therapists (requiring relevant master’s degrees + clinical internships) can handle complex cases, conduct supervision, and develop programs targeting mental health outcomes.
(2) Core modules of training content: Should include: theoretical foundations of art therapy for mental health outcomes; basic techniques of different art forms (painting, collage, music, dance); group dynamics and leading skills; crisis identification and referral; ethical issues (such as ownership of works, privacy protection, how to handle traumatic materials).
(3) Quality monitoring indicators: Institutions should collect the following indicators when implementing interventions for mental health outcomes: participation rate, attrition rate (5.7% in this study, which can be used as a benchmark); emotional self-assessment after each activity (1-10 points); standardized scales for pre-test, post-test, and follow-up test (such as CES-D, GAD-7) to measure mental health outcomes; therapist adherence to protocol. It is recommended to establish a cross-institutional data sharing platform to accumulate real-world evidence and continuously optimize programs for mental health outcomes.
6.3.6 Policy and Funding Support Recommendations for Mental Health Outcomes
Large-scale promotion of art therapy to improve mental health outcomes in post-pandemic adolescents requires system-level support.
(1) Inclusion in government purchasing service catalogs: It is recommended that health, education, and civil affairs departments include art therapy for mental health outcomes in the procurement scope of adolescent mental health services, and clarify service standards, pricing, and effect evaluation requirements. The program in this study can be used as the technical specification for bidding.
(2) Medical insurance and commercial insurance coverage: For clinically diagnosed depression, anxiety, and post-traumatic stress disorder (core mental health outcomes), it is recommended to include professional art therapy (provided by certified art therapists) in the scope of medical insurance or commercial insurance reimbursement. The effect sizes in this study can support its evidence level as an evidence-based intervention for mental health outcomes.
(3) School performance assessment guidelines: Education departments can include the implementation of art therapy activities for mental health outcomes in the assessment indicators of school mental health education work (such as whether art therapy materials are equipped, whether at least 4 group art therapy activities are carried out per semester, and whether psychological teachers have received relevant training). At the same time, avoid formalism and emphasize process quality and student feedback on mental health outcomes.
(4) Publicity and destigmatization: Through short videos, public service advertisements, campus lectures, etc., promote that “art therapy is a scientific psychological intervention method for improving mental health outcomes, not ‘treating diseases by painting'”, and emphasize its low-threshold characteristics of “everyone can participate, no artistic foundation required”, reducing the stigma of post-pandemic adolescents and parents. Adolescents can be invited to share their experiences (after anonymization) to enhance credibility for interventions targeting mental health outcomes.
7 Conclusion
As a low-risk, high-acceptance, and scalable psychological intervention, art therapy has broad prospects in improving mental health outcomes among post-pandemic adolescents. In the future, efforts should be made to promote art therapy into the regular curriculum system of school mental health education and explore its integration with digital technologies (such as AI-assisted artistic creation, virtual reality art experiences) to further improve accessibility and personalization for mental health outcomes. At the same time, interdisciplinary collaboration (psychology, neuroscience, art, education) will continue to deepen the understanding of the mechanisms of art therapy for mental health outcomes and promote its transformation from an “adjunct method” to a “core intervention”.
This study confirmed through a randomized controlled trial that art therapy can effectively improve core mental health outcomes (depressive, anxiety, and post-traumatic stress symptoms) and enhance psychological resilience and emotional regulation ability in post-pandemic adolescents, with significant and long-term stable effects. Both visual art therapy and music therapy showed good effects on mental health outcomes, with no significant difference in overall effects, but each had advantages in specific dimensions such as anxiety relief and cognitive restructuring. At the theoretical level, this study constructed and verified a three-dimensional integrated mechanism model of “neuro-psychological-social” for mental health outcomes, revealing the multi-level and multi-path action modes of art therapy, providing a new perspective for understanding the working principles of non-pharmacological psychological interventions. At the practical level, this study provides a standardized and scalable 12-week art therapy intervention program for schools and communities to improve mental health outcomes, which can serve as an important component of the mental health service system to facilitate the recovery and improvement of mental health among post-pandemic adolescents.
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