Aims: There has been a burgeoning interest in arts and the environment in healthcare. While research has been undertaken on the clinical impact of disciplines, relatively little research has studied the impact of broader arts for health interventions. This paper reports findings from a systematic review of the arts for health literature, encompassing research on the impact of visual art, design and the environment on the well-being of patients and staff in mental healthcare settings. Methods: A systematic review of over 600 papers published between 1985 and 2005 on the impact of arts, design and environments in mental healthcare was undertaken. The review includes a discussion of contextual and policy literature, as well as 19 reports of quantitative and qualitative studies that met our inclusion criteria. Results: The largest number of studies focused on the aspects of art, design and environment that were relevant to mental healthcare. These studies suggest that this can affect health, including physiological, psychological, clinical and behavioural effects. Exposure to stressful visual and aural environments may reduce levels of stress and enhance recovery. Architectural design consideration is important in mental health settings, especially for patients with conditions such as dementia that can make wayfinding difficult. Exposure to art in healthcare environments has been found to reduce anxiety and depression. Environment features have also been found to affect staff, and improvements in visual and acoustic conditions may reduce risks of errors in some care settings. Qualitative studies provide insights into factors affecting the impact of arts, including issues of power and control, perceptions and influence of key stakeholders, and user participation. A key issue to emerge from this study is that arts interventions do not necessarily address the lack of control exercised by patients in healthcare environments. Conclusions: While there is extensive literature on the impact of design, environment and the arts on health, there is still a need for further research that addresses methodological challenges of evaluating complex interventions. Our review found evidence that environmental enhancements can have a positive impact on health and well-being of staff and patients in mental healthcare. Arts, when considered within this framework of evidence-based design, can also contribute to well-being, offering reassurance and creating identity in healthcare settings. Further research is needed in this area, as well as research that explores the contribution of other models of art that do not fit within the framework of `evidence-based design'. Finally, responses to the arts are contingent on a number of complex social and political factors; further understanding of these is needed in order to inform future research and evaluation of the arts in healthcare.

Objectives: To evaluate he clinical effectiveness of group art therapy for people with schizophrenia and to test whether any benefits exceed those of an active control treatment.\ud Design: Three arm, rater blinded, pragmatic, randomised controlled trial.\ud Setting: Secondary care services across 15 sites in the United Kingdom.\ud Participants: 417 people aged 18 or over, who had a diagnosis of schizophrenia and provided written informed consent to take part in the study.\ud Interventions: Participants, stratified by site, were randomised to 12 months of weekly group art therapy plus standard care alone. Art therapy and activity groups had up to eight members and lasted for 90 minutes. In art therapy, members were given access to a range of art materials and encouraged to use these to express themselves freely. Members of activity groups were offered various activities that did not involve use of art or craft materials and were encouraged to collectively select those they wanted to pursue.\ud Main outcome measures: The primary outcomes were global functioning, measured using the global assessment of functioning scale, and mental health systems, measured using the positive and negative syndrome scale, 24 months after randomisation. Main secondary outcomes were levels of group attendance, social functioning, and satisfaction with care at 12 and 24 months.\ud Results: 24 participants were assigned to either art therapy (n=140), activity groups (n=140), or standard care alone (n=137). Primary outcomes between the three study arms did not differ. The adjusted mean difference between art therapy and standard care at 24 months on the global assessment of functioning scale was -0.9 (95% confidence interval -3.8 to 2.1), and on the positive and negative syndrome scale was 0.7 (-3.1 to 4.6). Secondary outcomes did not differ between those referred to art therapy or those referred to standard care at 12 or 24 months.\ud Conclusions: Referring people with established schizophrenia to group art therapy as delivered in this trial did not improve global functioning, metnal health, or other health related outcomes.\ud Trial registration: Current Controlled Trials ISRCTN46150447

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These findings have policy and practical implications and highlight the need for development of genuinely collaborative partnerships between the research and clinical communities. Importantly, we suggest that the CONSORT recommendations be further refined to identify the potential study population.

Involving people with dementia in research raises many ethical and practical issues for people with dementia, carers and family members, researchers and care professionals. Internationally, the legal, governance and ethical framework for such research is rapidly changing, and there is considerable debate about how these changes will affect social research that needs to involve people with advancing dementia. This article is based on challenges that the authors faced when trying to develop a follow-up research proposal that would have involved people with advancing dementia, and consequential loss of capacity, in social research. It explores a range of issues and concerns, including accessing data to identify potential participants, assessing mental capacity, obtaining consent and the role of gatekeepers. These issues are discussed in the context of emerging governance in social care research and current and new legislation in the UK, the rest of Europe and beyond. The existing processes of ethical review are outlined and the implications for research of the new Mental Capacity Act, recently implemented in England and Wales, are considered. The difficult balance between protecting vulnerable individuals, recognizing the importance and benefits to society of research and maintaining an individual's right to take part in research is discussed. The article concludes with recommendations for researchers planning to undertake projects that may include people with reduced capacity as participants.