Music/Music Therapy

Music/Music Therapy

PEP Topic 
Depression
Description 

Music therapy involves using music to influence physiologic, psychological, and emotional functioning. In many cases it is used with other behavioral techniques, such as relaxation. Music interventions range from listening to recorded or live music to formal interventions provided by music therapists. Professional music therapy involves individualization of the intervention and a systematic process including assessment, treatment, and evaluation. Music therapy may involve the patient in music making. Researchers have evaluated the effect of music and music therapy in the treatment of anxiety, chemotherapy-induced nausea and vomiting, dyspnea, depression, pain, fatigue, and caregiver strain and burden.

Effectiveness Not Established

Systematic Review/Meta-Analysis

Archer, S., Buxton, S., & Sheffield, D. (2015). The effect of creative psychological interventions on psychological outcomes for adult cancer patients: A systematic review of randomised controlled trials. Psycho-Oncology, 24, 1–10. doi:10.1002/pon.3607

doi: 10.1002/pon.3607
Print

Purpose:

STUDY PURPOSE: To measure the effect of creative psychological interventions on psychological outcomes such as anxiety and depression, quality of life, coping, stress, anger, and mood in adults with breast or mixed cancers. 
 
TYPE OF STUDY: Systematic review

Search Strategy:

DATABASES USED: OVIDsp, Wiley Online Library, PsycINFO, Web of Knowledge, CINAHL Plus, Cochrane Database
 
KEYWORDS: An extensive listing of search terms was provided and included American and European spelling and truncation. 
 
INCLUSION CRITERIA: Studies that conformed to RCT design and had an intervention and a control group; studies that include adult patients who have any type of cancer at any stage and who may or may not be undergoing medical treatment; studies that used creative psychological intervention delivered by a qualified arts therapist; studies that included pre-/post and follow-up intervention outcome measures
 
EXCLUSION CRITERIA: Studies of patients engaging in the arts without a qualified art therapist or in a non-therapeutic manner were excluded.

Literature Evaluated:

TOTAL REFERENCES RETRIEVED: 157 articles were initially retrieved and evaluated.
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Two reviewers hand searched relevant journals for articles to include, reviewed the abstracts from the database search, and discussed inclusion or suitability for the study to arrive at the final number of articles to include in the review. The final selection of studies was evaluated for quality and bias risk.

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED = 10
  • TOTAL PATIENTS INCLUDED IN REVIEW = 488 (62 lost to attrition)
  • KEY SAMPLE CHARACTERISTICS: The frequency of intervention and type of intervention varied (Note: 10 studies of 8 different intervention foci.): 70% of the sample studies held intervention sessions once per week for a total of three to eight weeks. Participants with terminal cancer were studies either weekly or bi-weekly until death. The dance movement study held sessions two times per week for six weeks then once weekly for six weeks. One study held a music therapy session during chemotherapy.

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Mutliple phases of care
  • APPLICATIONS: Elder care 

Results:

Depression and anxiety were shown to improve in three of the studies although the interventions were different (music therapy, art therapy, and mindfulness-based art therapy). Other psychological factors also improved: lower ratings of somatic symptoms in an art therapy study and a creative arts study, and psychiatric symptom improvement. Improvements in various measures of quality of life were reported in studies of mindfulness-based art therapy, art therapy, music therapy, creative arts therapy, and dance/movement therapies. Art therapy showed improvements in coping resources and mood states. Music therapy showed improvements in stress and anger. Creative arts therapy showed improvements in specific aspects of the Profile of Mood States (POMS) that were reported: tension-anxiety, depression-dejection, anger-hostility, and confusion-bewilderment.

Conclusions:

Evidence reviewed in this study is inconclusive regarding effectiveness of various creative interventions.

Limitations:

  • Selected articles using creative psychological interventions did not include writing therapy or drama therapy.  
  • Meta-analysis was not possible, although rationale was clearly explained by the writers.
  • Only one of the 10 articles was evaluated as having high quality; the remaining were satisfactory.
  • Follow-up measures were not included in several studies.
  • The number of articles included in the sample was small (n = 10).
  • There appear to be discrepancies in accuracy of references to specific studies in the table: example, page 4, last paragraph indicates lack of replicated findings, whereas the table indicates otherwise.
  • Specified Creative Psychological Interventions delivered by a qualified therapist were shown to improve well-being on several measures. 

