research paper on music therapy

REVIEW article

The state of music therapy studies in the past 20 years: a bibliometric analysis.

• 1 School of Kinesiology, Shanghai University of Sport, Shanghai, China
• 2 Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China
• 3 Department of Sport Rehabilitation Medicine, Shanghai Shangti Orthopedic Hospital, Shanghai, China

Purpose: Music therapy is increasingly being used to address physical, emotional, cognitive, and social needs of individuals. However, publications on the global trends of music therapy using bibliometric analysis are rare. The study aimed to use the CiteSpace software to provide global scientific research about music therapy from 2000 to 2019.

Methods: Publications between 2000 and 2019 related to music therapy were searched from the Web of Science (WoS) database. The CiteSpace V software was used to perform co-citation analysis about authors, and visualize the collaborations between countries or regions into a network map. Linear regression was applied to analyze the overall publication trend.

Results: In this study, a total of 1,004 studies met the inclusion criteria. These works were written by 2,531 authors from 1,219 institutions. The results revealed that music therapy publications had significant growth over time because the linear regression results revealed that the percentages had a notable increase from 2000 to 2019 ( t = 14.621, P < 0.001). The United States had the largest number of published studies (362 publications), along with the following outputs: citations on WoS (5,752), citations per study (15.89), and a high H-index value (37). The three keywords “efficacy,” “health,” and “older adults,” emphasized the research trends in terms of the strongest citation bursts.

Conclusions: The overall trend in music therapy is positive. The findings provide useful information for music therapy researchers to identify new directions related to collaborators, popular issues, and research frontiers. The development prospects of music therapy could be expected, and future scholars could pay attention to the clinical significance of music therapy to improve the quality of life of people.

Introduction

Music therapy is defined as the evidence-based use of music interventions to achieve the goals of clients with the help of music therapists who have completed a music therapy program ( Association, 2018 ). In the United States, music therapists must complete 1,200 h of clinical training and pass the certification exam by the Certification Board for Music Therapists ( Devlin et al., 2019 ). Music therapists use evidence-based music interventions to address the mental, physical, or emotional needs of an individual ( Gooding and Langston, 2019 ). Also, music therapy is used as a solo standard treatment, as well as co-treatment with other disciplines, to address the needs in cognition, language, social integration, and psychological health and family support of an individual ( Bronson et al., 2018 ). Additionally, music therapy has been used to improve various diseases in different research areas, such as rehabilitation, public health, clinical care, and psychology ( Devlin et al., 2019 ). With neurorehabilitation, music therapy has been applied to increase motor activities in people with Parkinson's disease and other movement disorders ( Bernatzky et al., 2004 ; Devlin et al., 2019 ). However, limited reviews about music therapy have utilized universal data and conducted massive retrospective studies using bibliometric techniques. Thus, this study demonstrates music therapy with a broad view and an in-depth analysis of the knowledge structure using bibliometric analysis of articles and publications.

Bibliometrics turns the major quantitative analytical tool that is used in conducting in-depth analyses of publications ( Durieux and Gevenois, 2010 ; Gonzalez-Serrano et al., 2020 ). There are three types of bibliometric indices: (a) the quantity index is used to determine the number of relevant publications, (b) the quality index is employed to explore the characteristics of a scientific topic in terms of citations, and (c) the structural index is used to show the relationships among publications ( Durieux and Gevenois, 2010 ; Gonzalez-Serrano et al., 2020 ). In this study, the three types of bibliometric indices will be applied to conduct an in-depth analysis of publications in this frontier.

While research about music therapy is extensively available worldwide, relatively limited studies use bibliometric methods to analyze the global research about this topic. The aim of this study is to use the CiteSpace software to perform a bibliometric analysis of music therapy research from 2000 to 2019. CiteSpace V is visual analytic software, which is often utilized to perform bibliometric analyses ( Falagas et al., 2008 ; Ellegaard and Wallin, 2015 ). It is also a tool applied to detect trends in global scientific research. In this study, the global music therapy research includes publication outputs, distribution and collaborations between authors/countries or regions/institutions, intense issues, hot articles, common keywords, productive authors, and connections among such authors in the field. This study also provides helpful information for researchers in their endeavor to identify gaps in the existing literature.

Materials and Methods

Search strategy.

The data used in this study were obtained from WoS, the most trusted international citation database in the world. This database, which is run by Thomson & Reuters Corporation ( Falagas et al., 2008 ; Durieux and Gevenois, 2010 ; Chen C. et al., 2012 ; Ellegaard and Wallin, 2015 ; Miao et al., 2017 ; Gonzalez-Serrano et al., 2020 ), provides high-quality journals and detailed information about publications worldwide. In this study, publications were searched from the WoS Core Collection database, which included eight indices ( Gonzalez-Serrano et al., 2020 ). This study searched the publications from two indices, namely, the Science Citation Index Expanded and the Social Sciences Citation Index. As the most updated publications about music therapy were published in the 21st century, publications from 2000 to 2019 were chosen for this study. We performed data acquisition on July 26, 2020 using the following search terms: title = (“music therapy”) and time span = 2000–2019.

Inclusion Criteria

Figure 1 presents the inclusion criteria. The title field was music therapy (TI = music therapy), and only reviews and articles were chosen as document types in the advanced search. Other document types, such as letters, editorial materials, and book reviews, were excluded. Furthermore, there were no species limitations set. This advanced search process returned 718 articles. In the end, a total of 1,004 publications were obtained and were analyzed to obtain comprehensive perspectives on the data.

Figure 1 . Flow chart of music therapy articles and reviews inclusion.

Data Extraction

Author Lin-Man Weng extracted the publications and applied the EndNote software and Microsoft Excel 2016 to conduct analysis on the downloaded publications from the WoS database. Additionally, we extracted and recorded some information of the publications, such as citation frequency, institutions, authors' countries or regions, and journals as bibliometric indicators. The H-index is utilized as a measurement of the citation frequency of the studies for academic journals or researchers ( Wang et al., 2019 ).

Analysis Methods

The objective of bibliometrics can be described as the performance of studies that contributes to advancing the knowledge domain through inferences and explanations of relevant analyses ( Castanha and Grácio, 2014 ; Merigó et al., 2019 ; Mulet-Forteza et al., 2021 ). CiteSpace V is a bibliometric software that generates information for better visualization of data. In this study, the CiteSpace V software was used to visualize six science maps about music therapy research from 2000 to 2019: the network of author co-citation, collaboration network among countries and regions, relationship of institutions interested in the field, network map of co-citation journals, network map of co-cited references, and the map (timeline view) of references with co-citation on top music therapy research. As noted, a co-citation is produced when two publications receive a citation from the same third study ( Small, 1973 ; Merigó et al., 2019 ).

In addition, a science map typically features a set of points and lines to present collaborations among publications ( Chen, 2006 ). A point is used to represent a country or region, author, institution, journal, reference, or keyword, whereas a line represents connections among them ( Zheng and Wang, 2019 ), with stronger connections indicated by wider lines. Furthermore, the science map includes nodes, which represent the citation frequencies of certain themes. A burst node in the form of a red circle in the center indicates the number of co-occurrence or citation that increases over time. A purple node represents centrality, which indicates the significant knowledge presented by the data ( Chen, 2006 ; Chen H. et al., 2012 ; Zheng and Wang, 2019 ). The science map represents the keywords and references with citation bursts. Occurrence bursts represent the frequency of a theme ( Chen, 2006 ), whereas citation bursts represent the frequency of the reference. The citation bursts of keywords and references explore the trends and indicate whether the relevant authors have gained considerable attention in the field ( Chen, 2006 ). Through this kind of map, scholars can better understand emerging trends and grasp the hot topics by burst detection analysis ( Liang et al., 2017 ; Miao et al., 2017 ).

Publication Outputs and Time Trends

A total of 1,004 articles and reviews related to music therapy research met the criteria. The details of annual publications are presented in Figure 2 . As can be seen, there were <30 annual publications between 2000 and 2006. The number of publications increased steadily between 2007 and 2015. It was 2015, which marked the first time over 80 articles or reviews were published. The significant increase in publications between 2018 and 2019 indicated that a growing number of researchers became interested in this field. Linear regression can be used to analyze the trends in publication outputs. In this study, the linear regression results revealed that the percentages had a notable increase from 2000 to 2019 ( t = 14.621, P < 0.001). Moreover, the P < 0.05, indicating statistical significance. Overall, the publication outputs increased from 2000 to 2019.

Figure 2 . Annual publication outputs of music therapy from 2000 to 2019.

