essay on music therapy

The Transformative Power of Music in Mental Well-Being

August 01, 2023
Healthy living for mental well-being, Patients and Families, Treatment

Music has always held a special place in our lives, forming an integral part of human culture for centuries. Whether we passively listen to our favorite songs or actively engage in music-making by singing or playing instruments, music can have a profound influence on our socio-emotional development and overall well-being.

Recent research suggests that music engagement not only shapes our personal and cultural identities but also plays a role in mood regulation. 1 A 2022 review and meta-analysis of music therapy found an overall beneficial effect on stress-related outcomes. Moreover, music can be used to help in addressing serious mental health and substance use disorders. 2 In addition to its healing potential, music can magnify the message of diversity and inclusion by introducing people to new cultures and amplifying the voice of marginalized communities, thereby enhancing our understanding and appreciation for diverse communities.

Healing Trauma and Building Resilience

Many historically excluded groups, such as racial/ethnic and sexual minorities and people with disabilities, face systemic injustices and traumatic experiences that can deeply impact their mental health. Research supports the idea that discrimination, a type of trauma, increases risk for mental health issues such as anxiety and depression. 3

Music therapy has shown promise in providing a safe and supportive environment for healing trauma and building resilience while decreasing anxiety levels and improving the functioning of depressed individuals. 4 Music therapy is an evidence-based therapeutic intervention using music to accomplish health and education goals, such as improving mental wellness, reducing stress and alleviating pain. Music therapy is offered in settings such as schools and hospitals. 1 Research supports that engaging in music-making activities, such as drumming circles, songwriting, or group singing, can facilitate emotional release, promote self-reflection, and create a sense of community. 5

Empowerment, Advocacy and Social Change

Music has a rich history of being used as a tool for social advocacy and change. Artists from marginalized communities often use music to shed light on social issues (.pdf) , challenge injustices, and inspire collective action. By addressing topics such as racial inequality, gender discrimination, and LGBTQ+ rights, music becomes a powerful medium for advocating for social justice and promoting inclusivity. Through music, individuals can express their unique experiences, struggles, and triumphs, forging connections with others who share similar backgrounds. Research has shown that exposure to diverse musical genres and artists can broaden perspectives, challenge stereotypes, and foster empathy among listeners especially when dancing together. 7

Genres such as hip-hop, reggae, jazz, blues, rhythm & blues and folk have historically served as platforms for marginalized voices, enabling them to reclaim their narratives and challenge societal norms. The impact of socially conscious music has been observed in movements such as civil rights, feminism, and LGBTQ+ rights, where songs have played a pivotal role in mobilizing communities and effecting change. Music artists who engage in activism can reach new supporters and help their fans feel more connected to issues and motivated to participate. 6

Fostering Social Connection and Support

Music can also serve as a catalyst for social connection and support, breaking down barriers and bridging divides. Emerging evidence indicates that music has the potential to enhance prosocial behavior, promote social connectedness, and develop emotional competence. 2 Communities can leverage music’s innate ability to connect people and foster a sense of belonging through music programs, choirs, and music education initiatives. These activities can create inclusive spaces where people from diverse backgrounds can come together, collaborate, and build relationships based on shared musical interests. These experiences promote social cohesion, combat loneliness, and provide a support network that can positively impact overall well-being.

Musicians and Normalizing Mental Health

Considering the healing effects of music, it may seem paradoxical that musicians may be at a higher risk of mental health disorders. 8 A recent survey of 1,500 independent musicians found that 73% have symptoms of mental illness. This could be due in part to the physical and psychological challenges of the profession. Researchers at the Max Planck Institute for Empirical Aesthetics in Germany found that musically active people have, on average, a higher genetic risk for depression and bipolar disorder.

Commendably, many artists such as Adele, Alanis Morrisette, Ariana Grande, Billie Eilish, Kendrick Lamar, Kid Cudi and Demi Lovato have spoken out about their mental health battles, from postpartum depression to suicidal ideation. Having high-profile artists and celebrities share their lived experiences has opened the conversation about the importance of mental wellness. This can help battle the stigma associated with seeking treatment and support.

Dr. Regina James (APA’s Chief of the Division of Diversity and Health Equity and Deputy Medical Director) notes “Share your story…share your song and let's help each other normalize the conversation around mental wellness through the influence of music. My go-to artist for relaxation is jazz saxophonist, “Grover Washington Jr” …what’s yours?” Submit to [email protected] to get featured!

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The Healing Power of Music

Music therapy is increasingly used to help patients cope with stress and promote healing.

By Richard Schiffman

“Focus on the sound of the instrument,” Andrew Rossetti, a licensed music therapist and researcher said as he strummed hypnotic chords on a Spanish-style classical guitar. “Close your eyes. Think of a place where you feel safe and comfortable.”

Music therapy was the last thing that Julia Justo, a graphic artist who immigrated to New York from Argentina, expected when she went to Mount Sinai Beth Israel Union Square Clinic for treatment for cancer in 2016. But it quickly calmed her fears about the radiation therapy she needed to go through, which was causing her severe anxiety.

“I felt the difference right away, I was much more relaxed,” she said.

Ms. Justo, who has been free of cancer for over four years, continued to visit the hospital every week before the onset of the pandemic to work with Mr. Rossetti, whose gentle guitar riffs and visualization exercises helped her deal with ongoing challenges, like getting a good night’s sleep. Nowadays they keep in touch mostly by email.

The healing power of music — lauded by philosophers from Aristotle and Pythagoras to Pete Seeger — is now being validated by medical research. It is used in targeted treatments for asthma, autism, depression and more, including brain disorders such as Parkinson’s disease, Alzheimer’s disease, epilepsy and stroke.

Live music has made its way into some surprising venues, including oncology waiting rooms to calm patients as they wait for radiation and chemotherapy. It also greets newborns in some neonatal intensive care units and comforts the dying in hospice.

While musical therapies are rarely stand-alone treatments, they are increasingly used as adjuncts to other forms of medical treatment. They help people cope with their stress and mobilize their body’s own capacity to heal.

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Essay on Music Therapy

Students are often asked to write an essay on Music Therapy in their schools and colleges. And if you’re also looking for the same, we have created 100-word, 250-word, and 500-word essays on the topic.

Let’s take a look…

100 Words Essay on Music Therapy

Introduction.

Music therapy is a therapeutic technique that uses music to improve health. It’s used by certified professionals to promote emotional, cognitive and social well-being.

Types of Music Therapy

There are two types: active and receptive. In active therapy, individuals make music using instruments. In receptive therapy, individuals listen to music and discuss feelings.

Benefits of Music Therapy

Music therapy helps reduce stress and anxiety. It can also improve mood, concentration, and communication skills. It’s beneficial for all, especially those with mental health conditions.

Music therapy is a powerful tool for healing. It’s a unique way to express emotions and improve overall health.

250 Words Essay on Music Therapy

Music therapy: a multifaceted approach.

Music therapy is not a one-size-fits-all approach. It can be passive, where individuals listen to music, or active, involving music creation. Techniques are tailored to individual needs, whether it’s to improve cognitive functioning, motor skills, emotional development, or social skills.

Neurological Underpinnings

Music therapy’s effectiveness is rooted in neurology. Music stimulates both hemispheres of the brain, promoting neural plasticity and aiding in recovery from neurological damage. The “Mozart Effect”, a theory suggesting that listening to Mozart’s music can increase IQ, exemplifies the potential neurological benefits of music.

Therapeutic Applications

Music therapy is used in diverse settings like hospitals, schools, and rehabilitation centers. It has proven beneficial for a range of conditions, from autism and dementia to depression and PTSD. The non-verbal, creative, and emotional qualities of music provide unique avenues for therapy.

The power of music therapy lies in its ability to tap into the fundamental human connection to music. This innovative therapy approach has the potential to revolutionize healthcare, offering a holistic, patient-centered method to enhance quality of life. As research continues, it’s clear that the therapeutic power of music is only beginning to be understood.

500 Words Essay on Music Therapy

Introduction to music therapy.

Music therapy, a rapidly evolving field in the realm of health and wellness, is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional. It is an intersection of music, psychology, and healthcare, aiming to improve the quality of life for individuals.

The Mechanism of Music Therapy

Applications of music therapy.

Music therapy has a broad range of applications. It can be used in mental health treatment, aiding in managing stress, anxiety, and depression. It’s also employed in the field of neurology, where it helps patients with Parkinson’s disease, Alzheimer’s, and other cognitive disorders improve motor function and memory recall. In palliative care, music therapy can provide comfort and pain relief. Moreover, in educational settings, it can enhance learning and development in children with special needs.

Evidence Supporting Music Therapy

Empirical evidence validates the effectiveness of music therapy. A meta-analysis published in the Cochrane Library showed that music therapy improves social interaction, verbal communication, and initiating behavior in autistic children. Another study published in the Journal of Music Therapy demonstrated that music therapy can reduce anxiety levels in patients undergoing invasive procedures.

Challenges and Future Directions

More research is needed to develop standardized treatment protocols and to understand the neurobiological mechanisms underpinning music therapy. Furthermore, interdisciplinary collaboration between music therapists, neuroscientists, psychologists, and healthcare professionals can foster a more comprehensive understanding of this field.

Music therapy is a potent tool in the arsenal of healthcare, offering a unique approach to treatment. It transcends traditional boundaries of therapy, harnessing the universal language of music to heal and uplift. As we continue to explore its potential, we can expect to see music therapy become an integral part of holistic healthcare, enhancing the quality of life for countless individuals.

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Music therapy is increasingly being used as an intervention for stress reduction in both medical and mental healthcare settings. Music therapy is characterized by personally tailored music interventions initiated by a trained and qualified music therapist, which distinguishes music therapy from other music interventions, such as ‘music medicine’, which concerns mainly music listening interventions offered by healthcare professionals. To summarize the growing body of empirical research on music therapy, a multilevel meta-analysis, containing 47 studies, 76 effect sizes and 2.747 participants, was performed to assess the strength of the effects of music therapy on both physiological and psychological stress-related outcomes, and to test potential moderators of the intervention effects. Results showed that music therapy showed an overall medium-to-large effect on stress-related outcomes ( d = .723, [.51–.94]). Larger effects were found for clinical controlled trials (CCT) compared to randomized controlled trials (RCT), waiting list controls instead of care as usual (CAU) or other stress-reducing interventions, and for studies conducted in Non-Western countries compared to Western countries. Implications for both music therapy and future research are discussed.

Music therapy

state anxiety
music intervention
multilevel meta-analysis

Stress is a well-known risk factor for the onset and progression of a range of physical and emotional problems, such as cardiovascular diseases, cancers, anxiety disorders, depression, and burnout (American Psychological Association [APA], Citation 2017 ; Australian Psychological Society [APS], Citation 2015 ; Steptoe & Kivimäki, Citation 2012 ). To cope with stress and the demands of today's society, millions of people over the world use tranquilizing medications, which have a lot of negative contraindications and side effects, including substance dependence and abuse (Bandelow et al., Citation 2015 ; Olfson et al., Citation 2015 ; Puetz et al., Citation 2015 ; World Health Organization [WHO], Citation 2010 ). Therefore, it is important to examine the effects of non-pharmacological therapeutic interventions for the prevention and management of stress (de Witte et al., Citation 2020a ; Kamioka et al., Citation 2014 ; Martin et al., Citation 2018 ; Raglio et al., Citation 2015 ).

For decades and all over the world music has been used to provide calmness and relaxation. These stress reducing qualities are the most widely studied effects of music (Chanda & Levitin, Citation 2013 ; de Witte et al., Citation 2020a ; Juslin & Västfjäll, Citation 2008 ; Koelsch, Citation 2015 ; Mehr et al., Citation 2019 ). Therefore, music therapy interventions are increasingly being used to reduce stress and enhance the well-being of clients across a variety of clinical populations (Agres et al., Citation 2020 ; Bainbridge et al., Citation 2020 ; Juslin & Västfjäll, Citation 2008 ; Kemper & Danhauer, Citation 2005 ; Koelsch, Citation 2012 , Citation 2015 ; Landis-Shack et al., Citation 2017 ; Thaut & Hoemberg, Citation 2014 ).

Music therapy is specifically characterized by using the specific qualities of music in a therapeutic relationship with a music therapist. This distinguishes music therapy from other music interventions, mostly offered by medical or healthcare professionals and referred to as music medicine (Agres et al., Citation 2020 ; Bradt et al., Citation 2013b ; de Witte et al., Citation 2020a ; Gold et al., Citation 2011 ; Magee, Citation 2019 ). The body of research on music therapy is much smaller compared to the amount of research on music listening interventions. Our previous meta-analytic review (de Witte et al., Citation 2020a ) was focused on the effects of music interventions in general and included mainly music listening interventions. In none of these studies a trained music therapist was involved.

In order to integrate the available knowledge on the effects of music therapy on stress, we conducted a systematic review and meta-analysis of quantitative studies testing the effects of music therapy on both physiological and psychological stress-related outcomes in mental and medical healthcare settings.

The influence of music on the stress response

Stress can be regarded as the quality of an experience, produced through a person-environment transaction that may result in physiological or psychological distress (Aldwin, Citation 2007 ). Responses to stress can be related to both increased physiological arousal and specific emotional states, while the underlying systems of those responses regulate and affect each other during stress (e.g., de Witte et al., Citation 2020a ; Linnemann et al., Citation 2017 ; McEwen & Gianaros, Citation 2010 ). The stress reducing effect of music therapy interventions is explained by music itself as well as the continuous attunement of music by the music therapist to the individual needs of a patient.

Music listening is strongly associated with stress reduction by the decrease of physiological arousal as indicated by reduced cortisol levels, lowered heart rate, and decreases in mean arterial pressure (e.g., Burrai et al., Citation 2016 ; Koelsch et al., Citation 2016 ; Kreutz et al., Citation 2012 ; Linnemann et al., Citation 2015 ). Music can also reduce negative emotions and feelings, such as subjective worry, state anxiety, restlessness or nervousness (Akin & Iskender, Citation 2011 ; Cohen et al., Citation 1983 ; Pittman & Kridli, Citation 2011 ; Pritchard, Citation 2009 ), and increase positive emotions and feelings, such as happiness (Jäncke, Citation 2008 ; Juslin & Västfjäll, Citation 2008 ). This is in line with studies showing that music modulates activity in brain structures, such as the amygdala and the mesolimbic reward brain system, which are known to be involved in emotional and motivational processes (Blood & Zatorre, Citation 2001 ; Koelsch, Citation 2015 ; Koelsch et al., Citation 2016 , Citation 2016 ; Levitin, Citation 2009 ; Moore, Citation 2013 ; Salimpoor et al., Citation 2013 ; Zatorre, Citation 2015 ). Furthermore, it is assumed that the systematic application of music in therapy in response to the needs of the patient(s) can strengthen the impact of music (Agres et al., Citation 2020 ; Bradt & Dileo, Citation 2014 ). In addition, empirical evidence shows that music activities in a group may result in synchronization among group members, which leads to positive feelings of togetherness and bonding (Linnemann et al., Citation 2016 ; Tarr et al., Citation 2014 ). These feelings of togetherness and bonding may be explained by the release of the neurotransmitters endorphin and oxytocin, which both play an important role in the defensive response to stress (e.g., Amir et al., Citation 1980 ; Dief et al., Citation 2018 ; Myint et al., Citation 2017 ). Lastly, music listening can help to lower stress levels through its quality to provide ‘distraction’ from stress-increasing feelings or thoughts (Bernatzky et al., Citation 2011 ; Chanda & Levitin, Citation 2013 ).

Music therapy can be defined as the clinical and evidence-informed use of music interventions to accomplish individualized goals within a therapeutic relationship in order to achieve physical, emotional, mental, social and cognitive needs (Aalbers et al., Citation 2019 ; Agres et al., Citation 2020 ; American Music Therapy Association [AMTA], Citation 2018 ; de Witte et al., Citation 2020a ). Music therapy has been applied as a therapeutic intervention in a wide spectrum of health care contexts, such as mental health care, forensic care, nursing homes, rehabilitation, and oncology (e.g., Agres et al., Citation 2020 ; Kamioka et al., Citation 2014 ; Martin et al., Citation 2018 ). Although the term ‘music therapy’ sometimes refers to any kind of use of music as an intervention in health care settings, music therapy should be offered by a trained music therapist, who is a licensed and qualified therapist with the required knowledge in psychology, medicine, and music (Agres et al., Citation 2020 ; AMTA, Citation 2018 ; Bradt et al., Citation 2015 ; Magee, Citation 2019 ).

Music therapists use the unique qualities of music (e.g., melody, rhythm, tempo, dynamics, pitch) within the therapeutic relationship to access patient's emotions and memories, to address social experiences or influence behavior (Bruscia, Citation 1987 ; Wheeler, Citation 2015 ). This specific kind of responsivity to the patient's needs can be regarded as the key competencies of the music therapist, referring to the processes that take place between therapist and patient supporting coordination, empathy and shared perspectives (Agres et al., Citation 2020 ). More specifically, during music therapy the music therapist attunes to the patient by adjusting the music created as an immediate response to the patient's needs (Aalbers et al., Citation 2019 ; Magee, Citation 2019 ).

To work on patient-therapist attunement, the music therapist synchronizes with the patient moment-by-moment, which may be considered as a mirroring technique. This means that the (musical) actions of the music therapist and the patient can become simultaneous and regulated through time, yielding a similar expression in movement, matching pulse, rhythm, dynamics and/or melody (Aalbers et al., Citation 2019 ; Bruscia, Citation 1987 ; Schumacher & Calvet, Citation 2008 ). For example, the music therapist may influence patients’ perceived stress during musical improvization by synchronizing with the patient's music-making, subsequently changing the musical expression by playing slower and less loudly. This specific way of patient-therapist attunement is commonly used in music therapy practice and refers to the so-called Iso Principle (e.g., Altshuler, Citation 1948 ; Heiderscheit & Madson, Citation 2015 ). Literature shows that the tempo and loudness are important for the experienced intensity of the music (Gabrielsson & Lindström, Citation 2010 ), and music with a slow steady rhythm may provide stress reduction by altering inherent body rhythms, such as heart rate (Thaut et al., Citation 1999 ; Thaut & Hoemberg, Citation 2014 ). The music therapist uses several types of interventions, which can be offered to a group of patients as well as individually. The number, frequency, and duration of the music therapy session may vary widely, and depend on the targeted outcome, patients’ preferences, and/or the setting in which the music therapy is offered (Agres et al., Citation 2020 ; AMTA, Citation 2018 ). Furthermore, music therapy interventions can be subdivided in two broad categories: active and receptive interventions (Magee, Citation 2019 ; Magee et al., Citation 2017 ; Wheeler, Citation 2015 ).

Active interventions involve the patient doing something with the music during the music therapy sessions, such as musical improvization, composing music or songs, movement to music, or singing or vocalizing. According to both literature and clinical practice, it seems that musical improvization is the most used intervention within music therapy, meaning that patient(s) and therapist improvize on musical instruments they have chosen and play together freely or with a given structure (Gold et al., Citation 2009 ; Wigram, Citation 2004 ). In receptive music therapy interventions, the patient is not actively making music, but rather responds to music provided by the music therapist, such as listening to live or prerecorded music (Bruscia, Citation 1998 ; Magee, Citation 2019 ; Wheeler, Citation 2015 ). The patient listens to the music and may process verbally their own emotions and/or experiences. During both active and receptive music interventions music therapists make specific use of the unique qualities of music (also known as ‘musical components’), such as rhythm, pitch, tempo, dynamics, melody and harmony, to facilitate and promote personal contact, communication, learning, mobilization, expression and other relevant goals (Agres et al., Citation 2020 ; Câmara et al., Citation 2013 ; Taets et al., Citation 2019 ; Thaut & Hoemberg, Citation 2014 ; Wheeler, Citation 2015 ).

Summarized, whereas music medicine does not involve a personal therapeutic process, music therapy requires such a process, characterized by personally tailored music interventions initiated by a trained/qualified music therapist (de Witte et al., Citation 2020a ; Leubner & Hinterberger, Citation 2017 ). These music therapy interventions can be divided in receptive music therapy interventions (music listening) or active music therapy interventions (live music-making), and are specifically characterized by musical attunement, facilitated by the music therapist, which distinguishes music therapy from other music interventions.

Music therapy versus music medicine

Research on music therapy is fast-growing (de Witte et al., Citation 2020a ). The effects of music listening interventions, such as ‘music medicine’, are mainly caused by the general influence of music on the stress response, whereas the effects of music therapy may also be explained by the therapeutic relationship through patient-therapist attunement by the use of music. Dileo ( Citation 2006 ) stated that music therapy is more effective than ‘music medicine’ interventions, and attributed this difference to the fact that music therapists individualize their interventions to meet patients’ specific needs (Bradt et al., Citation 2010 ; Dileo, Citation 1999 , Citation 2006 ).

In a Cochrane review of Bradt et al. ( Citation 2016 ) it was shown that ‘music medicine’ interventions and music therapy were equally effective in decreasing (state) anxiety. Bradt et al. ( Citation 2015 ) compared ‘music medicine’ with music therapy, and also found that both types of interventions were equally effective for anxiety and stress reduction, although 77.4% of the participants expressed a preference for music therapy for future treatments. This patient's preference for music therapy was related to quality of therapeutic relationships, interactive music making and the possibility of emotional expression, which is precisely what music therapy distinguishes from music listening interventions (Bradt et al., Citation 2015 ; Gutgsell et al., Citation 2013 ).

In our previous meta-analytic review on Randomized Controlled Trials (RCTs) examining the effects of music interventions on stress-related outcomes (de Witte et al., Citation 2020a ), we showed that music therapy did have at least as much effect on physiological stress-related outcomes ( d = .423) as ‘music medicine’ ( d = .379). However, only 7 studies on music therapy were included against 54 studies examining music medicine. Therefore, findings on music therapy were compromised by low generalizability and lack of statistical power to examine factors that might affect the effectiveness of music therapy by means of moderator analyses. Notably, most effectiveness studies on music therapy are quasi-experimental, because it is often difficult to meet the requirements for randomization and/or masking procedures (Bradt et al., Citation 2013b ; de Witte et al., Citation 2020a ; Magee et al., Citation 2017 ).

The present study

The present study is a systematic review and meta-analysis on the effects of music therapy on both physiological stress-related arousal (e.g., blood pressure, heart rate, hormone levels) and psychological stress-related experiences (e.g., state anxiety, restlessness or nervousness) in clinical health care settings. In our previous meta-analysis, we examined the effect of music interventions on stress-related outcomes. The included studies primarily used prerecorded music offered by medical professionals, whereas music therapy involves a trained music therapist who is responsive to the needs of the patient and can influence emotions and/or behavior of the patient by the use of music.

In the present meta-analysis, we included both RCTs and quasi-experimental designs with a control condition (Clinical Controlled Trials [CCT]), accounting for the effect of study design and quality in moderator analyses. The inclusion of quasi-experimental studies, which have been conducted under clinically representative conditions, increases external validity of meta-analytic findings and substantially increases statistical power of a meta-analysis (Shadish et al., Citation 2002 ; Shadish et al., Citation 2008 ).

