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Peer-reviewed

Research Article

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

Roles Conceptualization, Writing – original draft

Affiliation Bengbu Medical University, Bengbu, Anhui, China

Roles Methodology, Software

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

Roles Writing – review & editing

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

Roles Conceptualization, Writing – review & editing

* E-mail: [email protected]

• Qishou Tang, 
• Zhaohui Huang, 
• Huan Zhou, 

• Published: November 18, 2020
• https://doi.org/10.1371/journal.pone.0240862
• Peer Review
• Reader Comments

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

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

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

Conclusions

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

Citation: Tang Q, Huang Z, Zhou H, Ye P (2020) Effects of music therapy on depression: A meta-analysis of randomized controlled trials. PLoS ONE 15(11): e0240862. https://doi.org/10.1371/journal.pone.0240862

Editor: Sukru Torun, Anadolu University, TURKEY

Received: June 10, 2020; Accepted: October 4, 2020; Published: November 18, 2020

Copyright: © 2020 Tang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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

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

Competing interests: The authors have declared that no competing interests exist.

Introduction

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

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

Materials and methods

Search strategy and selection criteria.

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

Data extraction

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

Assessment of risk of bias in included studies

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

Music therapy and music medicine

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

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

Evaluation of depression

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

Statistical analysis

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

Characteristics of the eligible studies

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

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

https://doi.org/10.1371/journal.pone.0240862.g001

https://doi.org/10.1371/journal.pone.0240862.t001

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

https://doi.org/10.1371/journal.pone.0240862.g002

The overall effects of music therapy

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

https://doi.org/10.1371/journal.pone.0240862.g003

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

https://doi.org/10.1371/journal.pone.0240862.g004

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

https://doi.org/10.1371/journal.pone.0240862.g005

Sub-group analyses and meta-regression analyses

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

https://doi.org/10.1371/journal.pone.0240862.t002

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

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

https://doi.org/10.1371/journal.pone.0240862.g006

https://doi.org/10.1371/journal.pone.0240862.t003

Sensitivity analyses

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

https://doi.org/10.1371/journal.pone.0240862.t004

Evaluation of publication bias

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

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

https://doi.org/10.1371/journal.pone.0240862.g007

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

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

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

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

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

Supporting information

S1 checklist. prisma checklist..

https://doi.org/10.1371/journal.pone.0240862.s001

S1 Dataset.

https://doi.org/10.1371/journal.pone.0240862.s002

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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.

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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

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• Published: 22 June 2021

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

• Daniel E. Gustavson   ORCID: orcid.org/0000-0002-1470-4928 1 , 2 ,
• Peyton L. Coleman   ORCID: orcid.org/0000-0001-5388-6886 3 ,
• John R. Iversen 4 ,
• Hermine H. Maes 5 , 6 , 7 ,
• Reyna L. Gordon 2 , 3 , 8 , 9 &
• Miriam D. Lense 2 , 8 , 9  

Translational Psychiatry volume  11 , Article number:  370 ( 2021 ) Cite this article

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• Medical genetics
• Psychiatric disorders

Is engaging with music good for your mental health? This question has long been the topic of empirical clinical and nonclinical investigations, with studies indicating positive associations between music engagement and quality of life, reduced depression or anxiety symptoms, and less frequent substance use. However, many earlier investigations were limited by small populations and methodological limitations, and it has also been suggested that aspects of music engagement may even be associated with worse mental health outcomes. The purpose of this scoping review is first to summarize the existing state of music engagement and mental health studies, identifying their strengths and weaknesses. We focus on broad domains of mental health diagnoses including internalizing psychopathology (e.g., depression and anxiety symptoms and diagnoses), externalizing psychopathology (e.g., substance use), and thought disorders (e.g., schizophrenia). Second, we propose a theoretical model to inform future work that describes the importance of simultaneously considering music-mental health associations at the levels of (1) correlated genetic and/or environmental influences vs. (bi)directional associations, (2) interactions with genetic risk factors, (3) treatment efficacy, and (4) mediation through brain structure and function. Finally, we describe how recent advances in large-scale data collection, including genetic, neuroimaging, and electronic health record studies, allow for a more rigorous examination of these associations that can also elucidate their neurobiological substrates.

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Introduction.

Music engagement, including passive listening and active music-making (singing, instrument playing), impacts socio-emotional development across the lifespan (e.g., socialization, personal/cultural identity, mood regulation, etc.), and is tightly linked with many cognitive and personality traits [ 1 , 2 , 3 ]. A growing literature also demonstrates beneficial associations between music engagement and quality of life, well-being, prosocial behavior, social connectedness, and emotional competence [ 4 , 5 , 6 , 7 , 8 ]. Despite these advances linking engagement with music to many wellness characteristics, we have a limited understanding of how music engagement directly and indirectly contributes to mental health, including at the trait-level (e.g., depression and anxiety symptoms, substance use behaviors), clinical diagnoses (e.g., associations with major depressive disorder (MDD) or substance use disorder (SUD) diagnoses), or as a treatment. Our goals in this scoping review are to (1) describe the state of music engagement research regarding its associations with mental health outcomes, (2) introduce a theoretical framework for future studies that highlight the contribution of genetic and environmental influences (and their interplay) that may give rise to these associations, and (3) illustrate some approaches that will help us more clearly elucidate the genetic/environmental and neural underpinnings of these associations.

Scope of the article

People interact with music in a wide variety of ways, with the concept of “musicality” broadly including music engagement, music perception and production abilities, and music training [ 9 ]. Table 1 illustrates the breadth of music phenotypes and example assessment measures. Research into music and mental health typically focuses on measures of music engagement, including passive (e.g., listening to music for pleasure or as a part of an intervention) and active music engagement (e.g., playing an instrument or singing; group music-making), both of which can be assessed using a variety of objective and subjective measures. We focus primarily on music engagement in the current paper but acknowledge it will also be important to examine how mental health traits relate to other aspects of musicality as well (e.g., perception and production abilities).

Our scoping review and theoretical framework incorporate existing theoretical and mechanistic explanations for how music engagement relates to mental health. From a psychological perspective, studies have proposed that music engagement can be used as a tool for encouraging self-expression, developing emotion regulation and coping skills, and building community [ 10 , 11 ]. From a physiological perspective, music engagement modulates arousal levels including impacts on heart rate, electrodermal activity, and cortisol [ 12 , 13 ]. These effects may be driven in part by physical aspects of music (e.g., tempo) or rhythmic movements involved in making or listening to music, which impact central nervous system functioning (e.g., leading to changes in autonomic activity) [ 14 ], as well as by personality and contextual factors (e.g., shared social experiences) [ 15 ]. Musical experiences also impact neurochemical processes involved in reward processing [ 10 , 13 , 14 , 16 , 17 , 18 ], which are also implicated in mental health disorders (e.g., substance use; depression). Thus, an overarching framework for studying music-mental health associations should integrate the psychological, physiological, and neurochemical aspects of these potential associations. We propose expanding this scope further through consideration of genetic and environmental risk factors, which may give rise to (and/or interact with) other factors to impact health and well-being.

Regarding mental health, it is important to recognize the hierarchical structure of psychopathology [ 19 , 20 ]. Common psychological disorders share many features and cluster into internalizing (e.g., MDD, generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD)), externalizing (e.g., SUDs, conduct disorder), and thought disorders (e.g., bipolar disorder, schizophrenia), with common variance shared even across these domains [ 20 ]. These higher-order constructs tend to explain much of the comorbidity among individual disorders, and have helped researchers characterize associations between psychopathology, cognition, and personality [ 21 , 22 , 23 ]. We use this hierarchical structure to organize our review. We first summarize the emerging literature on associations between music engagement and generalized well-being that provides promising evidence for associations between music engagement and mental health. Next, we summarize associations between music engagement and internalizing traits, externalizing traits/behaviors, and thought disorders, respectively. Within these sections, we critically consider the strengths and shortcomings of existing studies and how the latter may limit the conclusions drawn from this work.

Our review considers both correlational and experimental studies (typically, intervention studies; see Fig. 1 for examples of study designs). We include not only studies that examine symptoms or diagnoses based on diagnostic interviews, but also those that assess quantitative variation (e.g., trait anxiety) in clinical and nonclinical populations. This is partly because individuals with clinical diagnoses may represent the extreme end of a spectrum of similar, sub-clinical, problems in the population, a view supported by evidence that genetic influences on diagnosed psychiatric disorders or DSM symptom counts are similar to those for trait-level symptoms in the general population [ 24 , 25 ]. Music engagement may be related to this full continuum of mental health, including correlations with trait-level symptoms in nonclinical populations and alleviation of symptoms from clinical disorders. For example, work linking music engagement to subjective well-being speaks to potential avenues for mental health interventions in the population at large.

Within experimental studies, music interventions can include passive musical activities (e.g., song listening, music and meditation, lyric discussion, creating playlists) or active musical activities (e.g., creative methods, such as songwriting or improvisation and/or re-creative methods, such as song parody).