Distribution by Country or Region and Institution

The 1,004 articles and reviews collected were published in 49 countries and regions. Table 1 presents the top 10 countries or regions. Figure 3 shows an intuitive comparison of the citations on WoS, citations per study, Hirsch index (H-index), and major essential science indicator (ESI) studies of the top five countries or regions. The H-index is a kind of index that is applied in measuring the wide impact of the scientific achievements of authors. The United States had the largest number of published studies (362 publications), along with the following outputs: citations on WoS (5,752), citations per study (15.89), and a high H-index value (37). Norway has the largest number of citations per study (27.18 citations). Figure 4 presents the collaboration networks among countries or regions. The collaboration network map contained 32 nodes and 38 links. The largest node can be found in the United States, which meant that the United States had the largest number of publications in the field. Meanwhile, the deepest purple circle was located in Austria, which meant that Austria is the country with the most number of collaborations with other countries or regions in this research field. A total of 1,219 institutions contributed various music therapy-related publications. Figure 5 presents the collaborations among institutions. As can be seen, the University of Melbourne is the most productive institution in terms of the number of publications (45), followed by the University of Minnesota (43), and the University of Bergen (39). The top 10 institutions featured in Table 2 contributed 28.884% of the total articles and reviews published. Among these, Aalborg University had the largest centrality (0.13). The top 10 productive institutions with details are shown in Table 2 .

Table 1 . Top 10 countries or regions of origin of study in the music therapy research field.

Figure 3 . Publications, citations on WoS (×0.01), citations per study, H-index, and ESL top study among top five countries or regions.

Figure 4 . The collaborations of countries or regions interested in the field. In this map, the node represents a country, and the link represents the cooperation relationship between two countries. A larger node represents more publications in the country. A thicker purple circle represents greater influence in this field.

Figure 5 . The relationship of institutions interested in the field. University of Melbourne, Florida State University, University of Minnesota, Aalborg University, Temple University, University of Queensland, and University of Bergen. In this map, the node represents an institution, and the link represents the cooperation relationship between two institutions. A larger node represents more publications in the institution. A thicker purple circle represents greater influence in this field.

Table 2 . Top 10 institutions that contributed to publications in the music therapy field.

Distribution by Journals

Table 3 presents the top 10 journals that published articles or reviews in the music therapy field. The publications are mostly published in these journal fields, such as Therapy, Medical, Psychology, Neuroscience, Health and Clinical Care. The impact factors (IF) of these journals ranged between 0.913 and 7.89 (average IF: 2.568). Four journals had an impact factor >2, of which Cochrane Database of Systematic Reviews had the highest IF, 2019 = 7.89. In addition, the Journal of Music Therapy (IF: 2019 = 1.206) published 177 articles or reviews (17.629%) about music therapy in the past two decades, followed by the Nordic Journal of Music Therapy (121 publications, 12.052%, IF: 2019 = 0.913), and Arts in Psychotherapy (104 publications, 10.359%, IF: 2019 = 1.322). Furthermore, the map of the co-citation journal contained 393 nodes and 759 links ( Figure 6 ). The high co-citation count identifies the journals with the greatest academic influence and key positions in the field. The Journal of Music Therapy had the maximum co-citation counts (658), followed by Cochrane Database of Systematic Reviews (281), and Arts in Psychotherapy (279). Therefore, according to the analysis of the publications and co-citation counts, the Journal of Music Therapy and Arts in Psychotherapy occupied key positions in this research field.

Table 3 . Top 10 journals that published articles in the music therapy field.

Figure 6 . Network map of co-citation journals engaged in music therapy from 2000 to 2019. Journal of Music Therapy, Arts in Psychotherapy, Nordic Journal of Music Therapy, Music Therapy Perspectives, Cochrane Database of Systematic Reviews. In this map, the node represents a journal, and the link represents the co-citation frequency between two journals. A larger node represents more publications in the journal. A thicker purple circle represents greater influence in this field.

Distribution by Authors

A total of 2,531 authors contributed to the research outputs related to music therapy. Author Silverman MJ published most of the studies (46) in terms of number of publications, followed by Gold C (41), Magee WL (19), O'Callaghan C (15), and Raglio A (15). According to co-citation counts, Bruscia KE (171 citations) was the most co-cited author, followed by Gold C (147 citations), Wigram T (121 citations), and Bradt J (117 citations), as presented in Table 4 . In Figure 7 , these nodes highlight the co-citation networks of the authors. The large-sized node represented author Bruscia KE, indicating that this author owned the most co-citations. Furthermore, the linear regression results revealed a remarkable increase in the percentages of multiple articles of authors ( t = 13.089, P < 0.001). These also indicated that cooperation among authors had increased remarkably, which can be considered an important development in music therapy research.

Table 4 . Top five authors of publications and top five authors of co-citation counts.

Figure 7 . The network of author co-citaion. In this map, the node represents an author, and the link represents the co-citation frequency between two authors. A larger node represents more publications of the author. A thicker purple circle represents greater influence in this field.

Analysis of Keywords

The results of keywords analysis indicated research hotspots and help scholars identify future research topics. Table 5 highlights 20 keywords with the most frequencies, such as “music therapy,” “anxiety,” “intervention,” “children,” and “depression.” The keyword “autism” has the highest centrality (0.42). Figure 8 shows the top 17 keywords with the strongest citation bursts. By the end of 2019, keyword bursts were led by “hospice,” which had the strongest burst (3.5071), followed by “efficacy” (3.1161), “health” (6.2109), and “older adult” (4.476).

Table 5 . Top 20 keywords with the most frequency and centrality in music therapy study.

Figure 8 . The strongest citation bursts of the top 17 keywords. The red measures indicate frequent citation of keywords, and the green measures indicate infrequent citation of keywords.

Analysis of Co-cited References

The analysis of co-cited references is a significant indicator in the bibliometric method ( Chen, 2006 ). The top five co-cited references and their main findings are listed in Table 6 . These are regarded as fundamental studies for the music therapy knowledge base. In terms of co-citation counts, “individual music therapy for depression: randomized controlled trial” was the key reference because it had the most co-citation counts. This study concludes that music therapy mixed with standard care is an effective way to treat working-age people with depression. The authors also explained that music therapy is a valuable enhancement to established treatment practices ( Erkkilä et al., 2011 ). Meanwhile, the strongest citation burst of reference is regarded as the main knowledge of the trend ( Fitzpatrick, 2005 ). Figure 9 highlights the top 71 strongest citation bursts of references from 2000 to 2019. As can be seen, by the end of 2019, the reference burst was led by author Stige B, and the strongest burst was 4.3462.

Table 6 . Top five co-cited references with co-citation counts in the study of music therapy from 2000 to 2019.

Figure 9 . The strongest citation bursts among the top 71 references. The red measures indicate frequent citation of studies, and the green measures indicate infrequent citation of studies.

Figure 10A presents the co-cited reference map containing 577 nodes and 1,331 links. The figure explains the empirical relevance of a considerable number of articles and reviews. Figure 10B presents the co-citation map (timeline view) of reference from publications on top music therapy research. The timeline view of clusters shows the research progress of music therapy in a particular period of time and the thematic concentration of each cluster. “Psychosis” was labeled as the largest cluster (#0), followed by “improvisational music therapy” (#1) and “paranesthesia anxiety” (#2). These clusters have also remained hot topics in recent years. Furthermore, the result of the modularity Q score was 0.8258. That this value exceeded 0.5 indicated that the definitions of the subdomain and characters of clusters were distinct. In addition, the mean silhouette was 0.5802, which also exceeded 0.5. The high homogeneity of individual clusters indicated high concentration in different research areas.

Figure 10. (A) The network map of co-cited references and (B) the map (timeline view) of references with co-citation on top music therapy research. In these maps, the node represents a study, and the link represents the co-citation frequency between two studies. A larger node represents more publications of the author. A thicker purple circle represents greater influence in this field. (A) The nodes in the same color belong to the same cluster. (B) The nodes on the same line belong to the same cluster.

Global Trends in Music Therapy Research

This study conducted a bibliometric analysis of music therapy research from the past two decades. The results, which reveal that music therapy studies have been conducted throughout the world, among others, can provide further research suggestions to scholars. In terms of the general analysis of the publications, the features of published articles and reviews, prolific countries or regions, and productive institutions are summarized below.

I. The distribution of publication year has been increasing in the past two decades. The annual publication outputs of music therapy from 2000 to 2019 were divided into three stages: beginning, second, and third. In the beginning stage, there were <30 annual publications from 2000 to 2006. The second stage was between 2007 and 2014. The number of publications increased steadily. It was 2007, which marked the first time 40 articles or reviews were published. The third stage was between 2015 and 2019. The year 2015 was the key turning point because it was the first time 80 articles or reviews were published. The number of publications showed a downward trend in 2016 (72), but it was still higher than the average number of the previous years. Overall, music therapy-related research has received increasing attention among scholars from 2000 to 2020.

II. The articles and reviews covered about 49 countries or regions, and the prolific countries or regions were mainly located in the North American and European continents. According to citations on WoS, citations per study, and the H-index, music therapy publications from developed countries, such as United States and Norway, have greater influence than those from other countries. In addition, China, as a model of a developing country, had published 53 studies and ranked top six among productive countries.

