Date: February 28th, 2020

Reference: Rajendran et al. Randomised control trial of adult therapeutic colouring for the management of significant anxiety in the Emergency Department. AEM February 2020

Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine.

Case: One night during an overnight shift, you are taking care of a patient who presented to the emergency department (ED) due to anxiety and vague suicidal ideation. The process for medical clearance and psychiatric evaluation can take quite a while, and you notice that this patient seems stressed and anxious. You wonder if there’s a way to assist them during the prolonged wait without resorting to sedative medication.

Background: Psychological disorders are a common reason for presenting to the ED. Anxiety disorders are the most common (Marchesi et al EMJ 2004). However, we have only covered mental health issues a few times on the SGEM:

  • SGEM#45: Vitamin H (Haloperidol for Psychosis)
  • SGEM#178: Mindfulness – It’s not Better to Burnout than it is to Rust
  • SGEM#218: Excited Delirium Syndrome
  • SGEM#237: Screening Tool for Child Sex Trafficking
  • SGEM#252: Blue Monday- Screening Adult ED Patients for Risk of Future Suicidality

Patients with psychological disorders are often kept in the ED for a prolonged period of time. The ED itself can be a stressful environment and exacerbate anxiety.

Emergency physicians have pharmaceutical options to treat anxiety. One of the most common medications to use is a benzodiazepine like lorazepam or diazepam.

There is a need for non-pharmacological therapies to treat anxiety, and in some settings, art therapy has been studied. Specifically, adult coloring books have been used in the community and seem to function through cognitive easing (Rigby et al BMJ 2016 and Curry et al Art There 2005).

Clinical Question: Can colouring decrease anxiety in adult patients presenting to the emergency department?

Reference: Rajendran et al. Randomised control trial of adult therapeutic colouring for the management of significant anxiety in the Emergency Department. AEM February 2020

  • Population: Patients >15 years old with a score of >6 on the Hospital Anxiety and Depression Scale Anxiety (HADS-A). A score of >6 is considered moderate to severe anxiety.
  • Intervention: Colouring pack (10 adult colouring pages and 36 pencil colours)
  • Comparison: Placebo pack (10 plain sheets of paper, a Bic pen and instructions to draw or write freely)
  • Outcome:
    • Primary Outcome: Within-patient change in HADS-A score from baseline after two hours of therapy.
    • Secondary Outcomes: Survey questions regarding value of therapy and level of engagement with treatment packs (length of time)

Dr. Naveen Rajendran

This is an SGEMHOP episode which means we have the lead author on the show. Dr. Naveen Rajendran is an intern at the Westmead Hospital in Sydney with a keen interest in emergency medicine and the investigation of novel therapies that could aid in alleviating the growing stress on modern emergency departments. This study was conducted when he was a medical student at the University of Sydney with Dr. Coggins (@coggi33) who was his research supervisor.

Authors’ Conclusions: “Among ED patients, exposure to adult colouring books resulted in lower self-reported levels of anxiety at 2-hours compared to placebo.”

Quality Checklist for Randomized Clinical Trials:

  1. The study population included or focused on those in the emergency department. Yes
  2. The patients were adequately randomized. Unsure
  3. The randomization process was concealed. Yes
  4. The patients were analyzed in the groups to which they were randomized. Yes
  5. The study patients were recruited consecutively (i.e. no selection bias). Unsure
  6. The patients in both groups were similar with respect to prognostic factors. Yes
  7. All participants (patients, clinicians, outcome assessors) were unaware of group allocation. No
  8. All groups were treated equally except for the intervention. Yes
  9. Follow-up was complete (i.e. at least 80% for both groups). Yes
  10. All patient-important outcomes were considered. Yes
  11. The treatment effect was large enough and precise enough to be clinically significant. Yes

Key Results: They screened 179 patients that were flagged as being anxious. The cohort included 53 participants with a mean age of 33 years and 73% were female.