The goal of this scoping review was to integrate across related, but often disconnected, literatures in order to propose a comprehensive theoretical framework for advancing our understanding of music-mental health associations. For this reason, we did not conduct a fully systematic search or quality appraisal of documents. Rather, we first searched PubMed and Google Scholar for review articles and meta-analyses using broad search terms (e.g., “review” and “music” and [“anxiety” or “depression” or “substance use”]). Then, when drafting each section, we searched for additional papers that have been published more recently and/or were examples of higher-quality research in each domain. When giving examples, we emphasize the most recent and most well-powered empirical studies. We also conducted some targeted literature searches where reviews were not available (e.g., “music” and [“impulsivity” or “ADHD”]) using the same databases. Our subsequent framework is intended to contextualize diagnostic, symptom, and mechanistic findings more broadly within the scope of the genetic and environmental risk factors on psychopathology that give rise to these associations and (potentially) impact the efficacy of treatment efforts. As such, the framework incorporates evidence from review articles and meta-analyses from various literatures (e.g., music interventions for anxiety [ 26 ], depression [ 27 ]) in combination with experimental evidence of biological underpinnings of music engagement and the perspective provided by newly available methods for population-health approaches (i.e., complex trait genetics, gene–environment interactions).

Music engagement and well-being

A growing body of studies report associations between music engagement and general indices of mental health, including increased well-being or emotional competence, lending support for the possibility that music engagement may also be associated with better specific mental health outcomes. In over 8000 Swedish twins, hours of music practice and self-reported music achievement were associated with better emotional competence [ 5 ]. Similarly, a meta-ethnography of 46 qualitative studies revealed that participation in music activities supported well-being through management of emotions, facilitation of self-development, providing respite from problems, and facilitating social connections [ 28 ]. In a sample of 1000 Australian adults, individuals who engaged with music, such as singing or dancing with others or attending concerts reported greater well-being vs. those who engaged in these experiences alone or did not engage. Other types of music engagement, such as playing an instrument or composing music were not associated with well-being in this sample [ 4 ]. Earlier in life, social music experiences (including song familiarity and synchronous movement to music) are associated with a variety of prosocial behaviors in infants and children [ 6 ], as well as positive affect [ 7 ]. Thus, this work provides some initial evidence that music engagement is associated with better general mental health outcomes in children and adults with some heterogeneity in findings depending on the specific type of music engagement.

Music engagement and internalizing problems

MDD, GAD, and PTSD are the most frequently clustered aspects of internalizing psychopathology [ 19 , 24 , 29 , 30 ]. Experimental studies provide evidence for the feasibility of music intervention efforts and their therapeutic benefits but are not yet rigorous enough to draw strong conclusions. The most severe limitations are small samples, the lack of appropriate control groups, few interventions with multiple sessions, and publications omitting necessary information regarding the intervention (e.g., intervention fidelity, inclusion/exclusion criteria, education status of intervention leader) [ 31 , 32 , 33 ]. Correlational studies, by contrast, suggest musicians are at greater risk for internalizing problems, but that they use music engagement as a tool to help manage these problems [ 34 , 35 ].

Experimental studies

Randomized controlled trials have revealed that music interventions (including both music therapies administered by board-certified music therapists and other music interventions) are associated with reduced depression, anxiety, and PTSD symptoms [ 26 , 27 , 33 , 36 ]. A review of 28 studies reported that 26 revealed significantly reduced depression levels in music intervention groups compared to control groups, including the 9 studies which included active non-music intervention control groups (e.g., reading sessions, “conductive-behavior” psychotherapy, antidepressant drugs) [ 27 ]. A similar meta-analysis of 19 studies demonstrated that music listening is effective at decreasing self-reported anxiety in healthy individuals [ 26 ]. A review of music-based treatment studies related to PTSD revealed similar conclusions [ 36 ], though there were only four relevant studies. More recent studies confirm these findings [ 37 , 38 , 39 ], such as one randomized controlled trial that demonstrated reduced depression symptoms in older adults following musical improvisation exercises compared to an active control group (gentle gymnastic activities) [ 39 ].

This work is promising given that some studies have observed effects even when compared to traditional behavior therapies [ 40 , 41 ]. However, there are relatively few studies directly comparing music interventions to traditional therapies. Some music interventions incorporate components of other therapeutic methods in their programs including dialectic or cognitive behavior therapies [ 42 ], but few directly compare how the inclusion of music augments traditional behavioral therapy. Still other non-music therapies incorporate music into their practice (e.g., background music in mindfulness therapies) [ 43 , 44 ], but the specific contribution of music in these approaches is unclear. Thus, there is a great need for further systematic research relating music to traditional therapies to understand which components of music interventions act on the same mechanisms as traditional therapies (e.g., developing coping mechanisms and building community) and which bolster or synchronize with other approaches (e.g., by adding structure, reinforcement, predictability, and social context to traditional approaches).

Aside from comparison with other therapeutic approaches, an earlier review of 98 papers from psychiatric in-patient studies concluded that promising effects of music therapy were limited by small sample sizes and methodological shortcomings including lack of reporting of adverse events, exclusion criteria, possible confounders, and characteristics of patients lost to follow-up [ 33 ]. Other problems included inadequate reporting of information on the source population (e.g., selection of patients and proportion agreeing to take part in the study), the lack of masking of interviewers during post-test, and concealment of randomization. Nevertheless, there was some evidence that therapies with active music participation, structured sessions, and multiple sessions (i.e., four or more) improved mood, with all studies incorporating these characteristics reporting significant positive effects. However, most studies have focused on passive interventions, such as music listening [ 26 , 27 ]. Active interventions (e.g., singing, improvising) have not been directly compared with passive interventions [ 27 ], so more work is needed to clarify whether therapeutic effects are indeed stronger with more engaging and active interventions.

Correlational studies

Correlational studies have focused on the use of music in emotional self-regulation. Specifically, individuals high in neuroticism appear to use music to help regulate their emotions [ 34 , 35 ], with beneficial effects of music engagement on emotion regulation and well-being driven by cognitive reappraisal [ 45 ]. Music listening may also moderate the association between neuroticism and depression in adolescents [ 46 ], consistent with a protective effect.

A series of recent studies have used validated self-reported instruments that directly assess how individuals use music activities as an emotion regulation strategy [ 47 , 48 , 49 , 50 ]. In adults, the use of music listening for anger regulation and anxiety regulation was positively associated with subjective well-being, psychological well-being, and social well-being [ 50 ]. In studies of adolescents and undergraduates, the use of music listening for entertainment was associated with fewer depression and anxiety symptoms [ 51 ]. “Healthy” music engagement in adolescents (i.e., using music for relaxation and connection with others) was also positively associated with happiness and school satisfaction [ 49 ]. However, the use of music listening for emotional discharge was also associated with greater depression, anxiety, and stress symptoms [ 51 ], and “unhealthy” music engagement (e.g., ‘hiding’ in music to block others out) was associated with lower well-being, happiness, school satisfaction, and greater depression and rumination [ 49 ]. Other work has highlighted the role of valence in these associations, with individuals who listen to happier music when they are in a bad mood reporting stronger ability for music to influence their mood than those who listen to sad music while in a negative mood [ 52 , 53 ].

This work highlights the importance of considering individuals’ motivations for engaging with music in examining associations with well-being and mental health, and are consistent with the idea that individuals already experiencing depression, anxiety, and stress use music as a therapeutic tool to manage their emotions, with some strategies being more effective than others. Of course, these correlational effects may not necessarily reflect causal associations, but could be due to bidirectional influences, as suggested by claims that musicians may be at higher risk for internalizing problems [ 54 , 55 , 56 ]. It is also necessary to consider demographic and socioeconomic factors in these associations [ 57 ], for example, because arts engagement may be more strongly associated with self-esteem in those with higher education [ 58 ].

It is also necessary to clarify if musicians (professional and/or nonprofessional) represent an already high-risk group for internalizing problems. In one large study conducted in Norway ( N  = 6372), professional musicians were higher in neuroticism than the general population [ 56 ]. Another study of musician cases ( N  = 9803) vs. controls ( N  = 49,015) identified in a US-based research database through text-mining of medical records found that musicians are at greater risk of MDD (Odds ratio [OR] = 1.21), anxiety disorders (OR = 1.25), and PTSD (OR = 1.13) [ 55 ]. However, other studies demonstrate null associations between musician status and depression symptoms [ 5 ] or mixed associations [ 59 ]. In N  = 10,776 Swedish twins, for example, professional and amateur musicians had more self-reported burnout symptoms [ 54 ]. However, neither playing music in the past, amateur musicianship, nor professional musicianship was significantly associated with depression or anxiety disorder diagnoses.

Even if musicians are at higher risk, such findings can still be consistent with music-making being beneficial and therapeutic (e.g., depression medication use is elevated in individuals with depressive symptoms because it is a treatment). Clinical samples may be useful in disentangling these associations (i.e., examining if those who engage with music more frequently have reduced symptoms), and wider deployment of measures that capture emotion regulation strategies and motivations for engaging with music will help shed light on whether high-risk individuals engage with music in qualitatively different ways than others [ 51 , 57 ]. Later, we describe how also considering the role of genetic and environmental risk factors in these associations (e.g., if individuals at high genetic and/or environmental risk self-select into music environments because they are therapeutic) can help to clarify these questions.