III. In terms of the collaboration map of institutions, the most productive universities engaged in music therapy were located in the United States, namely, University of Minnesota (43 publications), Florida State University (33 publications), Temple University (27 publications), and University of Kansas (20 publications). It indicated that institutions in the US have significant impacts in this area.

IV. According to author co-citation counts, scholars can focus on the publications of such authors as Bruscia KE, Gold C, and Wigram T. These three authors come from the United States, Norway, and Denmark, and it also reflected that these three countries are leading the research trend. Author Bruscia KE has the largest co-citation counts and is based at Temple University. He published many music therapy studies about assessment and clinical evaluation in music therapy, music therapy theories, and therapist experiences. These publications laid a foundation and facilitate the development of music therapy. In addition, in Figure 11 , the multi-authored articles between 2000 and 2003 comprised 47.56% of the sample, whereas the publications of multi-authored articles increased significantly from 2016 to 2019 (85.51%). These indicated that cooperation is an effective factor in improving the quality of publications.

Figure 11 . The percentage of single- vs. multiple-authored articles. Blue bars mean multiple-author percentage; orange bars mean single-author percentage.

Research Focus on the Research Frontier and Hot Topics

According to the science map analysis, hot music therapy topics among publications are discussed.

I. The cluster “#1 improvisational music therapy” (IMT) is the current research frontier in the music therapy research field. In general, music therapy has a long research tradition within autism spectrum disorders (ASD), and there have been more rigorous studies about it in recent years. IMT for children with autism is described as a child-centered method. Improvisational music-making may enhance social interaction and expression of emotions among children with autism, such as responding to communication acts ( Geretsegger et al., 2012 , 2015 ). In addition, IMT is an evidence-based treatment approach that may be helpful for people who abuse drugs or have cancer. A study applied improving as a primary music therapeutic practice, and the result indicated that IMT will be effective in treating depression accompanied by drug abuse among adults ( Albornoz, 2011 ). By applying the interpretative phenomenological analysis and psychological perspectives, a study explained the significant role of music therapy as an innovative psychological intervention in cancer care settings ( Pothoulaki et al., 2012 ). IMT may serve as an effective additional method for treating psychiatric disorders in the short and medium term, but it may need more studies to identify the long-term effects in clinical practice.

II. Based on the analysis of co-citation counts, the top three references all applied music therapy to improve the quality of life of clients. They highlight the fact that music therapy is an effective method that can cover a range of clinical skills, thus helping people with psychological disorders, chronic illnesses, and pain management issues. Furthermore, music therapy mixed with standard care can help individuals with schizophrenia improve their global state, mental state (including negative and general symptoms), social functioning, and quality of life ( Gold et al., 2009 ; Erkkilä et al., 2011 ; Geretsegger et al., 2017 ).

III. By understanding the keywords with the strongest citation bursts, the research frontier can be predicted. Three keywords, “efficacy,” “health,” and “older adults,” emphasized the research trends in terms of the strongest citation bursts.

a. Efficacy: This refers to measuring the effectiveness of music therapy in terms of clinical skills. Studies have found that a wide variety of psychological disorders can be effectively treated with music. In the study of Fukui, patients with Alzheimer's disease listened to music and verbally communicated with their music therapist. The results showed that problematic behaviors of the patients with Alzheimer's disease decreased ( Fukui et al., 2012 ). The aim of the study of Erkkila was to determine the efficacy of music therapy when added to standard care. The result of this study also indicated that music therapy had specific qualities for non-verbal expression and communication when patients cannot verbally describe their inner experiences ( Erkkilä et al., 2011 ). Additionally, as summarized by Ueda, music therapy reduced anxiety and depression in patients with dementia. However, his study cannot clarify what kinds of music therapy or patients have effectiveness. Thus, future studies should investigate music therapy with good methodology and evaluation methods ( Ueda et al., 2013 ).

b. Health: Music therapy is a methodical intervention in clinical practice because it uses music experiences and relationships to promote health for adults and children ( Bruscia, 1998 ). Also, music therapy is an effective means of achieving the optimal health and well-being of individuals and communities, because it can be individualized or done as a group activity. The stimulation from music therapy can lead to conversations, recollection of memories, and expression. The study of Gold indicated that solo music therapy in routine practice is an effective addition to usual care for mental health care patients with low motivation ( Gold et al., 2013 ). Porter summarized that music therapy contributes to improvement for both kids and teenagers with mental health conditions, such as depression and anxiety, and increases self-esteem in the short term ( Porter et al., 2017 ).

c. Older adults: This refers to the use of music therapy as a treatment to maintain and slow down the symptoms observed in older adults ( Mammarella et al., 2007 ; Deason et al., 2012 ). In terms of keywords with the strongest citation bursts, the most popular subjects of music therapy-related articles and reviews focused on children from 2005 to 2007. However, various researchers concentrated on older adults from 2017 to 2019. Music therapy was the treatment of choice for older adults with depression, Parkinson's disease, and Alzheimer's disorders ( Brotons and Koger, 2000 ; Bernatzky et al., 2004 ; Johnson et al., 2011 ; Deason et al., 2012 ; McDermott et al., 2013 ; Sakamoto et al., 2013 ; Benoit et al., 2014 ; Pohl et al., 2020 ). In the study of Zhao, music therapy had positive effects on the reduction of depressive symptoms for older adults when added to standard therapies. These standard therapies could be standard care, standard drug treatment, standard rehabilitation, and health education ( Zhao et al., 2016 ). The study of Shimizu demonstrated that multitask movement music therapy was an effective intervention to enhance neural activation in older adults with mild cognitive impairment ( Shimizu et al., 2018 ). However, the findings of the study of Li explained that short-term music therapy intervention cannot improve the cognitive function of older adults. He also recommended that future researchers can apply a quality methodology with a long-term research design for the care needs of older adults ( Li et al., 2015 ).

Strengths and Limitations

To the best of our knowledge, this study was the first one to analyze large-scale data of music therapy publications from the past two decades through CiteSpace V. CiteSpace could detect more comprehensive results than simply reviewing articles and studies. In addition, the bibliometric method helped us to identify the emerging trend and collaboration among authors, institutions, and countries or regions.

This study is not without limitations. First, only articles and reviews published in the WoS Science Citation Index Expanded and Social Sciences Citation Index were analyzed. Future reviews could consider other databases, such as PubMed and Scopus. The document type labeled by publishers is not always accurate. For example, some publications labeled by WoS were not actually reviews ( Harzing, 2013 ; Yeung, 2021 ). Second, the limitation may induce bias in frequency of reference. For example, some potential articles were published recently, and these studies could be not cited with frequent times. Also, in terms of obliteration by incorporation, some common knowledge or opinions become accepted that their contributors or authors are no longer cited ( Merton, 1965 ; Yeung, 2021 ). Third, this review applied the quantitative analysis approach, and only limited qualitative analysis was performed in this study. In addition, we applied the CitesSpace software to conduct this bibliometric study, but the CiteSpace software did not allow us to complicate information under both full counting and fractional counting systems. Thus, future scholars can analyze the development of music therapy in some specific journals using both quantitative and qualitative indicators.

Conclusions

This bibliometric study provides information regarding emerging trends in music therapy publications from 2000 to 2019. First, this study presents several theoretical implications related to publications that may assist future researchers to advance their research field. The results reveal that annual publications in music therapy research have significantly increased in the last two decades, and the overall trend in publications increased from 28 publications in 2000 to 111 publications in 2019. This analysis also furthers the comprehensive understanding of the global research structure in the field. Also, we have stated a high level of collaboration between different countries or regions and authors in the music therapy research. This collaboration has extremely expanded the knowledge of music therapy. Thus, future music therapy professionals can benefit from the most specialized research.

Second, this research represents several practical implications. IMT is the current research frontier in the field. IMT usually serves as an effective music therapy method for the health of people in clinical practice. Identifying the emerging trends in this field will help researchers prepare their studies on recent research issues ( Mulet-Forteza et al., 2021 ). Likewise, it also indicates future studies to address these issues and update the existing literature. In terms of the strongest citation bursts, the three keywords, “efficacy,” “health,” and “older adults,” highlight the fact that music therapy is an effective invention, and it can benefit the health of people. The development prospects of music therapy could be expected, and future scholars could pay attention to the clinical significance of music therapy to the health of people.

Finally, multiple researchers have indicated several health benefits of music therapy, and the music therapy mechanism perspective is necessary for future research to advance the field. Also, music therapy can benefit a wide range of individuals, such as those with autism spectrum, traumatic brain injury, or some physical disorders. Future researchers can develop music therapy standards to measure clinical practice.

Author Contributions

KL and LW: conceptualization, methodology, formal analysis, investigation, resources, writing—review, and editing. LW: software and data curation. KL: validation and writing—original draft preparation. XW: visualization, supervision, project administration, and funding acquisition. All authors contributed to the article and approved the submitted version.