Nursing Implications:

The therapies were implemented by qualified therapists and were varied in nature, although not exhaustive of available therapies. The value of music, art, and movement therapies are shown to effectively reduce symptoms of anxiety and depression and improve quality of life, coping, and mood. Suggestions for further research are offered.

Bradt, J., Dileo, C., Grocke, D., & Magill, L. (2011). Music interventions for improving psychological and physical outcomes in cancer patients. Cochrane Database of Systematic Reviews, 8, CD006911.

doi: 10.1002/14651858.CD006911.pub2
Print

Purpose:

To examine the effects of music therapy and "medical music" on patients with cancer.

Search Strategy:

  • Databases searched were MEDLINE, EMBASE, LILACS, CINAHL, Computer-Assisted Information Retrieval Service System (CAIRSS), and Cochrane Collaboration. The investigators also evaluated for inclusion studies listed on web sites about clinical trials or on the web sites of relevant professional organizations, those cited in journals dealing with music and music therapy, and those included in the reference lists of relevant articles.
  • The investigators provided an extensive list of search terms in the report.
  • Studies were included if patients, of any age, had cancer and if the studies compared music interventions to standard care, alternative interventions plus standard care, or placebo. Studies were included if they were randomized, controlled trials or incorporated quasiexperimental designs.
  • Studies were excluded if they involved patients who were undergoing diagnostic procedures.

Literature Evaluated:

  • The investigators retrieved a total of 773 studies.
  • The investigators evaluated the quality of the studies according to the criteria in the Cochrane Handbook for Systematic Reviews of Interventions.

Sample Characteristics:

  • The final number of studies analyzed was 30.
  • The studies analyzed included a total of 1,891 patients.
  • The range of mean patients per study was 8 to 86.
  • The analyzed studies comprised multiple cancer types and age groups.

Phase of Care and Clinical Applications:

  • Patients were undergoing multiple phases of care.
  • The study has clinical applicability for pediatrics and palliative care.

Results:

  • Findings from seven trials, regarding effect on anxiety, showed positive effects for reducing anxiety (standardized mean difference [SMD] = –0.61; 95% confidence interval [CI] [–0.97, –0.26]; p = 0.0007).
  • Findings from six trials, regarding effect on pain, showed positive effects on perceived pain (SMD = –0.59; 95% CI [–0.92, –0.27]; p = 0.0003).
  • The investigators noted no significant effects on depression or fatigue.
  • Several studies showed that music listening and music interventions affected physical findings—for example, the studies reduced pulse rate.
  • Many studies had high risks of bias, and the type, duration, and timing of the interventions varied greatly.

Conclusions:

Music interventions appear to have beneficial effects regarding pain reduction and short-term reduction of anxiety.

Limitations:

  • The investigators found a relatively small number of studies that examined a specific symptom or outcome.
  • The interventions were very different in terms of sample types, timing, and duration; therefore, synthesizing the findings was difficult. 
  • Most studies had small sample sizes and high risks of bias.

Nursing Implications:

Music therapy and listening to music may be helpful means of reducing anxiety and perceived pain, and these interventions can have an effect of moderate size. The effects may be relatively short-lived, and the evidence is somewhat weak in terms of study design. However, listening to music has no risks for patients, can be easy to implement, and is an intervention that patients can do themselves. Nurses can suggest that patients use this approach to help manage pain and anxiety.

Tsai, H.F., Chen, Y.R., Chung, M.H., Liao, Y.M., Chi, M.J., Chang, C.C., & Chou, K.R. (2014). Effectiveness of music intervention in ameliorating cancer patients' anxiety, depression, pain, and fatigue: A meta-analysis. Cancer Nursing, 37, E35–E50.

doi: 10.1097/NCC.0000000000000116
Print

Purpose:

STUDY PURPOSE: To evaluate the effects of music on symptoms in patients with cancer

TYPE OF STUDY: Meta-analysis and systematic review

Search Strategy:

DATABASES USED: Ovid, PsycARTICLES, and PsycINFO (2002–2012)

KEYWORDS: neoplasms, cancer, and music or melody

INCLUSION CRITERIA: Used a music intervention in patients with cancer; quantitative methods; quasi-experimental or experimental design; reported statistical information to describe results; evaluated effects on anxiety, depression, pain, or fatigue

EXCLUSION CRITERIA: Qualitative design, case studies, or single-group studies

Literature Evaluated:

TOTAL REFERENCES RETRIEVED = 367

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Quality assessment with adapted Cochrane guidelines; the k value between reviewers was 0.9.

