Randomized Controlled Trial of Adult Therapeutic Coloring for the Management of Significant Anxiety in the Emergency Department

Acad Emerg Med. 2020 Feb;27(2):92-99. doi: 10.1111/acem.13838. Epub 2020 Jan 20.


Background: Anxiety and acute distress are significant concerns in the emergency department (ED). Adult coloring books are often utilized as an effective means of relaxation in waiting rooms and newsstands, but there are no reported randomized trials examining their effectiveness as a treatment for anxiety.

Methods: We set out to examine the effectiveness of adult coloring books using a randomized placebo-controlled trial at a university-affiliated tertiary ED. Anxiety was measured using a validated self-reporting score, the Hospital Anxiety and Depression Scale (HADS-A), with a range of 0 to 21. Patients with HADS-A ≥ 7 were randomly assigned to either an adult coloring pack (n = 26) or placebo pack (n = 27). The primary outcome measure was the within-patient change in HADS-A scores following 2 hours of exposure.

Results: A convenience sample of 117 patients were screened, and 53 patients were randomized. Characteristics of allocated groups were similar in terms of sex, diagnosis, and ethnicity. A higher proportion of intervention subjects spent ≥1 hour engaged with their activity (46.2% vs. 4.0%, p = 0.01). For the primary outcome measure, the mean within-patient decrease in HADS-A score at 2 hours for intervention subjects was 3.7 (95% confidence interval [CI] = 2.4 to 5.1, p < 0.001) versus a decrease of 0.3 (95% CI = -0.6 to 1.2, p = 0.51) in the placebo group.

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

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Adult
  • Anxiety / psychology
  • Anxiety / therapy*
  • Art Therapy / methods*
  • Emergency Service, Hospital / organization & administration
  • Female
  • Humans
  • Male
  • Middle Aged
  • Self Report
  • Time Factors