This study was supported by the Fok Ying-Tong Education Foundation of China (161092), the scientific and technological research program of the Shanghai Science and Technology Committee (19080503100), and the Shanghai Key Lab of Human Performance (Shanghai University of Sport) (11DZ2261100).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Abbreviations

WoS, Web of Science; ESI, essential science indicators; IF, impact factor; IMT, improvisational music therapy; ASD, autism spectrum disorder.

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Keywords: music therapy, aged, bibliometrics, health, web of science

Citation: Li K, Weng L and Wang X (2021) The State of Music Therapy Studies in the Past 20 Years: A Bibliometric Analysis. Front. Psychol. 12:697726. doi: 10.3389/fpsyg.2021.697726

Received: 20 April 2021; Accepted: 12 May 2021; Published: 10 June 2021.

Reviewed by:

Copyright © 2021 Li, Weng and Wang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Xueqiang Wang, wangxueqiang@sus.edu.cn

† These authors have contributed equally to this work and share first authorship

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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

Affiliations.

• 1 Research Institute of Child Development and Education, University of Amsterdam, Amsterdam, Netherlands.
• 2 HAN University of Applied Sciences, Nijmegen, Netherlands.
• 3 Stevig, Expert Centre for People with Mild Intellectual Disabilities, Gennep, Netherlands.
• 4 KenVaK, Research Centre for the Arts Therapies, Heerlen, Netherlands.
• 5 Department of Psychology, University of Amsterdam, Amsterdam, Netherlands.
• 6 Faculty of Healthcare, Zuyd University of Applied Sciences, Heerlen, Netherlands.
• 7 Faculty of Psychology, Open University, Heerlen, Netherlands.
• PMID: 33176590
• DOI: 10.1080/17437199.2020.1846580

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.

Keywords: Music therapy; arousal; multilevel meta-analysis; music intervention; state anxiety; stress.

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• 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.

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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

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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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The effect of music therapy on cognitive functions in patients with Alzheimer’s disease: a systematic review of randomized controlled trials

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• Ali El Cheikh 2 ,
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The use of music interventions as a non-pharmacological therapy to improve cognitive and behavioral symptoms in Alzheimer’s disease (AD) patients has gained popularity in recent years, but the evidence for their effectiveness remains inconsistent.

To summarize the evidence of the effect of music therapy (alone or in combination with pharmacological therapies) on cognitive functions in AD patients compared to those without the intervention.

A systematic literature search was performed in PubMed, Cochrane library, and HINARI for papers published from 1 January 2012 to 25 June 2022. All randomized controlled trials that compared music therapy with standard care or other non-musical intervention and evaluation of cognitive functions are included. Cognitive outcomes included: global cognition, memory, language, speed of information processing, verbal fluency, and attention. Quality assessment and narrative synthesis of the studies were performed.

A total of 8 studies out of 144 met the inclusion criteria (689 participants, mean age range 60.47–87.1). Of the total studies, 4 were conducted in Europe (2 in France, 2 in Spain), 3 in Asia (2 in China, 1 in Japan), and 1 in the USA. Quality assessment of the retrieved studies revealed that 6 out of 8 studies were of high quality. The results showed that compared to different control groups, there is an improvement in cognitive functions after music therapy application. A greater effect was shown when patients are involved in the music making when using active music intervention (AMI).

The results of this review highlight the potential benefits of music therapy as a complementary treatment option for individuals with AD and the importance of continued investigation in this field. More research is needed to fully understand the effects of music therapy, to determine the optimal intervention strategy, and to assess the long-term effects of music therapy on cognitive functions.

Introduction

Alzheimer’s disease (AD) is a progressive, incurable neurological illness that is the most common cause of dementia, affecting an estimated 5% of men and 6% of women over the age of 60 worldwide [ 1 ]. The prevalence of AD increases exponentially with age, with 1% of those aged 60 to 64 years old and 24% to 33% of those aged 85 years or older affected [ 2 ]. As the global population ages, it is anticipated that the number of individuals with Alzheimer’s disease will increase.

Neuropsychiatric symptoms, such as apathy, depression, and agitation, are commonly observed in individuals with AD, in addition to the more well-known cognitive symptoms such as memory loss, visuospatial problems, and difficulties with executive functions [ 3 , 4 ]. These symptoms can cause a significant burden to patients, caregivers, and society as a whole [ 5 ]. While pharmacological therapies have been used to manage these symptoms, they have not always been effective in achieving long-term clinical efficacy [ 6 ]. As a result, non-pharmacological interventions have gained increasing attention as a complementary treatment option for managing neuropsychiatric symptoms in AD. Such therapies include cognitive training and music therapy which have been used for decades to improve symptoms of dementia [ 7 ].

Music Therapy is the use of music to address the physical, emotional, cognitive, and social needs of individuals [ 8 ]. The American Music Therapy Association describes music therapy as the use of music interventions in a clinical and evidence-based manner to achieve specific goals, which are tailored to the individual, by a professional who is credentialed and has completed an approved music therapy program [ 8 ]. Music therapy incorporates a crucial aspect of the interaction between the client and therapist through an evidence-based model [ 9 ]. It can include both active techniques, such as improvisation, singing, clapping, or dancing, and receptive techniques, where the client listens to music with the intention of identifying its emotional content [ 9 ]. In music listening approaches, the therapist creates a personalized playlist for the client, which can either be an individualized program or chosen by the therapist [ 9 , 10 ]. Generalized music interventions use music without a therapist present, with the goal of enhancing the patient’s well-being, and can include both active and music listening protocols. Music listening is used to stimulate memories, verbalization, or encourage relaxation [ 9 ].

For many years, music therapy has been used to help manage symptoms of dementia [ 9 , 11 ]. Music therapy can improve mood, cognitive functions, memory, and provide a sense of connection and socialization for patients who may be isolated [ 12 , 13 ]. Studies have found that musical training may help mitigate the effects of age-related cognitive impairments, and the capacity of persons to remember music makes it a good stimulus that engages AD patients [ 7 , 14 , 15 ]. After listening to music, AD patients showed improvement in categorical word fluency [ 16 ], autobiographical memory [ 17 , 18 ], and the memory of the lyrics [ 15 ]. Additionally, it can provide an opportunity for caregivers to participate in therapy sessions, which can improve the overall caregiving experience by giving them the opportunity for self-expression allowing them to depict their thoughts and emotions [ 19 ].

The specific mechanisms by which music therapy is beneficial are not fully understood. In 2003, research indicates that music may activate neural networks that remain intact in individuals with AD [ 20 ]. A recent study by Jacobsen et al. [ 21 ] used 7 T functional magnetic resonance imaging to examine the brain’s response to music and identify regions involved in encoding long-term musical memory. When these regions were evaluated for Alzheimer’s biomarkers, such as amyloid accumulation, hypometabolism, and cortical atrophy, the results showed that, although amyloid disposition was not significantly lower in the AD group compared to the control group, there was a substantial reduction in cortical atrophy and glucose metabolism disruption in AD patients [ 21 ]. These findings suggest that musical memory regions are largely spared and well-preserved in AD, which could help explain why music therapy is so effective in retrieving verbal and musical memories in individuals with the disease [ 21 ].

One experimental paradigm used to study the effects of music therapy in AD is the use of live music performances, in which a music therapist plays live music for individuals with the disease in a group setting [ 22 ]. Another paradigm is the use of individualized music, in which a music therapist creates a playlist of personalized music for an individual with the disease to listen to at home [ 23 ]. Both paradigms have been shown to be effective in improving mood and reducing agitation in individuals with AD [ 22 , 23 ].

The advantages of music therapy for AD patients include its non-invasive nature and lack of side effects, its ability to address multiple symptoms at once, and its cost-effectiveness and ease of implementation [ 9 , 18 , 24 , 25 ]. However, there are also some limitations to its application. Music therapy may not be suitable for patients with severe dementia [ 26 ] as their cognitive and physical abilities may be too impaired to fully participate in therapy sessions. Additionally, it requires trained therapists [ 8 , 9 ], who may not be easily accessible in some areas. In this review, we aimed to summarize the evidence of the effect of music therapy (alone or in combination with pharmacological therapies) on cognitive functions in AD patients compared to those without the intervention.

This systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA 2009) guidelines [ 27 ]. The protocol of this study was registered in PROSPERO. A statement of ethics was not required.

We used the PICO framework (population, intervention, comparator, and outcome) as follows:

P: Alzheimer patients

I: Music therapy (alone or in combination with pharmacological therapies)

C: Alzheimer patients with and without the intervention

O: Cognitive functions

Search strategy and databases

A systematic literature search of PubMed, Cochrane, and HINARI was performed for studies published in peer-reviewed journals from 1 January 2012 up to 25 June 2022. The databases were searched using the keywords of “Alzheimer’s Disease,” “AD,” “music therapy,” “music intervention,” “cognitive functions,” and “cognition.” Keywords were combined using the Boolean operators “OR” and “AND.”