Sample Characteristics:

  • FINAL NUMBER STUDIES INCLUDED =  21–17 for anxiety, 8 for depression, 6 for pain, and 5 for fatigue
  • SAMPLE RANGE ACROSS STUDIES = 32–126

Phase of Care and Clinical Applications:

  • APPLICATIONS: Pediatrics, palliative care

Results:

For anxiety, music therapy had a moderate and significant effect with an effect size of -0.553 (Hedges; g) (95% CI -0.716, -0.398). There was significant heterogeneity in the sample. For depression, music therapy moderately and significantly reduced depression with an effect size for each study ranging from -0.151 to -0.787. Results were homogenous. Five of eight studies showed significant effects. For pain, music had an overall effect size of -0.656 (Hedges' g) (95% CI -1.016 to about -0.295), showing moderate-level effects on pain. There was significant heterogeneity among studies. For fatigue, music therapy had a small effect size of -0.422 (Hedges' g) (95% CI -0.669, -0.175). Results were homogenous. Studies were seen to be of good quality. Results of subgroup analysis suggest that music therapy is more effective in adults than children and more beneficial when the music is selected by the patient rather than the therapist.

Conclusions:

This analysis shows that music interventions can reduce anxiety, depression, pain, and fatigue in patients with cancer with small-to-moderate effect sizes.

Limitations:

In several areas, there was high heterogeneity. Sample sizes, timing, and types of music interventions varied substantially, and, in most, the impact was evaluated immediately after the music intervention. Whether music has ongoing effectiveness with continued use or any lasting effect on the symptoms assessed is unclear.

Nursing Implications:

Music interventions can be a good adjunctive and non-medication therapy that is of benefit in reducing anxiety, depression, pain, and fatigue in patients with cancer. The most beneficial ways and times to use music therapy are unclear. Nurses can suggest that patients use listening to music as part of self-care and can advocate for use of music as a low-risk intervention to ameliorate acute anxiety and pain symptoms.

Guideline/Expert Opinion

Greenlee, H., Balneaves, L.G., Carlson, L.E., Cohen, M., Deng, G., Hershman, D., . . . Society for Integrative Oncology. (2014). Clinical practice guidelines on the use of integrative therapies as supportive care in patients treated for breast cancer. Journal of the National Cancer Institute.Monographs, 2014, 346–358. 

PROFESSIONAL GROUP: Society for Integrative Oncology Guidelines Working Group

doi: 10.1093/jncimonographs/lgu041
Print

Purpose & Patient Population:

PURPOSE: To inform clinicians and patients about evidence regarding complementary and integrative therapy use to manage symptoms and side effects
 
TYPES OF PATIENTS ADDRESSED: Women with breast cancer during and beyond treatment

Type of Resource/Evidence-Based Process:

RESOURCE TYPE: Evidence-based guideline  
 
PROCESS OF DEVELOPMENT: A literature search was done, and study quality was evaluated using the Jadad scale and an adapted Delphi scale. A modified version of the U.S. Preventive Services Task Force scale was used for grading the evidence. A panel of experts compiled results and drafted recommendations, which were reviewed by clinicians, researchers, patient advocates, and other stakeholders. Feedback was incorporated into the final recommendations.
 
SEARCH STRATEGY:
DATABASES USED: Medline, EMBASE, CINAHL, SCOPUS, AMED, PubMed, PsychINFO, and Web of Science
KEYWORDS: Not stated
INCLUSION CRITERIA: Randomized, controlled trials; at least 50% of patients had breast cancer; breast cancer results separately reported an outcome of interest; used an integrative intervention
EXCLUSION CRITERIA: Systematic review or meta-analysis

Phase of Care and Clinical Applications:

PHASE OF CARE: Multiple phases of care
 
APPLICATIONS: Palliative care

Results Provided in the Reference:

4,900 references were identified that were published between January 1, 1990 and December 31, 2013. 203 articles were included in the final review although only 174 were referenced. Grades used and reported here were A: recommended, high certainty of benefit, B: recommended, high certainty of moderate to substantial benefit, D: recommends against use, moderate to high certainty of no net benefit, and H: recommends against use, moderate to high certainty that harms outweigh benefits.