The methodology of the present meta-analytic study is in line with our recent three-level meta-analysis (de Witte et al., Citation 2020a ), in which 104 randomized controlled trials were included. Results showed a significant small-to-medium effect of music interventions on physiological stress-related outcomes ( d = .380; 61 trials), and a medium effect of music interventions on psychological stress-related outcomes ( d = .545; 79 trials), indicating that groups receiving music intervention benefited more than the comparison groups. In the present meta-analysis, we examine the overall effect of music therapy on stress reduction, accounting for differences in physiological and psychological stress-related outcomes, and we aim to gain more insight into study, sample, outcome and intervention characteristics that might moderate the effects of music therapy on stress reduction.

Inclusion criteria

For the current meta-analysis, multiple inclusion criteria were formulated. First, only Randomized Controlled Trials (RCTs) and Clinical Controlled Trials (CCTs) that examined the effect of music therapy on the experience of stress and/or state anxiety were included. The type of intervention concerned important inclusion criteria for this meta-analysis. Only studies that offered music therapy by an educated and certified music therapist were included in this meta-analysis. Outcome measures related to quality of life (QoL) or pain were excluded, because in this study only the primary outcome measures of stress were included. The physiological effects of stress had to be measured by heart rate (HR), heart rate variability (HRV), blood pressure and hormone levels. The psychological effects of stress had to be measured by self-report instruments aiming at ‘stress' or ‘state anxiety’. Second, studies examining people with dementia or participants younger than 18 years of age were excluded. Although many studies showed cognitive and emotional benefits in dementia patients when they sing or listen to familiar songs (Särkämö et al., Citation 2008 , Citation 2014 ), these findings are not directly related to ‘stress reduction’. In addition, the stress measurement instruments which are used in the included studies are not used in studies examining people with dementia or young participants.

Selection of the studies

All randomized controlled trials (RCTs) and clinical controlled trials (CCTs) available until the 8th of May 2019 that met the inclusion criteria were included in this meta-analytic review. Multiple systematic searches were performed with the help of an independent medical librarian, as librarian engagement is significantly associated with higher quality of reported search strategies (Rethlefsen et al., Citation 2015 ). We conducted a computer-based search of the psychological and medical electronic literature databases, including Medline, Academic Search Complete, Cochrane Library, Web of Science, Embase, Wiley Online Library, Springerlink, PubMed, PiCarta, Academic Search Premier, ScienceDirect, PsycINfo and Google Scholar. The search string comprised three elements: a music therapy element, a stress-related outcome element and a study design element. For the music therapy element, the following keywords were used: ‘music therapy’, ‘musical therapy’ or ‘music-based therapy’. For the stress-related outcome element, the following keywords were used: ‘stress’, ‘anxiety’, ‘arousal’, ‘psychological stress,’ ‘occupational stress’, ‘physiological stress’, ‘mental suffer’, ‘anguish’, ‘hypertension,’ ‘relaxation’, ‘heart rate,’ ‘blood pressure’, ‘nervousness’, ‘cortical vigilance’, ‘distress’, ‘cortisol’, ‘intravascular pressure’, ‘vascular pressure’ or ‘STAI’. Concerning the study design element, the keywords: ‘randomized controlled trial’, ‘randomised controlled trial’, ‘clinical controlled trial’, ‘randomised’, ‘randomized’, ‘ RCT’, ‘review’ or ‘meta-analysis’ were used. Furthermore, reference sections of review – and meta-analytic articles about the effect of music (therapy) interventions on stress-related outcomes were inspected for qualifying studies. The search protocol of this meta-analytic review is registered at the international prospective register of systematic reviews (ref.no. CRD42020160222).

Figure 1. Flow chart of the search results.

Coding and moderators

The included studies were coded by the first and second author using a coding sheet according to the guidelines of Lipsey and Wilson ( Citation 2001 ). Stress can be considered as the dependent variable and was coded into physiological or psychological stress-related outcomes, resulting in one meta-analysis. Multiple variables with a potential moderating effect on the relation between music therapy and stress were identified. These moderators were divided into outcome-, study-, sample-, and intervention characteristics.

Regarding the psychological stress-related outcomes, it was coded whether the psychological outcomes were assessed by means of questionnaires measuring stress or (state) anxiety. State anxiety can be seen as a psychological stress-related outcome, because many studies (e.g., de Witte et al., Citation 2020a ; Hook et al., Citation 2008 ; Ng et al., Citation 2016 ; Zhang et al., Citation 2014 ) considered state anxiety to be a result of stress and outcome measures related to state anxiety or stress. Therefore, in the literature these concepts are used interchangeably (Bradt & Dileo, Citation 2014 ; Lazarus & Folkman, Citation 1984 ; Ozer et al., Citation 2013 ; Pittman & Kridli, Citation 2011 ; Wetsch et al., Citation 2009 ). This is in line with the results of our previous meta-analysis, which showed no significant differences in effect sizes between state-anxiety self-report scales ( d = .553) and stress self-report scales ( d = .512). In the present study, 30% of the studies used Visual Analog Scales (VAS) to measure perceived stress or state anxiety. Overall, stress is often measured by the Perceived Stress Scale (PSS) (Cohen et al., Citation 1983 ), the Quick Mood Scale (Woodruffe-Peacock et al., Citation 1998 ), and the Profile of Mood States (POMS) (McNair et al., Citation 1981 ), which instruments are used in 19% of the included studies. State anxiety is predominantly measured by the state version of the Spielberger State-Trait Anxiety Inventory (STAI) (Spielberger et al., Citation 1983 ) and the anxiety version of the Hospital Anxiety and Depression Scale (HADS-A), which are used in 45% of the included studies.

Regarding the study characteristics, we coded the design, study quality, type of setting, type of control condition and whether the study was conducted in Western- or non-Western countries. Studies with prospective group design, such as RCTs and CCTs were considered relevant for the current research. Therefore, we coded study design as RCT when participants were allocated to treatment conditions through randomization (e.g., computer-generated randomization lists), and CCT design when authors did not explicitly mention randomization, or quasi-randomized studies. The quality of the study was coded as strong, moderate or weak after assessment with the ‘Quality Assessment Tool for Quantitative Studies’ (Effective Public Health Practice Project [EPHPP], Citation 2009 ). This tool measures the quality of a study by providing a comprehensive and structured assessment of study quality (Armijo-Olivo et al., Citation 2012 ). The EPHPP has been reported to have high content and construct validity (Jackson & Waters, Citation 2005 ; Thomas et al., Citation 2004 ). Low quality studies negatively affect the internal (causal conclusion) validity, which can lead to a biased estimation of the overall effect estimate (Higgins & Green, Citation 2011 ; Zeng et al., Citation 2015 ).

Regarding the setting in which the study was conducted, we coded whether the study was conducted in a mental healthcare setting or in a medical setting (e.g., during polyclinic treatments, before or after surgery, palliative care). Furthermore, the type of control condition was coded, because different control conditions can yield different effect sizes (Finney, Citation 2000 ; Karlsson & Bergmark, Citation 2015 ). We coded care as usual (CAU) when no stress-reducing intervention was offered, but patients did receive regular care within medical or mental healthcare, waiting list when there was no care or intervention offered, or stress intervention when another stress-reducing intervention was delivered, such as listening to prerecorded music, verbal support, or mindfulness-based therapy. Further, we coded whether the study was conducted in Western countries (European countries, Australia, USA, Canada, New Zealand) or whether the study was conducted in countries designated as non-Western countries (mainly Asiatic countries). The cultural environment has been shown to influence the way people respond to and cope with stress (Lonner, Citation 2007 ; Tweed et al., Citation 2004 ), which could influence the effect of music on stress. In our previous meta-analysis, the country in which the study was conducted just failed to reach the conventional level of statistical significance ( p = 0.089), indicating that non-Western studies yielded larger effects on physiological stress-related outcomes than studies conducted in Western countries.

Sample characteristics were also coded, such as the percentage of men in each study. There are indications that men and women react differently to stress, both psychologically and physiologically, leading to substantiated gender differences in measured stress levels (Galanakis et al., Citation 2009 ; Kajantie & Phillips, Citation 2006 ; Verma et al., Citation 2011 ). We also coded the average age of the participants per study, because research on occupational stress revealed several differences in stress levels between different age groups (Galanakis et al., Citation 2009 ).

Additionally, we coded nine music therapy characteristics. First, we coded whether the music therapy was offered to an individual patient or whether it concerned a group music therapy. Empirical evidence shows that during group music therapy interventions people synchronize with each other, which evokes positive feelings of togetherness and bonding, and decreases stress levels (Linnemann et al., Citation 2016 ; Tarr et al., Citation 2014 ). Second, we coded music therapy interventions as ‘protocolized’ or ‘non-protocolized’. Music therapy protocols not only enable researchers to compare and replicate studies, but also to understand consistencies and strategies used by music therapists across sessions with participants (de Witte et al., Citation 2020a ; Vink & Hanser, Citation 2018 ). Both structure as well as strategies used during the therapy session may have impact on participants’ outcomes, such as stress levels. Third, the quality of the intervention description was coded in reported detailed or reported briefly and poor . We considered the description of the therapy as detailed if authors mentioned or elaborated on components of a session of music therapy, such as the number or duration of the sessions, listening to live or recorded music, or which musical instruments or music therapeutic techniques were used. If authors did not explicitly report on most of the characteristics of the delivered music therapy (as mentioned above), the description was regarded as brief/poor.

Fourth, music style was divided into three categories: classical music offered by the music therapist, relaxation music, and selection of own-preference music by patient. Fifth, we made a distinction between the way the music was offered: whether the music therapist used live music alone, pre-recorded music alone or both. Sixth, with regard to music selection, we coded whether the music was selected based on the preferences of the patient, on the choice of the music therapist himself, or whether a pre-selected choice of music was offered. In some studies, in which the effects of music listening on stress-related outcomes was examined, it was advised to allow the subjects to choose the music themselves, because this may have a greater stress reducing impact (Brannon & Fiest, Citation 2007 ; Juslin et al., Citation 2008 ). However, our previous meta-analytic review showed that the term ‘self-selected music’ is used both in studies where the patient could bring her/his own preference music and in studies where the patient had to choose from a pre-selected list of music styles or songs (de Witte et al., Citation 2020a ). Therefore, we coded as such in the present study.

Seventh, we coded whether the tempo of the music was 60–90 bpm or whether the music had another tempo. Tempo can be considered as one of the most significant moderators of music-related arousal and relaxation effects. In the previous meta-analytic review (de Witte et al., Citation 2020a ) of the effects of music interventions on stress-related outcomes, larger effect sizes were found in music with a tempo of 60–90 bpm compared to music with another tempo. Music with a slow tempo, such as meditative music, has often been demonstrated to initiate reductions in heart rate, resulting in greater relaxation (e.g., Bernardi et al., Citation 2005 ; Bringman et al., Citation 2009 ; Chlan, Citation 2000 ; Hilz et al., Citation 2014 ; Nomura et al., Citation 2013 ). Lastly, we coded the number of music intervention sessions and the frequency of the sessions per week. The number of interventions has been shown to be positively correlated with stress and anxiety regulation (Cassileth et al., Citation 2003 ; Gold et al., Citation 2009 ; Robb et al., Citation 2011 ).

Calculation and analyses

The effect sizes were transformed into Cohen's d by using the calculator of Wilson ( Citation 2013 ) and formulas of Lipsey and Wilson ( Citation 2001 ). Negative effect sizes indicate that music therapy had a negative effect on stress-related outcomes. Most d -values were calculated based on reported means and standard deviations. To correct for pre-treatment differences, pre-test effects were subtracted from post-test effects. The effect size was coded as zero when a study reported that an effect was not significant without providing any statistics (Lipsey & Wilson, Citation 2001 ). For both meta-analyses, the continuous moderators (age of the participants, gender of the participants, duration of the music intervention and frequency of the music intervention) were centered on their means. For categorical variables, dichotomous dummy variables were created. Extreme outliers in effect sizes were identified using box plots (Tabachnick & Fidell, Citation 2013 ), and were winsorized (i.e., replaced by the highest or lowest acceptable score falling within the normal range) for both meta-analyses. Standard errors were estimated using formulas of Lipsey and Wilson ( Citation 2001 ).

In some of the studies, it was possible to calculate more than one effect size, as most studies reported on multiple stress-related outcome variables, multiple scales or measurement instruments. It is possible that the effect sizes from the same study are more alike than effect sizes from other studies. The assumption of independent effect sizes underlying traditional meta-analytic methods was therefore violated (Hox, Citation 2010 ; Lipsey & Wilson, Citation 2001 ). We applied a multilevel approach to meta-analysis in order to account for the interdependency of effect sizes (see Assink et al., Citation 2015 ; Cheung, Citation 2014 ; de Witte et al., Citation 2020a ; Houben et al., Citation 2015 ; Spruit et al., Citation 2016 ).

A three-level meta-analytic model was used to calculate the combined effect sizes and to perform the moderator analyses. Three sources of variance were modeled, including the sampling variance for each effect sizes (level-one), the variance between effect sizes within studies (level-two), and the variance between studies (level-three) (Assink & Wibbelink, Citation 2016 ). The meta-analysis was conducted in R (version 3.4.3) with the metafor-package, employing a multilevel random effects model (Houben et al., Citation 2015 ; Van den Bussche et al., Citation 2009 ; Viechtbauer, Citation 2010 ). This model is often used for multilevel meta-analyses and, in general, it is superior to the fixed-effects approaches used in traditional meta-analyses (Van Den Noortgate & Onghena, Citation 2003 ). We used likelihood-ratio-tests to compare the deviance scores of the full model and the models without variance parameters on level two or three to determine if the level-two and -three variances were significant, indicating heterogeneity of effect sizes. A heterogeneous effect size distribution indicates that the effect sizes cannot be treated as estimates of a common overall effect size. In that case, we conducted moderator analyses, because the differences among effect sizes may be explained by outcome, study, sample, and/or intervention characteristics.

Publication bias

A common problem in conducting a meta-analysis is that studies with non-significant or negative results are less likely to be published than studies with positive and significant results. The studies included in this meta-analysis may therefore not be an adequate representation of all studies that have been conducted, which is called the ‘file drawer problem’ (Rosenthal, Citation 1995 ).

In order to check the presence of publication bias in the current meta-analysis, a trim and fill procedure was performed (Duval & Tweedie, Citation 2000a , Citation 2000b ). In case of publication bias, the funnel plot of the distribution of effect sizes is asymmetric. We tested if effect sizes were missing on the left and right side of the distribution. Publication bias would only be likely to occur in case of non-significant or unfavorable (i.e., negative) results, resulting in left-sided funnel plot asymmetry. Right-sided funnel plot asymmetry is indicative of selection bias. We imputed estimations of effect sizes of missing studies through trim and fill analyses in the case of left or right-sided asymmetry, and subsequently computed an overall effect size that would take the influence of publication bias or selection bias into account (Duval & Tweedie, Citation 2000a , Citation 2000b ), providing an estimate of the degree to which publication bias or selection bias might have affected the overall mean effect size.

Overall effect of music therapy on stress-related outcomes

Table 1. overall effects of music therapy on stress-related outcomes., table 2. moderator effects of music therapy on stress-related outcomes., results of moderator analyses of music therapy on stress-related outcomes.

Outcome characteristics. Both the domain of outcomes (physiological or psychological stress-related outcomes) and the type psychological measure (stress or state-anxiety measurements) did not influence the effects of music therapy on stress-related outcomes.

Study characteristics. Firstly, the strongest effects of music therapy on stress-related outcomes were measured by CCTs ( d = 1.449, [1.01–1.89]) compared to RCTs ( d = .555, [.35–.76]). Secondly, the continent in which the study was conducted did also moderate the overall effect. Studies from non-Western countries had a stronger influence on the overall effect of music therapy on stress-related outcomes ( d = 1.306, [.79–1.82]) compared to studies from Western countries ( d = .611, [.39–.83]). Thirdly, a significant moderating effect was found for type of control condition. Studies with a waiting list control condition yielded a larger effect ( d = 1.415, [.95–1.88]) than studies with CAU ( d = .561, [.33–.79]) or another stress-reducing intervention ( d = .594, [.29–.90]). The clinical setting in which the study was conducted, did not moderate the effect. No significant differences were found between the effects of music therapy on stress-related outcomes in mental health care settings and medical settings. Furthermore, we observed that study quality moderated the overall effect with low quality studies ( d = 1.056, [.71–1.40]) yielding larger effects compared to studies with a moderate ( d = .589, [.28–.90]) or strong ( d = .444, [.02–.87]) study quality.

Sample characteristics. The age ( d = .718, [.50–.94]) and gender ( d = .728, [.51–.94]) of the samples did not show to have a moderating effect on stress symptoms.

Intervention characteristics. Music tempo between 60 and 90 bpm yielded a larger effect ( d = .900 [.54–1.26]) compared to music with no specific tempo ( d = .631 [.37–.90]). Similarly, more than one session of music therapy had a larger effect ( d = .894 [.56–1.23]) than one session ( d = .594 [.17–1.02]). The effect size of preselected choice was larger ( d = 1.059 [.66–1.46]) than music selection by the music therapist ( d = .695 [.37–1.02]) and by the patient ( d = .766 [.47–1.06]). With respect to music style, relaxation had a greater effect ( d = .826 [.49–1.16]) compared to own preference music ( d = .688 [.40–.97]) and classical music ( d = .562 [−.07 to 1.19]). Additionally, group music therapy yielded a larger effect ( d = .927 [.54–1.32]) than individual music therapy ( d = .679 [.41–.95]). However, due to the small number of studies in certain categories (see Table 2 ), these differences were not statistically significant, and further studies are necessary to estimate these differences with more precision. Other differences had similar effect sizes (e.g., treatment protocol ( d = .683 [.33–1.04]) or not ( d = .747 [.48–1.02]); detailed intervention description ( d = .775 [.52–1.03]) or brief/poor description ( d = .637 [.31–96]); and the way the music therapist induced the music – live music ( d = .726 [.46–.99]), prerecorded music ( d = .664 [.26–1.07]) and both ( d = .767 [.37–1.16]). Lastly, the effect of frequency of sessions per week ( d = .746 [.49–1.01]) was not significant.

Overall effects

Overall, we found a significant medium-to-strong effect ( d = 0.723, [0.51, 0.94]) of music therapy on stress-related outcomes, indicating that participants receiving music therapy benefited more than controls. We conclude that music therapy is effective in reducing stress-related symptoms in both mental healthcare and medical settings. In our previous meta-analytic review, we found positive small-to-medium effects of music interventions on stress-related outcomes (see for more details: de Witte et al., Citation 2020a ), while the findings of the present study demonstrate that music therapy yields a medium-to-strong effect on stress reduction. The difference in the strength of overall effect sizes may be explained by the different way both types of interventions are offered. The active involvement of a music therapist who is specifically trained to tailor interventions to the needs of patients and their musical preferences might give a reasonable explanation for the larger effect size for music therapy compared to music interventions (Bradt & Dileo, Citation 2014 ; Dileo, Citation 1999 , Citation 2006 ; Magee, Citation 2019 ; Magee et al., Citation 2017 ; Stegemann et al., Citation 2019 ). Music therapists are especially trained to deliver music therapy sessions to meet participants/patients’ needs at the individual or group level (Rafieyan & Ries, Citation 2007 ).

The overall findings of the present meta-analysis are consistent with the findings of previous reviews and/or meta-analyses on the effects of music therapy on stress- and anxiety-related outcomes (Bradt & Dileo, Citation 2014 ; Bradt et al., Citation 2013a ; Bradt et al., Citation 2013b ; Bradt et al., Citation 2016 ; Carr et al., Citation 2013 ; de Witte et al., Citation 2020a ; Gold et al., Citation 2009 ; Kamioka et al., Citation 2014 ). In addition, the promising results of music therapy established in the current meta-analysis are in line with the findings of previous systematic reviews and meta-analyses on the effects of music interventions on the reduction of stress and/or (state) anxiety (Bradt & Dileo, Citation 2014 ; Bradt et al., Citation 2013a ; Bradt et al., Citation 2013b ; Bradt et al., Citation 2016 ; de Witte et al., Citation 2020a ; Gillen et al., Citation 2008 ; Kim et al., Citation 2015 ; Pelletier, Citation 2004 ; Rudin et al., Citation 2007 ).

Both the present meta-analysis and previous reviews show a growth in controlled clinical studies testing the effects of music therapy and/or music interventions on stress-related outcomes, which is important in order to formulate valid conclusions on the effects of non-pharmaceutical interventions for stress reduction (Casey, Citation 2017 ; de Witte et al., Citation 2020a ). The demand for more non-pharmaceutical interventions, such as music therapy, may be explained by the increasing awareness of the negative side effects of tranquilizing medication, such as substance dependence and abuse (Casey, Citation 2017 ; World Health Organization [WHO], Citation 2010 ). Although a considerable number of people around the world use tranquilizing medications to cope with daily life stressors or anxiety (e.g., Bandelow et al., Citation 2015 ; Olfson et al., Citation 2015 ; Puetz et al., Citation 2015 ), previous studies show no convincing evidence for the short-term effectiveness of pharmacological treatment in the reduction of stress-related problems (Donovan et al., Citation 2019 ; Olfson et al., Citation 2015 ).

Effect moderating variables

Results of the present meta-analysis indicate that moderators explain differences in the strength of the effect size. Significant larger effects were found for studies using quasi-experimental CCTs compared to RCTs. Regardless of ethical concerns about the randomization of patients, the results of RCTs are still considered to provide the most robust evidence, because RCT designs can better exclude alternative explanations for established intervention effects than non-randomized designs. Selection bias in non-randomized effect studies can lead to overestimations of treatment effects (Page et al., Citation 2018 ; Valentine & Thompson, Citation 2013 ). In addition, we also found a significant moderating effect on the type of control condition: comparisons with a waiting list control group showed larger effects than comparisons with CAU or another stress-reducing intervention. This finding is in line with our expectation that CAU or another intervention would lead to reduction of stress, and thus to more stress reduction compared to a waiting list group. In addition, participants on a waiting list may also show a reduction in the stress level of symptomatology, which is shown in previous research in psychiatric populations (Arrindell, Citation 2001 ; Haeyen et al., Citation 2018 ). Specifically, Crawford et al. ( Citation 2013 ) found that in spite of the positive scores of subjects of the music therapy group on stress reduction compared to subjects of the wait-list control group, the control participants also showed an improvement on stress reduction compared to baseline.