Study selection and eligibility criteria

All randomized controlled trials (RCTs) published between 2012 and 2022 in the English language and providing quantitative measures of the association between AD and music therapy and its effect on cognitive functions were included in our review. Studies that assess the effect of music therapy on patients with a probable diagnosis of AD or studies where the music therapy was combined with another non-pharmacological therapy are excluded.

Data extraction

Search and identification of eligibility according to inclusion criteria and extraction of data were performed by the two reviewers MB and AC. For each paper, detailed information was collected on: study information (author’s name, publication year, and location), sample characteristics (sample size, age, and gender), study design, intervention details (description, duration) the control group, and the cognitive outcome measures.

Methodological quality assessment

A methodological quality assessment of all included studies was performed by two independent reviewers (MB and AC) using the Jadad scale for RCTs [ 28 ]. Although not used as a criterion for study inclusion or exclusion. Jadad scale is developed to assess randomized controlled trials on the bases of 3 essential items: (1) randomization, 1 point if randomization is mentioned 1 additional point if the method of randomization is appropriate and deduct 1 point if the method of randomization is inappropriate,(2) blinding 1 point if blinding is mentioned, 1 additional point if the method of blinding is appropriate, deduct 1 point if the method of blinding is inappropriate; (3) an account of all patients, the fate of all patients in the trial is known. If there are no data, the reason is stated. It is commonly considered that a study is of “high quality” if it scores 3 points or more.

Study selection

The flowchart of the study selection process is presented in Fig.  1 . The literature search identified a total of 144 records. After the exclusion of duplicate records and non-relevant abstracts, 57 studies were retained. After reviewing the full text, 49 studies were excluded according to our inclusion and exclusion criteria. In the end, a total of 8 full-text studies were included in the qualitative synthesis.

PRISMA flow diagram of the selection procedure

Study characteristics

Characteristics of included studies are presented in Table 1 . The final sample was composed of 8 RCTs, 4 studies were conducted in Europe (2 in France, 2 in Spain), 3 studies in Asia (2 in China, 1 in Japan), and one in the USA. All these studies were published in the English language in peer-reviewed journals. Included trials showed a total of 689 participants (300 females, 43.54%). Sample sizes ranged from 39 [ 29 ] to 298 [ 30 ]. Mean ages ranged from 60.47 [ 31 ] to 87.1 [ 26 ]. Participants’ stages of AD dementia varied from mild to severe. Mean Mini-Mental State Examination (MMSE) [ 32 ] at baseline is assessed in 7 trials out of 8 and varied from 4.65 [ 29 ] to 25.07 [ 33 ].

Intervention characteristics

Music therapy approach.

Music therapy methods were heterogeneous across the included studies. In one study, the active music therapy approach used was singing with the played songs [ 33 ]. Two other studies used the receptive (passive) music therapy approach which consists in listening to music and songs played on a CD player [ 31 , 35 ]. The remaining five studies were based on a combination of both active and receptive music approaches [ 26 , 29 , 30 , 34 , 36 ].

Comparators

In four studies, music therapy intervention was compared to standard care [ 29 , 30 , 34 , 35 , 36 ], while in the four remaining studies, different interventions other than music therapy were used as comparators such as: watching nature videos [ 36 ], painting [ 33 ], cooking [ 26 ], and practicing meditation [ 31 ].

Application of the intervention

Only three trials were conducted by a music therapist [ 29 , 34 , 36 ], 1 trial was conducted by a professional choir conductor [ 33 ], 1 by musicians [ 30 ] and the 3 remaining trials were conducted with facilitators with no musical expertise [ 26 , 31 , 35 ].

Types of applied music

Seven trials out of 8 were based on individualized songs (chosen according to patient’s preferences or songs that are used to evoke positive emotions in them) [ 29 , 30 , 31 , 33 , 34 , 35 , 36 ]. The remaining trial was based on familiar songs chosen without considering the patient’s preferences [ 26 ].

Outcome characteristics

The included studies assessed different outcomes, but we focused on domains directly related to outcome inclusion criteria: global cognition, memory, language, speed of information processing, verbal fluency, and attention. All cognitive outcomes and measurement tools used across studies are listed in Table 1 .

Risk of bias

The quality of trials was assessed by Jadad scales [ 28 ]. Studies with scores ≥ 3 were classified as high-quality studies and those of ≤ 2 were classified as “low-quality” studies. [ 26 , 29 , 30 , 31 , 33 , 36 ] studies were considered high-quality studies while [ 34 , 35 ] studies were considered of low-quality. Blinding of participants was not possible due to the nature of the intervention considered in this review. Randomization was mentioned in all studies except one study [ 34 ]. Results of the quality assessment of all studies using the Jadad scales are summarized in Table 2 .

Results of individual studies

Sakamoto et al. [ 29 ] studied the effect of music intervention (active and passive) on patients with severe dementia. Results showed that there is a short-term improvement in emotional state assessed by the facial scale which is a tool commonly used by psychologists and healthcare professionals to assess and code facial expressions, both positive and negative, to determine a patient’s emotional state [ 37 , 38 ]. In addition to eliciting positive emotions, music therapy has been shown to have long-term benefits in reducing behavioral and psychological symptoms of dementia assessed by the Behavioral Pathology in Alzheimer’s Disease (BEHAVE-AD) Rating Scale, a well-established instrument to assess and evaluate behavioral symptoms in AD patients, as well as to evaluate treatment outcomes and identify potentially remediable symptoms [ 39 ].

The study by Narme et al. [ 26 ] was conducted to evaluate the effectiveness of music and cooking interventions in improving the emotional, cognitive, and behavioral well-being of AD and mixed dementia patients. The study lasted 4 weeks and involved 48 patients, who received two 1-h sessions of either music or cooking interventions per week. Both interventions showed positive results, such as improved emotional state and reduced the severity of behavioral disorders, as well as reduced caregiver distress. However, there was no improvement in the cognitive status of the patients. Although the study did not find any specific benefits of music interventions, it suggests that these non-pharmacological treatments can improve the quality of life for patients with moderate to severe dementia and help to ease caregiver stress [ 26 ].

The study by Gómez Gallego and Gómez García [ 34 ] showed a significant increase in MMSE scores, especially in the domains of orientation, language and memory [ 34 ]. Subsequent study from the same author aiming to compare the benefits from active music therapy versus receptive music therapy or usual care on 90 AD patients showed impressive results of active music intervention improving cognitive deficits and behavioral symptoms [ 36 ]. Other supportive data revealed an increase of MMSE and MoCA scores over the study duration in the intervention group, in comparison to the control group [ 35 ].

The study by Pongan et al. [ 33 ] examined the effects of singing versus painting on 50 AD patients over a period of 12 weeks. Results showed that both therapies elicited benefits in reducing depression, anxiety, and pain. The only advantage that the singing group had over the painting group is the stabilization of verbal memory (assessed using FCRT) over time [ 33 ].

Lyu et al. [ 30 ] study aimed to investigate the effects of music therapy on cognitive functions and mental well-being in AD patients. The study utilized the World Health Organization University of California-Los Angeles Auditory Verbal Learning Test (WHO-UCLA AVLT) to assess the short-term and long-term memory of the participants. Subjects were tested on their ability to recall 15 verbal words immediately and after a delay of 30 min. The results showed that music therapy was more effective in improving verbal fluency and alleviating psychiatric symptoms and caregiver distress than lyric reading in AD patients. The stratified analysis revealed that music therapy improved memory and language ability in mild AD patients and reduced psychiatric symptoms (delusions, hallucinations, agitation/aggression, dysphoria, anxiety, euphoria, apathy, disinhibition, irritability/lability, and aberrant motor activity) and caregiver distress in moderate or severe AD patients. However, no significant effect was found on daily activities in any group of patients [ 30 ].

Innes et al. [ 31 ] study consisted of testing music listening therapy over a period of 12 weeks. Cognitive functions were assessed through various measures, including memory (using the Memory Functioning Questionnaire MFQ), executive function (using the Trail Making Test (TMT) Parts A and B), and psychomotor speed, attention, and working memory (using the 90-s Wechsler Digit-Symbol Substitution Test). The scores assessed at baseline, 3 months, and 6 months after therapy showed an improvement in measures of memory function, psychological status, and cognitive performance including executive functions, working memory, processing speed, and attention [ 31 ].

Neurodegenerative diseases, such as dementia, pose a major challenge to global health and will continue to increase in impact with the aging population. AD is a widespread form of dementia affecting a large number of elderly individuals globally and may contribute to 60–70% of cases [ 40 ]. Despite efforts to find effective treatments through pharmacological means, the results have been disappointing in recent decades. As a result, non-pharmacological therapies have gained more attention as a way to improve cognitive, behavioral, social, and emotional functions in AD patients.

