Iran Journal of Nursing

Introduction
According to the report of the World Health Organization (WHO), mental health problems account for many diseases and disabilities in the world. Mental health and its maintenance until old age should receive more attention from scientists, policymakers, clinical experts, and even older people. For several reasons, older people are very vulnerable regarding mental health, such that about 15-25% of older people have serious mental problems. According to the WHO, old age is defined as 60 years and above. In Iran, the general census in 2015 showed that about 4,900 million people in Iran have over 60 years of age. Based on the definition of the United Nations, when the aged population of a country reaches more than 7%, that country is called old. According to the data of a national survey in 2015, Iran is expected to become an old country in the near future. 
In Iran, depression is one of the most common mental disorders among the elderly, such that about 25% of people over 65 suffer from depression. Depression is one factor that reduces efficiency and increases the death rate of the elderly. It is one of the most common risk factors for suicide among the elderly in the world. Anxiety is another common disorder in old age. Older people have higher depression and anxiety due to reduced self-confidence, lack of activity and mobility, loss of friends and relatives, reduced financial and physical independence, and suffering from chronic diseases, which can cause sleep problems and decreased quality of life. It should be noted that depression and anxiety always have a two-way relationship, such that controlling one causes the reduction of the other. Stress is another factor that affects the physical and mental health of the elderly. After the youth, the elderly are the most vulnerable group in the face of stress. Recently, emphasis has been placed on improving self-management methods to reduce stress and anxiety. 
One of the popular self-management techniques is the use of mandala coloring books. Mandalas as an art therapy has been accepted for different populations and purposes. They have been used to reduce stress in people with mental disabilities, to reduce pain in children, and to express emotions in children with cancer. Studies have reported that the positive effect of adult coloring is due to offering a distraction and avoiding thoughts that can cause anxiety. 
The results of many studies on different age groups have proven the positive effect of coloring mandalas. No art therapy studies using mandalas on older adults have been conducted in Iran yet. Due to the positive effect of mandala coloring on mental health, as well as its cost-effectiveness and ease of use for the elderly in nursing homes and daycare centers, this study aims to determine the effect of coloring mandala designs on depression, anxiety, and stress of older people in Tehran, Iran.

Methods 
This is a quasi-experimental, single-group study (clinical trial) with a pre-test/post-test design on 40 older people referred to Yas Elderly Day Care Center in Tehran in 2021. They were selected non-randomly and based on the inclusion criteria. They colored the mandala designs with six colored pencils provided by the researcher for 20 minutes, two days a week, for 8 consecutive weeks. Before and immediately after the intervention, the depression, anxiety, and stress scale-21 items questionnaire was used to measure their psychological health. The data were analyzed in SPSS software, version 16. The significance level was set at 0.05.

Results 
Of 40 participants, 57.5% were women. The mean age of participants was 72.03±5.34 years, and their mean duration of visiting the daycare center was 4.95±3.47 years. Data analysis showed that coloring mandalas significantly reduced the level of depression (P=0.001), anxiety (P=0.001), and stress (P=0.001).

Conclusion 
The obtained results showed that the depression, anxiety, and stress of older adults were not at a favorable level. Their depression, anxiety, and stress were significantly reduced after coloring mandala patterns. Therefore, this method can be used as a simple and affordable method to improve the mental health of the elderly.

Ethical Considerations
Compliance with ethical guidelines
All ethical principles were considered in this research, and a written informed consent was obtained from the participants. They were assured of the confidentiality of their information. This study was approved by the ethics committee of Shahed University (Code: IR.SHAHED.REC.1400.004) and was registered by the Iranian Registry of clinical trials (ID: IRCT20220512054828N1).

Funding
This article was extracted from the master’s thesis of Parisa Ahmadi registered by Shahed University .This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors' contributions
Conceptualization: implementation of the intervention, data collection, data analysis and interpretation, and writing: Parisa Ahmadi;  design, data analysis, and review: Nasrin Alaee; data analysis and review: Mahshid Foroughan.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank Shirazikhah, the head of Yas Elderly Care Center, and the seniors participated in this study for their cooperation.

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