Guidelines & Recommendations:

Interventions for specific symptoms that had strong recommendations for or against use were:

  • Anxiety: Music therapy during RT and chemotherapy sessions, meditation, and yoga for patients undergoing therapy (B-level recommendation)
  • Depression: Mindfulness-based stress reduction for patients undergoing radiotherapy, relaxation, and yoga (level A recommendation); massage and music therapy (level B)
  • Fatigue: Energy conservation (level B)
  • CINV: Acupressure and electroacupuncture in addition to antiemetics (B level)
  • Neuropathy: Acetyl L carnitine was not recommended because of harm (H level).
  • Radiodermatitis: Aloe vera and hyaluronic acid cream were not recommended as standard therapy because of lack of effect (D level).

Limitations:

It appears that only specific types of interventions were included, and there are numerous types of integrative or complementary interventions that were not considered in this review. The findings considered were limited to women with breast cancer. Quality rating of evidence was not discussed individually.

Nursing Implications:

These guidelines provided an evidence-based evaluation of various integrative therapies in women with breast cancer. This set of interventions is not all-inclusive; however, it does provide some guidance to clinicians and others regarding evidence strength in these areas as assessed by this specific study group.

Research Evidence Summaries

Zhou, K., Li, X., Li, J., Liu, M., Dang, S., Wang, D., & Xin, X. (2015). A clinical randomized controlled trial of music therapy and progressive muscle relaxation training in female breast cancer patients after radical mastectomy: Results on depression, anxiety and length of hospital stay. European Journal of Oncology Nursing, 19, 54–59. 

doi: 10.1016/j.ejon.2014.07.010
Print

Study Purpose:

To examine effects of music therapy and progressive muscle relaxation (PMR) training on depression and anxiety in Chinese patients with breast cancer 

Intervention Characteristics/Basic Study Process:

Patients randomly were assigned to the intervention group (which received the music and PMR intervention) or a usual care group after a radical mastectomy. To avoid contamination, intervention and control patients were placed in different inpatient areas. Music therapy involved listening to music via headphones connected to an MP3 player for 30 minutes twice per day. This began within 48 hours after surgery. Patients selected their preferred music. PMR training was conducted on the second postoperative day. Training was conducted twice per day for 30 minutes until discharge. Patients were encouraged to do PMR and music listening exercises together. Patients in the control group received the usual postoperative nursing care only. Study measures were obtained the day before surgery and the day before hospital discharge. Data collectors were blinded to group assignment.

Sample Characteristics:

  • N = 170  
  • MEAN AGE = 47.01 years (SD = 9.5 years)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Most had modified radical mastectomy and 89% had chemotherapy immediately after surgery

Setting:

  • SITE: Single-site    
  • SETTING TYPE: Inpatient    
  • LOCATION: China

Phase of Care and Clinical Applications:

  • PHASE OF CARE: Active antitumor treatment

Study Design:

Randomized, controlled, single-blinded trial

Measurement Instruments/Methods:

  • Zung Self-Rating Depression Scale (SDS)
  • State-Trait Anxiety Inventory (STAI)

Results:

Analysis showed that there was a significant reduction in anxiety and depression over time alone (p < .001) as well as by group (p < .001), and there was a significant interaction between group and time (p = .0009). Depression scores declined an average of 7.2 points in the intervention group and 4.6 points in the control group. Anxiety scores declined an average of 16 points in the intervention group and 11 points in the control group. Hospital stay time was significantly lower in the intervention group (p < .001). Hospital stay length was shorter in the intervention group.

Conclusions:

The findings of this study suggest that the combination of PMR and listening to music was helpful in reducing anxiety and depression in women after mastectomies.

Limitations:

  • Risk of bias (no blinding)
  • Risk of bias (no appropriate attentional control condition)
  • Unintended interventions or applicable interventions not described that would influence results
  • Findings not generalizable
  • Other limitations/explanation: No information was provided regarding other potential confounders such as postoperative complications, pain levels, etc. that could influence reported outcomes. Data collection was conducted via face-to-face interview, and although it was stated that data collectors were blinded, it is not clear where the data collection took place. If it took place in the hospital, data collectors could deduce group assignment because of the different locations in the hospital. This study was of Chinese women, so applicability to other groups is not known. It is not clear in the report whether all sessions of the intervention were guided by the investigators or done by the patients on their own. It is not clear how, if supervised by investigators, the patient could listen to the PMR training if they also were listening to music via headphones.