Music therapy has been shown to induce plastic changes in some brain networks [ 41 ], facilitate brain recovery processes, modulate emotions, and promote social communication [ 42 ], making it a promising rehabilitation approach. Thus, the present systematic review aimed to systematically synthesize the impact of music therapy on cognitive functions in AD patients. Out of the eight studies reviewed, totaling 689 subjects, seven studies found a significant and positive effect of music therapy on enhancing cognitive functions in individuals with AD. However, one study by Narme et al. [ 26 ] did not find evidence of the efficacy of music therapy on cognitive functions [ 26 ]. This result may be due to the use of music that was chosen by the therapist, rather than being based on the patient’s preferences, and the use of cooking as a control group rather than a standard group to test the efficacy of the intervention. Furthermore, Narme et al. [ 26 ] suggested that a larger sample size would be beneficial in conducting parametric analysis, which could provide more robust results [ 26 ]. These findings highlight the potential benefits of music therapy as a non-pharmacological intervention for AD patients.

Six out of eight studies revealed that patients who underwent Active Music Intervention (AMI) had better outcomes compared to those who underwent Receptive Music Intervention (RMI) [ 29 , 30 , 33 , 34 , 35 , 36 ]. On the other hand, the findings of the studies by Innes et al. [ 31 ] and Wang et al. [ 35 ] that used only the RMI approach, showed a positive impact on cognitive functions in AD patients [ 31 , 35 ].

In the study by Innes et al. [ 31 ], both the meditation and music listening groups showed significant improvements in cognitive functions, without a significant difference between the two groups. In the study by Wang et al. [ 35 ], music therapy was found to be an effective adjuvant to support pharmacological interventions in AD, leading to significant improvements in the MMSE and MoCA scores. It is worth noting that AMI and RMI differ in terms of the level of patient involvement and the objectives of the therapy. AMI involves the direct participation of patients in musical activities such as singing, playing an instrument, or moving to the beat, whereas RMI consists of passive listening to music. From a functional and physiological perspective, AMI may have a greater impact on cognitive and emotional processes due to the increased level of engagement and interaction with the music [ 36 ]. AMI has been shown to activate brain regions involved in auditory processing, motor control, and emotional regulation, leading to improved cognitive functions and reduced agitation and anxiety [ 41 ]. On the other hand, RMI may have a more relaxing effect, as it can induce changes in heart rate and breathing, reducing stress levels and improving sleep quality [ 42 ]. Based on our systematic review, it is not possible to draw conclusions about the optimal music types (classic music, familiar songs, individualized songs…) for music therapy in patients with AD. This is due to the heterogeneity of the studies included in our review, including differences in the types of music used and the methods of exposure. Therefore, it is not possible to determine with certainty which type of music is most effective for improving cognitive functions in AD patients. Further research is needed to establish the optimal music types and optimal duration of music therapy in this population. Our findings also revealed that individualized music playlists, consisting of songs chosen based on the patient’s preferences, showed improvement in cognitive functions, particularly in memory. A study by [ 31 ] used relaxing music in the intervention group, chosen according to patients’ preferences. The music listening CD to be heard by patients in this study contained selections from Bach, Beethoven, Debussy, Mozart, Pachelbel, and Vivaldi, which resulted in an improvement in cognitive functions. This is consistent with the [ 43 ] study which showed that listening to classical music, specifically selections from Mozart, could result in a temporary improvement in certain cognitive tasks such as abstract/spatial reasoning tests. While the “Mozart Effect” has been linked more to the acute arousal brought on by the pleasure of listening to music, rather than a direct impact on cognitive ability [ 44 ], both studies highlight the potential for listening to classical music to have a positive impact on cognitive functions.

The improvement in orientation, language, and memory domains in individuals with AD, as reported in the studies by [ 34 , 36 ], can be attributed to several factors such as the use of an individualized playlist or the presence of a music therapist to perform the sessions. The study by [ 30 ] suggests that music intervention has a positive effect on verbal fluency, memory, and language in individuals with AD. The rhythmic and repetitive elements of music regulate brain function, and musical activities such as singing and playing instruments can activate neural networks involved in memory and language processing.

Further beneficial effects other than improved cognitive behaviors, memory, language, and orientation, the study by [ 29 ] showed a positive impact on the emotional state of the patients. This is consistent with the idea that several cognitive processes such as perception, attention, learning, memory, reasoning, and problem-solving, are all influenced by emotions [ 45 ]. However, the positive effects observed in the emotional state of the patients disappeared 3 weeks after the intervention period. The effects of the intervention lasted after the follow-up for a period that varied between studies [ 29 , 30 , 31 , 33 , 35 ], from 1 month [ 33 ] to 6 months [ 30 , 31 ]. Further research is needed to determine the most effective and optimal duration for music therapy interventions.

Our review has some limitations including differences in participant characteristics (participant age/severity of illness/cognitive ability…), outcome measures, and intervention methods, that may have influenced the results. Additionally, the music therapy interventions used in the studies differed, with activities ranging from singing to playing instruments. These factors, combined with the small number of studies included in the review, limit the power of our findings. Furthermore, the heterogeneity of the interventions and outcome measures used in the studies makes it difficult to perform a meta-analysis and combine the data in a meaningful way. The varying methods of music selection and exposure also pose challenges in synthesizing the results.

The findings of this review suggest that music therapy could have a positive impact on cognitive functions in patients with AD. This supports the growing body of evidence that targets music therapy as a promising cognitive rehabilitating process aiming to improve cognitive functions in individuals with AD dementia like memory, executive functions, or attention. Improvements in these cognitive functions can, in turn, enhance the quality of life of both the patients and their caregivers. However, more research is needed to fully understand the mechanisms behind these effects and to determine the optimal approach to music therapy for this population, including the time frame for follow-up evaluations. Nevertheless, the results of this review highlight the potential benefits of music therapy as a treatment option for individuals with AD and the importance of continued investigation in this field, including long-term follow-up assessments to determine the sustained impact of music therapy on cognitive functions.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Abbreviations

• Alzheimer’s disease

Active music therapy

Behavior Pathology in Alzheimer’s Disease

Digit Symbol Substitution Test

Frontal assessment battery

Free and Cued Recall Test

Memory Functioning Questionnaire

Mini-Mental State Examination

Montreal Cognitive Assessment

Positron emission tomography

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

Randomized controlled trials

Receptive music therapy

Severe impairment battery

Trail Making Test

United States of America

World Health Organization University of California-Los Angeles Auditory Verbal Learning test

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Bleibel, M., El Cheikh, A., Sadier, N.S. et al. The effect of music therapy on cognitive functions in patients with Alzheimer’s disease: a systematic review of randomized controlled trials. Alz Res Therapy 15 , 65 (2023). https://doi.org/10.1186/s13195-023-01214-9

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Science Watch

Music as medicine

Researchers are exploring how music therapy can improve health outcomes among a variety of patient populations, including premature infants and people with depression and Parkinson’s disease.

By Amy Novotney

November 2013, Vol 44, No. 10

Print version: page 46

The beep of ventilators and infusion pumps, the hiss of oxygen, the whir of carts and the murmur of voices as physicians and nurses make rounds — these are the typical noises a premature infant hears spending the first days of life in the neonatal intensive care unit (NICU). While the sounds of such life-saving equipment are tough to mute, a new study suggests that some sounds, such as lullabies, may soothe pre-term babies and their parents, and even improve the infants' sleeping and eating patterns, while decreasing parents' stress ( Pediatrics , 2013).

Researchers at Beth Israel Medical Center's Louis Armstrong Center for Music and Medicine conducted the study, which included 272 premature babies 32 weeks gestation or older in 11 mid-Atlantic NICUs. They examined the effects of three types of music: a lullaby selected and sung by the baby's parents; an "ocean disc," a round instrument, invented by the Remo drum company, that mimics the sounds of the womb; and a gato box, a drum-like instrument used to simulate two-tone heartbeat rhythms. The two instruments were played live by certified music therapists, who matched their music to the babies' breathing and heart rhythms.

The researchers found that the gato box, the Remo ocean disc and singing all slowed a baby's heart rate, although singing was the most effective. Singing also increased the amount of time babies stayed quietly alert, and sucking behavior improved most with the gato box, while the ocean disc enhanced sleep. The music therapy also lowered the parents' stress, says Joanne Loewy, the study's lead author, director of the Armstrong center and co-editor of the journal Music and Medicine .

"There's just something about music — particularly live music — that excites and activates the body," says Loewy, whose work is part of a growing movement of music therapists and psychologists who are investigating the use of music in medicine to help patients dealing with pain, depression and possibly even Alzheimer's disease. "Music very much has a way of enhancing quality of life and can, in addition, promote recovery."

Music to treat pain and reduce stress

While music has long been recognized as an effective form of therapy to provide an outlet for emotions, the notion of using song, sound frequencies and rhythm to treat physical ailments is a relatively new domain, says psychologist Daniel J. Levitin, PhD, who studies the neuroscience of music at McGill University in Montreal. A wealth of new studies is touting the benefits of music on mental and physical health. For example, in a meta-analysis of 400 studies, Levitin and his postgraduate research fellow, Mona Lisa Chanda, PhD, found that music improves the body's immune system function and reduces stress. Listening to music was also found to be more effective than prescription drugs in reducing anxiety before surgery ( Trends in Cognitive Sciences , April, 2013).