Music engagement and externalizing problems

The externalizing domain comprises SUDs, and also includes impulsivity, conduct disorder, and attention-deficit hyperactivity disorder (ADHD), especially in adolescents [ 20 , 24 , 60 , 61 ]. Similar to the conclusions for internalizing traits, experimental studies show promising evidence that music engagement interventions may reduce substance use, ADHD, and other externalizing symptoms, but conclusions are limited by methodological limitations. Correlational evidence is sparce, but there is less reason to suspect musicians are at higher risk for externalizing problems.

Intervention studies have demonstrated music engagement is helpful in patients with SUDs, including reducing withdrawal symptoms and stress, allowing individuals to experience emotions without craving substance use, and making substance abuse treatment sessions more enjoyable and motivating [ 62 , 63 , 64 ] (for a systematic review, see [ 65 ]). Similar to the experimental studies of internalizing traits, however, these studies would also benefit from larger samples, better controls, and higher-quality reporting standards.

Music intervention studies for ADHD are of similar quality. Such interventions have been shown to reduce inattention [ 66 ], decrease negative mood [ 67 ], and increase reading comprehension for those with ADHD [ 68 ]. However, there is a great amount of variability among children with ADHD, as some may find music distracting while others may focus better in the presence of music [ 69 ].

Little research has been conducted to evaluate music engagement interventions for impulsivity or conduct disorder problems, and findings are mixed. For example, a music therapy study of 251 children showed that beneficial effects on communication skills (after participating in a free improvisation intervention) was significant, though only for the subset of children above age 13 [ 70 ]. Another study suggested the promising effects of music therapy on social skills and problem behaviors in 89 students selected based on social/emotional problem behaviors, but did not have a control group [ 71 ]. Other smaller studies ( N  < 20 each) show inconsistent results on disruptive behaviors and aggression [ 72 , 73 ].

Correlational studies on externalizing traits are few and far between. A number of studies examined how listening habits for different genres of music relate to more or less substance use [ 74 , 75 , 76 , 77 ]. However, these studies do not strongly illuminate associations between music engagement and substance use because musical genres are driven by cultural and socioeconomic factors that vary over the lifespan. In the previously cited large study of American electronic medical records [ 55 ] where musicianship was associated with more internalizing diagnoses, associations were nonsignificant for “tobacco use disorder” (OR = 0.93), “alcoholism” (OR = 1.01), “alcohol-related disorders” (OR = 1.00), or “substance addiction and disorders” (OR = 1.00). In fact, in sex-stratified analyses, female musicians were at significantly decreased risk for tobacco use disorder (OR = 0.85) [ 55 ]. Thus, there is less evidence musicians are at greater risk for externalizing problems than in other areas.

Regarding other aspects of externalizing, some studies demonstrate children with ADHD have poor rhythm skills, opening a possibility that working on rhythm skills may impact ADHD [ 78 , 79 ]. For example, music might serve as a helpful scaffold (e.g., for attention) due to its regular, predictable rhythmic beat. It will be important to examine whether these associations with music rhythm are also observed for measures of music engagement, especially in larger population studies. Finally, musicians were reported to have lower impulsiveness than prior population samples, but were not compared directly to non-musicians [ 80 , 81 ].

Music engagement and thought disorders

Thought disorders typically encompass schizophrenia and bipolar disorder [ 20 ]. Trait-level measures include schizotypal symptoms and depression symptoms. Much like internalizing, music interventions appear to provide some benefits to individuals with clinical diagnoses, but musicians may be at higher risk for thought disorders. Limitations of both experimental and correlational studies are similar to those for internalizing and externalizing.

Music intervention studies have been conducted with individuals with schizophrenia and bipolar disorder. A recent meta-analysis of 18 music therapy studies for schizophrenia (and similar disorders) [ 82 ] demonstrated that music therapy plus standard care (compared to standard care alone) demonstrated improved general mental health, fewer negative symptoms of schizophrenia, and improved social functioning. No effects were observed for general functioning or positive symptoms of schizophrenia. Critiques echoed those described above. Most notably, although almost all studies had low risk of biases due to attrition, unclear risk of bias was evident in the vast majority of studies (>75%) for selection bias, performance bias, detection bias, and reporting bias. These concerns highlight the need for these studies to report more information about their study selection, blinding procedure, and outcomes.

More recent papers suggest similar benefits of music therapies in patients with psychosis [ 83 ] and thought disorders [ 84 ], with similar limitations (e.g., one study did not include a control group). Finally, although a 2021 review did not uncover more recent articles related to bipolar disorder, they argued that existing work suggests music therapy has the potential both to treat bipolar disorder symptoms and alleviate subthreshold symptoms in early stages of the disorder [ 85 ].

Much like internalizing, findings from the few existing studies suggest that musicians may be at higher risk for thought disorders. In the large sample of Swedish twins described earlier [ 54 ], playing an instrument was associated with more schizotypal symptoms across multiple comparisons (professional musicians vs. non-players; amateur musicians vs. non-players; still plays an instrument vs. never played). However, no associations were observed for schizophrenia or bipolar disorder diagnoses across any set of comparison groups. Another study demonstrated that individuals with higher genetic risk for schizophrenia or bipolar disorder were more likely to be a member of a creative society (i.e., actor or dancer, musician, visual artist, or writer) or work in a profession in these fields [ 86 ]. Furthermore, musician status was associated with “bipolar disorder” (OR = 1.18) and “schizophrenia and other psychotic disorders” (OR = 1.18) in US electronic health records (EHRs) [ 55 ].

Interim summary

There is promising evidence that music engagement is associated with better mental health outcomes. Music engagement is positively associated with quality of life, well-being, social connectedness, and emotional competence. However, some individuals who engage with music may be at higher risk for mental health problems, especially internalizing and thought disorders. More research is needed to disentangle these contrasting results, including clarifying how “healthy” music engagement (e.g., for relaxation or social connection) leads to greater well-being or successful emotion regulation, and testing whether some individuals are more likely to use music as a tool to regulate emotions (e.g., those with high neuroticism) [ 34 , 35 ]. Similarly, it will be important to clarify whether the fact that musicians may be an at-risk group is an extension of working in an artistic field in general (which may feature lower pay or lack of job security) and/or if similar associations are observed with continuous music engagement phenotypes (e.g., hours of practice). As we elaborate on later, genetically informative datasets can help clarify these complex associations, for example by tested whether musicians are at higher genetic risk for mental health problems but their music engagement mitigates these risks.

Music intervention studies are feasible and potentially effective at treating symptoms in individuals with clinical diagnoses, including depression, anxiety, and SUDs. However, it will be essential to expand these studies to include larger samples, random sampling, and active control groups that compare the benefits of music interventions to traditional therapies and address possible confounds. These limitations make it hard to quantify how specific factors influence the effectiveness of interventions, such as length/depth of music training, age of sample, confounding variables (e.g., socioeconomic status), and type of intervention (e.g., individual vs. group sessions, song playing vs. songwriting, receptive vs. active methods). Similarly, the tremendous breadth of music engagement activities and measures makes it difficult to identify the specific aspects of music engagement that convey the most benefits to health and well-being [ 87 ]. It is therefore necessary to improve reporting quality of studies so researchers can better identify these potential moderators or confounds using systematic approaches (e.g., meta-analyses).

Various mechanisms have been proposed to explain the therapeutic effects of music on mental health, including psychological (e.g., building communities, developing coping strategies) [ 10 , 11 ] and specific neurobiological drivers (e.g., oxytocin, cortisol, autonomic nervous system activity) [ 12 , 13 , 14 ]. However, it will be vital to conduct more systematic research comparing the effects of music interventions to existing therapeutic methods and other types of creative activities (e.g., art [ 88 ]) to quantify which effects and mechanisms are specific to music engagement. Music interventions also do not have to be an alternative to other treatments, but may instead support key elements of traditional interventions, such as being engaging, enjoyable, providing social context, and increasing structure and predictability [ 89 ]. Indeed, some music therapists incorporate principals from existing psychotherapeutic models [ 42 , 90 ] and, conversely, newer therapeutic models (e.g., mindfulness) incorporate music into their practice [ 43 , 44 ]. It is not yet possible to disentangle which aspects of music interventions best synergize with or strengthen standard psychotherapeutic practices (which are also heterogeneous), but this will be possible with better reporting standards and quality experimental design.

To encapsulate and extend these ideas, we next propose a theoretical framework that delineates key aspects of how music engagement may relate to mental health, which is intended to be useful for guiding future investigations in a more systematic way.

Theoretical framework for future studies

Associations between music engagement and mental health may take multiple forms, driven by several different types of genetic predispositions and environmental effects that give rise to, and interact with, proposed psychological and neurobiological mechanisms described earlier. Figure 2 displays our theoretical model in which potential beneficial associations with music are delineated into testable hypotheses. Four key paths characterize specific ways in which music engagement may relate to (and influence) mental health traits, and thus represent key research questions to be addressed in future studies.

Progression of mental health problems is based on a diathesis-stress model, where genetic predispositions and environmental exposures result in later problems (which can be remedied through treatment). Potential associations with music engagement include (Path 1; blue arrows) correlated genetic/environmental influences and/or causal associations between music engagement and trait-level mental health outcomes; (Path 2; red arrows) interactions between music engagement and risk factors to predict later trait-level or clinical level symptoms; and (Path 3; gold arrow) direct effects of music engagement on reducing symptoms or improving treatment efficacy. Path 4 (orange arrows) illustrates the importance of understanding how these potential protective associations are driven by neuroanatomy and function. MDD major depressive disorder, GAD generalized anxiety disorder, PTSD posttraumatic stress disorder, SUD substance use disorder(s).