The overall effect size proved to be strongly moderated by the country in which the study was conducted (i.e., non-Western versus Western countries). Larger effects were found in non-Western studies ( n = 8), including studies conducted in Asian countries, such as China, Korea, and Taiwan, but also studies conducted in Iran, Brazil and Nigeria. It has been shown that the cultural environment influences how people respond to stress (Lonner, Citation 2007 ; Tweed et al., Citation 2004 ), which might explain differences between Western and non-Western countries. On the other hand, the non-Western countries show great heterogeneity in culture, socioeconomic characteristics or topographical region. Moreover, Western countries with large proportions of immigrants – such as the USA, Canada, and Australia – make it difficult to equate country with culture (Morales & Ladhari, Citation 2011 ). Additionally, post-hoc analyses showed a weak correlation between Non-Western countries and study design ( r = .34 , p = <.01 ) , which indicates that the CCT design was more frequently used in Non-Western countries than in Western studies . Further research is needed to test particular explanations for cultural differences in effects between studies in Western and non-Western countries. Not only culture should be taken into account in future research, but also socioeconomic characteristics of study samples and the delivery of care in different health care systems, because of great heterogeneity both within and between countries.

Contrary to our expectations, we did not find evidence for a moderating effect of studies using a specific therapy protocol compared to studies without such a protocol. This can be explained by the fact that most studies included in our meta-analysis did not report on the use of such a therapy protocol, but still showed an adequate and rich description of the content of music therapy interventions. From the perspective of the music therapist, who is trained to tune in to the patient by adjusting the way of music-making as an immediate response to the patient's needs (Aalbers et al., Citation 2019 ; Magee, Citation 2019 ), music therapy protocols might often equal the flexibility of non-protocolled treatment in order to deliver personalized treatment, which increases the comparability or sameness of protocolled and non-protocolled treatment.

Notwithstanding we believe that there is a need for developing music therapy protocols and intervention descriptions that facilitate further replication of music therapy interventions and, subsequently, will better inform clinicians and practitioners in both mental health care and medical settings (de Witte et al., Citation 2020a ). In addition, in future trials we strongly recommend examining treatment integrity as well, because music therapists may choose not to offer some of the elements specified in the protocol or to add new treatment elements. Having information on treatment integrity allows for the examination of the degree to which the implemented intervention approximates the intended intervention, and possible effects of treatment integrity on client outcomes (Perepletchikova, Citation 2011 ; Vermilyea et al., Citation 1984 ).

Study quality just failed to reach the conventional level of statistical significance, which indicates that low quality studies may yield larger effects compared to studies with a moderate or strong study quality. An explanation for this result could be that the degree of ‘masking’ was an important factor in assessing study quality. Masking of participants in music therapy studies is usually not possible unless two types of music therapy interventions are compared, such as receptive music therapy versus active music therapy (Bradt et al., Citation 2013b ). Masking procedures in which only the investigator is masked to the allocation of the intervention is much more feasible in music therapy trials (Day & Altman, Citation 2000 ). Nevertheless, the present meta-analysis contained several studies in which the way of masking was not reported at all ( n = 12), which is in line with the findings of Magee et al. ( Citation 2017 ), who conclude in their Cochrane review that in future research reporting on the masking of participants and outcome assessors requires improvement. The lack of participant masking is problematic when studies examine subjective outcomes, such as mood or quality of life. Masking of therapists is often not possible in music therapy studies when active music-making is examined. When due to setting constrains the interventions cannot assure masking procedures, they should at least be masked to the purpose of the study where possible. In either case, masking procedures should be reported or discussed (Bradt et al., Citation 2013b ; Magee et al., Citation 2017 ).

Statistical analyses showed that the selected music therapy characteristics do not seem to moderate the overall effects of music therapy on stress-related outcomes. This could be explained by the diversity of the music therapeutic approaches and/or the applied interventions of the included music therapy studies, which is also mentioned in several previous reviews (Carr et al., Citation 2013 ; Gold et al., Citation 2009 ; Mössler et al., Citation 2011 ; Silverman, Citation 2003 ). On the other hand, this diversity in the content of music therapy can also be related to the core competence of a qualified music therapist, which means that the interventions are often tailored to what the patient needs or shows at that moment. Precisely this aspect of music therapy is the main difference with music interventions without a music therapist and could therefore have resulted in a larger effect size.

The selected intervention characteristics did not have a statistically significant impact on the effectiveness of music therapy. However, some substantial differences in effect sizes were found ( d = .30 or larger) in moderator analyses that did not reach the conventional level of significance due to lack of statistical power, mostly caused by an unequal distribution of studies (and effect sizes) among moderator categories (see Table 2 ). We discuss some of these findings because they may be of particular theoretical interest, and probably should be addressed in future research.

First, there was a difference of d = .30 between the impact of only one session of music therapy ( d = .594, [.17–1.02]) and more than one session ( d = .894, [.56–1.23]), indicating that the effect of music therapy on stress-related outcomes increases with the use of multiple sessions. The larger effect size for more than one session is in line with the study of Gold et al. ( Citation 2009 ), which showed more substantial benefits in patients who took a longer course of music therapy or more frequent sessions. However, Gold's study examined the effects of music therapy in patients with severe mental disorders, whereas the present meta-analysis mostly included studies with patients suffering from much milder mental problems or patients with stress due to medical conditions. This does not diminish the importance of stress reduction, since stress is globally recognized as a major risk factor for the development of serious health problems (American Psychological Association [APA], Citation 2017 ; Australian Psychological Society [APS], Citation 2015 ).

Notably, the effect of the number of sessions seems to be related to the type of setting (medical healthcare versus mental healthcare). In our meta-analysis, only studies conducted in medical healthcare settings measured one-session effects of music therapy on stress-related outcomes, which of course does not exclude the possibility that positive effects can just as well be measured within mental healthcare settings after only one session of music therapy. Nevertheless, our meta-analysis found empirical evidence for the short-term effectiveness of music therapy (i.e., a single session of music therapy) in reducing stress, and therefore puts the assumption that pharmacological treatment should be started due to its immediate and rapid effect in a critical light (Bandelow et al., Citation 2015 ; de Witte et al., Citation 2020a ; Fedoroff & Taylor, Citation 2001 ). Moreover, the shown efficacy of only one single session may facilitate the implementation of music therapy in cases where for logistic reasons or in more complicated settings (e.g., during chemotherapy in the treatment of cancer, before or after surgery, or in palliative care) multiple sessions of music therapy would not be possible.

Second, the large effect of music with a tempo of 60–90 bpm ( d = .900, n = 16) is worth mentioning. It is larger than the effect obtained in our previous meta-analytic review (de Witte et al., Citation 2020a ), showing a medium effect ( d = . 625, n = 36). The larger effect size found in the current meta-analysis may be ascribed to a lower amount of studies using prerecorded music than in our previous meta-analysis, which included mostly ‘music medicine’ interventions. Interestingly, a post-hoc analysis showed a significant strong correlation between music tempo of 60–90 bpm and prerecorded music ( r = .61, p = <.01). Unfortunately, several studies did not report on the tempo used due to the fact that (1) interventions could vary across the music therapy session depending on participants’ needs, and (2) the use of musical instruments varied considerably within and across the music therapy sessions. Moreover, the music tempo is usually not measured during a music therapy session of live improvised music are. We strongly recommend to investigate the influence of music tempo as a component of music therapy interventions, especially when targeting stress reduction. Moreover, literature also shows that music with a slow tempo and steady rhythm may provide stress reduction by altering inherent body rhythms, such as heart rate (Thaut et al., Citation 1999 ; Thaut & Hoemberg, Citation 2014 ).

Lastly, the moderator ‘therapy setting’ revealed a large effect for group music therapy ( d = .927, [.54–1.32]). There is empirical evidence showing that group music activities stimulate the release of the stress-reducing neurotransmitters endorphin and oxytocin as a result of positive feelings of togetherness and bonding among group members (Linnemann et al., Citation 2016 ; Tarr et al., Citation 2014 ). In group music therapy, feelings of togetherness and bonding may be the result of non-verbal synchronization with each other by making music or listening to music, which offers a different experience of communicating and relating to others in a medium that has been shown to be motivating for people who otherwise find it difficult to share or engage (Carr et al., Citation 2017 ; Gold et al., Citation 2013 ; Stern, Citation 2010 ). Moreover, research shows that achieving synchronization by musical attunement is considered one of the most important (pre-)conditions in music therapy for eventually reaching stress reduction (Aalbers et al., Citation 2019 ; de Witte et al., Citation 2020b ). Facilitating synchronization as the basis for further interventions in music therapy is therefore regarded as one of the key competencies of a music therapist (e.g., Aalbers et al., Citation 2019 ; Bruscia, Citation 1987 ; Schumacher & Calvet, Citation 2008 ; Wheeler, Citation 2015 ). Finally, a post-hoc analysis showed a significant moderate correlation ( r = .45, p = <.01) between individual music therapy and medical settings, which indicates that individual music therapy is relatively more used in medical setting compared other settings.

Limitations of the present study

The current study has some limitations that need to be mentioned. Firstly, a significant number ( n = 16) of the studies included in this meta-analysis had a small sample size (10–25 participants). Studies with small sample sizes are fairly common in meta-analyses (Davey et al., Citation 2011 ), particularly when studies are conducted in medical or palliative settings where time and logistic constraints occur. It is important to highlight that small sample sizes in primary studies may result in great heterogeneity in treatment effects due to relatively large standard errors. Studies with small samples may also show greater clinical heterogeneity among patients compared to studies with large sample sizes, which may affect the outcome of the experimental treatment (IntHout et al., Citation 2015 ; Schwarzer et al., Citation 2015 ). Furthermore, the findings from small sample size studies tend to be less generalizable compared to studies with large number of participants. Furthermore, a limitation of any meta-analysis is that there is not a completely satisfactory way to test the presence of publication bias (Carter et al., Citation 2019 ). The presence of publication bias can therefore never be ruled out, even if formal tests indicate that publication bias is unlikely. In fact, it is imperative that all clinical trials be preregistered in effectiveness research, including publication of the research protocols. In the present study, we chose to conduct a funnel-plot-based trim and fill method (Duval & Tweedie, Citation 2000a , Citation 2000b ), which is commonly used in three-level meta-analyses in the domain of psychological studies (see Assink et al., Citation 2019 ; Assink & Wibbelink, Citation 2016 ; Zeegers et al., Citation 2017 ), which seems a sufficiently sensitive method to detect publication bias in the current meta-analysis given the substantial number of studies and effect sizes, the magnitude of the effect sizes, and the degree of level 2 (within studies) and level 3 (between studies) heterogeneity of the overall effect size (See Assink & Wibbelink, Citation 2016 ; Carter et al., Citation 2019 ).

Although a clear search strategy to identify relevant studies has been performed, by for instance excluding observational and retrospective studies, most studies included in our meta-analysis lack masking procedure to participants. This particularly occurred in medical settings where due to the clinical condition of the participants the treatment group was disclosed. The majority of studies with small sample sizes and without a masking procedure were conducted in medical care. This might have influenced some of the study outcomes. Specifically, the lack of masking may have contributed to therapist expectancy (leading to therapist bias) and/or a patient expectancy-effect (also known as placebo effect), eliciting a desirable therapeutic outcome (Tambling, Citation 2012 ). In future studies, efforts need to be made to reduce expectancy or placebo effects, for example, by measuring expectation and/or adopting alternative experimental designs to control for these effects (Atwood et al., Citation 2020 ; Boot et al., Citation 2013 ). Notwithstanding the ethical reasons to refrain from a masking procedure and waiting-list design in anxiety and stress studies, it is important to further improve study quality and use larger samples. Next, we strongly recommend that future trials report on power analyses.

The current meta-analytic review provides evidence that music therapy can be effective in reducing stress and provides justifications for the increasing use of music therapy carried out by a qualified music therapist in both mental health care practice and medical settings. Given the added value of the presence of a well-trained and qualified music therapist who offers music therapy, it is advisable to carefully consider whether music therapy is needed, or whether music listening interventions, mostly offered by healthcare professionals, are sufficient. In addition, low costs and lack of side effects of music therapy, and the moderate-to-strong stress-relieving effects of music therapy are very important for the prevention and treatment of stress-related problems. Nevertheless, with respect to the methodology of future trials, we strongly recommend reducing the risk of selection bias by aligning with the conditions of RCTs. Finally, the development of standardized music therapy protocols is necessary to conduct more robust research on the effects of music therapy, and to gain more insight into the moderating effects of characteristics of music therapy for stress reduction.

Special thanks are due to Arjan Doolaar and Thomas Pelgrim from HAN university of applied sciences (Nijmegen, The Netherlands), for their advice and assist with the systematic search.

No potential conflict of interest was reported by the author(s).

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Studies included in the meta-analysis

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Table A1. Characteristics of included studies.

Figure A1. Trim-and-fill plot.

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> Journals
> The British Journal of Psychiatry
> Volume 199 Issue 2
> Music therapy for depression: it seems to work, but...

Article contents

Meaningfulness and pleasure, physicality, music - therapy, music therapy for depression: it seems to work, but how.

Published online by Cambridge University Press: 02 January 2018

Evidence is beginning to emerge that music therapy can improve the mental health of people with depression. We examine possible mechanisms of action of this complex intervention and suggest that music therapy partly is effective because active music-making within the therapeutic frame offers the patient opportunities for new aesthetic, physical and relational experiences.

According to a national poll of listeners to a popular BBC music station in 2004, the best way to ameliorate one's depressive symptoms musically is to listen to ‘I Know It's Over’ by The Smiths. 1 Alas, the widespread availability of down-hearted rock does not appear to have diminished the prevalence of depression. And although listening alone to music that is personally meaningful is what many people imagine music therapy to be, the reality as practised in the UK and in many other parts of Europe is quite different.

It is therefore gratifying to read the article by Erkkilä et al Reference Erkkilä, Punkanen, Fachner, Ala-Ruona, Pöntiö and Tervaniemi 2 in this issue of the Journal that reports the results of a randomised controlled trial of interactive one-to-one music therapy for adults of working age with depression. In this study, conducted in Finland, trained music therapists engaged participants in up to 20 sessions of co-improvisational active music-making as the basis of a therapeutic relationship. This is a high-quality randomised trial of music therapy specifically for depression and the results suggest that it can improve the mood and global functioning of people with this disorder.

Among the challenges involved in evaluating complex interventions such as music therapy are those associated with treatment fidelity. Erkkilä et al have addressed this issue by ensuring that the music therapists who delivered treatment all completed an extensive induction focused on ensuring fidelity, and videotaped their sessions with participants to monitor adherence. The attention to fidelity is borne out in results that do not vary between therapists. This suggests that the agent of change is not likely to be the personality of the therapist or the nature of the particular therapist-patient alliance (as highlighted by the common factors approach, for example Messer & Wampold Reference Messer and Wampold 3 ) but rather may be attributable to the music or the therapy (if they are indeed distinguishable).

So why might this be so? Aside from any explanations derived from non-musical aspects of the therapy, the authors report that ‘active doing’ (i.e. the playing of musical instruments with the music therapists) was important to many participants in the active arm of the trial. They suggest that this is an important characteristic of music therapy and a meaningful way of dealing with issues associated with depression. We would like to suggest that this ‘active doing’ within music therapy has at least three interlinked dimensions: aesthetic, physical and relational.

First, the relationship between a diagnosis of depression and an experienced lack of pleasure and meaningfulness in life is well established. Perhaps in response to this, there is also a well-established recognition of the value of meaning-making via aesthetic experience within psychotherapy (e.g. Zukowski, Reference Zukowski 4 Hagman & Press Reference Hagman and Press 5 ). Here the conception is of the whole (verbal) therapeutic process as essentially aesthetic: how much more of an immediate aesthetic experience is on offer where the therapeutic interaction is musical? In music therapy, the therapist brings their musicianship to the musical encounter by listening acutely and attuning to the musical components implied in the patient's improvised sounds. For example, the therapist might draw out a shaky pulse or reinforce an implied tonal centre. Or they might create suspense or an implied direction (using a bass line or a harmonic progression underpinning an individual's melodic fragment) to entice a withdrawn person to engage in the relationship. There are often moments in music therapy when there is a ‘buzz’ between the two players, for example when they spontaneously come together at a cadence point or somehow know when to end or where to go next.

When a satisfying aesthetic is achieved within a co-improvised musical relationship there is potential not just for some kind of catharsis but for development, even if the music is not used as a springboard to discussion and insight: the aesthetic draws in the players to take the risk of doing things differently with others - to behave differently towards each other and to experience themselves differently. Reference Ansdell 6

Second, and rather obviously, the act of playing musical instruments requires purposeful physical movement. The role of physical activity in averting depression and alleviating its effects is well recognised. This is not simply a matter of getting people moving, but also of enabling people to experience themselves as physical beings. Music has its own internal sense of meaning founded on structure and cultural norms: this engages us and draws us into it whether or not we are aware of it on a technical level. Hence we find ourselves tapping our foot along to a song on the radio or being dissatisfied by a piece that does not finish as we expect. We are therefore entrained into musical participation: music itself offers us ways in - even in circumstances where we may feel distinctly unmotivated. Where we find ourselves musically entrained into physical participation with others we can have a physical experience of ourselves with others. This mirrors the experiences of musicians when playing in groups as can be seen in the coordinated movements of the players in a string quartet. Reference Davidson and Good 7 Our participation in turn enables us to hear (and feel) ourselves in the context of the aesthetic experiences outlined earlier, and this lends a potent sense of being part of something meaningful in the here-and-now:

… music heard so deeply That it is not heard at all, but you are the music While the music lasts. (T. S. Eliot: p. 48) Reference Eliot and De Masirevich 8

This leads to a third category of ‘active doing’: the relational. Our first experiences of relating (with our primary caregiver) are fundamentally musical. Developmental psychologists use musical vocabulary to describe the finely attuned interplay of gesture and sound between parent and newborn baby (e.g. Hobson Reference Hobson 9 ): it is in this pre-verbal interaction that we first learn who we are, how to think and to take pleasure in the possibilities that the world around us has to offer. Where mothers of infants are depressed, the musicality of infant-directed speech and conversational engagement is demonstrably affected with significant developmental implications for the child. Reference Marwick, Murray, Malloch and Trevarthen 10 These early experiences of musicality are frequently offered as a rationale for music therapy as a whole (e.g. Trevarthen & Malloch Reference Trevarthen and Malloch 11 ) and from this perspective the role of the therapist can be seen as neo-parental: musically nurturing the patient in order to facilitate a similar process of discovery of self and self in relation to others, including the capacity for experiencing meaning and pleasure. Once again, it is music itself that facilitates this: a melodic riff, a harmonic progression, a rhythmic catch - these all naturally engage people in active participation (and hence meaning-making) in ways that words may simply not be able to. It has been argued that music therapy builds on people's capacity for communicative musicality, that we are hard-wired for this kind of engagement and interaction, and that through music-making we experience a kind of relating that is very different from that which talking has to offer. Reference Ansdell, Pavlicevic, Miell, MacDonald and Hargreaves 12

In these respects, then, music cannot be treated simply as a stimulus intended to provoke a predetermined behavioural response. Rather, music-making offers what DeNora Reference DeNora 13 terms affordances - physical, relational and aesthetic. Above all, music-making is social (and hence interpersonal), pleasurable and meaningful: this may also be why randomised trials of music therapy have shown high levels of engagement with patient groups who are traditionally difficult to engage (e.g. Talwar et al Reference Talwar, Crawford, Maratos, Nur, McDermott and Procter 14 ).

Clinical trials inevitably focus on the outcomes of interventions rather than the process through which these outcomes may be achieved. Further research using mixed methods is needed if a better understanding of the active ingredients of music therapy that enhance patient outcomes is to be reached.

Nevertheless, Erkkilä et al Reference Erkkilä, Punkanen, Fachner, Ala-Ruona, Pöntiö and Tervaniemi 2 lay down a clear marker for the value of music therapy as part of the range of interventions available for the treatment of people with depression.

See pp. 132–139, this issue.

Declaration of interest

A.M. and M.J.C. are members of the International Centre for Research in Arts Therapies (ICRA), a non-profit group that aims to promote research in the arts therapies.

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Volume 199, Issue 2
Anna Maratos (a1) , Mike J. Crawford (a2) and Simon Procter (a3)
DOI: https://doi.org/10.1192/bjp.bp.110.087494

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What to Know About Music Therapy

Music can help improve your mood and overall mental health.

Verywell / Lara Antal

Effectiveness

Things to consider, how to get started.

Music therapy is a therapeutic approach that uses the naturally mood-lifting properties of music to help people improve their mental health and overall well-being. It’s a goal-oriented intervention that may involve:

Making music
Writing songs
Listening to music
Discussing music

This form of treatment may be helpful for people with depression and anxiety, and it may help improve the quality of life for people with physical health problems. Anyone can engage in music therapy; you don’t need a background in music to experience its beneficial effects.

Types of Music Therapy

Music therapy can be an active process, where clients play a role in creating music, or a passive one that involves listening or responding to music. Some therapists may use a combined approach that involves both active and passive interactions with music.

There are a variety of approaches established in music therapy, including:

Analytical music therapy : Analytical music therapy encourages you to use an improvised, musical "dialogue" through singing or playing an instrument to express your unconscious thoughts, which you can reflect on and discuss with your therapist afterward.
Benenzon music therapy : This format combines some concepts of psychoanalysis with the process of making music. Benenzon music therapy includes the search for your "musical sound identity," which describes the external sounds that most closely match your internal psychological state.
Cognitive behavioral music therapy (CBMT) : This approach combines cognitive behavioral therapy (CBT) with music. In CBMT, music is used to reinforce some behaviors and modify others. This approach is structured, not improvisational, and may include listening to music, dancing, singing, or playing an instrument.
Community music therapy : This format is focused on using music as a way to facilitate change on the community level. It’s done in a group setting and requires a high level of engagement from each member.
Nordoff-Robbins music therapy : Also called creative music therapy, this method involves playing an instrument (often a cymbal or drum) while the therapist accompanies using another instrument. The improvisational process uses music as a way to help enable self-expression.
The Bonny method of guided imagery and music (GIM) : This form of therapy uses classical music as a way to stimulate the imagination. In this method, you explain the feelings, sensations, memories, and imagery you experience while listening to the music.
Vocal psychotherapy : In this format, you use various vocal exercises, natural sounds, and breathing techniques to connect with your emotions and impulses. This practice is meant to create a deeper sense of connection with yourself.

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Music Therapy vs. Sound Therapy

Music therapy and sound therapy (or sound healing ) are distinctive, and each approach has its own goals, protocols, tools, and settings:

Music therapy is a relatively new discipline, while sound therapy is based on ancient Tibetan cultural practices .
Sound therapy uses tools to achieve specific sound frequencies, while music therapy focuses on addressing symptoms like stress and pain.
The training and certifications that exist for sound therapy are not as standardized as those for music therapists.
Music therapists often work in hospitals, substance abuse treatment centers, or private practices, while sound therapists may offer their service as a component of complementary or alternative medicine.

When you begin working with a music therapist, you will start by identifying your goals. For example, if you’re experiencing depression, you may hope to use music to naturally improve your mood and increase your happiness . You may also want to try applying music therapy to other symptoms of depression like anxiety, insomnia, or trouble focusing.

During a music therapy session, you may listen to different genres of music , play a musical instrument, or even compose your own songs. You may be asked to sing or dance. Your therapist may encourage you to improvise, or they may have a set structure for you to follow.