"We've found compelling evidence that musical interventions can play a health-care role in settings ranging from operating rooms to family clinics," says Levitin, author of the book "This is Your Brain on Music" (Plume/Penguin, 2007). The analysis also points to just how music influences health. The researchers found that listening to and playing music increase the body's production of the antibody immunoglobulin A and natural killer cells — the cells that attack invading viruses and boost the immune system's effectiveness. Music also reduces levels of the stress hormone cortisol.

"This is one reason why music is associated with relaxation," Levitin says.

One recent study on the link between music and stress found that music can help soothe pediatric emergency room patients ( JAMA Pediatrics , July, 2013). In the trial with 42 children ages 3 to 11, University of Alberta researchers found that patients who listened to relaxing music while getting an IV inserted reported significantly less pain, and some demonstrated significantly less distress, compared with patients who did not listen to music. In addition, in the music-listening group, more than two-thirds of the health-care providers reported that the IVs were very easy to administer — compared with 38 percent of providers treating the group that did not listen to music.

"There is growing scientific evidence showing that the brain responds to music in very specific ways," says Lisa Hartling, PhD, professor of pediatrics at the University of Alberta and lead author of the study. "Playing music for kids during painful medical procedures is a simple intervention that can make a big difference."

Music can help adult patients, too. Researchers at Khoo Teck Puat Hospital in Singapore found that patients in palliative care who took part in live music therapy sessions reported relief from persistent pain ( Progress in Palliative Care , July, 2013). Music therapists worked closely with the patients to individually tailor the intervention, and patients took part in singing, instrument playing, lyric discussion and even song writing as they worked toward accepting an illness or weighed end-of-life issues. 

"Active music engagement allowed the patients to reconnect with the healthy parts of themselves, even in the face of a debilitating condition or disease-related suffering," says music therapist Melanie Kwan, co-author of the study and president of the Association for Music Therapy, Singapore. "When their acute pain symptoms were relieved, patients were finally able to rest."

The healing power of vibration

At its core, music is sound, and sound is rooted in vibration. Led by Lee Bartel, PhD, a music professor at the University of Toronto, several researchers are exploring whether sound vibrations absorbed through the body can help ease the symptoms of Parkinson's disease, fibromyalgia and depression. Known as vibroacoustic therapy, the intervention involves using low frequency sound — similar to a low rumble — to produce vibrations that are applied directly to the body. During vibroacoustic therapy, the patient lies on a mat or bed or sits in a chair embedded with speakers that transmit vibrations at specific computer-generated frequencies that can be heard and felt, says Bartel. He likens the process to sitting on a subwoofer.

In 2009, researchers led by Lauren K. King of the Sun Life Financial Movement Disorders Research and Rehabilitation Centre at Wilfrid Laurier University, in Waterloo, Ontario, found that short-term use of vibroacoustic therapy with Parkinson's disease patients led to improvements in symptoms, including less rigidity and better walking speed with bigger steps and reduced tremors ( NeuroRehabilitation , December, 2009). In that study, the scientists exposed 40 Parkinson's disease patients to low-frequency 30-hertz vibration for one minute, followed by a one-minute break. They then alternated the two for a total of 10 minutes. The researchers are now planning a long-term study of the use of vibroacoustic therapy with Parkinson's patients, as part of a new partnership with the University of Toronto's Music and Health Research Collaboratory, which brings together scientists from around the world who are studying music's effect on health.

The group is also examining something called thalmocortical dysrhythmia — a disorientation of rhythmic brain activity involving the thalamus and the outer cortex that appears to play a role in several medical conditions including Parkinson's, fibromyalgia and possibly even Alzheimer's disease, says Bartel, who directs the collaboratory.

"Since the rhythmic pulses of music can drive and stabilize this disorientation, we believe that low-frequency sound might help with these conditions," Bartel says. He is leading a study using vibroacoustic therapy with patients with mild Alzheimer's disease. The hope is that using the therapy to restore normal communication among brain regions may allow for greater memory retrieval, he says.

"We've already seen glimmers of hope in a case study with a patient who had just been diagnosed with the disorder," Bartel says. "After stimulating her with 40-hertz sound for 30 minutes three times a week for four weeks, she could recall the names of her grandchildren more easily, and her husband reported good improvement in her condition."

The goal of all of this work is to develop "dosable" and "prescribable" music therapy and music as medicine protocols that serve specific neurologic functions and attend to deficits that may result from many of these neurologically based conditions. Rather than viewing music only as a cultural phenomenon, Bartel says, the art should be seen as a vibratory stimulus that has cognitive and memory dimensions.

"Only when we look at it in this way do we start to see the interface to how the brain and body work together."

Amy Novotney is a writer in Chicago.

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Bill Matney, CharCarol Fisher, Anthony Meadows, Elizabeth Schwartz, Alan Turry, Philosophical Reflections on Music Therapy Musicianship, Journal of Music Therapy , 2024;, thae012, https://doi.org/10.1093/jmt/thae012

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This philosophical inquiry critically examines music therapy musicianship in order to reconceptualize the ways in which musicianship is conceived of and taught in education and training programs in the United States. Through a constructive and critical interaction with historical and extant literature, we seek to create space for the uniqueness of musicianship in our field. We challenge the relevance of the conservatory model, the primacy of the work concept, and the focus on fine art often found in educational settings. In doing so, we align music therapy musicianship with relevant musics, instrumentation, and the unique contextual and relational components of music experiences in our work. We construct multidirectional connections between musicality, musical identity, musicianship, music therapy context, musicking, and the clients’/participants’ lifeworld, introducing subconcepts within and between each concept. This co-construction with the literature asserts our identity in education, training, practice, and research. We conclude by offering preliminary guidance that may further develop music therapy musicianship in education and clinical training programs, in alignment with current reports on education.

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Analysis of the effectiveness of music therapy on mental health of college students.

Art College of Sichuan University, Chengdu, Sichuan 610021, China

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The data used to support the findings of this study are included within the article.

Music therapy is a relatively mature marginal subject at present, and it is also a relatively common treatment method. This kind of treatment can better help college students get rid of bad psychology and guide their psychology to develop in a healthy direction. Mental health is one of the important indicators to measure the comprehensiveness of human quality and plays an important role in the sustainable development of human beings. Music therapy plays a very important role in college students' mental health education. As a marginal subject, music therapy combines music, medicine, and psychology, which is beneficial to alleviate students' bad emotions and psychological problems, and helps college students form a sound personality. Using music therapy can let college students vent their emotions in a suitable environment and atmosphere and then guide them correctly. This paper introduces the effectiveness of music therapy in college students' mental health education and then puts forward important measures to promote the implementation of music therapy in college students' mental health education.

1. Introduction

In the stage of higher education, college students' psychology and physiology are not yet mature, but they have high sensitivity and perception, high sensitivity to the changes of the objective world, and poor psychological quality, and are easy to go to extremes [ 1 ]. In terms of the current college students' mental health, there are a variety of problems, which have a negative impact on learning and physical and mental development [ 2 ]. Therefore, the reality also requires colleges and universities to carry out appropriate mental health education to help college students establish good psychological quality. From the current development, college students' mental health has become a very concerned problem. In the teaching process of colleges and universities, we need to choose teaching methods that are more close to students' real life to promote the development of college students' mental health [ 3 ]. From the relevant investigation and analysis, college students are interested in learning music, which provides an effective basis for college students to use music to treat psychological problems [ 4 ]. Music therapy can let college students vent their emotions in the appropriate environment and atmosphere and then guide them correctly to get out of the haze and welcome the sunshine [ 5 ]. The soothing effect of music can enable college students to maintain stable emotions and actively detect their own psychological changes, so as to achieve the effect of self-regulation and self-healing [ 6 ]. It can be seen that music therapy has good feasibility in the intervention of college students' psychological problems, which can promote the improvement of college students' self-cognitive ability and interpersonal skills and make them maintain a good psychological state.

Music has the function of arousing personal personality. Colleges and universities can use music to treat and solve the psychological obstacles of college students, which requires colleges to pay attention to college students' psychological counseling, cultivate students' healthy emotions, and promote the healthy development of college students' psychology [ 7 ]. When the emotion of college students is vented to a certain extent, the mood gradually changes to a positive direction. At this time, the teacher will play some music full of positive energy, so as to stimulate the positive emotion of the treated and help them get rid of their psychological problems [ 8 ]. Music therapy uses music as a carrier to help college students improve their psychological environment and promote emotional communication. At the same time, music is a common medium; using music can carry out a variety of activities, which can not only play the therapeutic role of music, but also create a good growth environment for college students [ 9 ]. This paper introduces the effectiveness of music therapy in college students' mental health education and then puts forward some important methods to promote the implementation of music therapy in college students' mental health education.