Path 1: Music engagement relates to mental health through correlated genetic and environmental risk factors and/or causation

The diathesis-stress model of psychiatric disease posits that individuals carry different genetic liabilities for any given disorder [ 91 , 92 , 93 ], with disorder onset depending on the amount of negative vs. protective environmental life events and exposures the individual experiences. Although at first glance music engagement appears to be an environmental exposure, it is actually far from it. Twin studies have demonstrated that both music experiences and music ability measures are moderately heritable and genetically correlated with cognitive abilities like non-verbal intelligence [ 94 , 95 , 96 , 97 ]. Music engagement may be influenced by its own set of environmental influences, potentially including socioeconomic factors and availability of instruments. Thus, music engagement can be viewed as a combination of genetic and environmental predispositions and availability of opportunities for engagement [ 98 ] that are necessary to consider when evaluating associations with mental health [ 54 ].

When examining music-mental health associations, it is thus important to evaluate if associations are in part explained by correlated genetic or environmental influences (see Fig. 3 for schematic and explanation for interpreting genetic/environmental correlations). On one hand, individuals genetically predisposed to engage with music may be at lower risk of experiencing internalizing or externalizing problems. Indeed, music engagement and ability appear associated with cognitive abilities through genetic correlations [ 3 , 99 ], which may apply to music-mental health associations as well. On the other, individuals at high genetic risk for neuroticism or psychopathology may be more likely to engage with music because it is therapeutic, suggesting a genetic correlation in the opposite direction (i.e., increased genetic risk for musicians). To understand and better contextualize the potential therapeutic effects of music engagement, it is necessary to quantify these potential genetic associations, while simultaneously evaluating whether these associations are explained by correlated environmental influences.

Variance in any given trait is explained by a combination of genetic influences (i.e., heritability) and environmental influences. For complex traits (e.g., MDD or depression symptoms), cognitive abilities (e.g., intelligence), and personality traits (e.g., impulsivity), many hundreds or thousands of independent genetic effects are combined together in the total heritability estimate. Similarly, environmental influences typically represent a multitude of factors, from individual life events to specific exposures (e.g., chemicals, etc.). The presence of a genetic or environmental correlation between traits indicates that some set of these influences have an impact on multiple traits. A Displayed using a Venn diagram. Identifying the strength of genetic vs. environmental correlations can be useful in testing theoretical models and pave the way for more complex genetic investigations. Beyond this, gene identification efforts (e.g., genome-wide association studies) and additional analyses of the resulting data can be used to classify whether these associations represent specific genetic influences that affect both traits equally (i.e., genetic pleiotropy ( B )) or whether a genetic influence impacts only one trait which in turn causes changes in the other (i.e., mediated genetic pleiotropy ( C )). Environmental influences can also act pleiotropically or in a mediated-pleiotropy manner, but only genetic influences are displayed for simplicity.

Beyond correlated genetic and environmental influences, music engagement and mental health problems may be associated with one another through direct influences (including causal impacts). This is in line with earlier suggestions that music activities (e.g., after-school programs, music practice) engage adolescents, removing opportunities for drug-seeking behaviors [ 100 ], increasing their social connections to peers [ 101 ], and decreasing loneliness [ 41 ]. Reverse causation is also possible, for example, if experiencing mental health problems causes some individuals to seek out music engagement as a treatment. Longitudinal and genetically informative studies can help differentiate correlated risk factors (i.e., genetic/environmental correlations) from causal effects of music engagement (Fig. 2 , blue arrows) [ 102 ].

Path 2: Engagement with music reduces the impact of genetic risk

Second, genetic and environmental influences may interact with each other to influence a phenotype. For example, individual differences in music achievement are more pronounced in those who engage in practice or had musically enriched childhood environments [ 97 , 98 ]. Thus, music exposures may not influence mental health traits directly but could impact the strength of the association between genetic risk factors and the emergence of trait-level symptoms and/or clinical diagnoses. Such associations might manifest as decreased heritability of trait-level symptoms in musicians vs. non-musicians (upper red arrow in Fig. 2 ). Alternatively, if individuals high in neuroticism use music to help regulate their emotions [ 34 , 35 ], those who are not exposed to music environments might show stronger associations between neuroticism and later depressive symptoms or diagnoses than those engaged with music (lower red arrow in Fig. 2 ). Elucidating these possibilities will help disentangle the complex associations between music and mental health and could be used to identify which individuals would benefit most from a music intervention (especially preventative interventions). Later, we describe some specific study designs that can test hypotheses regarding this gene-environment interplay.

Path 3: Music engagement improves the efficacy of treatment (or acts as a treatment)

For individuals who experience severe problems (e.g., MDD, SUDs), engaging with music may reduce symptoms or improve treatment outcomes. This is the primary goal of most music intervention studies [ 27 , 33 ] (Fig. 2 , gold arrow). However, and this is one of the central messages of this model, it is important to consider interventions in the context of the paths discussed above. For example, if music engagement is genetically correlated with increased risk for internalizing or externalizing problems (Path 1) and/or if individuals at high genetic risk for mental health problems have already been using music engagement to develop strategies to deal with subthreshold symptoms (Path 2), then may be more likely to choose music interventions over other alternatives and find them more successful. Indeed, the beneficial aspects of music training on cognitive abilities appear to be drastically reduced in samples that were randomly sampled [ 103 ]. Therefore, along with other necessary reporting standards discussed above [ 32 , 33 ], it will be useful for studies to report participants’ prior music experience and consider these exposures in evaluating the efficacy of interventions.

Path 4: Music engagement influences brain structure and function

Exploring associations between music engagement and brain structure and function will be necessary to elucidate the mechanisms driving the three paths outlined above. Indeed, there are strong links between music listening and reward centers of the brain [ 104 , 105 ] including the nucleus accumbens [ 106 , 107 ] and ventral tegmental areas [ 108 ] that are implicated in the reward system for all drugs of abuse [ 109 , 110 , 111 , 112 ] and may relate to internalizing problems [ 113 , 114 , 115 ]. Moreover, activity in the caudate may simultaneously influence rhythmic sensorimotor synchronization, monetary reward processing, and prosocial behavior [ 116 ]. Furthermore, music listening may help individuals control the effect of emotional stimuli on autonomic and physiological responses (e.g., in the hypothalamus) and has been shown to induce the endorphinergic response blocked by naloxone, an opioid antagonist [ 18 , 117 ].

This work focusing on music listening and reward processing has not been extended to music making (i.e., active music engagement), though some differences in brain structure and plasticity between musicians and non-musicians have been observed for white matter (e.g., greater fractional anisotropy in corpus callosum and superior longitudinal fasciculus) [ 118 , 119 , 120 , 121 ]. In addition, longitudinal studies have revealed that instrument players show more rapid cortical thickness maturation in prefrontal and parietal areas implicated in emotion and impulse control compared to non-musician children/adolescents [ 122 ]. Importantly, because the existing evidence is primarily correlational, these cross-sectional and longitudinal structural differences between musicians and non-musicians could be explained by genetic correlations, effects of music training, or both, making them potentially relevant to multiple paths in our model (Fig. 2 ). Examining neural correlates of music engagement in more detail will shed light on these possibilities and advance our understanding of the correlates and consequences of music engagement, and the mechanisms that drive the associations discussed above.

New approaches to studying music and mental health

Using our theoretical model as a guide, we next highlight key avenues of research that will help disentangle these music-mental health associations using state-of-the-art approaches. They include the use of (1) genetic designs, (2) neuroimaging methods, and (3) large biobanks of EHRs.

Genetic designs

Genetic designs provide a window into the biological underpinnings of music engagement [ 123 ]. Understanding the contribution of genetic risk factors is crucial to test causal or mechanistic models regarding potential associations with mental health. At the most basic level, twin and family studies can estimate genetic correlations among music ability or engagement measures and mental health traits or diagnoses. Genetic associations can be examined while simultaneously quantifying environmental correlations, as well as evaluating (bidirectional) causal associations, by testing competing models or averaging across different candidate models [ 102 , 124 ], informing Path 1.

By leveraging samples with genomic, music engagement, and mental health data, investigators can also examine whether individuals at higher genetic risk for psychopathology (e.g., for MDD) show stronger associations between music engagement measures and their mental health outcomes (Path 2). As a theoretical example, individuals with low genetic risk for MDD are unlikely to have many depressive symptoms regardless of their music engagement, so the association between depressive symptoms and music engagement may be weak if focusing on these individuals. However, individuals at high genetic risk for MDD who engage with music may have fewer symptoms than their non-musician peers (i.e., a stronger negative correlation). This is in line with recent work revealing the heritability of depression is doubled in trauma exposed compared to non-trauma exposed individuals [ 125 ].

Gene–environment interaction studies using polygenic scores (i.e., summed indices of genetic risk based on genome-wide association studies; GWAS) are becoming more common [ 126 , 127 ]. There are already multiple large GWAS of internalizing and externalizing traits [ 128 , 129 , 130 ], and the first large-scale GWAS of a music measure indicates that music rhythm is also highly polygenic [ 131 ]. Importantly, is not necessary to have all traits measured in the same sample to examine cross-trait relationships. Studies with only music engagement and genetic data, for example, can still examine how polygenic scores for depression predict music engagement, or interact with music engagement measures to predict other study outcomes. Figure 4 displays an example of a GWAS and how it can be used to compute and apply a polygenic score to test cross-trait predictions.