You may be asked to tune in to your emotions as you perform these tasks or to allow your feelings to direct your actions. For example, if you are angry, you might play or sing loud, fast, and dissonant chords.

You may also use music to explore ways to change how you feel. If you express anger or stress, your music therapist might respond by having you listen to or create music with slow, soft, soothing tones.

Music therapy is often one-on-one, but you may also choose to participate in group sessions if they are available. Sessions with a music therapist take place wherever they practice, which might be a:

Community health center
Correctional facility
Private office
Physical therapy practice
Rehabilitation facility

Wherever it happens to be, the room you work in together will be a calm environment with no outside distractions.

What Music Therapy Can Help With

Music therapy may be helpful for people experiencing:

Alzheimer’s disease
Anxiety or stress
Cardiac conditions
Chronic pain
Difficulties with verbal and nonverbal communication
Emotional dysregulation
Feelings of low self-esteem
Impulsivity
Negative mood
Post-traumatic stress disorder (PTSD)
Problems related to childbirth
Rehabilitation after an injury or medical procedure
Respiration problems
Substance use disorders
Surgery-related issues
Traumatic brain injury (TBI)
Trouble with movement or coordination

Research also suggests that it can be helpful for people with:

Obsessive-compulsive disorder (OCD)
Schizophrenia
Stroke and neurological disorders

Music therapy is also often used to help children and adolescents:

Develop their identities
Improve their communication skills
Learn to regulate their emotions
Recover from trauma
Self-reflect

Benefits of Using Music as Therapy

Music therapy can be highly personalized, making it suitable for people of any age—even very young children can benefit. It’s also versatile and offers benefits for people with a variety of musical experience levels and with different mental or physical health challenges.

Engaging with music can:

Activate regions of the brain that influence things like memory, emotions, movement, sensory relay, some involuntary functions, decision-making, and reward
Fulfill social needs for older adults in group settings
Lower heart rate and blood pressure
Relax muscle tension
Release endorphins
Relieve stress and encourage feelings of calm
Strengthen motor skills and improve communication for children and young adults who have developmental and/or learning disabilities

Research has also shown that music can have a powerful effect on people with dementia and other memory-related disorders.

Overall, music therapy can increase positive feelings, like:

Confidence and empowerment
Emotional intimacy

The uses and benefits of music therapy have been researched for decades. Key findings from clinical studies have shown that music therapy may be helpful for people with depression and anxiety, sleep disorders, and even cancer.

Depression

Studies have shown that music therapy can be an effective component of depression treatment. According to the research cited, the use of music therapy was most beneficial to people with depression when it was combined with the usual treatments (such as antidepressants and psychotherapy).

When used in combination with other forms of treatment, music therapy may also help reduce obsessive thoughts , depression, and anxiety in people with OCD.

In 2016, researchers conducted a feasibility study that explored how music therapy could be combined with CBT to treat depression . While additional research is needed, the initial results were promising.

Many people find that music, or even white noise, helps them fall asleep. Research has shown that music therapy may be helpful for people with sleep disorders or insomnia as a symptom of depression.

Compared to pharmaceuticals and other commonly prescribed treatments for sleep disorders, music is less invasive, more affordable, and something a person can do on their own to self-manage their condition.

Pain Management

Music has been explored as a potential strategy for acute and chronic pain management in all age groups. Research has shown that listening to music when healing from surgery or an injury, for example, may help both kids and adults cope with physical pain.

Music therapy may help reduce pain associated with:

Chronic conditions : Music therapy can be part of a long-term plan for managing chronic pain, and it may help people recapture and focus on positive memories from a time before they had distressing long-term pain symptoms.
Labor and childbirth : Music therapy-assisted childbirth appears to be a positive, accessible, non-pharmacological option for pain management and anxiety reduction for laboring people.
Surgery : When paired with standard post-operative hospital care, music therapy is an effective way to lower pain levels, anxiety, heart rate, and blood pressure in people recovering from surgery.

Coping with a cancer diagnosis and going through cancer treatment is as much an emotional experience as a physical one. People with cancer often need different sources of support to take care of their emotional and spiritual well-being.

Music therapy has been shown to help reduce anxiety in people with cancer who are starting radiation treatments. It may also help them cope with the side effects of chemotherapy, such as nausea.

Music therapy may also offer emotional benefits for people experiencing depression after receiving their cancer diagnosis, while they’re undergoing treatment, or even after remission.

On its own, music therapy may not constitute adequate treatment for medical conditions, including mental health disorders . However, when combined with medication, psychotherapy , and other interventions, it can be a valuable component of a treatment plan.

If you have difficulty hearing, wear a hearing aid, or have a hearing implant, you should talk with your audiologist before undergoing music therapy to ensure that it’s safe for you.

Similarly, music therapy that incorporates movement or dancing may not be a good fit if you’re experiencing pain, illness, injury, or a physical condition that makes it difficult to exercise.

You'll also want to check your health insurance benefits prior to starting music therapy. Your sessions may be covered or reimbursable under your plan, but you may need a referral from your doctor.

If you’d like to explore music therapy, talk to your doctor or therapist. They can connect you with practitioners in your community. The American Music Therapy Association (AMTA) also maintains a database of board-certified, credentialed professionals that you can use to find a practicing music therapist in your area.

Depending on your goals, a typical music therapy session lasts between 30 and 50 minutes. Much like you would plan sessions with a psychotherapist, you may choose to have a set schedule for music therapy—say, once a week—or you may choose to work with a music therapist on a more casual "as-needed" basis.

Before your first session, you may want to talk things over with your music therapist so you know what to expect and can check in with your primary care physician if needed.

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American Music Therapy Association (AMTA). Music therapy with specific populations: Fact sheets, resources & bibliographies .

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Bidabadi SS, Mehryar A. Music therapy as an adjunct to standard treatment for obsessive compulsive disorder and co-morbid anxiety and depression: A randomized clinical trial . J Affect Disord . 2015;184:13-7. doi:10.1016/j.jad.2015.04.011

Kamioka H, Tsutani K, Yamada M, et al. Effectiveness of music therapy: A summary of systematic reviews based on randomized controlled trials of music interventions . Patient Prefer Adherence . 2014;8:727-754. doi:10.2147/PPA.S61340

Raglio A, Attardo L, Gontero G, Rollino S, Groppo E, Granieri E. Effects of music and music therapy on mood in neurological patients . World J Psychiatry . 2015;5(1):68-78. doi:10.5498/wjp.v5.i1.68

Altenmüller E, Schlaug G. Apollo’s gift: New aspects of neurologic music therapy . Prog Brain Res . 2015;217:237-252. doi:10.1016/bs.pbr.2014.11.029

Werner J, Wosch T, Gold C. Effectiveness of group music therapy versus recreational group singing for depressive symptoms of elderly nursing home residents: Pragmatic trial . Aging Ment Health . 2017;21(2):147-155. doi:10.1080/13607863.2015.1093599

Dunbar RIM, Kaskatis K, MacDonald I, Barra V. Performance of music elevates pain threshold and positive affect: Implications for the evolutionary function of music . Evol Psychol . 2012;10(4):147470491201000420. doi:10.1177/147470491201000403

Pavlicevic M, O'neil N, Powell H, Jones O, Sampathianaki E. Making music, making friends: Long-term music therapy with young adults with severe learning disabilities . J Intellect Disabil . 2014;18(1):5-19. doi:10.1177/1744629513511354

Chang YS, Chu H, Yang CY, et al. The efficacy of music therapy for people with dementia: A meta-analysis of randomised controlled trials . J Clin Nurs . 2015;24(23-24):3425-40. doi:10.1111/jocn.12976

Aalbers S, Fusar-Poli L, Freeman RE, et al. Music therapy for depression . Cochrane Database Syst Rev . 2017;11:CD004517. doi:10.1002/14651858.CD004517.pub3

Trimmer C, Tyo R, Naeem F. Cognitive behavioural therapy-based music (CBT-music) group for symptoms of anxiety and depression . Can J Commun Ment Health . 2016;35(2):83-87. doi:10.7870/cjcmh-2016-029

Jespersen KV, Koenig J, Jennum P, Vuust P. Music for insomnia in adults . Cochrane Database Syst Rev . 2015;(8):CD010459. doi:10.1002/14651858.CD010459.pub2

Redding J, Plaugher S, Cole J, et al. "Where's the Music?" Using music therapy for pain management . Fed Pract . 2016;33(12):46-49.

Novotney A. Music as medicine . Monitor on Psychology . 2013;44(10):46.

McCaffrey T, Cheung PS, Barry M, Punch P, Dore L. The role and outcomes of music listening for women in childbirth: An integrative review . Midwifery . 2020;83:102627. doi:10.1016/j.midw.2020.102627

Liu Y, Petrini MA. Effects of music therapy on pain, anxiety, and vital signs in patients after thoracic surgery . Complement Ther Med . 2015;23(5):714-8.doi:10.1016/j.ctim.2015.08.002

Rossetti A, Chadha M, Torres BN, et al. The impact of music therapy on anxiety in cancer patients undergoing simulation for radiation therapy . Int J Radiat Oncol Biol Phys . 2017;99(1):103-110. doi:10.1016/j.ijrobp.2017.05.003

American Music Therapy Association (AMTA). Guidance for music listening programs .

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Effects of music therapy on depression: A meta-analysis of randomized controlled trials

Qishou tang.

1 Bengbu Medical University, Bengbu, Anhui, China

Zhaohui Huang

2 Anhui Provincial Center for Women and Child Health, Hefei, Anhui, China

3 National Drug Clinical Trial Institution, The First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui, China

Associated Data

All relevant data are within the manuscript and its Supporting Information files.

We aimed to determine and compare the effects of music therapy and music medicine on depression, and explore the potential factors associated with the effect.

PubMed (MEDLINE), Ovid-Embase, the Cochrane Central Register of Controlled Trials, EMBASE, Web of Science, and Clinical Evidence were searched to identify studies evaluating the effectiveness of music-based intervention on depression from inception to May 2020. Standardized mean differences (SMDs) were estimated with random-effect model and fixed-effect model.

A total of 55 RCTs were included in our meta-analysis. Music therapy exhibited a significant reduction in depressive symptom (SMD = −0.66; 95% CI = -0.86 to -0.46; P <0.001) compared with the control group; while, music medicine exhibited a stronger effect in reducing depressive symptom (SMD = −1.33; 95% CI = -1.96 to -0.70; P <0.001). Among the specific music therapy methods, recreative music therapy (SMD = -1.41; 95% CI = -2.63 to -0.20; P <0.001), guided imagery and music (SMD = -1.08; 95% CI = -1.72 to -0.43; P <0.001), music-assisted relaxation (SMD = -0.81; 95% CI = -1.24 to -0.38; P <0.001), music and imagery (SMD = -0.38; 95% CI = -0.81 to 0.06; P = 0.312), improvisational music therapy (SMD = -0.27; 95% CI = -0.49 to -0.05; P = 0.001), music and discuss (SMD = -0.26; 95% CI = -1.12 to 0.60; P = 0.225) exhibited a different effect respectively. Music therapy and music medicine both exhibited a stronger effects of short and medium length compared with long intervention periods.

Conclusions

A different effect of music therapy and music medicine on depression was observed in our present meta-analysis, and the effect might be affected by the therapy process.

Introduction

Depression was reported to be a common mental disorders and affected more than 300 million people worldwide, and long-lasting depression with moderate or severe intensity may result in serious health problems [ 1 ]. Depression has become the leading causes of disability worldwide according to the recent World Health Organization (WHO) report. Even worse, depression was closely associated with suicide and became the second leading cause of death, and nearly 800 000 die of depression every year worldwide [ 1 , 2 ]. Although it is known that treatments for depression, more than 3/4 of people in low and middle-income income countries receive no treatment due to a lack of medical resources and the social stigma of mental disorders [ 3 ]. Considering the continuously increased disease burden of depression, a convenient effective therapeutic measures was needed at community level.

Music-based interventions is an important nonpharmacological intervention used in the treatment of psychiatric and behavioral disorders, and the obvious curative effect on depression has been observed. Prior meta-analyses have reported an obvious effect of music therapy on improving depression [ 4 , 5 ]. Today, it is widely accepted that the music-based interventions are divided into two major categories, namely music therapy and music medicine. According to the American Music Therapy Association (AMTA), “music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program” [ 6 ]. Therefore, music therapy is an established health profession in which music is used within a therapeutic relationship to address physical, emotional, cognitive, and social needs of individuals, and includes the triad of music, clients and qualified music therapists. While, music medicine is defined as mainly listening to prerecorded music provided by medical personnel or rarely listening to live music. In other words, music medicine aims to use music like medicines. It is often managed by a medical professional other than a music therapist, and it doesn’t need a therapeutic relationship with the patients. Therefore, the essential difference between music therapy and music medicine is about whether a therapeutic relationship is developed between a trained music therapist and the client [ 7 – 9 ]. In the context of the clear distinction between these two major categories, it is clear that to evaluate the effects of music therapy and other music-based intervention studies on depression can be misleading. While, the distinction was not always clear in most of prior papers, and no meta-analysis comparing the effects of music therapy and music medicine was conducted. Just a few studies made a comparison of music-based interventions on psychological outcomes between music therapy and music medicine. We aimed to (1) compare the effect between music therapy and music medicine on depression; (2) compare the effect between different specific methods used in music therapy; (3) compare the effect of music-based interventions on depression among different population [ 7 , 8 ].

Materials and methods

Search strategy and selection criteria.

PubMed (MEDLINE), Ovid-Embase, the Cochrane Central Register of Controlled Trials, EMBASE, Web of Science, and Clinical Evidence were searched to identify studies assessing the effectiveness of music therapy on depression from inception to May 2020. The combination of “depress*” and “music*” was used to search potential papers from these databases. Besides searching for electronic databases, we also searched potential papers from the reference lists of included papers, relevant reviews, and previous meta-analyses. The criteria for selecting the papers were as follows:(1) randomised or quasi-randomised controlled trials; (2) music therapy at a hospital or community, whereas the control group not receiving any type of music therapy; (3) depression rating scale was used. The exclusive criteria were as follows: (1) non-human studies; (2) studies with a very small sample size (n<20); (3) studies not providing usable data (including sample size, mean, standard deviation, etc.); (4) reviews, letters, protocols, etc. Two authors independently (YPJ, HZH) searched and screened the relevant papers. EndNote X7 software was utilized to delete the duplicates. The titles and abstracts of all searched papers were checked for eligibility. The relevant papers were selected, and then the full-text papers were subsequently assessed by the same two authors. In the last, a panel meeting was convened for resolving the disagreements about the inclusion of the papers.

Data extraction

We developed a data abstraction form to extract the useful data: (1) the characteristics of papers (authors, publish year, country); (2) the characteristics of participators (sample size, mean age, sex ratio, pre-treatment diagnosis, study period); (3) study design (random allocation, allocation concealment, masking, selection process of participators, loss to follow-up); (4) music therapy process (music therapy method, music therapy period, music therapy frequency, minutes per session, and the treatment measures in the control group); (5) outcome measures (depression score). Two authors independently (TQS, ZH) abstracted the data, and disagreements were resolved by discussing with the third author (YPJ).

Assessment of risk of bias in included studies

Two authors independently (TQS, ZH) assessed the risk of bias of included studies using Cochrane Collaboration’s risk of bias assessment tool, and disagreements were resolved by discussing with the third author (YPJ) [ 10 ].

Music therapy and music medicine

Music Therapy is defined as the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program. Music medicine is defined as mainly listening to prerecorded music provided by medical personnel or rarely listening to live music. In other words, music medicine aims to use music like medicines.

Music therapy mainly divided into active music therapy and receptive music therapy. Active music therapy, including improvisational, re-creative, and compositional, is defined as playing musical instruments, singing, improvisation, and lyrics of adaptation. Receptive music therapy, including music-assisted relaxation, music and imagery, guided imagery and music, lyrics analysis, and so on, is defined as music listening, lyrics analysis, and drawing with musing. In other words, in active methods participants are making music, and in receptive music therapy participants are receiving music [ 6 , 7 , 9 , 11 – 13 ].

Evaluation of depression

Depression was evaluated by the common psychological scales, including Beck Depression Inventory (BDI), Children’s Depression Inventory (CDI), Center for Epidemiologic Studies Depression (CES-D), Cornell Scale (CS), Depression Mood Self-Report Inventory for Adolescence (DMSRIA), Geriatric Depression Scale-15 (GDS-15); Geriatric Depression Scale-30 (GDS-30), Hospital Anxiety and Depression Scale (HADS), Hamilton Rating Scale for Depression (HRSD/HAMD), Montgomery-sberg Depression Rating Scale (MADRS), Patient Reported Outcomes Measurement Information System (PROMIS), Self-Rating Depression Scale (SDS), Short Version of Profile of Mood States (SV-POMS).

Statistical analysis

The pooled effect were estimated by using the standardized mean differences (SMDs) and its 95% confidence interval (95% CI) due to the different depression rate scales were used in the included papers. Heterogeneity between studies was assessed by I-square ( I 2 ) and Q-statistic (P<0.10), and a high I 2 (>50%) was recognized as heterogeneity and a random-effect model was used [ 14 – 16 ]. We performed subgroup analyses and meta-regression analyses to study the potential heterogeneity between studies. The subgroup variables included music intervention categories (music therapy and music medicine), music therapy methods (active music therapy, receptive music therapy), specific receptive music therapy methods (music-assisted relaxation, music and imagery, and guided imagery and music (Bonny Method), specific active music therapy methods (recreative music therapy and improvisational music therapy), music therapy mode (group therapy, individual therapy), music therapy period (weeks) (2–4, 5–12, ≥13), music therapy frequency (once weekly, twice weekly, ≥3 times weekly), total music therapy sessions (1–4, 5–8, 9–12, 13–16, >16), time per session (minutes) (15–40, 41–60, >60), inpatient settings (secure [locked] unit at a mental health facility versus outpatient settings), sample size (20–50, ≥50 and <100, ≥100), female predominance(>80%) (no, yes), mean age (years) (<50, 50–65, >65), country having music therapy profession (no, yes), pre-treatment diagnosis (mental health, depression, severe mental disease/psychiatric disorder). We also performed sensitivity analyses to test the robustness of the results by re-estimating the pooled effects using fixed effect model, using trim and fill analysis, excluding the paper without information on music therapy, excluding the papers with more high biases, excluding the papers with small sample size (20< n<30), excluding the papers using an infrequently used scale, excluding the studies focused on the people with a severe mental disease. We investigated the publication biases by a funnel plot as well as Egger’s linear regression test [ 17 ]. The analyses were performed using Stata, version 11.0. All P-values were two-sided. A P-value of less than 0.05 was considered to be statistically significant.

Characteristics of the eligible studies

Fig 1 depicts the study profile, and a total of 55 RCTs were included in our meta-analysis [ 18 – 72 ]. Of the 55 studies, 10 studies from America, 22 studies from Europe, 22 studies from Asia, and 1 study from Australia. The mean age of the participators ranged from 12 to 86; the sample size ranged from 20 to 242. A total of 16 different scales were used to evaluate the depression level of the participators. A total of 25 studies were conducted in impatient setting and 28 studies were in outpatients setting; 32 used a certified music therapist, 15 not used a certified music therapist (for example researcher, nurse), and 10 not reported relevent information. A total of 16 different depression rating scales were used in the included studies, and HADS, GDS, and BDI were the most frequently used scales ( Table 1 ).

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Object name is pone.0240862.g001.jpg

PRISMA diagram showing the different steps of systematic review, starting from literature search to study selection and exclusion. At each step, the reasons for exclusion are indicated. Doi: 10.1371/journal.pone.0052562.g001.