This paper is divided into four sections. Section 1 expounds the relationship between music therapy and college students' mental health. The relevant background is described. Section 2 expounds the influence of music therapy on college students' mental health. Section 3 expounds the application of music therapy in college students' mental health. The related research is summarized. Finally, the full text is summarized.

2. Effectiveness of Music Therapy on Mental Health of College Students

With the improvement of living standards and the acceleration of social rhythm, today's college students are facing the dual pressure of employment and study. At the same time, colleges and universities have begun to implement all kinds of education reform. Due to the immature judgment of the relationship between the two sexes, some college students have unpleasant communication experience with the opposite sex. As time goes by, it is easy to cause long-term depression and depression in their heart and even lead to suicide due to excessive inferiority. The purpose of psychological education is to guide college students to establish correct emotional values. It is worth noting that because the college students are in the regional mature stage of physical and mental development and gradually enter the society, they may have doubts about many social problems or phenomena, or even show psychological barriers, which are a manifestation of mental loss. The stage of college students is an important period for one's growth. Through years of knowledge preparation, one is about to enter the society. A sincere, enthusiastic, confident, and charming person is easier to base himself on society and integrate into social life. Music itself can help college students cultivate their temperament, constantly improve their personality, and bring people a happy mood. In the development of mental health education, music therapy is introduced. Under the alternation of rhythm and melody, people's emotional experience is mobilized and psychological barriers and problems are relieved. Therefore, the application of music therapy in college students' mental health education plays a positive role in strengthening students' emotional experience. In the role of school education, music therapy is suitable for the educational situation of the school. It plays an important role in preventing and treating students' physical and mental diseases, adjusting bad emotions, cultivating students' healthy emotions and cooperative spirit, and promoting students' self-expression, development, and innovation.

With the promotion of socialist spiritual civilization construction, it is an important task for colleges and universities to strengthen the spiritual civilization construction of college students and help them build healthy psychology. Music can help people express their feelings and, at the same time, correct people in interpersonal communication in a variety of bad state and establish a positive way of communication. In music therapy, other forms, such as role play and music performance, can create specific situations for students. While students enjoy the fun, they also know how to use music to express their emotions and emotions and get a successful experience. This kind of experience is the key to promote students' correct self-evaluation and self-concept, so the application of music therapy is an important way to solve students' psychological problems. In treatment, college students are allowed to not only listen to cheerful and inspirational music but also listen to some sad and slow music [ 10 ], so as to induce students to release their deep feelings, release their negative emotions, and then listen to some positive, full of positive energy, and inspirational music, guide them to break the psychological problems, re-face themselves, get a new life in spirit, and move towards a new life journey. From the specific form of music therapy, the main part is body participation. Take the common chorus as an example; if there is a discordant tone, it will reduce the overall chorus effect, so the cooperation of all participants is extremely important. No matter in training or performance, students pay attention to how to control their own individual reactions and strive to cooperate with and respect other members.

For music, it is not good music if it keeps going up or down. Use the following formula to evaluate the overall outline of a piece of music:

For music, it is not good to keep the pitch rising or falling. Use the following formula to evaluate the overall outline of a piece of music:

The original audio file is not conducive to research, so the audio file is converted into frequency spectrum, that is, the time domain is converted into frequency domain, and the frequency spectrum of the audio file is obtained. The process of realizing this function is shown in Figure 1 .

Audio file feature extraction process.

At present, college students are in their youth, with broad hobbies, being willing to make friends and good mental outlook. They hope to constantly know the world, broaden their horizons, increase their knowledge, make interesting friends, seek recognition from others, and gain sincere friendship. It is easy for the cooperative spirit in music activities to migrate to real life, which helps most students who are pessimistic and self-enclosed to open their hearts, promote their ability to communicate and understand with others, and build a good relationship with others while knowing themselves correctly. In the daily treatment process, the counselor will not just play positive energy songs, but first play a series of sad, lyrical, and soothing songs in a guiding way to guide students to fully release their inner feelings and help them express the most fundamental, depressed, and contradictory emotions in their hearts. In the stage of higher education, it is an important period for college students to shape their personality, and music can play a positive role in cultivating human sentiment and promote the realization of emotional training [ 11 ]. From the content of music art, it is the synthesis of hearing art, expression art, and emotion art. With the development of economy, society, and times, people's life rhythm is becoming faster and faster, while college students have already felt various pressures in school, such as studying, interacting with others, and employment, which make them upset and seriously affect the healthy development of college students' psychology.

3. The Application of Music Therapy in College Students' Mental Health

College students' mental health problems need to be solved, and music therapy is a relatively simple form of treatment. Many students have a wrong understanding of music therapy or do not understand the situation. Colleges and universities should pay attention to the propaganda of music therapy, guide college students to correctly understand their psychological problems, and timely relieve and treat the problems that may or have occurred. The new music therapy mode is based on the theoretical essence of different psychotherapy schools. According to the different needs of college students, it chooses adaptive music therapy technology to help college students release bad emotions, purify the mind and improve interpersonal relationships in a good experience, and create a campus cultural atmosphere of knot, friendship, and mutual help. As an important implementer of music therapy, music therapists have a very important impact on the future development of college students. Music therapists in colleges and universities need to improve their own music therapy propaganda ability, promotion ability, teaching ability, and scientific research ability. Based on the actual situation of music therapists at home and abroad, combined with the characteristics of college students' mental health education, music teachers are encouraged to participate in music therapy training and obtain technical qualification certificate.

Music therapy is a comprehensive subject, which involves music, medicine, psychology, and other aspects of professional knowledge, so the requirements of music therapy for practitioners are relatively high. In order to carry out music therapy activities or courses, colleges and universities need to build a team of high-quality music therapists. According to the basic and complex characteristics of music, the overall characteristics of music are identified, including musical form structure, style, and emotional connotation. The specific structure is shown in Figure 2 .

Composition of music form.

Today's society is full of impetuousness, and college students are prone to breed bad emotions due to various negative influences in their study and life. We help them to prevent bad emotions in time, digest negative emotions, and even help their relatives and friends solve psychological problems by popularizing music therapy. Receptive music therapy is to use the unique rhythm, harmony, and other factors in music to awaken the positive inner strength of college students, so as to adjust and improve their emotional and social adaptability and finally get cured. On the choice of listening music tracks, music therapists tailor-made and choose different tracks according to different objects and psychological problems. College music therapists need not only rich music knowledge but also professional knowledge in psychology, medicine, and pedagogy. Due to the limitation of university environment, music therapists need to truly love students and enhance their affinity.

Emotion plays an important and undeniable role in the formation of personality and cognition. At the same time, music can influence our emotions in some way. Therefore, we can use music therapy to stabilize students' emotions, make their values, world outlook, and outlook on life development in a positive direction, and help students better face setbacks in life and meet new challenges with enthusiasm. The interactive relationship of students' social development is shown in Figure 3 .

Interactive relationship of students' social development.

Music therapy is mainly divided into group therapy and individual therapy, and colleges and universities should prepare for music therapy rooms from these two aspects. Using environmental construction, building a harmonious and friendly state between music therapists and students, using audition and games to carry out effective music therapy activities, and promoting the healthy development of college students' psychology, music teachers in colleges and universities have very strong musical ability. Music teachers should not only have basic knowledge of music major but also have knowledge of pedagogy and psychology and improve their comprehensive quality with the help of psychological counselor training. Colleges and universities need to pay attention to the propaganda work of music therapy, carry out university lectures and public elective courses, and use various channels such as publicity columns and campus networks to guide college students to correctly understand music therapy, feel the benefits of music therapy, and mobilize students' enthusiasm for participating in music therapy. In the process of music therapy, we need to choose music-related activities, such as music creation, impromptu singing, and music games, but most people just think that music therapy is listening to music and relaxing. Music therapy itself is a kind of therapeutic activity, so there are certain requirements for the environment in order to achieve therapeutic effect. First of all, we need a relatively basic environment, which is quiet and comfortable and can make students in a relaxed and warm environment. In such a therapeutic environment, it is easier for students to open their hearts and tell their inner emotional world.

4. Conclusions

With the development of society, college students face a more complex environment during their growth, which has an important impact on their mental health. Therefore, it is necessary for colleges and universities to actively carry out mental health education activities for college students through effective teaching strategies, so as to guide students to keep a good mood, actively cope with difficulties and frustrations, establish a correct outlook on life and values, and realize self-worth in life. In the process of mental health education for college students, music therapy plays an irreplaceable role. Music therapy can effectively interfere with college students' mental health, promote their physical and mental health, improve their psychological quality, guide them to form healthy personality, and cultivate their sentiment. Music therapy, as a new psychological treatment method, has its unique advantages, and its rich treatment methods can effectively meet the diversified needs of college students for mental health. The music therapy is extended to the field of mental health education for college students, which effectively expands the channels of mental health education for college students and further promotes the innovation and development of mental health education in colleges and universities [ 12 ].

Data Availability

Conflicts of interest.

The authors declare that they have are no conflicts of interest in this study.