A GWAS are conducted by examining whether individual genetic loci (i.e., single-nucleotide polymorphisms, or SNPs, depicted with G, A, C, and T labels within a sample (or meta-analysis) differentiate cases from controls. The example is based on a dichotomous mental health trait (e.g., major depressive disorder diagnosis), but GWAS can be applied to other dichotomous and continuous phenotypes, such as trait anxiety, musician status, or hours of music practice. Importantly, rather than examining associations on a gene-by-gene basis, GWAS identify relevant genetic loci using SNPs from across the entire genome (typically depicted using a Manhattan plot, such as that displayed at the bottom of A ). B After a GWAS has been conducted on a given trait, researchers can use the output to generate a polygenic score (sometimes called a polygenic risk score) in any new sample with genetic data by summing the GWAS effect sizes for each SNP allele present in a participant’s genome. An individual with a z  = 2.0 would have many risk SNPs for that trait, whereas an individual with z = −2 would have much fewer risk SNPs. C Once a polygenic score is generated for all participants, it can be applied like any other variable in the new sample. In this example, researchers could examine whether musicians are at higher (or lower) genetic risk for a specific disorder. Other more complex analyses are also possible, such as examining how polygenic scores interact with existing predictors (e.g., trauma exposure) or polygenic scores for other traits to influence a phenotype or predict an intervention outcome. Created with BioRender.com.

Finally, longitudinal twin and family studies continue to be a promising resource for understanding the etiology and developmental time-course of the correlates of mental health problems. Such designs can be used to examine whether associations between music and mental health are magnified based on other exposures or psychological constructs (gene-by-environment interactions) [ 132 ], and whether parents engaged with music are more likely to pass down environments that are protective or hazardous for later mental health (gene-environment correlations) in addition to passing on their genes. These studies also provide opportunities to examine whether these associations change across key developmental periods. The publicly available Adolescent Brain Cognitive Development study, for example, is tracking over 10,000 participants (including twin and sibling pairs) throughout adolescence, with measures of music engagement and exhaustive measures of mental health, cognition, and personality, as well as neuroimaging and genotyping [ 133 , 134 ]. Although most large samples with genomic data still lack measures of music engagement, key musical phenotypes could be added to existing study protocols (or to similar studies under development) with relatively low participant burden [ 135 ]. Musical questionnaires and/or tasks may be much more engaging and enjoyable than other tasks, improving volunteers’ research participation experience.

Neuroimaging

Another way to orient the design of experiments is through the exploration of neural mechanisms by which music might have an impact on mental health. This is an enormous, growing, and sometimes fraught literature, but there is naturally a great potential to link our understanding of neural underpinnings of music listening and engagement with the literature on neural bases of mental health. These advances can inform the mechanisms driving successful interventions and inform who may benefit the most from such interventions. We focus on two areas among many: (1) the activation of reward circuitry by music and (2) the impact music has on dynamic patterns of neural activity, both of which are likely vectors for the interaction of music and mental health and provide examples of potential interactions.

Music and reward

The strong effect of music on our emotions has been clearly grounded in its robust activation of reward circuitry in the brain, and motivational and hedonic effects of music listening have been shown to be specifically modulated by dopamine [ 16 , 105 , 136 ]. The prevalence of reward and dopaminergic dysfunction in mental illness makes this a rich area for future studies. For example, emotional responses to music might be used as a substitute for reward circuit deficiencies in depression, and it is intriguing to consider if music listening or music engagement could potentiate such function [ 137 , 138 ].

Music and brain network dynamics

The search for neuronally based biomarkers of aspects of mental illness has been a central thrust within the field [ 139 ], holding promise for the understanding of heterogeneity within disorders and identification of common mechanistic pathways [ 140 ]. A thorough review is beyond the scope of this paper, but several points of contact can be highlighted that might suggest neuro-mechanistic mediators of musical effects on mental health. For example, neurofeedback-directed upregulation of activity in emotion circuitry has been proposed as a therapy for MDD [ 141 ]. Given the emotional effects of music, there is potential for using musical stimuli as an adjuvant, or as a more actively patient-controlled output target for neurofeedback. Growing interest in measures of the dynamic complexity of brain activity in health and disease as measured by magnetic resonance imaging or magneto/electroencephalography (M/EEG) [ 142 ] provides a second point of contact, with abnormalities in dynamic complexity suggested as indicative of mental illness [ 143 ], while music engagement has been suggested to reflect and perhaps affect dynamic complexity [ 144 , 145 ].

The caveats identified in this review apply equally to such neuro-mechanistic studies [ 146 ]. High-quality experimental design (involving appropriate controls and randomized design) has been repeatedly shown to be critical to providing reliable evidence for non-music outcomes of music engagement [ 103 ]. For such studies to have maximal impact, analysis of M/EEG activity not at the scalp level, but at the source level, has been shown to improve the power of biomarkers, and their mechanistic interpretability [ 147 , 148 ]. Moreover, as with genetic influences that typically influence a trait through a multitude of small individual effects [ 149 ], the neural underpinnings of music-mental health associations may be highly multivariate. In the longer term, leveraging large-scale studies and large-scale data standardization and aggregation hold the promise of gleaning deeper cross-domain insights, for which current experimentalists can prepare by adopting standards for the documentation, annotation, and storage of data [ 150 ].

Biobanks and electronic health records

Finally, the use of EHR databases can be useful in quantifying associations between music engagement and mental health in large samples. EHR databases can include hundreds of thousands of records and allow for examination with International Statistical Classification of Diseases and Related Health Problems codes, including MDD, SUD, and schizophrenia diagnoses. This would allow for powerful estimates of music-mental health associations, and exploration of music engagement with other health outcomes.

The principal roadblock to this type of research is that extensive music phenotypes are not readily available in EHRs. However, there are multiple ways to bypass this limitation. First, medical records can be scraped using text-mining tools to identify cases of musician-related terms (e.g., “musician”, “guitarist”, “violinist”). For example, the phenome-wide association study described earlier [ 55 ] compared musician cases and controls identified in a large EHR database through text-mining of medical records and validated with extensive manual review charts. This study was highly powered to detect associations with internalizing and thought disorders (but showed null or protective effects for musicians for SUDs). Many EHR databases also include genomic data, allowing for integration with genetic models even in the absence of music data (e.g., exploring whether individuals with strong genetic predispositions for musical ability are at elevated or reduced risk for specific health diagnosis).

EHRs could also be used as recruitment tools, allowing researchers to collect additional data for relevant music engagement variables and compare with existing mental health diagnoses without having to conduct their own diagnostic interviews. These systems are not only relevant to individual differences research but could also be used to identify patients for possible enrollment in intervention studies. Furthermore, if recruitment for individual differences or intervention studies is done in patient waiting rooms of specific clinics, researchers can target specific populations of interest, have participants complete some relevant questionnaires while they wait, and be granted access to medical record data without having to conduct medical interviews themselves.

Concluding remarks

Music engagement, a uniquely human trait which has a powerful impact on our everyday experience, is deeply tied with our social and cultural identities as well as our personality and cognition. The relevance of music engagement to mental health, and its potential use as a therapeutic tool, has been studied for decades, but this research had not yet cohered into a clear picture. Our scoping review and framework integrated across a breadth of smaller literatures (including extant reviews and meta-analyses) relating music engagement to mental health traits and treatment effects, though it was potentially limited due to the lack of systematic literature search or formal quality appraisal of individual studies. Taken together, the current body of literature suggests that music engagement may provide an outlet for individuals who are experiencing internalizing, externalizing, or thought disorder problems, potentially supporting emotion regulation through multiple neurobiological pathways (e.g., reward center activity). Conducting more rigorous experimental intervention studies, improving reporting standards, and harnessing large-scale population-wide data in combination with new genetic analytic methods will help us achieve a better understanding of how music engagement relates to these mental health traits. We have presented a framework that illustrates why it will be vital to consider genetic and environmental risk factors when examining these associations, leading to new avenues for understanding the mechanisms by which music engagement and existing risk factors interact to support mental health and well-being.

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Acknowledgements

This work was supported by NIH grants DP2HD098859, R01AA028411, R61MH123029, R21DC016710, U01DA04112, and R03AG065643, National Endowment for the Arts (NEA) research lab grants 1863278-38 and 1855526-38, and National Science Foundation grant 1926794. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or National Endowment for the Arts. The authors would like to thank Navya Thakkar and Gabija Zilinskaite for their assistance.

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Gustavson, D.E., Coleman, P.L., Iversen, J.R. et al. Mental health and music engagement: review, framework, and guidelines for future studies. Transl Psychiatry 11 , 370 (2021). https://doi.org/10.1038/s41398-021-01483-8

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Bryan C Hunter, An Introduction to Music Therapy Research, Journal of Music Therapy , Volume 57, Issue 1, Spring 2020, Pages 123–125, https://doi.org/10.1093/jmt/thz016

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From its outset as a profession, music therapists have embraced the importance of research in the development of theory and clinical practice. The first and only committee formed by the nascent National Association for Music Therapy in June 1950 was a research committee chaired by the Rev. Arthur Flagler Fultz ( Boxberger, 1963). His namesake is borne by the current American Music Therapy Association Fultz research grant award.