Studies	Country	Ample size	Mean age (SD)	Pre-intervention diagnosis	Music intervention method (total)	Intervenor or therapist	Intervention description	Control group	Outcome Measures
Biasutti et al., 2019	Italy	N = 45, Female = 29	84.6 (7.17)	Healthy or with cognitive impairment	Active music therapy (improvisational music therapy)	Certified music therapist	Twice weekly (70 min/session) for 6 weeks	45-minute gymnastic activities	GDS-15
Burrai et al., [ ]	Italy	N = 159, Female = 124	73.05 (11.5)	Heart failure	Music medicine	Researchers	Once daily (30 min/session) for 36 weeks	Standard HF treatment	HADS
Burrai et al., [ ]	Italy	N = 24, Female = 9	62.3(2.8)	End-stage kidney disease	Music medicine	Nurse	Once daily (15 min/session) for 2 weeks	Standard hemodialysis	HADS
Chan et al., 2009	Hong Kong China	N = 47, Female = 26	>60	No mental illness	Music medicine	Researchers	Once weekly (30 min/session) for 4 weeks	Without any intervention	GDS-30
Chan et al., 2010	Hong Kong China	N = 42, Female = 23	>60	No mental illness	Music medicine	Researchers	Once weekly (45 min/session) for 4 weeks	Without any intervention	GDS-15
Chan et al., 2012	Singapore	N = 50, Female = 32	>55	No mental illness	Music medicine	Researchers	Once weekly (30 min/session) for 8 weeks	Without any intervention	GDS-15
Chen et al., 2015	Taiwan China	N = 71, Female = 69	18.5	Depressive disorder	Music medicine	Researchers	Twice weekly (40 min/session) for 10 weeks	Without any intervention	DMSRIA
Chen et al., 2018	China	N = 52, Female = 52	-	Breast cancer	Receptive music therapy	Certified music therapist	Once weekly (60 min/session) for 8 weeks	Standard care	HADS
Chen et al., 2019	Taiwan China	N = 65, Female = 56	72.7(5.97)	No mental illness	Active music therapy (improvisational music therapy)	Not reported	Twice weekly (40 min/session) for 10 weeks	No music therapy	BDI
Cheung et al., 2019	Hong Kong, China	N = 60, Female = 25	13.2(3.27)	Pediatric brain tumor with a significant level of depression	Active music therapy (recreative music therapy)	Certified music therapist	Once weekly (45 min/session) for 52 weeks	No music therapy	CES-D
Chirico et al., 2020	Italy	N = 64, Female = 64	55.95(5.92)	Breast cancer	Receptive music therapy	Certified music therapist	20 min/session	Standard care	SV-POMS
Choi et al., 2008	Korea	N = 26, Female = 14	36.15(10.2)	Psychiatric disorder	Active music therapy (recreative music therapy)	Certified music therapist	Once-two weekly (60 min/session) for 12 weeks	Routine care	BDI
Chu et al., 2014	Taiwan, China	N = 100, Female = 53	82(6.8)	Dementia	Active music therapy (improvisational music therapy)	Certified music therapist	Twice weekly (30 min/session) for 6 weeks	Standard care	CS
Cooke et al., 2010	Australia	N = 47, Female = 33	>65	Dementia	Active music therapy (improvisational music therapy)	Musicians	Thrice weekly (40 min/session) for 8 weeks	Educational/entertainment activities	GDS
Erkkilä et al., 2011	Finland	N = 79, Female = 62	35.6(9.75)	Depression disorder	Active music therapy (improvisational music therapy)	Certified music therapist	Twice weekly (60 min/session) for 12 weeks	Standard treatment	MADRS
Fancourt et al., 2019	UK	N = 62, Female = 48	54.5 (14.5)	Cancer carers	Active music therapy (improvisational music therapy)	Certified music therapist	Once weekly (90 min/session) for 12 weeks	No music therapy	HADS
Gok Ugur et al., 2017	Turkey	N = 64, Female = 22	76.35(7.88)	No mental illness	Receptive music therapy (music and imagery)	Certified music therapist	Three days in a week for 8 weeks	No music therapy	GDS-15
Guétin et al., 2009	France	N = 30, Female = 22	86(5.6)	Moderate stages of Alzheimer’s disease	Receptive music therapy (music-assisted relaxation)	Certified music therapist	Once weekly (20 min/session) for 16 weeks	Educational/entertainment activities	GDS-30
Hanser et al., 1994	USA	N = 30, Female = 23	67.9	Depressive disorder	Receptive music therapy (guided imagery and music)	Certified music therapist	Once weekly (1 h/session; 20 min/session) for 8 weeks	No music therapy	GDS
Hars et al., 2014	Switzerland	N = 134, Female = 129	75(7)	No mental illness	Music medicine	Not reported	Once weekly (1 h/session) for 26 weeks	No music therapy	HADS
Liao et al., 2018	China	N = 107, Female = 66	71.79(7.71)	Mild to moderate depressive symptoms	Music medicine	Not reported	Once weekly (50 min/session) for 12 weeks	Routine health education	GDS-30
Low et al., 2020	USA	N = 43, Female = 33	50.07(5.48)	Chronic pain	Active+receptive music therapy	Certified music therapist	Once weekly (90 min/session) for 12 weeks	Standard care	PROMIS
Mahendran et al., 2018	Singapore	N = 68, Female = 56	71.1(5.3)	Mild cognitive impairment	Receptive music therapy (guided imagery and music)	Certified music therapist	Once weekly for 3 months, then fortnightly for 36 weeks.	No music therapy	GDS-15
Park et al., 2015	South Korea	N = 29, Female = 16	8.17(1.47)	No mental illness	Active music therapy (improvisational music therapy)	Music therapist	Once weekly (120 min/session) for 15 weeks	Educational creative movement program	CDI
Pérez-Ros et al., 2019	Spain	N = 119, Female = 61	80.52(7.44)	No mental illness	Active music therapy (improvisational music therapy)	Physiotherapists	5 times weekly (60 min/session) for 8 weeks	No music therapy	CS
Ploukou et al., 2018	Greece	N = 48, Female = 46	-	Oncology nurses without diseases	Music medicine	Not reported	Once weekly (60 min/session) for 4 weeks	No music therapy	HADS
Ribeiro et al., 2018	Brazil	N = 21, Female = 21	22.5(6.5)	Mothers of preterm	Receptive music therapy (music and discuss)	Certified music therapist	Once weekly (30–40 min/session) for 7–9 weeks	No music therapy	BDI
Sigurdardóttir et al., 2019	Denmark	N = 38, Female = 25	25.4	Mild and moderate depression	Music medicine	Not reported	Twice weekly (20 min/session) for 4 weeks	No music therapy	HRSD-6, HRSD-17
Toccafondi et al., 2018	Italy	N = 242, Female = 147	>18	Cancer	Receptive music therapy	Certified music therapist	Once weekly	Standard care	HADS
Trimmer et al., 2018	Canada	N = 28, Female = 15	43(13.8)	Depression and anxiety	Active music therapy (recreative music therapy)	Not reported	Once weekly (90 min/session) for 9 weeks	Treatment as usual	HADS
Volpe et al., 2018	Italy	N = 106, Female = 106	43.83(12.7)	Psychosis	Active music therapy (improvisational music therapy)	Certified music therapist	Twice daily (60 min/session) for 6 weeks	Standard drug treatment	HADS
Wu et al., 2019	China	N = 60, Female = 60	36.2(9.47)	Methamphetamine use disorder	Active+receptive music therapy	Certified music therapist	Once weekly (90 min/session) for 13 weeks	Standard treatment	SDS
Albornoz et al., 2011	Venezuela	N = 24, Female = 0	16–60	Depressed adults with substance abuse	Active music therapy (improvisational music therapy)	Therapist	Once weekly (120 min/session) for 12 weeks	Standard treatment	BDI, HRSD
Hendricks et al., 1999	USA	N = 20	14–15	Depression	Active+receptive music therapy	Therapist	Once weekly for 8 weeks	Individual psychotherapy	BDI
Hendricks et al., 2001	USA	N = 63	12–18	Depression	Music medicine	counsellor-researcher	Once weekly (60 min/session) for 12 weeks	Cognitive-based psychotherapy	BDI
Radulovic et al., 1996	Serbia	N = 60	21–62 (40)	Depression	Receptive music therapy	Therapist	Twice weekly (20 min/session) for 6 weeks	Treatment as usual	BDI
Zerhusen et al., 1995	USA	N = 60	70–82 (77)	Moderate to severe depression	Music medicine	Not reported	Twice weekly (30 min/session) for 10 weeks	psychological therapy or treatment as usual	BDI
Chang et al., 2008	Taiwan China	N = 236, Female = 236	22-41(30.03)	Pregnant women	Music medicine	Music faculty members	Once a day (30 min/session) for 2 weeks	General prenatal care	EPDS
Chen et al., 2020	Taiwan China	N = 100 Female = 100	30.19(9.50)	Beast cancer undergoing chemotherapy.	Receptive music therapy	Trained music therapist	Once weekly (45 min/session) for 3 weeks	Routine nursing care	HADS
Chen et al., 2016	China	N = 200, Female = 0	35.5(9.75)	Prisoners with mild depression;	Active+receptive music therapy, including music and imagery, improvisation, and song writing	Music therapist	Twice weekly (90 min/session) for 3 weeks	Standard care	BDI
Esfandiari et al., 2014	Iran	N = 30, Female = 30	Not reported	Severe depressive disorder	Music medicine	not reported	90 min/session	Standard care	BDI
Fancourt et al., 2016	UK	N = 45, Female = 37	53.54 (13.85)	Mental health service users	Music medicine	Professional drummer	Once weekly (90 min/session) for 10 weeks	Without any intervention	HADS
Giovagnoli et al., 2017	Italy	N = 39, Female = 24	73.64(7.11)	Mild to moderate Alzheimer’s disease	Active music therapy (Improvisational music therapy)	Music therapist	Twice weekly (45 min/session) for 12 weeks	Cognitive training or neuroeducation	BDI
Harmat et al., 2008	Hungary	N = 94, Female = 73	22.6(2.83)	Seep complaints	Music medicine	Investigators	Once a day (45 min/session) for 3 weeks	listening to an audiobook or no intervention	BDI
Koelsch et al., 2010	Germany	N = 154, Female = 78	24.6	No disease	Active music therapy	Music therapist	Not reported	Individual psychotherapy	POMS
Liao et al., 2018	China	N = 60, Female = 30	61.82(13.20)	Cancer	Receptive music therapy+muscle relaxation training	not reported	Once a day (40 min/session) for 8 weeks	Muscle relaxation training	HADS
Lu et al., 2013	Taiwan China	N = 80, Female = 21	52.02 (7.64)	Schizophrenia	Active music therapy+receptive music therapy	Trained research assistant	Twice weekly (60 min/session) for 5 weeks	Usual care	CDSS
Mahendran et al., 2018	Singapore	N = 68, Female = 56	71.1(5.05)	Mild cognitive impairment	Receptive music therapy	Music therapist	Weekly in the first 3 months, then fortnightly for 6 months.	Standard care without any intervention	GDS-15
Mondanaro et al., 2017	Italy	N = 60, Female = 35	48.20(4.49)	Patients after spine surgery	Active music therapy (improvisational music therapy)	Music therapist	30-minute music therapy session during an 8-hour period within 72 hours after surgery	Standard care without any intervention	HADS
Nwebube et al., 2017	UK	N = 36, Female = 36	Not reported	Pregnant women	Music medicine	Investigators	Once a day (20 min/session) for 12 weeks	Standard care without any intervention	EPDS
Porter et al., 2017	Northern Ireland	N = 184, Female = 73	12.7 (2.5)	Adolescents with behavioural and emotional problems	Active music therapy (improvisational music therapy)	Music therapist	Once weekly (30 min/session) for 13 weeks	Usual care	CES-D
Raglio et al., 2016	Italy	N = 30, Female = 17	64 (10.97)	Amyotrophic lateral sclerosis	Active music therapy	Music therapist	Three times weekly (30 min/session) for 4 weeks	Standard care	HADS
Torres, et al., 2018	Spanish	N = 70, Female = 70	35-65(51.3)	Fibromyalgia	Receptive music therapy	Music therapist	Once weekly (120 min/session) for 12 weeks	Without any additional service	ST/DEP
Wang et al., 2011	China	N = 80, Female = 21	19.35(1.68)	Student	Receptive music therapy	Not reported	Not reported	Without any additional service	SDS
Yap et al., 2017	Singapore	N = 31, Female = 29	74.65(6.4)	Elderly people	Active music therapy (improvisational music therapy)	Experienced instructors	Once weekly (60 min/session) for 11 weeks	Without any intervention	GDS

Note: BDI = Beck Depression Inventory; CDI = Children’s Depression Inventory; CDSS = depression scale for schizophrenia; CES-D = Center for Epidemiologic Studies Depression; CS = Cornell Scale; DMSRIA = Depression Mood Self-Report Inventory for Adolescence; EPDS = Edinburgh Postnatal Depression Scale; GDS-15 = Geriatric Depression Scale-15; GDS-30 = Geriatric Depression Scale-30; HADS = Hospital Anxiety and Depression Scale; HRSD (HAMD) = Hamilton Rating Scale for Depression; MADRS = Montgomery-sberg Depression Rating Scale; PROMIS = Patient Reported Outcomes Measurement Information System; SDS = Self-Rating Depression Scale; State-Trait Depression Questionnaire = ST/DEP; SV-POMS = short version of Profile of Mood States; NA = not available.

Of the 55 studies, only 2 studies had high risks of selection bias, and almost all of the included studies had high risks of performance bias ( Fig 2 ).

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The overall effects of music therapy

Of the included 55 studies, 39 studies evaluated the music therapy, 17 evaluated the music medicine. Using a random-effects model, music therapy was associated with a significant reduction in depressive symptoms with a moderate-sized mean effect (SMD = −0.66; 95% CI = -0.86 to -0.46; P <0.001), with a high heterogeneity across studies ( I 2 = 83%, P <0.001); while, music medicine exhibited a stronger effect in reducing depressive symptom (SMD = −1.33; 95% CI = -1.96 to -0.70; P <0.001) ( Fig 3 ).

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Twenty studies evaluated the active music therapy using a random-effects model, and a moderate-sized mean effect (SMD = −0.57; 95% CI = -0.90 to -0.25; P <0.001) was observed with a high heterogeneity across studies ( I 2 = 86.3%, P <0.001). Fourteen studies evaluated the receptive music therapy using a random-effects model, and a moderate-sized mean effect (SMD = −0.73; 95% CI = -1.01 to -0.44; P <0.001) was observed with a high heterogeneity across studies ( I 2 = 76.3%, P <0.001). Five studies evaluated the combined effect of active and receptive music therapy using a random-effects model, and a moderate-sized mean effect (SMD = −0.88; 95% CI = -1.32 to -0.44; P <0.001) was observed with a high heterogeneity across studies ( I 2 = 70.5%, P <0.001) ( Fig 4 ).

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Among specific music therapy methods, recreative music therapy (SMD = -1.41; 95% CI = -2.63 to -0.20; P <0.001), guided imagery and music (SMD = -1.08; 95% CI = -1.72 to -0.43; P <0.001), music-assisted relaxation (SMD = -0.81; 95% CI = -1.24 to -0.38; P <0.001), music and imagery (SMD = -0.38; 95% CI = -0.81 to 0.06; P = 0.312), improvisational music therapy (SMD = -0.27; 95% CI = -0.49 to -0.05; P = 0.001), and music and discuss (SMD = -0.26; 95% CI = -1.12 to 0.60; P = 0.225) exhibited a different effect respectively ( Fig 5 ).

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Sub-group analyses and meta-regression analyses

We performed sub-group analyses and meta-regression analyses to study the homogeneity. We found that music therapy yielded a superior effect on reducing depression in the studies with a small sample size (20–50), with a mean age of 50–65 years old, with medium intervention frequency (<3 times weekly), with more minutes per session (>60 minutes). We also found that music therapy exhibited a superior effect on reducing depression among people with severe mental disease /psychiatric disorder and depression compared with mental health people. While, whether the country have the music therapy profession, whether the study used group therapy or individual therapy, whether the study was in the outpatients setting or the inpatient setting, and whether the study used a certified music therapist all did not exhibit a remarkable different effect ( Table 2 ). Table 2 also presents the subgroup analysis of music medicine on reducing depression.

Subgroups	Music therapy					Music medicine
	Trials number	Effects		Heterogeneity		Trials number	Effects		Heterogeneity
	Trials number	SMD (95%CI)				Trials number	SMD (95%CI)
Sample size
20–50	16	-1.24(-2.08, -0.39)	<0.001	143.19	<0.001	7	-1.21(-1.79, -0.62)	<0.001	26.30	<0.001
≥50, <100	17	-0.62(-0.84, -0.38)	<0.001	51.58	<0.001	5	-1.17(-2.45, 0.11)	0.073	86.86	<0.001
≥100	8	-0.36(-0.60, -0.11)	0.005	31.33	<0.001	4	-1.56(-3.10, -0.02)	0.047	206.10	<0.001
Female predominance (>80%)
Yes	13	-0.73(-1.23, -0.22)	0.005	112.85	<0.001	8	-1.71(-2.76, -0.65)	0.001	247.54	<0.001
No	24	-0.58(-0.81, -036)	<0.001	109.59	<0.001	6	-0.93(-1.32, -0.54)	<0.001	12.51	0.028
Mean age (years)
<50	20	-0.6(-0.85, -0.35)	<0.001	84.50	<0.001	5	-1.36(-2.30, -0.41)	0.005	69.99	<0.001
50–65	7	-1.43(-2.28, -0.58)	0.001	78.58	<0.001	2	-1.10(-1.66, -0.53)	<0.001	1.22	<0.001
>65	12	-0.48(-0.84, -0.13)	0.008	48.47	<0.001	6	-1.21(-2.66, 0.24)	0.102	237.19	<0.001
Pre-treatment diagnosis
Mental health	23	-0.58(-0.85, -0.32)	<0.001	141.40	<0.001	10	-1.26(-2.04, -0.47)	0.002	218.03	<0.001
Depression	9	-0.79(-1.13, -0.46)	<0.001	20.83	<0.001	6	-1.49(-2.72, -0.25)	0.018	106.87	<0.001
Severe mental disease /psychiatric disorder	9	-0.78(-1.34, -0.23)	<0.001	62.14	<0.001	0	-	-	-
Intervention frequency
Once weekly	21	-0.72 (-1.04, -0.41)	<0.001	118.78	<0.001	7	-1.11(-1.77, -0.44)	0.001	67.58	<0.001
Twice weekly	10	-0.79 (-1.13, -0.46)	<0.001	38.43	<0.001	3	-0.56(-2.49, 1.37)	0.570	53.98	<0.001
≥3 times weekly	6	-0.14 (-0.53, 0.25)	0.476	18.65	0.002	5	-1.67(-3.28, -0.06)	0.042	185.98	<0.001
Time per session (minutes)
15–40	12	-0.52(-0.86, -0.19)	0.002	59.84	<0.001	9	-1.34(-2.38, -0.29)	0.012	245.42	<0.001
41–60	10	-0.56(-0.99, -0.13)	0.012	62.25	<0.001	6	-0.96(-1.65, -0.27)	0.006	57.46	<0.001
>60	12	-0.96(-1.46, -0.47)	<0.001	81.18	<0.001	1	-4.1(-5.7, -2.50)	<0.001	0	-
Country having music therapy profession
Yes	39	-0.65(-0.86, -0.45)	<0.001	234.06	<0.001	13	-1.26(-1.99, -0.53)	0.001	309.93	<0.001
No	2	-0.83(-1.42, -0.23)	<0.001	0.03	0.864	3	-1.60(-2.86, -0.34)_	0.003	16.49	<0.001
Group therapy or individual therapy
Group therapy	30	-0.66 (-0.92, -0.41)	<0.001	177.02	<0.001	8	-1.23(-2.10, -0.36)	0.006	128.59	<0.001
Individual therapy	10	-0.67 (-1.05, -0.29)	0.001	56.14	<0.001	7	-1.57(-2.71, -0.42)	0.007	190.82	<0.001
Setting
Outpatient	16	-0.89(-1.30, -0.47)	<0.001	103.66	<0.001	12	-1.26(-1.94, -0.57)	<0.001	255.53	<0.001
Inpatient	22	-0.57(-0.83, -0.31)	<0.001	127.51	<0.001	3	-0.91(-3.10, 1.28)	0.414	54.87	<0.001
Used a certified music therapist
Yes	32	-0.69 (-0.88, -0.49)	<0.001	131.76	<0.001	-	-	-	-	-
No	5	-0.93 (-2.12, 0.25)	0.123	82.69	<0.001	10	-1.71(-2.61, -0.81)	<0.001	234.94	<0.001

In the subgroup analysis by total session, music therapy and music medicine both exhibited a stronger effects of short (1–4 sessions) and medium length (5–12 sessions) compared with long intervention periods (>13sessions) ( Fig 6 ). Meta-regression demonstrated that total music intervention session was significantly associated with the homogeneity between studies ( P = 0.004) ( Table 3 ).

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A, evaluating the effect of music therapy; B, evaluating the effect of music medicine.

Characteristics	Music therapy		Music medicine
Characteristics	Coef. 95%CI		Coef. 95%CI
Sample size	0(-0.01, 0.03)	0.704	0(-0.01, 0.01)	0.926
Mean age (years)	0.01(-0.03, 0.05)	0.39	-	-
Setting
Inpatient	1		1
Outpatient	0.13(-1.98, 2.23)	0.901	1.48(-0.59, 3.55)	0.139
Pre-treatment diagnosis
Mental health	1	1	1
Depression	-0.24(-1.20, 0.72)	0.622	-0.24(-2.08, 1.61)	0.789
Severe mental disease /psychiatric disorder	-0.22(-1.18, 0.75)	0.652	-
Music therapy method
Active music therapy	1
Receptive music therapy	0.13(-1.89, 2.14)	0.895	-	-
Active+receptive	0.48(-2.26, 3.21)	0.716	-	-
Total music intervention sessions	0.01(-0.05, 0.06)	0.83	-0.02(-0.03, -0.01)	0.004
Music intervention frequency	-0.08(-1.74, 1.58)	0.918	0.45(-0.66, 1.57)	0.376
Time per session (minutes)	-0.01(-0.04, 0.02)	0.482	-0.01(-0.07, 0.05)	0.778

Sensitivity analyses

We performed sensitivity analyses and found that re-estimating the pooled effects using fixed effect model, using trim and fill analysis, excluding the paper without information regarding music therapy, excluding the papers with more high biases, excluding the papers with small sample size (20< n<30), excluding the studies focused on the people with a severe mental disease, and excluding the papers using an infrequently used scale yielded the similar results, which indicated that the primary results was robust ( Table 4 ).

Outcomes	Trials number	Effects		Heterogeneity		Egger’s est
		SMD (95%CI)
Music therapy
Using fixed effect model	41	-0.50 (-0.58, -0.43)	<0.001	83	<0.001	-2.82(-4.71, -0.93)	0.005
Using trim and fill analysis	41	-0.66 (-0.86, -0.46)	<0.001	-	<0.001	-	-
Excluding the paper without information regarding music therapy (Chirico et al., 2020; Koelsch et al., 2010; Toccafondi et al., 2017; Porter et al., 2017)	37	-0.66 (-0.88, -0.43)	<0.001	82.2	<0.001	-3.03(-5.26, -0.81)	0.009
Excluding the papers with high bias (Toccafondi et al., 2017 and Fancourt et al., 2019)	39	-0.69 (-0.91, -0.47)	<0.001	83.6	<0.001	-2.95(-5.04, -0.86)	0.007
Excluding the papers with small sample size (20< n<30)	35	-0.57 (-0.77, -0.38)	<0.001	81.3	<0.001	2.22(-4.53, 0.08)	0.058
Excluding the studies focused on the people with a severe mental disease (Choi et al., 2008; Cheung et al. 2019)	32	-0.64(-0.86, -0.42)	<0.001	82.1	<0.001	‘-2.54(-4.67, -0.40)	0.022
Excluding the papers using an infrequently used scale (Erkkilä et al., 2011; Chen et al., 2015; Cheung et al., 2019; Chirico et al., 2020; Park et al., 2015; Sigurdardóttir et al., 2019; Wu et al., 2019; Low et al., 2020)	34	-0.62 (-0.84, -0.39)	<0.001	83.2	<0.001	-2.63(-4.67, -0.60)	0.013
Music medicine
Using fixed effect model	16	-0.86(-0.98, -0.73)	<0.001	95.4	<0.001	-5.78(-11.65, 0.10)	0.053
Using trim and fill analysis	16	-1.33(-1.96, -0.70)	<0.001	-	<0.001	-	-
Excluding the papers with small sample size (20< n<30) [ ]	15	-1.32(-1.98, -0.66)	<0.001	95.7	<0.001	-6.09(-12.53, 0.36)	0.062
Excluding the papers using an infrequently used scale (Chen et al., 2015)	14	-1.25(-1.92, -0.57)	<0.001	95.7	<0.001	-5.71(-12.38, 0.98)	0.98

Evaluation of publication bias

We assessed publication bias using Egger’s linear regression test and funnel plot, and the results are presented in Fig 7 . For the main result, the observed asymmetry indicated that either the absence of papers with negative results or publication bias.

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A, evaluating the publication bias of music therapy; B, evaluating the publication bias of music medicine; BDI = Beck Depression Inventory; CDI = Children’s Depression Inventory; CDSS = depression scale for schizophrenia; CES-D = Center for Epidemiologic Studies Depression; CS = Cornell Scale; DMSRIA = Depression Mood Self-Report Inventory for Adolescence; EPDS = Edinburgh Postnatal Depression Scale; GDS-15 = Geriatric Depression Scale-15; GDS-30 = Geriatric Depression Scale-30; HADS = Hospital Anxiety and Depression Scale; HRSD (HAMD) = Hamilton Rating Scale for Depression; MADRS = Montgomery-sberg Depression Rating Scale; PROMIS = Patient Reported Outcomes Measurement Information System; SDS = Self-Rating Depression Scale; State-Trait Depression Questionnaire = ST/DEP; SV-POMS = short version of Profile of Mood Stat.