HADS-A decreased significantly more in the adult colouring group

  • Primary Outcome:
    • Intervention Group: Mean HADS-A decrease at two hours was 3.7 (95%CI 2.4 to 5.1, p<0.001)
    • Control Group: Mean HADS-A decrease at two hours: 0.3 (95%CI -0.6 to 1.2, p=0.51)
  • Secondary Outcomes: 
    • For the question “would you recommend colouring” on a Likert Scale (1-5) the average satisfaction score was 4.2.

We asked Naveen ten questions to get a greater understand of his publication. Listen to the SGEMHOP podcast to hear all of his answers.

  1. Single Centre: This was a relatively small sample size of 53 patients. However, you did recruit enough to meet your power calculation of 48 participants to find a 2.5-point decrease with 80% power. We were more concerned that this was conducted in a single center and raises question of external validity to other populations.
  2. Consecutive Patients: We are unsure if this was a consecutive sample. The methods section says; “all patients in the ED were potentially eligible for the study.”  However, patients needed to be flagged by residents, consultants, triage nurses or social workers as being “anxious”. People have unconscious biases and this method could have introduced some selection bias. Why not just ask patients if they were feeling anxious and then ask them to be included in the trial?
  3. Exclusions: A significant number of patients were excluded after initial screening. Can you discuss how this might affect real-world utility of something like this?
  4. Lack of Blinding: The patients would know if they were in the colouring pack vs. placebo pack. Could this have impacted the results?
  5. Blinding to Hypothesis: Were the patients, clinicians, and outcome assessors blinded to the research hypothesis?
  6. HADS-A Scoring: The HADS-A has been validated in various languages and groups of patients. You say this anxiety scoring system has been validated in the ED setting. We pulled that study and it was done in Saudi Arabia (Al Aseri et al BMC Emerg Med 2015). Has it been validated in any other countries like the USA or Canada?
  7. Placebo Control: There is a difference between a placebo control and an active control. Can you discuss how your placebo control group is a true placebo? It seemed to us more like an active control group. How is the activity such as coloring so different from having a pen and paper and being told to occupy yourself with them?
  8. Medication: You compared the colouring activity to the placebo pack (Bic Pen, plain paper and encouragement to draw). Why not comparing it to usual care such as a benzodiazepine?
  9. Magnitude of Effect: The intervention decreased the HADS-A score by 3.4 more than the control. While it was statistically significant is this observed decrease clinically significant.
  10. Duration of Effect: Your primary outcome was at two hours. Did you measure any anxiety outcomes after the activity has ended? Do we know how long it takes someone to return to a high anxiety level once art therapy is removed?
  11. Conflicts of Interest: Did you receive any funding or support from the adult colouring book industry?

Comment on Authors’ Conclusion Compared to SGEM Conclusion:  We agree with the authors’ conclusions

SGEM Bottom Line: Art therapy in the form of coloring may be a useful non-pharmacologic alternative treatment for ED patients with anxiety.

Case Resolution: You provide your patient with an adult coloring book and coloring pencils. Two hours later, they seem calmer, and their ED visit is almost over. They thank you for providing them something to ease their mind during their stay.

Dr. Corey Heitz

Clinical Application: Adult coloring books are a low risk and potentially rewarding non-pharmacologic way to treat anxiety in the ED.

What Do I Tell the Patient?  You seem anxious, and this visit may take some time. Some people have found that being able to spend some time colouring can help them cope with the stress of an ED visit. Would you like some supplies and try doing some colouring?

Keener Kontest: Last weeks’ winner was Jonathan Godfrey. He knew PARACHUTE stood for: “PArticipation in RAndomized trials Compromised by widely Held beliefs aboUt lack of Treatment Equipoise”.

Listen to the SGEM podcast to hear this weeks’ question. Send your answer to with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think about using adult colouring books to deal with patients’ anxiety in the ED? Tweet your comments using #SGEMHOP. What questions do you have for Naveen and Andrew and his team? Ask them on the SGEM blog. The best social media feedback will be published in AEM.

Also, don’t forget those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article. We will put the process on the SGEM blog:

  • Go to the Wiley Health Learningwebsite
  • Register and create a log in
  • Search for Academic Emergency Medicine – “February”
  • Complete the five questions and submit your answers
  • Please email Corey ( with any questions or difficulties.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.