Nursing Implications:

Listening to music and using progressive muscle relaxation may have a positive impact on anxiety and depression in patients postoperatively. These are low-risk, low-cost interventions that may be beneficial. The findings of this study showed that those who had the intervention also had shorter hospital stays. There is insufficient evidence to determine the real impact of this intervention on duration of hospitalization; however, these findings suggest that this area deserves further exploration.

Zhou, K.N., Li, X.M., Yan, H., Dang, S.N., & Wang, D.L. (2011). Effects of music therapy on depression and duration of hospital stay of breast cancer patients after radical mastectomy. Chinese Medical Journal, 124(15), 2321–2327.

Print

Study Purpose:

To study the effects of music therapy on depression in female patients with breast cancer after radical mastectomy; to study how music therapy affects duration of hospital stay  

Intervention Characteristics/Basic Study Process:

Subjects were randomly assigned to a music or usual-care group (control). Investigators collected data on the day before radical mastectomy (pretest), the day before hospital discharge (first post-test), and at the second and third hospital admissions for chemotherapy (second and third post-tests). Different chemo intervals meant that the second and third post-tests were between 14 and 28 days; the mean time was 18.6 days (SD = 7.4 days). Total intervention time involved the hospital stay after radical mastectomy (mean 13.6 days [SD = 2 days]) and the two chemotherapy periods (the mean time of each period was 8.9 days (SD = 7.1 days). The experimental group received an introduction to music, and participants selected preferred music. Each participant listened to his or her choice of music through headphones connected to an MP3 player. Participants listened to music twice a day, 30 minutes each time. Investigators did not offer music to the control group.

Sample Characteristics:

  • The sample was composed of 120 participants, 60 in each group.
  • The age range of participants was 25–65 years.
  • All the participants were female.
  • All the participants had breast cancer that required radical mastectomy.
     

Setting:

  • Single site
  • Medical college
  • Xi’an, Shaanxi, China
     

Phase of Care and Clinical Applications:

  • Phase of care: active treatment
  • Clinical applications: late effects and survivorship
     

Study Design:

Randomized controlled trial with repeated measures

Measurement Instruments/Methods:

  • Chinese version of the Zung Self-Rating Depression Scale (ZSDS)   
  • General questionnaire, for the collection of demographic data

Results:

  • Investigators retrieved 450 validated questionnaires. The rate lost to follow-up was 12.5%.
  • Clinical data and demographic data about age, education, income, marital status, and quality of spousal relationship revealed no significant baseline differences between the two groups (P > 0.05).
  • Before radical mastectomy, the mean depression score of all participants was 37.19 (SD = 6.30); 36 participants (30%) suffered from depression symptoms. At baseline, data revealed no statistical difference in depression between groups. Post-test depression scores did demonstrate significant differences between the two groups (F = 39.13, P < 0.001; F = 82.09, P < 0.001).
  • The depression scores of both groups trended downward during follow-up periods, but the score curve of the experimental group was lower than that of the control group (p < 0.001).
  • Postradical mastectomy, the mean duration of hospitalization, experimental group, was 13.62 days (SD = 2.04 days); mean duration of hospitalization, control group, was 15.53 days (SD = 2.75 days). This difference was significant (P < 0.001).

Conclusions:

Postmastectomy, depression scores of the experimental group were lower than those of the control group, and duration of hospital stay was shorter for patients receiving music therapy. However, lack of data regarding actual use of music therapy by patients and lack of information regarding patients’ health status and other types of treatment preclude recommendation of music therapy without further study.

Limitations:

  • Data were self-reported.
  • Double-blind methodology was not used because of the specificity of the intervention.
  • Investigation was from a quantitative aspect only; subjective experiences were not studied.
  • Subjects with extensive radical mastectomy played a small part in this trial.
  • The percentage lost to follow-up was high. 
  • The study had a potential testing effect as a result of repeated measurement.

Nursing Implications:

When caring for patients with breast cancer who are suffering from mood disturbance, nurses should select interventions whose evidence of mood-disturbance reduction is greater than the evidence of effect that listening to music presents. However, listening to music is a low-risk, low-cost intervention that might be helpful to some patients.

Menu