Given the foundational interest in research, it is somewhat surprising that it took the profession 45 years to publish its own research text for music therapy researchers and educators teaching research, who had been relying on research books from related disciplines. In 1995, editor Barbara Wheeler and publisher Kenneth Bruscia filled the longstanding vacuum with Music Therapy Research: Qualitative and Quantitative Perspectives ( Wheeler, 1995). In 2005, Wheeler revised the work as Music Therapy Research (2nd ed.; Wheeler, 2005). She was joined by associate editor Kathleen Murphy in the most recent 2016 revision Music Therapy Research (3rd ed.; see review by Rickson, 2017).

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Music Therapy in Autism Spectrum Disorder: a Systematic Review

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Individuals with autism spectrum disorder (ASD) can experience difficulties functioning in society due to social communication deficits and restrictive and repetitive behaviors. Music therapy has been suggested as a potential intervention used to improve these deficits in ASD. The current systematic literature review focuses on two methods of music therapy: improvisational music therapy (IMT) and singing/listening to songs. We review the extant literature and the associated methodological limitations, and we propose a framework to assess the effectiveness of music therapy as an intervention in ASD. We suggest the creation of a standardized framework that should utilize neuroimaging tools as an objective marker of changes induced by music therapy as well as a combination of functional and behaviourial outputs, rather than assessment methods addressing a broad range of functional and behavioural outputs, rather than only the main symptoms. The methodological limitations found in the current literature prevent us from making a strong statement about the effects of music therapy in autism. We consider treatment fidelity assessments as the key to successful future attempts to truly understand music therapy effects in ASD.

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Marquez-Garcia, A.V., Magnuson, J., Morris, J. et al. Music Therapy in Autism Spectrum Disorder: a Systematic Review. Rev J Autism Dev Disord 9 , 91–107 (2022). https://doi.org/10.1007/s40489-021-00246-x

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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

• Malak Bleibel 1 ,
• Ali El Cheikh 2 ,
• Najwane Said Sadier 1 , 3 &
• Linda Abou-Abbas   ORCID: orcid.org/0000-0001-9185-3831 1 , 4  

Alzheimer's Research & Therapy volume  15 , Article number:  65 ( 2023 ) Cite this article

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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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Music Therapy and Other Music-Based Interventions in Pediatric Health Care: An Overview

Thomas stegemann.

1 Department of Music Therapy, University of Music and Performing Arts Vienna, 1030 Vienna, Austria; ta.ca.wdm@m-anatems

2 WZMF—Music Therapy Research Centre Vienna, University of Music and Performing Arts Vienna, 1010 Vienna, Austria; ta.ca.wdm@couq-nahp (E.P.Q.); ta.ca.wdm@ldeir (H.R.)

Monika Geretsegger

3 GAMUT—The Grieg Academy Music Therapy Research Centre, NORCE, 5008 Bergen, Norway; on.hcraeserecron@egom

Eva Phan Quoc

Hannah riedl, monika smetana.

Background: In pediatric health care, non-pharmacological interventions such as music therapy have promising potential to complement traditional medical treatment options in order to facilitate recovery and well-being. Music therapy and other music-based interventions are increasingly applied in the clinical treatment of children and adolescents in many countries world-wide. The purpose of this overview is to examine the evidence regarding the effectiveness of music therapy and other music-based interventions as applied in pediatric health care. Methods: Surveying recent literature and summarizing findings from systematic reviews, this overview covers selected fields of application in pediatric health care (autism spectrum disorder; disability; epilepsy; mental health; neonatal care; neurorehabilitation; pain, anxiety and stress in medical procedures; pediatric oncology and palliative care) and discusses the effectiveness of music interventions in these areas. Results: Findings show that there is a growing body of evidence regarding the beneficial effects of music therapy, music medicine, and other music-based interventions for children and adolescents, although more rigorous research is still needed. The highest quality of evidence for the positive effects of music therapy is available in the fields of autism spectrum disorder and neonatal care. Conclusions: Music therapy can be considered a safe and generally well-accepted intervention in pediatric health care to alleviate symptoms and improve quality of life. As an individualized intervention that is typically provided in a person-centered way, music therapy is usually easy to implement into clinical practices. However, it is important to note that to exploit the potential of music therapy in an optimal way, specialized academic and clinical training and careful selection of intervention techniques to fit the needs of the client are essential.

1. Introduction

Music therapy is an evidence and art-based health profession which uses music experiences within a therapeutic relationship to address clients’ physical, emotional, cognitive, and social needs [ 1 ]. A recent worldwide survey among professional members of organizations affiliated with the World Federation of Music Therapy ( n = 2495) revealed that music therapists mainly worked in mental health settings, schools, geriatric facilities, and private practice [ 2 ]. About half of the respondents reported working with children/preteens (50.6%), and teens (45.7%), whereas 38.2% indicated working with infants/children. In the ranking of specific populations served, autism spectrum disorder, developmental disabilities, and depressive disorder are amongst the top three. Although music therapy with children and adolescents constitutes a huge and important part of music therapy practice since the beginnings of the profession, there is a dearth of scientific evidence—particularly when compared to music therapy with adults—and more rigorous research is needed.

The purpose of this overview is to examine the evidence regarding the effectiveness of music therapy and other music-based interventions as applied in pediatric health care.

1.1. Definitions

This overview defines and contrasts three music-based approaches used in health care: music medicine, music therapy, and other music-based interventions (see Figure 1 ).

Types of music-based interventions in health care.

In addition to the definition by the American Music Therapy Association (see above), music therapy (MT) can be described as “a systematic process of intervention wherein the therapist helps the client to promote health, using music experiences and the relationships that develop through them as dynamic forces of change” [ 3 ]. With these tailored music experiences provided by credentialed music therapists, music therapy can be contrasted to interventions which are “categorized as ’music medicine’ when passive listening to pre-recorded music is offered by medical personnel” [ 4 ], especially before, during and/or after medical interventions, and other music-based interventions such as musically-based activities like choir singing or playing drums that are provided by musicians or health professionals other than credentialed music therapists.

In MT, four main methods are usually distinguished which overlap in clinical practice or may be combined: improvising, listening, recreating, and composing [ 5 ]. Depending on the underlying MT model (see Section 1.2 .), the spontaneous creation of music by means of the voice, body, or simple musical instruments may be seen as the ‘via regia’ to the unconscious and may facilitate contact, communication, and emotional expression. Receptive methods (listening to music and responding verbally or in another modality) typically aim to activate or relax a client, to evoke specific body responses, memories, and fantasies, or to stimulate self-knowledge and reflection. Recreating methods encompasses any kind of pre-composed music that the client learns to play or sing. Composition means that the therapist helps the client to create (and to record or perform) music such as instrumental pieces, lyrics, and songs.

1.2. Fields of Application and Music Therapy Approaches

The first documentation of MT in children and adolescents comes from shortly after the Second World War, when pioneers in the USA, and from the late 1950s onwards also in Europe, started to use music for treating mentally ill people within various clinical fields [ 6 ].

Apart from various clinical areas (see Section 3 ), MT for children and adolescents is currently also applied in other health care fields such as chronic illness, as well as in non-medical and community contexts such as schools (special education, prevention) or refugee centers (integration, migration, trauma).

Music therapy is especially indicated when verbal language is not, or only limitedly, available or when music as a non-verbal medium enables access to one’s own feelings in cases where improved processing of emotions may help to decrease symptoms. Music therapy can also help to regulate activity and tension and positively influence mood and motivation. In music interventions, it is not necessary for clients to have any musical background such as musical talent, the ability to play an instrument, or to read music; it is one’s individual engagement with the music experience which is a key factor.

Functional and behavioristic approaches typically use the activating or relaxing effects of music for stimulation or calming, and to enhance learning of specific skills and behaviors. Humanistic approaches (represented by pioneers such as Juliette Alvin [ 7 ], or Paul Nordoff and Clive Robbins [ 8 ]) emphasize creativity and expression of the self within improvisational music making and the development of positive relationships by allowing the child to find his or her own musical way without fixed rules. Analytically-oriented MT (pioneered by Mary Priestley [ 9 ]) employs the symbolic content of improvised music in order to connect with emotions, thoughts, images, or bodily sensations that cannot be verbalized.

In addition to individual and group therapy settings, family-based approaches have been increasingly used in MT with children and adolescents within the last couple of years [ 10 ].

To evaluate the current evidence for the effectiveness of MT, music medicine, and other music-based interventions in selected fields of pediatric health care, we conducted database searches for systematic reviews published within the last five years (November 2013 to October 2018) using PubMed/Medline, Cinahl, PsycINFO, Scopus, and Web of Science. The following search terms were used: (1) music therapy/music intervention/music-based intervention or arts-based therapy combined with (2) children/pediatrics and with (3) respective fields of application as listed in Section 3 of this article. Based on screening of titles and abstracts, we retrieved eligible systematic reviews. We included those systematic reviews where full-texts were available in English. Findings from systematic reviews and meta-analyses are briefly presented along with a descriptions of assumed working mechanisms and specific goals of music interventions in the Results section.