Our present meta-analysis exhibited a different effect of music therapy and music medicine on reducing depression. Different music therapy methods also exhibited a different effect, and the recreative music therapy and guided imagery and music yielded a superior effect on reducing depression compared with other music therapy methods. Furthermore, music therapy and music medicine both exhibited a stronger effects of short and medium length compared with long intervention periods. The strength of this meta-analysis was the stable and high-quality result. Firstly, the sensitivity analyses performed in this meta-analysis yielded similar results, which indicated that the primary results were robust. Secondly, considering the insufficient statistical power of small sample size, we excluded studies with a very small sample size (n<20).

Some prior reviews have evaluated the effects of music therapy for reducing depression. These reviews found a significant effectiveness of music therapy on reducing depression among older adults with depressive symptoms, people with dementia, puerpera, and people with cancers [ 4 , 5 , 73 – 76 ]. However, these reviews did not differentiate music therapy from music medicine. Another paper reviewed the effectiveness of music interventions in treating depression. The authors included 26 studies and found a signifiant reduction in depression in the music intervention group compared with the control group. The authors made a clear distinction on the definition of music therapy and music medicine; however, they did not include all relevant data from the most recent trials and did not conduct a meta-analysis [ 77 ]. A recent meta-analysis compared the effects of music therapy and music medicine for reducing depression in people with cancer with seven RCTs; the authors found a moderately strong, positive impact of music intervention on depression, but found no difference between music therapy and music medicine [ 78 ]. However, our present meta-analysis exhibited a different effect of music therapy and music medicine on reducing depression, and the music medicine yielded a superior effect on reducing depression compared with music therapy. The different effect of music therapy and music medicine might be explained by the different participators, and nine studies used music therapy to reduce the depression among people with severe mental disease /psychiatric disorder, while no study used music medicine. Furthermore, the studies evaluating music therapy used more clinical diagnostic scale for depressive symptoms.

A meta-analysis by Li et al. [ 74 ] suggested that medium-term music therapy (6–12 weeks) was significantly associated with improved depression in people with dementia, but not short-term music therapy (3 or 4 weeks). On the contrary, our present meta-analysis found a stronger effect of short-term (1–4 weeks) and medium-term (5–12 weeks) music therapy on reducing depression compared with long-term (≥13 weeks) music therapy. Consistent with the prior meta-analysis by Li et al., no significant effect on depression was observed for the follow-up of one or three months after music therapy was completed in our present meta-analysis. Only five studies analyzed the therapeutic effect for the follow-up periods after music therapy intervention therapy was completed, and the rather limited sample size may have resulted in this insignificant difference. Therefore, whether the therapeutic effect was maintained in reducing depression when music therapy was discontinued should be explored in further studies. In our present meta-analysis, meta-regression results demonstrated that no variables (including period, frequency, method, populations, and so on) were significantly associated with the effect of music therapy. Because meta-regression does not provide sufficient statistical power to detect small associations, the non-significant results do not completely exclude the potential effects of the analyzed variables. Therefore, meta-regression results should be interpreted with caution.

Our meta-analysis has limitations. First, the included studies rarely used masked methodology due to the nature of music therapy, therefore the performance bias and the detection bias was common in music intervention study. Second, a total of 13 different scales were used to evaluate the depression level of the participators, which may account for the high heterogeneity among the trials. Third, more than half of those included studies had small sample sizes (<50), therefore the result should be explicated with caution.

Our present meta-analysis of 55 RCTs revealed a different effect of music therapy and music medicine, and different music therapy methods also exhibited a different effect. The results of subgroup analyses revealed that the characters of music therapy were associated with the therapeutic effect, for example specific music therapy methods, short and medium-term therapy, and therapy with more time per session may yield stronger therapeutic effect. Therefore, our present meta-analysis could provide suggestion for clinicians and policymakers to design therapeutic schedule of appropriate lengths to reduce depression.

Supporting information

S1 checklist, funding statement.

The Key Project of University Humanities and Social Science Research in Anhui Province (SK2017A0191) was granted by Education Department of Anhui Province; the Research Project of Anhui Province Social Science Innovation Development (2018XF155) was granted by Anhui Provincial Federation of Social Sciences; the Ministry of Education Humanities and Social Sciences Research Youth fund Project (17YJC840033) was granted by Ministry of Education of the People’s Republic of China. These funders had a role in study design, text editing, interpretation of results, decision to publish and preparation of the manuscript.

Data Availability

PLoS One. 2020; 15(11): e0240862.

Decision Letter 0

PONE-D-20-17706

Effects of music therapy on depression: a meta-analysis of randomized controlled trials

Dear Dr. Ye,

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Additional Editor Comments:

Dear Author,

Thank you for your valuable submission. I think it would be appropriate to emphasize the main problem first. Various musical interventions are used in medical settings to improve the patient's well-being, and of course, there are many publications on this subject. However, it is important to properly differentiate between these interventions for some important reasons I have pointed out below.

The music therapy definition you made, as "Music therapy was defined as music therapy provided by a qualified music teacher, psychological therapist, or nurse" is not universally accepted specific definition for music therapy. Moreover, the specific methods used in receptive music therapy include music-assisted relaxation, music and imagery, and Guided Imagery and Music (Bonny Method). Each of these may have different levels of effects on depression. It is not clear that which receptive music therapy studies in your review have used which of these methods. So, the majority of studies that you accepted as the receptive music therapy seems to be music medicine studies indeed. Similar critiques may also be apply to some of the studies you describe as active music therapy. Today, it is widely accepted that these music-based interventions should be divided into two major categories, namely music therapy (MT) and music medicine (MM). MM mainly based on patients' pre-recorded or rarely listening to live music and the direct effects of the music they listen to. In other words, MM aims to use music like medicines. It often managed by a medical professional other than a music therapist, and not needed a therapeutic relationship with the patients. Conversely, music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed music therapist who has completed an approved music therapy program. So, music therapy is a relational, interaction based form of therapy within a therapeutic relationship between the therapist and the client, and includes the triad of the music, the client and the music therapist. Since music therapy interventions is an evidence-based procedure using special music therapy methods of interventions and a more pragmatic approach than other music-based interventions, their effect levels and results are also different.

In the context of the above mentioned explanations, it is clear that to evaluate the effects of music therapy and other music based intervention studies together on depression can be misleading. The subjects I have mentioned so far have never been addressed in the introduction and discussion sections of your manuscript. I think that will be perceived as a major deficiency at least by the readers who are closer to the subject. In this sense, I think that an attentive revision considering the following views will be valuable and needed:

- The universally accepted definitions of music therapy (including active and receptive music therapy) and music medicine should be taken into account.

- It should be clarified that how many studies in your review did included a certified music therapist.

- Analyses, results and discussion should be submitted to the readers in accordance with all this distinctions and definitions. (The way to this seems to be to compare the effects of music medicine and music therapy on depression in parallel with the possible differences of music interventions used, and to discuss their possible implications on the results.)

- Another important point is that you did not mention nor discuss any of important reviews on same subject (for example please see: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004517.pub3/epdf/full or https://www.frontiersin.org/articles/10.3389/fpsyg.2017.01109/full or https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006911.pub3/full )

I am aware that such a major revision will, in a sense, be a challenging way that may require a new analysis of your data. However, I believe you would appreciate that a study aimed at shedding light on potential music-based interventions in an important public health problem such as depression should not be misleading.

Thank you for your effort in advance.

Besides, according to the statistical reviewer who only reviewed the statistical approach used in this paper, there are two caveats:

1. The authors state that they excluded studies with fewer than 20 participants in one place in the paper (page 4), but fewer than 30 participants in another place in the paper (Table 4). This needs to be corrected for consistency.

2. The authors mention stronger effects of short and medium length vs. long music therapy periods in their results but there is no accompanying figure. I think it would be beneficial to show these findings in a figure (Forest plot).

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: No

3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #2: Yes

4. Is the manuscript presented in an intelligible fashion and written in standard English?

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5. Review Comments to the Author

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Reviewer #1: Thank you for conducting this research and submitting it for publication consideration.

I recognize that English may not be the primary language of the authors. There are a few instances where the language could be improved, but that is mostly a copy-editing issue. There is also a lot of passive voice in the paper. I recommend making the voice active. This will enhance the readability of the paper.

I have a few comments that I hope will improve the paper.

1. Not all countries have an established music therapy profession. I recognize that this creates challenges for the authors! I'm wondering if the authors might consider including this as a factor in the analysis? For example, if a nurse provides "music therapy" in a country that does not have music therapy as a profession, is the effect equivalent as when a qualified music therapist in a country that has music therapy as a profession provides it? This might provide some incentive for occupational regulation and establishing professional music therapy associations.

2. please fix the "short title" (oxygen)

3. Music therapy with fewer minutes might yield superior effects. This may be misleading. Is there a minimum number of minutes? How many minutes might be optimal for therapeutic outcome? I believe it does make sense that longer sessions may result in less impact - quantity/duration does not always result in enhanced outcome.

4. I believe a stronger case needs to be made for the study. There are existing meta-analyses of MT for depression (Aalbers et al., 2017 Cochrane Review). What makes the current study unique and different? What are the gaps in the literature that warrant this study? Have there been a lot of recent additions to the literature that warrant a new meta-analysis?

5. A stronger discussion of the limitation of this study. Many studies did not evaluate a group with major depression/major depressive disorder (music therapy for chronic pain is important, but the variance of the populations under study does constitute a limitation). So, this study is not exclusive to adults with a major mental health condition. Might effects be different for people who are depressed versus people who are not depressed?

6. Instead of "blinding/blinded" please use "masking/masked."

7. Is there a citation that supports your classification of active versus receptive? (I would think Bruscia would be a good place to start with that...)

8. One item that I am not seeing is group therapy versus individual therapy. Did the authors screen for that? If so, is there an optimal group size? Are effects stronger when in a group format versus an individual format? This would have serious implications for clinical practice.

9. What about inpatient settings (such as a secure [locked] unit at a mental health facility) versus outpatient settings?

10. One item that I believe is missing is the dose. Not necessarily the duration (number of minutes) of each session, but the total number of sessions a participant has received. Gold has done some work in this area. Is there is a certain number of sessions that are needed to reach a therapeutic outcome? The number of sessions/week is good, but the number of total sessions is important.

11. Table 1 has the mean age. I recommend including the SD as well.

Thank you for taking the time to consider these suggestions. While receiving critical feedback can be difficult, please understand that my intentions are to improve the paper and ensure it has maximum impact. This is an important addition to the literature and I am grateful to the authors for their scholarship. I wish you the best!

Reviewer #2: This article addresses an important topic that is of interest to music therapists, psychiatrists and teachers and metal health practitioners. The statistics look promising. However, the major concern is that the definition of music therapy is theoretically and practically incorrect and misleading:

"7 Music therapy was defined as music therapy provided by a qualified music teacher, psychological

8 therapist, or nurse. " The study is missing several research studies that I am aware of and this makes its content suspicious. Also missing is a more depth-ful analysis of what active and passive music therapy is, and if it is indeed performed by those in other professions who have no training in 'musuc therapy;'-than the contents and findings are misleading and irrelevant.

Reviewer #3: I only reviewed the statistical approach used in this paper, which appeared appropriate for the research question under study. There are two caveats:

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Reviewer #1: No

Reviewer #3: No

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Author response to Decision Letter 0

29 Sep 2020

Response to Reviewers

Dear Editors and Reviewers:

Thank you for your letter and for the reviewers’ comments concerning our manuscript entitled " Effects of music therapy on depression: a meta-analysis of randomized controlled trials (PONE-D-20-17706)".

Those comments are all valuable and very helpful for revising and improving our paper, as well as the important guiding significance to our researches. We have studied comments carefully and have made revision which we hope meet with approval. All the revised portions were marked in red font in the new document. The main corrections in the paper and the responds to the reviewer’s comments are as flowing:

Response：We have studied comments carefully and revised the manuscript extensively according to the reviewer’s comments.

Firstly, We have amended the music therapy definition mainly based on the World Federation of Music Therapy (WFMT) and The American Music Therapy Association (AMTA), WFMT defines music therapy as “the professional use of music and its elements as an intervention inmedical, educational, and everyday environments with individuals, groups, families, or communities who seek to optimize their quality of life and improve their physical, social,communicative, emotional, intellectual, and spiritual health and wellbeing”. AMTA defines music therapy as “Music Therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program”. [American Music Therapy Association (2020). Definition and Quotes about Music Therapy. Available online at: https://www.musictherapy.org/about/quotes/ (Accessed Sep 13, 2020).][van der Steen, J. T., et al. (2017). "Music-based therapeutic interventions for people with dementia." Cochrane Database Syst Rev 5: CD003477.]

Secondly, we have re-studed all included papers carefully and added the specific intervention methods of each paper in table 1 (Table 1. Characteristics of clinical trials included in this meta-analysis). Two main types of music therapy were distinguished in our present study - receptive (or passive) and active music therapy. The specific methods used in receptive music therapy in our included papers including music-assisted relaxation, music and imagery, and guided imagery and music (Bonny Method), while the specific methods used in active music therapy included recreative music therapy, improvisational music therapy, song writing, and so on.

Thirdly, we have added some contents regarding the distinction between music therapy and music medicine in introduction and discussion sections of our manuscript.

The following contents are added in introduction section, “Today, it is widely accepted that the music-based interventions should be divided into two major categories, namely music therapy and music medicine. According to the American Music Therapy Association (AMTA), “music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program”. Therefore, music therapy is an established health profession in which music is used within a therapeutic relationship to address physical, emotional, cognitive, and social needs of individualst, and includes the triad of the music, the client and the qualified music therapist. [American Music Therapy Association (2020). Definition and Quotes about Music Therapy. Available online at: https://www.musictherapy.org/about/quotes/ (Accessed Sep 13, 2020).] While, music medicine is defined as mainly listening to prerecorded music provided by medical personnel or rarely listening to live music. In other words, music medicine aims to use music like medicines. It often managed by a medical professional other than a music therapist, and not needed a therapeutic relationship with the patients. Therefore, the essential difference of music therapy and music medicine is whether a therapeutic relationship is developed between a trained music therapist and the client.

[Yinger, O. S. and L. Gooding (2014). "Music therapy and music medicine for children and adolescents." Child and adolescent psychiatric clinics of North America 23(3): 535-553.]

【Tony Wigram．Inge Nyggard Pedersen＆Lars Ole Bonde，A Compmhensire Guide to Music Therapy．London and Philadelphia：Jessica Kingsley Publishen．2002：143．】

In the context of the clear distinction between these two major cagerories, it is clear that to evaluate the effects of music therapy and other music based intervention studies together on depression can be misleading. While, the distinction was not always clear in most of prior papers, and we found that no meta-analysis comparing the effects of music therapy and music medicine was conducted. Just a few studies made a comparison of music-based interventions on psychological outcomes between music therapy and music medicine. We aimed to (1) compare the effect between music therapy and music medicine on depression; (2) compare the effect between different specific methods used inmusic therapy on depression; (3) compare the effect of music-based interventions on depression among different population.

[Bradt, J., et al. (2015). "The impact of music therapy versus music medicine on psychological outcomes and pain in cancer patients: a mixed methods study." Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer 23(5): 1261-1271.[Yinger, O. S. and L. Gooding (2014). "Music therapy and music medicine for children and adolescents." Child and adolescent psychiatric clinics of North America 23(3): 535-553.]

The last, we have made a new analysis of our data. 1) including three new papers and re-analying of our data, 2) adding the comparison of music therapy and music medicine, 3) adding the comparison of impatient setting and outpatients setting, 4) adding the comparison of depressed people and not depressed people, 5）adding the comparison of countries have having music therapy profession and not, 6) adding the comparison of group therapy and individual therapy, 7) added the comparison of different intervention dose, and so on.

Response: (1)We have amended the of definitions of music therapy. The revised difinitons of music therapy was “Music Therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program”. [American Music Therapy Association (2020). Definition and Quotes about Music Therapy. Available online at: https://www.musictherapy.org/about/quotes/ (Accessed Sep 13, 2020).]

We have added some contents on the distinction between music therapy (MT) and music medicine (MM) in introduction and discussion sections of our manuscript.

We have added the analysis of the comparion of music therapy (MT) and music medicine (MM) in Methord and Results sections

Response: we have re-studed all included papers carefully and added a new varible (Intervenor or therapist) into table 1, and the corresponding description was addded in the results section. Of 55 studies, 32 used a certified music therapist, 15 not used a certified music therapist (for example researcher, nurse), and 10 not reported relevent information.

Response: We have divided music-based interventions into two major categories, namely music therapy and music medicine according to the difinition. With respect to specific methods used in music therapy, we also have divided music therapy into receptive (or passive) and active music therapy. The specific methods used in receptive music therapy in our included papers including music-assisted relaxation, music and imagery, and guided imagery and music (Bonny Method), and the specific methods used in active music therapy included recreative music therapy and improvisational music therapy.

We have added some sub-group analyses by different music intervention categories, different music therapy categories, and specific music therapy methords.

The the above mentioned content have been added to Intruduction Analyses, results and discussion section.

Response: we are very sorry for not mentioning these important reviews. We have studied these reviews carefully and discussed these reviews in Discussion sections.

Some prior reviews have evaluated the effects of music therapy for reducing depression. Aalbers and colleagues included nine studies in their review; they concluded that music therapy provides short-term benefificial effects for people with depression, and suggested that high-quality trials with large sample size were needed. However, this review was limited to studies of individuals with a diagnosis of depression, and did not differentiate music therapy from music medicine. Another paper reviewed the effectiveness of music interventions in treating depression. The authors included 26 studies and found a signifiant reduction in depression in the music intervention group compared with the controp group. The authors made a clear distincition on the definition of music therapy and music medicine; however, they did not include all relevant data from the most recent trials and did not conduct a meta-analysis. A recent meta-analysis compared the effects of music therapy and music medicine for reducing depression in people with cancer with seven RCTs; the authors found a moderately strong, positive impact of music intervention on depression , but found no difference between music therapy and music medicine.

【Aalbers, S., et al. (2017). "Music therapy for depression." Cochrane Database Syst Rev 11: CD004517.】

【Leubner, D. and T. Hinterberger (2017). "Reviewing the Effectiveness of Music Interventions in Treating Depression." Front Psychol 8: 1109.】

【Bradt, J., et al. (2016). "Music interventions for improving psychological and physical outcomes in cancer patients." Cochrane Database Syst Rev(8): CD006911.】

To date, many new trials focued on music therapy and depression in differnt poupulation (such as people with cancer, people with dementia, people with chronic disease, and so on ) have been performed, but they have not yet been systematically reviewed.

Response: Those comments are all valuable and very helpful for revising and improving our paper, as well as the important guiding significance to our researches. We have studied comments carefully and have made revision according to the comments.

Response: We are sorry for making this mistake. In the Methord section, we defined exclusive criteria as studies with a very small sample size (n<20),while in table 4 we performed the sensitivity analyses by excluding the papers with smale sample size ( 20< n<30). We have amended the table 4.

Response: We have added these findings with a forest plot (figure 6) according to the comment.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

Response: We have amended our manuscript according to PLOS ONE's style requirements

Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files.

Response: We have adjusted these content according to the comment.

3. Thank you for stating the following in the Acknowledgments Section of your manuscript:

Response: We would like to update our funding statement as follows: The funders had a role in study design, text editing, interpretation of results, decision to publish and preparation of the manuscript.

4.LOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

Response: We have created a new ORCID iD accordingly to your instructions.

Response: we are sorry for making this mistake, we have amended our list of authors on the manuscript accordingly.

Response: We have checked the refer to Figure 5 and found that the refer to figure 5 was a mistake, and we have amended it.

Response: we only have a Supporting Information files (PRISMA-2009-Checklist), and we have added the captions for this Supporting Information files accordingly. We also have updated in-text citations to match accordingly.

Response: Thinks very much for your comment.

Response: Thinks very much for your comment. Our manuscript have been edited for proper English language, grammar, punctuation, spelling, and overall style by one qualified native English speaking editors.

Response: This suggestion is valuable and we have tried to judge if the countries in our inluded papers have an established music therapy profession by checking the author's work address, literature review, visiting the important website about music therapy, and consulting to some famous music therapist via emails. The following table showed that four countries may be not have a music therapy profession. We have added the comparison of the country having music therapy profession and not.

https://erikdalton.com/find-a-certified-therapist/

https://www.musictherapy.org/about/listserv/

Table 1. The information on the music therapy profession in the inluded papers

Country Country having music therapy profession

Korea Korean Music Therapy Association

South Korea Korean Music Therapy Association

UK British Association for Music Therapy

Australia Australian Music Therapy Association

Canada Canadian Association of Music Therapists

China Chinese Professional Music Therapist Association

Taiwan China Chinese Professional Music Therapist Association

Denmark Dansk forbund for musikterapie

Finland Finnish Society for Music Therapy

Hong Kong China Hong Kong Music Therapy and Counseling Association

Serbia Music Therapists of Serbia organize workshops

Switzerland Swiss Association of Music Therapy

USA The American Music Therapy Association

Singapore The Association for Music Therapy (Singapore)

Brazil Uniao Braileira Das Associacoes De Musicoterapia

Germany YES

Northern Ireland YES

Spanish YES

Venezuela No

2.please fix the "short title" (oxygen)

Response: We’re sorry for making this mistake, and we have corrected this mistake.

Music therapy with fewer minutes might yield superior effects. This may be misleading. Is there a minimum number of minutes? How many minutes might be optimal for therapeutic outcome? I believe it does make sense that longer sessions may result in less impact - quantity/duration does not always result in enhanced outcome.

Response: In 33 included trials, intervention time each session was different, the mimimum time was 15 minutes in only one study (Burrai et al., 2019b), followed by 20 minuters in four studies (Chirico et al., 2020; Guétin et al., 2009; Hanser et al., 1994; Sigurdardóttir et al., 2019). In our subgroup analysis by time per session (minutes), we divided time per session into three groups, namely 15-40, 41-60, >60, and this presentation might be unclear.

In order to respond this comment, we have re-divided the time per session into four groups, namely 15-40, 41-60, 61-120, to explore the optimal minuter per session for therapeutic outcome.

I believe a stronger case needs to be made for the study. There are existing meta-analyses of MT for depression (Aalbers et al., 2017 Cochrane Review). What makes the current study unique and different? What are the gaps in the literature that warrant this study? Have there been a lot of recent additions to the literature that warrant a new meta-analysis?

Response: Some prior reviews have evaluated the effects of music therapy for reducing depression. Aalbers and colleagues (Aalbers et al., 2017）included nine studies in their review; they concluded that music therapy provides short-term benefificial effects for people with depression, and suggested that high-quality trials with large sample size were needed. However, this review was limited to studies of individuals with a diagnosis of depression, and did not differentiate music therapy from music medicine.

Another paper reviewed the effectiveness of music interventions in treating depression. The authors (Leubner D., 2017) included 26 studies and found a signifiant reduction in depression in the music intervention group compared with the controp group. The authors made a clear distincition on the definition of music therapy and music medicine; however, they did not include all relevant data from the most recent trials and did not conduct a meta-analysis. A recent meta-analysis (Bradt et al., 2016) compared the effects of music therapy and music medicine for reducing depression with seven RCTs; the authors found a moderately strong, positive impact of music intervention on depression , but found no difference between music therapy and music medicine. However, this review was limited to studies of individuals with a diagnosis of cancer.