Included articles were assessed regarding their quality and validity using AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews) guidelines [ 11 ]. AMSTAR 2 is a critical appraisal tool for systematic reviews that include randomized or non-randomized studies of healthcare interventions, or both. It includes 16 items on domains such as “adequacy of the literature search”, “justification for excluding individual studies”, “appropriateness of meta-analytical methods”, and “consideration of risk of bias when interpreting the results of the review”. Based on a scheme for interpreting weaknesses detected in critical and non-critical items, the overall confidence in the results of the review can then be categorized as “high”, “moderate”, “low”, or “critically low”. All of the systematic reviews and meta-analyses included in our overview were assessed and rated independently by two of the authors. Any disagreements were discussed further in order to reach mutual consent between the two authors.

We included a total of 13 systematic reviews/meta-analyses—published within the last five years—across the following fields of pediatric health care (in alphabetical order; in parentheses; number of systematic reviews included): autism spectrum disorder (2); disability (1); epilepsy (1); mental health (2); neonatal care (3); neurorehabilitation (1); pain, anxiety, and stress in medical procedures (2); pediatric oncology and palliative care (1). Key characteristics of the studies and an assessment of quality according to the AMSTAR 2 guidelines are summarized in Table 1 .

Key characteristics and ratings of overall confidence in the results (based on AMSTAR 2) of included systematic reviews.

* MT = music therapy; MM = music medicine; MBI = other music-based interventions. 1 In some of the included studies, the numbers of participants were not indicated or unclear. 2 In two of the nine publications [ 35 , 36 ], adolescent patients were studied (total n = 82). 3 Number of infant participants; in addition, 286 parent participants were included. 4 According to the selection criteria of the review, “studies that included people older than 16 years of age” were examined; based on the information given in the review it is not possible to indicate how many adolescents were included; most of the studies report a mean age > 50 years of age. 5 Eight of the 50 studies involved pediatric participants (total n = 705). 6 Five of the 52 publications were conducted in pediatric patients (total n = 201).

3.1. Autism Spectrum Disorders

Music therapy has been applied in the field of autism since the mid-1940s [ 12 ]. The latest update of a Cochrane review on music therapy for people with autism spectrum disorders (ASD) [ 13 ] summarizes results from 10 studies examining the short- and medium-term effect of MT interventions (one week to seven months) with a total of 165 participants who were all between two and nine years of age. Findings provide evidence for moderate to large effects of MT as compared to ‘placebo’ therapy or standard care in outcome areas constituting the core of the condition such as social interaction, non-verbal communicative skills, initiating behavior, and social–emotional reciprocity. Music therapy may also help to improve verbal communication, social adaptation, joy, and the quality of parent–child relationships. Due to low numbers of study participants and other study design issues, the quality of the evidence was assessed as moderate to low. Therefore, the review authors suggest that future studies need to be larger, more rigorous, and should also evaluate outcomes for people with ASD above nine years of age. Based on AMSTAR 2 criteria, the confidence in these results can be assessed as “high” (i.e., the SR provides an accurate and comprehensive summary of the results of the available studies).

Another meta-analysis that focused on randomized controlled trials (RCTs) published in Chinese [ 14 ] also came to favorable conclusions regarding MT for ASD, but only reached a rating of “low” confidence according to AMSTAR 2 (i.e., it has a critical methodological flaw and may not provide an accurate and comprehensive summary of the available studies). Summarizing the findings of six studies with a total of 300 children with autism, the authors found significant effects of MT (six weeks to three months) as compared to other forms of therapy on mood, language, sensory perception, behavior, and social skills. The risk of bias for all six included studies was assessed as moderate.

The potential of MT as an intervention within ASD, where difficulties with social interaction and communication are at the core by definition, is explained by processes that naturally occur in musical interactions within the relationship between client and therapist, where music is used as an expressive and communicative means. Behaviors necessary for social engagement such as joint attention, eye contact, and turn-taking are characteristic events in shared, active music making and therefore inherent components of MT processes. Structures in improvised or pre-composed music also provide opportunities to experience both predictability and flexibility, and attention and enjoyment typically increase in individuals when presented with musical as opposed to verbal stimuli. Music therapy for individuals with ASD is often provided as individual therapy, but there are also group-based, peer-mediated and family-based forms [ 13 ].

3.2. Disability

In MT, work with children and adolescents with disabilities is one of the traditional fields of application [ 6 ]. Children with ASD, trisomy 21, Rett syndrome, or Williams syndrome are known to be very responsive to music listening and musical activities. Thus, MT is applied for assessment as well as for fostering communication, social competencies, emotional regulation, and motor skills [ 15 , 16 ]. Although MT is a quite common approach in special education, there is still a dearth of research, in particular with respect to effectiveness studies.

Only one SR met our inclusion criteria [ 17 ]. This publication on “music research in inclusive school settings” covered the period from 1975 to 2013 and found evidence that music-based interventions in preschool settings positively influence reading/literacy outcomes in children with and without disabilities. Due to the high level of heterogeneity in study methodologies and outcomes, no other summary statements could be made. As a conclusion, the authors stress the necessity to conduct more studies in inclusive music settings. Due to several critical flaws in the review, the confidence in its results was rated as “critically low” according to AMSTAR 2 criteria, which means that it should not be relied upon to provide an accurate and comprehensive summary of the included studies.

3.3. Epilepsy

Musicogenic epilepsy, i.e. epileptic seizures induced by music, has been known of since at least the late 1930s, as Oliver Sacks mentions in his book “Musicophilia” [ 18 ]. At the same time, music has the potential to reduce seizure activity: “The dichotomous effect of music on seizures may be explained by modification of dopaminergic circuitry or counteractive cognitive and sensory input in ictogenesis” [ 19 ]. In a recent systematic review [ 20 ], eight publications were identified in which the influence of music by W.A. Mozart on seizures in children was studied. Although there is some substantial and serious doubt about the existence of a ‘Mozart effect’ as such, classical pieces of the ‘Wunderkind’ are still very popular stimuli in this type of research. Noteworthily, seven of the eight included studies were from the same research group in Taiwan. Brackney and Brooks [ 20 ] summarize their findings: “The evidence for the efficacy of the Mozart Effect on seizure activity in children is promising but not conclusive”. According to AMSTAR 2 criteria, the confidence in the systematic review’s results is rated as “critically low”. Seven of the studies were classified as “quasi-experimental”. In the only RCT [ 21 ], the treatment group ( n = 24) listened to Mozart’s sonata for two pianos in D major K.448 daily before bedtime for six months, while the control group ( n = 24) received treatment as usual (patients were between 8 and 13 years of age). Results showed that during the follow-up period of approximately one and a half years on average, eight of the 22 patients in the treatment group suffered seizure recurrence, while 18 of the 24 patients in the control group had seizure recurrence. Further, significant decreases in epileptiform discharges after one, two, and six months compared with EEGs before listening to music have been observed in the treatment group.

3.4. Mental Health

Mental health care for children and adolescents is one of the main clinical fields of music therapists. Music therapy with children and adolescents can include active methods such as improvisation or working with songs (song writing, performing of pre-composed songs) as well as receptive methods such as listening to pre-recorded music [ 5 ].

A Cochrane review on music therapy for depression [ 22 ]—for which the AMSTAR 2 level of confidence in the results was rated as “high”—included nine RCTs (total n = 421), of which two studied the effectiveness of “music therapy techniques” in high school students [ 23 , 24 ]. However, as it was not clear whether a trained music therapist was providing the interventions [ 22 ], these studies are categorized as music-based intervention studies according to our definitions provided above. Findings from these two studies suggest that the group music intervention in comparison to cognitive behavioral therapy is significantly more effective as measured by self-rating (Beck Depression Inventory).

The findings of a recent meta-analysis [ 25 ] on different music-based interventions (including MT, music medicine, and other music-based interventions) to reduce internalizing symptoms in children and adolescents also suggest that these interventions are beneficial, but due to a relatively small sample size (only five trials with a combined sample size of n = 100), the authors draw these implications with caution. The confidence in the results according to AMSTAR 2 criteria was estimated as “low”.

3.5. Neonatal Care

Music therapy and music interventions are of growing importance in neonatal intensive care units (NICUs) as documented by two recent publications: a systematic review of RCTs on various music-based interventions by van der Heijden and colleagues [ 26 ], and a meta-analysis on music therapy for infants and their parents by Bieleninik, Ghetti, and Gold [ 27 ]. Progress in medicine and new technical developments allow for higher survival rates in preterm newborns. However, the survival of preterm babies who are more premature and vulnerable also calls for better and more efficient integrated care as early as possible. This explains why there is a growing awareness for environmental factors influencing the newborn’s health and well-being, e.g. acoustic stimuli in the NICU. Van der Heijden and colleagues state: “Where unpredictable noise adversely affects sleep and physiologic stability, meaningful auditory stimulation, such as music, might contribute to the neurodevelopment of premature infants” [ 26 ].