Figure 1 presents the number of published paper ( search from Pubmed) focued on music therapy and depression from 1983 to 2020, the published paper was in the rapidly growing stage during the past five years. While, the above mentioned reviews all included papers published before 2017. To date, many new trials focued on music therapy and depression in differnt poupulation (such as people with cancer, people with dementia, people with chronic disease, and so on ) have been performed, but they have not yet been systematically reviewed.

While, no meta-analysis compared the the difference of music therapy on depression in differnt poupulation (such as people with depression, people with dementia, people with chronic disease, health people, and so on ) have been performed.

Figure 1 The pubished papers from 1983 to 2020 focused on music therapy and depression (searched from Pubmed)

In our persent meta-analysis, we aimed to (1) compare the effect between music therapy and music medicine on depression; (2) compare the effect between different specific methods used inmusic therapy on depression; (3) compare the effect of music-based interventions on depression among different population.

We have added the above content to Intruduction and Dissussion sections.

5.A stronger discussion of the limitation of this study. Many studies did not evaluate a group with major depression/major depressive disorder (music therapy for chronic pain is important, but the variance of the populations under study does constitute a limitation). So, this study is not exclusive to adults with a major mental health condition. Might effects be different for people who are depressed versus people who are not depressed?

Response: This is a very important comment. According to this comment, we have made some revision.

Firstly, we have added a sensitivity analysis by excluding the studes focused on the people with a major mental health condition.

Secondly, we have re-grouped the populations into three groups, namely mental health, severe mental disease /psychiatric disorder, and depression and we have added the subgroup analysis (table 2 in revised manuscript)..

Thirdly, we have added the analysis of the difference between people who are depressed versus people who are not depressed accordingly (table 2 in revised manuscript).

6.Instead of "blinding/blinded" please use "masking/masked."

Response: We have replaced "blinding/blinded" with "masking/masked" according to this comment.

Response: In active methods (improvisational, re-creative, compositional), participants are ‘making music’ , and in receptive music therapy (music-assisted relaxation, music and imagery, guided imagery and music, lyrics analysis ), participants are ‘receiving’ (e.g. listening to) music (Bruscia 2014; Wheeler 2015).

We have amended the difinition and added the citation to the Result section according to this commment.

[Bruscia KE. Defining Music Therapy. 3rd Edition.University Park, Illinois, USA: Barcelona Publishers, 2014.]

[Wheeler BL. Music Therapy Handbook. New York, New York, USA: Guilford Publications, 2015.]

Response: Of the 55 studies, 38 used group therapy, 17 used individual therapy, and 2 not reported. We have added the comparison of group therapy versus individual therapy according to this comment (table 2 in revised manuscript).

Response: Of 55 studies, a total of 25 studies were conducted in impatient setting,28 studies were in outpatients setting setting, and 2 studies not repoted the setting. We have added the subgroup analysis by inpatient settings (secure [locked] unit at a mental health facility versus outpatient settings) according to this comment (table 2 in revised manuscript).

Response: We have added the subgroup analysis by total sessions a participant has received according to this comment.

Response: We have added the SD in table 1

Response: Thanks very much for your important comments, these comments are all valuable and very helpful for revising and improving our paper, as well as the important guiding significance to our researches.

Response: (1) We have amendded the difinition of music therapy. According to the American Music Therapy Association (AMTA), “music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program”.. [American Music Therapy Association (2020). Definition and Quotes about Music Therapy. Available online at: https://www.musictherapy.org/about/quotes/ (Accessed Sep 13, 2020).]

(2)We are very sorry for missing several research studies in our present meta-analysis. According to this comment, we have performed more extensive electronic search using the following terms: depression or mood disorders or affective disorders and music. We also performed manual search for the reference of all relevent reviews. In order to ensure the study quality of included papers, we excluded the studies with a very small sample size (n<20), we also excluded the non-english papers due to our language barrier. We included 23 new papers and deleted 1 old paper, in the last a total of 55 paper were included in our present analysis. The following are the new included papers and some excluded papers:

New-included papers

1)Albornoz Y. The effects of group improvisational music therapy on depression in adolescents and adults with substance abuse: a randomised controlled trial. Nordic Journal of Music Therapy 2011;20(3):208–24.

2)Hendricks CB, Robinson B, Bradley B, Davis K. Using music techniques to treat adolescent depression. Journal of Humanistic Counseling, Education and Development 1999; 38:39–46. （unavaliable）

3)Hendricks CB. A study of the use of music therapy techniques in a group for the treatment of adolescent depression. Dissertation Abstracts International 2001;62(2-A):472.

4)Radulovic R. The using of music therapy in treatment of depressive disorders. Summary of Master Thesis. Belgrade: Faculty of Medicine University of Belgrade, 1996.

5)Zerhusen JD, Boyle K, Wilson W. Out of the darkness: group cognitive therapy for depressed elderly. Journal of Military Nursing Research 1995;1:28–32. PUBMED: 1941727]

6)Chen SC, Yeh ML, Chang HJ, Lin MF. Music, heart rate variability, and symptom clusters: a comparative study. Support Care Cancer. 2020;28(1):351-360. doi:10.1007/s00520-019-04817-x

7)Chang, M. Y., Chen, C. H., and Huang, K. F. (2008). Effects of music therapy on psychological health of women during pregnancy. J. Clin. Nurs. 17, 2580–2587. doi: 10.1111/j.1365-2702.2007.02064.x

8)Chen XJ, Hannibal N, Gold C. Randomized Trial of Group Music Therapy With Chinese Prisoners: Impact on Anxiety, Depression, and Self-Esteem. Int J Offender Ther Comp Criminol. 2016;60(9):1064-1081. doi:10.1177/0306624X15572795

9)Esfandiari, N., and Mansouri, S. (2014). The effect of listening to light and heavy music on reducing the symptoms of depression among female students. Arts Psychother. 41, 211–213. doi: 0.1016/j.aip.2014.02.001

10)Fancourt, D., Perkins, R., Ascenso, S., Carvalho, L. A., Steptoe, A., and Williamon, A. (2016). Effects of group drumming interventions on anxiety, depression, social resilience and inflammatory immune response among mental health service users. PLoS ONE 11:e0151136. doi: 10.1371/journal.pone.0151136

11)Giovagnoli AR, Manfredi V, Parente A, Schifano L, Oliveri S, Avanzini G. Cognitive training in Alzheimer's disease: a controlled randomized study. Neurol Sci. 2017;38(8):1485-1493. doi:10.1007/s10072-017-3003-9

12)Harmat, L., Takács, J., and Bodizs, R. (2008). Music improves sleep quality in students. J. Adv. Nurs. 62, 327–335. doi: 10.1111/j.1365-2648.2008.04602.x

13)Liao J, Wu Y, Zhao Y, et al. Progressive Muscle Relaxation Combined with Chinese Medicine Five-Element Music on Depression for Cancer Patients: A Randomized Controlled Trial. Chin J Integr Med. 2018;24(5):343-347. doi:10.1007/s11655-017-2956-0

14)Lu, S. F., Lo, C. H. K., Sung, H. C., Hsieh, T. C., Yu, S. C., and Chang, S. C. (2013). Effects of group music intervention on psychiatric symptoms and depression in patient with schizophrenia. Complement. Ther. Med. 21, 682–688. doi: 10.1016/j.ctim.2013.09.002

15)Mahendran R, Gandhi M, Moorakonda RB, et al. Art therapy is associated with sustained improvement in cognitive function in the elderly with mild neurocognitive disorder: findings from a pilot randomized controlled trial for art therapy and music reminiscence activity versus usual care. Trials. 2018;19(1):615. Published 2018 Nov 9. doi:10.1186/s13063-018-2988-6

16)Nwebube C, Glover V, Stewart L. Prenatal listening to songs composed for pregnancy and symptoms of anxiety and depression: a pilot study. BMC Complement Altern Med. 2017;17(1):256. Published 2017 May 8. doi:10.1186/s12906-017-1759-3

17)Porter S, McConnell T, McLaughlin K, et al. Music therapy for children and adolescents with behavioural and emotional problems: a randomised controlled trial. J Child Psychol Psychiatry. 2017;58(5):586-594. doi:10.1111/jcpp.12656

18)Raglio A, Giovanazzi E, Pain D, et al. Active music therapy approach in amyotrophic lateral sclerosis: a randomized-controlled trial. Int J Rehabil Res. 2016;39(4):365-367. doi:10.1097/MRR.0000000000000187

19)Torres E, Pedersen IN, Pérez-Fernández JI. Randomized Trial of a Group Music and Imagery Method (GrpMI) for Women with Fibromyalgia. J Music Ther. 2018;55(2):186-220. doi:10.1093/jmt/thy005

20)Verrusio, W., Andreozzi, P., Marigliano, B., Renzi, A., Gianturco, V., Pecci, M. T., et al. (2014). Exercise training and music therapy in elderly with depressive syndrome: a pilot study. Complement. Ther. Med. 22, 614–620. doi: 10.1016/j.ctim.2014.05.012

21)Wang, J. , Wang, H. and Zhang, D. (2011) Impact of group music therapy on the depression mood of college students. Health, 3, 151-155

22)Yap AF, Kwan YH, Tan CS, Ibrahim S, Ang SB. Rhythm-centred music making in community living elderly: a randomized pilot study. BMC Complement Altern Med. 2017 Jun 14;17(1):311. doi: 10.1186/s12906-017-1825-x. PMID: 28615007; PMCID: PMC5470187.

23)Koelsch, S., Offermanns, K., and Franzke, P. (2010). Music in the treatment of affective disorders: an exploratory investigation of a new method for music-therapeutic research. Music Percept. Interdisc. J. 27, 307–316. doi: 10.1525/mp.2010.27.4.307

Excluded papers：

24)Bally, K., Campbell, D., Chesnick, K., and Tranmer, J. E. (2003). Effects of patient controlled music therapy during coronary angiography on procedural pain and anxiety distress syndrome. Crit. Care Nurse 23, 50–58. （not provide useable data）

25)Atiwannapat P, Thaipisuttikul P, Poopityastaporn P, Katekaew W. Active versus receptive group music therapy for major depressive disorder - a pilot study. Complementary Therapies in Medicine 2016;26:141–5. (sample size<20)

26)Garrido S, Stevens CJ, Chang E, Dunne L, Perz J. Music and Dementia: Individual Differences in Response to Personalized Playlists. J Alzheimers Dis. 2018;64(3):933-941. doi:10.3233/JAD-180084 （not randomised or quasi-randomised controlled trials）

27)Sánchez A, Maseda A, Marante-Moar MP, de Labra C, Lorenzo-López L, Millán-Calenti JC. Comparing the Effects of Multisensory Stimulation and Individualized Music Sessions on Elderly People with Severe Dementia: A Randomized Controlled Trial. J Alzheimers Dis. 2016;52(1):303-315. doi:10.3233/JAD-151150 （the control group also received music intervention）

28)Mondanaro JF, Homel P, Lonner B, Shepp J, Lichtensztein M, Loewy JV. Music Therapy Increases Comfort and Reduces Pain in Patients Recovering From Spine Surgery. Am J Orthop (Belle Mead NJ). 2017;46(1):E13-E22. (No full text available)

29)Castillo-Pérez, S., Gómez-Pérez, V., Velasco, M. C., Pérez-Campos, E., and Mayoral, M. A. (2010). Effects of music therapy on depression compared with psychotherapy. Arts Psychother. 37, 387–390. doi: 0.1016/j.aip.2010.07.001 （not provide useable data)

30)Alcântara-Silva TR, de Freitas-Junior R, Freitas NMA, et al. Music Therapy Reduces Radiotherapy-Induced Fatigue in Patients With Breast or Gynecological Cancer: A Randomized Trial. Integr Cancer Ther. 2018;17(3):628-635. doi:10.1177/1534735418757349（not provide useable data)

31)Cheung CWC, Yee AWW, Chan PS, et al. The impact of music therapy on pain and stress reduction during oocyte retrieval - a randomized controlled trial. Reprod Biomed Online. 2018;37(2):145-152. doi:10.1016/j.rbmo.2018.04.049（not provide useable data)

32)Pezzin LE, Larson ER, Lorber W, McGinley EL, Dillingham TR. Music-instruction intervention for treatment of post-traumatic stress disorder: a randomized pilot study. BMC Psychol. 2018;6(1):60. Published 2018 Dec 19. doi:10.1186/s40359-018-0274-8 (the control group also received music intervention)

33)Silverman, M. J. (2011). Effects of music therapy on change and depression on clients in detoxification. J. Addict. Nurs. 22, 185–192. doi: 10.3109/10884602.2011.616606 （the control group also received music intervention）

34)Särkämö T, Laitinen S, Numminen A, Kurki M, Johnson JK, Rantanen P. Clinical and Demographic Factors Associated with the Cognitive and Emotional Efficacy of Regular Musical Activities in Dementia. J Alzheimers Dis. 2016;49(3):767-81. doi: 10.3233/JAD-150453. PMID: 26519435.

35)Tuinmann G, Preissler P, Böhmer H, Suling A, Bokemeyer C. The effects of music therapy in patients with high-dose chemotherapy and stem cell support: a randomized pilot study. Psychooncology. 2017 Mar;26(3):377-384. doi: 10.1002/pon.4142. Epub 2016 May 5. PMID: 27146798.（not provide useable data)

36)Hsu, W. C., and Lai, H. L. (2004). Effects of music on major depression in psychiatric inpatients. Arch. Psychiat. Nurs. 18, 193–199. doi: 10.1016/j.apnu.2004.07.007（not provide useable data)

（3）We have added some new analyses of our data. 1) including three new papers and re-analying of our data, 2) adding the comparison of music therapy and music medicine (figure 3 in revised manuscript) , 3) adding some subgroup analyses by country having music therapy profession, intervention settings, therapy mode, specific music therapy methord, intervenor /therapist, and total intervention session (table 2 in revised manuscript) .

Response: We are sorry for making this mistake. In the Methord section, we defined exclusive criteria as studies with a very small sample size (n<20),while in table4 we performed the sensitivity analyses by excluding the papers with smale sample size ( 20< n<30). We have amended the table 4.

Response: We have added these findings with a forest plot (figure 6 in revised manuscript) according to the comment.

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Open access
Published: 30 August 2019

The effects of playing music on mental health outcomes

Laura W. Wesseldijk 1 , 2 ,
Fredrik Ullén 1 na1 &
Miriam A. Mosing 1 , 3 na1

Scientific Reports volume 9 , Article number: 12606 ( 2019 ) Cite this article

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Behavioural genetics
Psychiatric disorders
Risk factors

The association between active musical engagement (as leisure activity or professionally) and mental health is still unclear, with earlier studies reporting contrasting findings. Here we tested whether musical engagement predicts (1) a diagnosis of depression, anxiety, schizophrenia, bipolar or stress-related disorders based on nationwide patient registers or (2) self-reported depressive, burnout and schizotypal symptoms in 10,776 Swedish twins. Information was available on the years individuals played an instrument, including their start and stop date if applicable, and their level of achievement. Survival analyses were used to test the effect of musical engagement on the incidence of psychiatric disorders. Regression analyses were applied for self-reported psychiatric symptoms. Additionally, we conducted co-twin control analyses to further explore the association while controlling for genetic and shared environmental confounding. Results showed that overall individuals playing a musical instrument (independent of their musical achievement) may have a somewhat increased risk for mental health problems, though only significant for self-reported mental health measures. When controlling for familial liability associations diminished, suggesting that the association is likely not due to a causal negative effect of playing music, but rather to shared underlying environmental or genetic factors influencing both musicianship and mental health problems.

A comprehensive investigation into the genetic relationship between music engagement and mental health

Mental health and music engagement: review, framework, and guidelines for future studies

Biological principles for music and mental health

Introduction.

The high suicide rate among famous musicians over the last few years, e.g. Soundgarden’s Chris Cornell, Linkin Park’s Chester Bennington, Avicii and the Prodigy’s Keith Flint, has received a lot of media attention and raised the question about a possible relationship between mental health problems and musicianship. In line with that, a recent survey among 2,211 British self-identified professional musicians found musicians to be up to three times more likely to report depressive problems than individuals in the general population 1 . Furthermore, several famous people engaged in creative professions other than musicianship were also known for their psychiatric illnesses, like Vincent van Gogh, Ernest Hemingway or John Nash. It has been shown that unaffected relatives of individuals with bipolar disorder or schizophrenia have higher levels of creativity 2 , 3 , 4 , 5 . Overall, such findings suggest that creativity and musicianship are risk factors for mental health problems.

On the other hand, there are many studies that report positive relationships between musical engagement and indicators of mental health, thus suggesting the opposite, namely that engagement in music could be protective against psychiatric problems. Although epidemiological studies investigating the association between music and the risk of mental health problems are rare – for a review, see 6 – the few existing ones all tend to suggest a positive effect of music 7 . For example, singing or playing music has been reported to be have a positive influence on various subjective health outcomes, including anxiety and depression 8 . Singing in a choir is related to higher self-rated quality of life and satisfaction with health 9 , and playing an instrument, and singing or performing in theater, tend to be associated with increased self-rated health in women, but decreased all-cause mortality in men and not vice versa 10 . Hours of music practice has been shown to be associated with lower alexithymia (i.e., a dysfunction in emotional awareness, social attachment, and interpersonal relating) 11 . Finally, in 50,797 Norwegian males, but not in females, it was found that active participation in music, singing or theater predicted significantly lower depressive symptoms 12 . It is important to note that the measures of health outcomes in these studies are retrospective self-reports. Therefore, the outcomes could partly reflect characteristics of the rater and may be subject to a recall bias.

Furthermore, there are numerous reviews on the effect of music interventions, both active (e.g. performing) and passive (e.g. listening), on individuals in clinical settings, e.g. during medical procedures or in mental health clinics (for reviews in children, see 13 , 14 , 15 , 16 , 17 ; for reviews in adults, see 18 , 19 , 20 ). The majority of reviews conclude that music interventions have a positive effect on pain, mood, and anxious or depressive symptoms in both children and adults in clinical settings. This suggests not only a positive association in line with the epidemiological research, but also potentially a causal relationship. It is important to note that most of the music interventions described in these studies have been tailored to address individually assessed needs of a client by a music therapist, which differs significantly from self-initiated musical engagement in daily life. Furthermore, as pointed out in most of these reviews, it is difficult to draw firm conclusions about protective effect of music due to the mixed quality of many of the conducted studies, i.e., studies had small samples, suffered from bias due to methodological issues, and there was great variability among the results of the studies.

In sum, the direction of the association between musical engagement and mental health is still unclear with powerful population based research still failing to establish a relation unequivocally. Furthermore, it seems that differentiating between active amateur and professional musicians might explain the discrepancy between, on the one hand research reporting beneficial effects of music in everyday life on mental health, and on the other hand the high rate of depression and suicides among professional musicians. This view is in line with findings from the recent study of Bonde, et al . 21 in which active professional musicians reported more health problems than active amateur musicians, while active amateur musicians reported significantly better self-reported health than non-musicians. Possibly, the strain and pressure experienced by professional musicians may override a possible overall positive effect of musical engagement. Furthermore, an association between engagement in music and mental health problems on a population level does not necessarily reflect causal effects; it could also reflect reverse causation or underlying shared genetic or shared environmental factors that influence both the choice to engage in music and the development of psychiatric problems. It is well known that genetic factors play a role both in mental health problems 22 and in individual variation in music-related abilities 23 . In line with that, there is evidence that the association between creativity and psychiatric disorders is largely driven by underlying shared genetic factors 24 . Studying twins can reduce genetic and shared environmental confounding and strengthen causal inferences.

Here, using a large genetically informative sample of Swedish twins, we aim to investigate whether there is an association between active musical engagement defined by whether an individual plays an instrument, on an amateur and professional level, and mental health and if so, whether the relationship is consistent with a causal hypothesis, i.e., that musical engagement truly affects mental health. We use data from the Swedish nationwide in-patient and outpatient registers for psychiatric diagnoses (i.e., diagnosis of depression, anxiety disorder, schizophrenia, bipolar, stress disorder) as well as self-reports on mental health problems (depressive, burnout and schizotypal symptoms). As the association between playing sport and mental health is already well established, we conducted sensitivity analyses investigating a protective effect of sport against psychiatric problems in this sample.

Participants

Data for the present study was collected as part of “the Study of Twin Adults: Genes and Environment” (STAGE), a sub-study in a cohort of approximately 32,000 adult twins registered with the Swedish Twin Register (STR). The STAGE study sent out a web survey in 2012–2013 inquiring about, musical engagement and musical achievement and other potentially music related traits. The 11,543 responders were aged between 27 and 54 years and data were available for 10,776 individuals on musical engagement and for 6,833 on musical achievement.

The National Patient Register (NPR) records the use of the health care system in Sweden, which has nationwide coverage ensuring equal access to health care for all residents, using a 10-digit personal identification number assigned to all Swedish residents 25 . The NPR includes an in-patient register (IPR) and out-patient register (OPR). The IPR contains information about hospitalizations since 1964 (with full national coverage since 1977), while the OPR covers outpatient visits since 2001 26 . The Cause of Death Register (CDR) contains information from death records since 1961 27 . The Swedish twins from the STAGE study were linked to records from the IPR, OPR and CDR.

Informed consent was obtained from all participants. The study was approved by the Regional Ethics Review Board in Stockholm (Dnr 2011/570-31/5, 2012/1107-32, 2018/866-32). All research methods were performed in accordance with relevant guidelines and regulations.

Musical engagement

Participants were asked whether they ever played an instrument. Those who responded positively were asked at what age they started to play, whether they still played an instrument and, if not, at what age they stopped playing. From these questions, a music status variable was created (0: does not play, 1: used to play, 2: plays).

Sport engagement

Participants reported on whether they ever actively trained a sport (excluding exercise training or physical activity in general). Information on age they started training a sport, whether they still played and at what age they stopped playing resulted in a sport status variable with 0 ‘does not play’, 1 ‘used to play’ and 2 ‘plays sport’.

Musical achievement

Musical achievement was measured with a Swedish version of the Creative Achievement Questionnaire (CAQ) that assesses different domains of creativity, including music 28 , 29 . Individuals were asked to rate their musical achievement on a seven-point scale: 1 ‘I am not engaged in music at all’, 2’I have played or sang privately, but I have never played, sang or showed my music to others’, 3’I have taken music lessons, but I have never played, sang or showed my music to others’, 4 ‘I have played or sung, or my music has been played in public concerts in my home town, but I have not been paid for this’, 5 ‘I have played or sung, or my music has been played in public concerts in my home town, and I have been paid for this’, 6 ‘I am professionally active as a musician’ and 7 ‘I am professionally active as a musician and have been reviewed/featured in national or international media and/or have received an award for my musical activities’. To differentiate between amateur and professional musicians, we converted the scale to three groups: 1 ‘no engagement in music’, 2–4 ‘making music on an amateur level’, and 5–7 ‘professionally active in music’.

Registry-based mental health outcomes

For each individual we derived information (diagnosis and date of first diagnosis) on incidence of depression, anxiety disorder, schizophrenia, bipolar disorder, or stress disorder based on clinical diagnoses after any inpatient or outpatient visit, or underlying cause of death registered in the national registers according to the International Classification of Diseases (ICD) codes as reported in Table 1 . We created an ‘any psychiatric diagnosis’ variable indicating whether the participant has ever been diagnosed with any of the five categories of clinical diagnoses above. For this variable, we selected the earliest date of diagnosis in case of comorbidity.

Questionnaire-based self-reported mental health

In addition, self-reports on mental health outcomes (i.e., depressive, burnout and schizotypal symptoms) obtained in the web survey were analyzed. Depressive symptoms were measured with the depression scale of the Hopkins Symptom Checklist 30 . This scale contains of six items all ranging from 0 to 4 (0 ‘not at all’ to 4 ‘extremely’), measuring depressive symptoms in a work-related context, with higher scores indicating more depressive symptoms. Burn-out symptoms related to work were measured with the Emotional exhaustion subscale of the Maslach Burnout Inventory-General Survey 31 . This scale consists of five items that range from 1 (every day) to 6 (a few times per year or less/never). Therefore, as higher scores reflect less burnout symptoms, we reversed this scale so that higher scores indicate more burnout symptoms in line with the other mental health outcomes. Schizotypal symptoms were measured with the “Positive Dimension Frequency Scale” of the Community Assessment of Psychic Experiences (CAPE) questionnaire 32 . The score is based on 20 positive symptom items that can be answered with four different symptom frequency levels, from 1 ‘never’ to 4 ‘almost always’. Higher scores indicate more schizotypal symptoms. The Cronbach alpha reliability in present study was 0.89 for the depressive symptom scale, 0.87 for the burnout symptom scale and 0.79 for the schizotypal symptom scale.

Level of education

Educational achievement was dichotomized into ‘low and intermediate’ (1 to 7; unfinished primary school to bachelor education) and ‘high’ (8 to 10; master education to PhD).

Statistical analyses

All analyses were conducted in STATA 15.

Survival analyses , i.e., Cox proportional hazard regression, were conducted to explore the effect of musical engagement and musical achievement on the risk to receive a registry-based diagnosis of a psychiatric disorder 33 . Survival analysis is a method to analyze data where the outcome variable is the time until an event happens. The time (years) from the age of twelve to either the date of first receiving a psychiatric diagnosis or to the date of censoring (i.e., date of death or end of follow-up at January 1, 2015) were used as the time scale (i.e., the survival time). For the analyses on the effect of musical engagement , we had to take into account that some individuals had not yet started playing an instrument at the age of twelve (i.e., would start at a later age), or stopped playing at some stage. Therefore, years were split on whether the individual did not play, stopped or started playing, or currently played a musical instrument using the stsplit statement to differentiate between the three levels of musical engagement. We used Cox proportional hazard regressions, a method that assumes the effect upon survival to be constant over time, to calculate hazard ratios (HRs) with 95% confidence intervals. The HRs represent the effects of 1) playing an instrument versus never having played an instrument or 2) having played an instrument (but stopped before diagnosis) versus never having played an instrument on the baseline risk for a mental health diagnosis (independent of playing status) during the follow-up period. A HR value greater than one indicates an increased risk, while a value below one indicates a protective effect. Additionally, we conducted the survival analyses to estimate the effect of musical achievement in a lifetime on the risk of a mental health diagnosis, in which the HRs represent 1) the effect of having performed music as an amateur versus not being involved in music, or 2) the effect of having performed music professionally versus not being involved in music. As we analyzed the three level musical achievement in a lifetime, we did not split years on age (assuming that individuals have been on a lifelong ‘achievement’ trajectory). To correct for relatedness in the twin sample, the robust standard error estimator for clustered observations was used 34 . We fitted separate survival models for each of the five psychiatric disorder diagnoses as well as for the ‘any psychiatric diagnosis’ variable. Thus, first, we in total fitted six models for the effect of musical engagement and another six models for musical achievement. All models included sex as a covariate. Additionally, we fitted all models corrected for level of education, resulting in a small loss of data due to missing information for some individuals, therefore reducing the power. For each model, the proportional hazards assumption was tested using Schoenfeld residuals. No evidence for deviation from the proportional hazards assumption was found for any of the models (all p values > 0.01). As a sensitivity analysis, the above-described models for musical engagement (in which we used the stsplit statement) were repeated with sport engagement as the exposure variable instead, to estimate the effect of playing sport on registry-based psychiatric disorder diagnoses.

Self-reported mental health outcomes

Linear regression analyses were performed to explore the effect of musical engagement and musical achievement on the self-rated continuous measures of depressive symptoms, burnout symptoms and schizotypal symptoms. To correct for relatedness in the twin sample, we used the robust standard error estimator for clustered observations. We included sex as a covariate. Additionally, we ran the analyses corrected for level of education. As a sensitivity analysis, we estimated the effect of sport engagement on depressive, burnout and schizotypal symptoms using linear regression analyses.

Co-twin control analyses (within-pair analyses)

Within-pair analyses in identical twins were conducted to further explore the association between musical engagement and receiving a mental health diagnosis when controlling for genetic and shared environmental factors. As monozygotic (MZ) twins are genetically identical and share their family environment, studying identical twins excludes confounding in case a genetic predisposition or shared environmental influence affects both outcome (mental health problems), and exposure (music engagement). Therefore, if music engagement truly causes a lower/higher risk for receiving a mental health diagnosis, we would expect the MZ twin that plays music to have a lower/higher risk of psychiatric problems than his or her co-twin that does not play music. Conditional Cox regression models, with the strata statement to stratify by pair identifier, were fitted for the mental health diagnoses to estimate HRs with 95% confidence intervals. Notably, only complete identical twin pairs discordant for exposure (i.e., music engagement) and outcome (i.e., the psychiatric disorder diagnosis) contribute to the within-pair analyses. The conditional logistic regression estimates the effect of the difference between the two observations in the strata. Twins are regarded as discordant for the outcome when the time of the psychiatric diagnosis differs. Due to the low prevalence of schizophrenia and bipolar disorder in the complete twin pairs, these phenotypes were excluded from the within-pair analyses.

Additionally, to explore further the effect of music engagement on the self-rated continuous measures of depressive symptoms, burnout symptoms and schizotypal symptoms, we conducted within-pair linear regression analyses using the xtreg fe statement to stratify by twin pair. In within-pair analyses in identical twins correcting for sex is not required as each twin is matched to his or her co-twin. To increase power, we also included data from same-sex dizygotic (DZ) twins (who share on average 50% of their genetic makeup and 100% of their family environment).

Descriptives

Information on mental health outcomes and musical engagement was available for 9,816 individuals [2,212 complete twin pairs (1,055 MZ, 661 dizygotic same-sex (DZ), 496 dizygotic opposite-sex (DOS) twins) and 5,392 individual twins]. Among these individuals, data on musical achievement were available for 6,295 individuals [1,208 complete twin pairs (627 MZ, 342 DZ, 239 DOS) and 3,879 individual twins]. Characteristics of the participants are reported in Table 2 .

Women were more likely to initiate playing an instrument than men (37.7% of men versus 20.5% of women), while roughly the same amount of men and women remained actively involved in music in adulthood (23.3% of men and 21.9% of women). More men (8.5%) than women (5%) played music professionally.

Although overall, there was an overall trend towards a somewhat elevated risk for psychiatric disease in those engaged with music, neither playing music nor having played music in the past (Fig. 1 ), nor professional musicianship (Fig. 2 ) was significantly associated with the risk for any of the psychiatric disorders. The analyses adjusted for level of education showed similar results (see Table S1 for musical engagement and Table S2 for musical achievement, in the supplementary material), with the exception that individuals who played an instrument had a significantly higher risk (39%) of being diagnosed with an anxiety disorder (HR 1.39, CI 1.01–1.92) compared to those who never played an instrument. In terms of covariates, we found females to have a higher risk for depression (92%), anxiety disorder (92%), and stress-related disorders (58%) (Table S1 ). Additionally, individuals with higher levels of education had a significantly lower risk for psychiatric disorders, depression, anxiety disorder, schizophrenia or bipolar disorder (Table S1 ).

Music engagement and registry-based mental health outcomes. Sex is included as covariate.

Music achievement and registry-based mental health outcomes. Sex is included as a covariate.

Self-reported mental health

Results of the regression analyses with self-reported mental health symptoms indicated that playing an instrument was significantly associated with more schizotypal symptoms and depressive and burnout symptoms in a work context (see left part of Table 3 ). Having played an instrument in the past did not significantly influence any of the self-rated mental health outcomes. Furthermore, even though professional and amateur musicians report more burnout and schizotypal symptoms than non-players, individuals who played music professionally did not experience significantly more depressive, burnout or schizotypal symptoms than individuals who play music on an amateur level (see right part of Table 3 ). When analyses were repeated adjusting for level of education (results not shown) all results remained the same.

Sensitivity sport analyses

Results of the sensitivity analyses on the registry-based mental health outcomes showed that individuals who actively played sports were less likely to develop any psychiatric disorder, as well as depression, anxiety, and bipolar disorder (see Fig. S1 ). There was no sustained beneficial effect of past sports engagement after stopping with exercise. The analyses adjusted for level of education showed the same results.

Regression analyses on the self-reported mental health outcomes showed that individuals who actively play sports were significantly less likely to report depressive symptoms (β = −0.23, p < 0.001) and burnout symptoms (β = −0.20, p < 0.001), but not schizotypal symptoms (β = 0.00, p = 0.96). Past sport activities were unrelated to the self-reported mental health outcomes (p values range between 0.08 and 0.20). Including level of education in the analyses did not affect the results.

Co-twin control analyses

Results of the co-twin control analyses for both the registry-based and self-reported mental health measures are shown in Table 4 . None of the within-pair estimates were significant. However, overall, the effect sizes (HR or beta) moved closer to zero with increased controlling of shared liability.

We aimed to investigate the association between musical engagement in everyday life and mental health in a large cohort of Swedish twins. Although the findings were somewhat mixed, overall results suggest that individuals who actively play a musical instrument (but not necessarily professionally) may have a somewhat increased risk for mental health problems. However, when controlling for familial liability these associations became weaker and non-significant suggesting that the association is likely explained by underlying shared factors influencing both musicianship and mental health problems.

While analyses using registry-based mental health diagnoses showed no significant association between music playing or professional musical engagement and psychiatric diagnoses, the direction of the effect was trending towards a somewhat increased risk for psychiatric diagnoses for those actively engaged with music. Results from the self-reported mental health outcomes further supported this; individuals playing an instrument report more depressive, burnout and schizotypal symptoms. This is in contrast with previous epidemiological and clinical studies reporting positive effects of musical engagement on anxious and depressive symptoms 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 . Further, a recent study by Fancourt and Steptoe 35 found cultural engagement to decrease the development of depression in older ages. However, it appears likely that it is important to distinguish between general cultural engagement, i.e., visits to the theatre, concerts or opera, the cinema or an art gallery, exhibition or museum) and active playing of a musical instrument, which is the focus of the present study. Playing a musical instrument is much more narrowly defined behavior and involves many (cognitive and physical) processes different from engaging in cultural musical activities or listening to music. On the other hand, our findings are in line with results from the survey among British professional musicians 1 and with previous findings of associations between creativity and mental health problems, i.e., that people engaging in creative activities tend to experience more psychiatric problems 4 . It is important to note that the previous epidemiological studies on mental health, the British musicians study, but also our continuous mental health outcomes, were based on self-report. An explanation could be that results of self-report reflect a different attitude towards mental health among more creative individuals, with higher acceptance and awareness of mental health problems, possibly resulting in over-reporting in the field.

Further, there is evidence that the association between creativity and psychiatric disorders can be largely attributed to underlying shared genetic factors 24 , 36 . This is in line with present results of our co-twin control analyses, which showed that the association between musicianship and mental health was attenuated when controlling for genetic and shared environmental confounding (although all analyses were non-significant). This suggests that the observed associations would partly be explained by a shared underlying etiology, (i.e., genetic or family environmental factors which affect both, individuals differences in music playing and mental health) and not by a causal effect of playing music. The within-pair results, however, should be interpreted with caution as only discordant twin pairs contribute to the co-twin control analyses, which reduced the power to find significant associations.

We found significant differences between professional or amateur musicians and non-players in self-rated health outcomes, which are in line with our findings on playing music in general. However, in neither self-rated nor registry-based data, we observed any significant differences in mental health problems between professional musicians compared to amateur musicians. This is in contrast to findings from the study of Bonde, et al . 21 in which active professional musicians reported higher numbers of overall health problems than active amateur musicians, while active amateur musicians reported significantly better self-reported health than non-musicians did. Whilst this was also a large population-based sample, this study analyzed general health instead of mental health, which likely contributes to the difference in findings.

The discrepancy in findings between registry-based mental health diagnoses and self-reported mental health could be due to an influence of rater and recall biases captured in the self-reported mental health outcomes, as discussed above. However, another explanation could be less power in the analyses with the registry-based mental health diagnoses to detect an existing effect. The power of a method to analyze survival time data depends partly on the number of psychiatric diagnoses rather than on the total sample size. In the present sample, observed post-hoc power for the survival analyses to detect a HR of 0.8 for music engagement is 88% for the incidence of a psychiatric disorder, 67% for depression, 61% for anxiety, 7% for schizophrenia, 18% for bipolar and 45% for stress disorder, reflecting the different incident rates of the disorders. As the self-reported mental health problems were measured on a continuous scale, these analyses have higher power (i.e., no cut-off score needs to be reached to obtain a full diagnosis). Nevertheless, our sensitivity analyses in the registry-based outcomes on the effect of sport did show a significant protective effect of sport against the risk of receiving a diagnosis of a psychiatric disorder, depression, anxiety and bipolar disorder in this sample, suggesting that an association can be found with the present distribution of the data if existent. Therefore, we conclude that a lack of power is not a likely explanation for our null findings in the registry-based health outcomes, and that if there truly were an effect, it would be very small.

There are some limitations of this study in addition to the ones we already touched upon. We analyzed data on psychiatric diagnoses obtained from the Swedish nationwide in-patient and outpatient registers. However, the outpatient register only reached full coverage in 2001 and it is therefore possible that some individuals were not classified with a psychiatric disorder, although they did experience mental health problems before 2001. The same holds for individuals with mental health problems who did not visit a doctor. In addition, the dichotomous rather than dimensional nature of psychiatric diagnoses excludes large parts of the continuous variation among individuals in psychiatric problems. The continuous symptom scales increase the power to detect an effect of engagement in music or sports, but may be somewhat biased. Furthermore, our study explored potential effects of active musical engagement (i.e., making music) in everyday life and therefore our findings do not allow for any conclusions about the potential effect of (personalized) musical interventions on mental health problems. Lastly, as mentioned earlier, the sample of discordant twin pairs contributing to the co-twin control analyses was small, resulting in low power to detect effects.

To our knowledge, the present population-based study is the only genetically informative large-scale study to investigate associations between active engagement in music (both as a leisure activity and professionally) and registry-based as well as self-reported mental health outcomes. Rather than a protective effect of music engagement in everyday life as often suggested, our findings suggest that individuals actively engaged in music playing, but not only professional musicians, may have a somewhat elevated risk for mental health problems. This association may at least partly be due to shared underlying etiology and it is unlikely that it reflects a causal effect of playing music.

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Acknowledgements

The present work was supported by the Marcus and Amalia Wallenberg Foundation (MAW 2018.0017), and the Bank of Sweden Tercentenary Foundation (M11-0451:1). We acknowledge The Swedish Twin Registry for access to data. The Swedish Twin Registry is managed by the Karolinska Institutet and receives funding through the Swedish Research Council under the grant no 2017-00641. Open access funding provided by Karolinska Institute.

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Fredrik Ullén and Miriam A. Mosing jointly supervised this work.

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Department of Neuroscience, Karolinska Institutet, Solnavägen 9, SE-171 77, Stockholm, Sweden

Laura W. Wesseldijk, Fredrik Ullén & Miriam A. Mosing

Department of Psychiatry, Amsterdam UMC, University of Amsterdam, Meibergdreef 5, 1105 AZ, Amsterdam, The Netherlands

Laura W. Wesseldijk

Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels v 12A, 171 77, Stockholm, Sweden

Miriam A. Mosing

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F.U., M.M. and L.W. developed the study design. L.W. performed the data analysis and interpretation under the supervision of F.U., M.M. L.W. and M.M. drafted the manuscript, and F.U. provided critical revisions. All authors approved the final version of the manuscript for submission.

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Wesseldijk, L.W., Ullén, F. & Mosing, M.A. The effects of playing music on mental health outcomes. Sci Rep 9 , 12606 (2019). https://doi.org/10.1038/s41598-019-49099-9

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80 Music Therapy Essay Topic Ideas & Examples

🏆 best music therapy topic ideas & essay examples, 📌 good research topics about music therapy, 🔍 interesting topics to write about music therapy, ❓ music therapy research questions.

Music Therapy as a Social Work Intervention One of such interventions is music therapy which is aimed at helping people in a sensitive way accurately adjusting the possibilities this therapy may offer to the requirements of a particular client of a group […]
Music Therapy as Experiential Activity For this reason, a technique was applied to the 10-year-old child with developmental delays to transform the lyrics of the favorite sad melody into a more positively inspiring and uplifting one.
Art and Music Therapy Coverage by Health Insurance However, I do believe that creative sessions should be available for all patients, and I am going to prove to you that music and art are highly beneficial for human health.
Music Therapy in Healthcare Therefore, the article suggests that music can be used for relaxation, as well as managing the health issues that may arise due to the lack of relaxation.
Music Therapy for Children With Learning Disabilities This review includes the evidence supporting music therapy as an effective strategy for promoting auditory, communication, and socio-emotional progression in children with ASD.
Music Therapy as a Related Service for Students With Disabilities From a neuroscientific perspective, how would music intervention improve classroom behaviors and academic outcomes of students with ADHD as a way to inform policy-makers of the importance of music therapy as a related service?
Music Therapy: The Impact on Older Adults There is therefore the need to focus more energy to aid more understating on the role of music therapy on older residents.”The recent qualitative review of literature in the area of music and music therapy […]
Music Therapy: Alternative to Traditional Pain Medicine The sources underline that therapists should pay attention to the subjects of music and their impact on the health of clients.
The Role of Music Therapy as Alternative Treatment Music therapy is the use of music interventions to achieve individualized goals of healing the body, mind, and spirit. Thereafter, several developments occurred in the field of music therapy, and the ringleaders founded the American […]
Music Therapy Effectiveness In addition to this, research has shown that stroke patients become more involved in therapy sessions once music is incorporated in the treatment program; this is the motivational aspect of music.
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Music Therapy Throughout the Soloist Globally, classical music in its sense has always been known to adjoin the listener to some transcendent understanding of the world order, the feeling of integrity with the Universe and enormous delight rising up from […]
Music Therapy: Where Words Cease In spite of the fact that, as a rule, one indulges into art to find the shelter from the reality, the author of the book called The Soloist explores quite a different issue of the […]
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How Music Affects Mental Health

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Introduction, music as a therapeutic tool, music as an emotional outlet, music and social connectivity.

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Women were more likely to initiate playing an instrument than men (37.7% of men versus 20.5% of women), while roughly the same amount of men and women remained actively involved in music in ...
Informative On Music Therapy: [Essay Example], 770 words
The Benefits of Music Therapy. Music therapy has been shown to have a wide range of benefits for individuals of all ages and abilities. One of the most well-known benefits is its ability to reduce stress and anxiety. Listening to calming music or participating in music-making activities can have a soothing effect on the mind and body.
Essays on Music Therapy
The choice of essay topics for music therapy is an important consideration for students and professionals in the field. By selecting a topic that is relevant, engaging, and informative, you can effectively communicate the value and potential of music therapy as a form of therapy. The essay topics outlined in this article provide a starting ...
80 Music Therapy Essay Topic Ideas & Examples
The Role of Music Therapy as Alternative Treatment. Music therapy is the use of music interventions to achieve individualized goals of healing the body, mind, and spirit. Thereafter, several developments occurred in the field of music therapy, and the ringleaders founded the American […] Music Therapy Effectiveness.
Informative Essay On Music Therapy
Music therapy is the clinical use of music to achieve individual goals and improve relationships; it is also considered a form of Psychotherapy (Music Therapy Medicine). Melodies and harmonies are used to transport patients to new and safe places. The sweet rhythms brings peace and relaxation to stressed minds.
The potential of music therapy: [Essay Example], 2049 words
Informative On Music Therapy Essay. Music therapy is a powerful and effective form of treatment that harnesses the healing power of music. It has a rich history, with roots in ancient civilizations, and has evolved into a recognized profession in the 20th century.
Neuroscientific Insights for Improved Outcomes in Music-based
Results showed that singing improved verbal fluency and alleviated psychiatric symptoms and caregiver distress compared to lyric reading. Specifically, music therapy was more effective for cognitive measures in mild cases of AD but more effective for emotional and social measures in moderate to severe cases.
Music Therapy Essay
Music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program (Gram, 2005). Music therapy can reach out to anyone, age. 2135 Words. 9 Pages. Decent Essays.
How Music Affects Mental Health: [Essay Example], 704 words
Informative On Music Therapy Essay. Music therapy is a powerful and effective form of treatment that harnesses the healing power of music. It has a rich history, with roots in ancient civilizations, and has evolved into a recognized profession in the 20th century.
Music Therapy Research: Context, Methodology, and Current and Future
Music therapy research aims to provide information about outcomes that support music therapy practice including contributing to theoretical perspectives that can explain why changes occur during treatment. Music therapy research has been conducted in a range of health, education, and community contexts throughout the world.

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Music therapy for stress reduction: a systematic review and meta-analysis

Introduction

Music therapy

The influence of music on the stress response

Music therapy versus music medicine

The present study

Inclusion criteria

Selection of the studies

Coding and moderators

Calculation and analyses

Publication bias

Overall effect of music therapy on stress-related outcomes

Overall effects

Effect moderating variables

Limitations of the present study

Studies included in the meta-analysis

Table A1. Characteristics of included studies.

Related research

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What to Know About Music Therapy

Effectiveness

Types of Music Therapy

Get Help Now

Music Therapy vs. Sound Therapy

What Music Therapy Can Help With

Benefits of Using Music as Therapy

Depression

Pain Management

Effects of music therapy on depression: A meta-analysis of randomized controlled trials

Zhaohui Huang

Associated Data

Conclusions

Introduction

Materials and methods

Data extraction

Assessment of risk of bias in included studies

Music therapy and music medicine

Evaluation of depression

Statistical analysis

Characteristics of the eligible studies

The overall effects of music therapy

Sub-group analyses and meta-regression analyses

Sensitivity analyses

Evaluation of publication bias

Supporting information

Data Availability

Decision Letter 0

Author response to Decision Letter 0

Decision Letter 1

Acceptance letter