Summarising the main findings of the two reviews—based on RCTs only, and both assessed as justifying “moderate” confidence in their findings according to AMSTAR 2 (i.e., they include weaknesses, but no critical flaws, so that they may provide an accurate summary of the results of included studies)—MT and other music-based interventions in NICUs lead to a reduction in heart and respiratory rate, improve the infant’s sleep and food intake, and reduce the anxiety of mothers [ 26 , 27 ]. Interestingly, not only from an economical point of view, a recent systematic review of RCTs [ 28 ] found that length of stay can be significantly reduced through music therapy interventions. In addition, O’Toole et al. [ 28 ] reported that music medicine interventions yield positive effects of pain management in preterm infants. However, the confidence in this review’s results had to be rated as “critically low” according to AMSTAR 2 criteria due to several critical flaws in its methodology.

Regardless of whether live or pre-recorded music is played, the ‘golden rules’ of music interventions in the NICU are “less is more”, and “minimal change, minimal range”. The former being true for duration and the number of musical instruments used, the latter applies to all musical parameters: “minimal change” in rhythm, harmony, dynamics, and volume, and “minimal range” in melody and pitch range—“like a lullaby” [ 29 ]. Thus, in live interventions, music therapists primarily use their voice (infant directed singing), accompanied maybe by a harp, a guitar or a small percussion instrument. For recorded acoustic interventions, music or the mother’s voice is played softly through loudspeakers inside or outside of the incubator.

3.6. Neurorehabilitation

A recent Cochrane review on MT for acquired brain injury came to the following conclusion: “The results suggest that music interventions using rhythm may be beneficial for improving walking in people with stroke, and this may improve quality of life. (…) Music interventions that use a strong beat within music may be more effective than interventions where a strong beat is used without music. Treatment delivered by a trained music therapist might be more effective than treatment delivered by other professionals” [ 30 ]. The quality of the evidence was assessed as “generally low” by the review authors [ 30 ]. The confidence in these results can be assessed as “high” based on AMSTAR 2 criteria. In the context of our focus on pediatric health care, it has to be noted however that it was not possible to determine the number of adolescents who were included based on the information given in the review. According to the selection criteria of the review, “studies that included people older than 16 years of age” were examined. Most of the studies report a mean age of more than 50 years of age, so the applicability of the review’s results to children and adolescents remains unclear.

3.7. Pain, Axiety, and Stress in Medical Procedures

A systematic review by Yinger and Gooding [ 31 ] on music-based interventions for procedural support identified 50 studies meeting the inclusion criteria, but only eight of them included children and adolescents. The confidence in the results of this systematic review according to AMSTAR 2 criteria was rated as “moderate”, i.e., it includes weaknesses, but no critical flaws, so that it may provide an accurate summary of the results of included studies. The authors came to the conclusion that the majority of studies (84%) were at high risk of bias and revealed limitations in adequate intervention reporting. Interestingly, two of the eight studies with a low or moderate risk of bias were music therapy studies involving pediatric participants [ 32 , 33 ], with significant effects for the reduction of pain and anxiety.

In a systematic review from 2016, Kim and Stegemann [ 34 ] searched the literature of the last 35 years with regard to music listening as an intervention for children and adolescents. The authors identified 36 studies of which 18 were from the field of pediatrics, encompassing 12 studies with pediatric patients undergoing either surgery or needle insertion procedures. Accordingly, pain, anxiety, and stress were the main outcome measures.

Pain perception in the context of medical procedures was investigated in 12 RCTs, of which nine found a significant decrease of pain in the music condition compared to the non-music condition or treatment as usual. In most of the studies, the music condition included recorded music (e.g., lullabies, classical music, pop) presented via loudspeaker or earphones. The largest effect sizes were reported in a study by Nguyen and colleagues [ 35 ] who investigated the reduction of pain and anxiety in children with cancer undergoing lumbar puncture (LP). Pain, heart and respiratory rates were significantly reduced in the music group during and after the LP (pain reduction: d = 1.53 (huge effect) during and d = 1.08 (large effect) after the LP).

Besides pain, anxiety plays a major role as a stressor for children in medical procedures. The effect of music listening in reducing anxiety was measured in 11 studies, of which seven favored the music condition while four studies found no significant difference between groups. Effect sizes for anxiety reduction ranged between d = 0.61 (medium effect) and d = 1.5 (huge effect). Kristjánsdóttir and Kristjánsdóttir [ 36 ] studied the effect of a specific music medicine intervention (a musical distraction strategy) in adolescents receiving immunization. They found the odds of participants experiencing “no pain” during the immunization if listening to music to be approximately 2.8 times higher than those of participants receiving standard nursing care. The authors concluded that musical distraction, pre-immunization fear and anxiety, and expected immunization pain were significant predictors of adolescent immunization pain sensation.

The effects of music listening on stress perceived by children and adolescents during painful medical procedures were measured by observational parameters (e.g., video analysis) as well as physiological parameters (e.g., heart rate, blood pressure, respiratory rate). The majority of the studies (four out of seven) were in favor of the music condition, while the other three studies found no significant differences. Results of an earlier RCT by Malone [ 37 ] who used live music interventions with children in a preoperative setting revealed that participants in the music condition showed significantly shorter duration of stress signs with a large effect size ( d = 1.01).

Only two of the 36 studies reviewed by Kim and Stegemann [ 30 ] were categorized as “relatively low risk of bias”; both of these studies [ 35 , 38 ] showed strong results in favor of the music medicine intervention. The confidence in the results of this systematic review by Kim and Stegemann [ 30 ] according to AMSTAR 2 criteria was also rated as “moderate”.

3.8. Pediatric Oncology and Palliative Care

In several countries, music therapy services are well-established in the field of pediatric oncology, and some treatment guidelines include creative arts therapies for this specific client population, as for instance in Germany [ 39 ]. Music therapists in pediatric oncology and palliative care have to deal with various somatic and psychological symptoms of their patients and often, therapy is provided for children together with their family members. Due to ethical concerns and feasibility issues regarding such vulnerable times in life, RCTs are scarce in this field, particularly within palliative care.

A Cochrane review by Bradt and colleagues [ 40 ]—for which the AMSTAR 2 level of confidence in the results was assessed as “high”—on music interventions for improving psychological and physical outcomes in cancer patients included studies with children, but only five of the 52 reviewed studies were conducted in pediatric fields. Outcomes of these studies varied from impact on immune system functioning [ 41 ] through to anxiety and pain management [ 35 , 42 ] and children´s coping behavior [ 43 , 44 ]. Due to the low number of studies in pediatrics, no overall conclusions were drawn. Findings from single studies indicate some benefits of MT and music-based interventions, particularly on anxiety, pain, and coping behaviors.

4. Discussion

According to the results from systematic reviews and meta-analyses, the evidence for the effectiveness of music therapy and other music-based interventions in areas relevant to pediatric health care can be summarized as displayed in Table 2 .

Summary of findings regarding evidence for the effectiveness of music therapy (MT), music medicine (MM) and other music-based interventions (MBI) in selected fields of applications relevant to pediatric health care.

Music therapy (MT) and other music-based interventions are applied and have shown to be beneficial in a broad variety of fields and seem effective especially in combination with other treatment forms and within a multimodal therapy approach—but they are certainly not the ‘magic bullet’ working for everyone at any time.

The growing body of evidence for MT and other music-based interventions (including music medicine) in childhood and adolescence indicates that MT is particularly effective in improving mood and affect regulation, communication, social skills, and quality of life; music medicine approaches are successfully applied in medical settings to alleviate pain, anxiety, and stress. As documented by meta-analyses, the best evidence regarding the effectiveness of MT today is reported in neonatal care and in children with autism spectrum disorders. In other fields, especially in children with disabilities, there is a clear need for more and better-quality research—which is of course not only a challenge for MT but holds true for medical and special education interventions in childhood and adolescence in general.

“Where words fail, music speaks”, as the writer Hans Christian Andersen put it. Thus, music-based interventions can open doors, especially for people who are not capable of communicating through spoken language. The communication beyond words is a unique feature of arts therapies such as MT—this may be one reason why MT works in NICUs and for people with ASD.

Music therapy can be considered a safe and generally well-accepted intervention in pediatric health care to alleviate symptoms and improve quality of life. None of the included systematic reviews reported adverse effects of music-based interventions for children and adolescents. This is in line with the findings of a study on the acceptance of specific complementary and alternative medicine modalities, where acceptance was highest for music therapy [ 45 ].

As an individualized intervention that is typically provided in a person-centered way, music therapy is usually easy to implement into clinical practices. In addition, it is important to note that to exploit the potential of music therapy in an optimal way, specialized academic and clinical training and careful selection of intervention techniques to fit the client’s needs are essential. More rigorous research on MT, music medicine, and other music-based interventions is still needed to determine what types of interventions work best for whom and under which circumstances.

Author Contributions

T.S. took the initiative for the study and coordinated study activities; T.S., M.G., and M.S. developed the concept and methodology; H.R. and E.P.Q. helped to revise the concept and methodology; T.S., M.G., and M.S. drafted the initial manuscript; H.R. and E.P.Q. conducted literature searches and helped in revising the manuscript. M.S., H.R., and E.P.Q. rated the systematic reviews according to AMSTAR 2 criteria. All authors extracted and analyzed data from eligible search results, summarized and interpreted findings, and approved the final version of the manuscript.

This research received no external funding.

Conflicts of Interest

The authors declare that the article was written in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All authors are clinically trained music therapists.

Music Therapy: A Useful Therapeutic Tool for Health, Physical and Mental Growth

• October 2017
• 2(1-2/2012)

• SMP GOVT.Girls P.G.COLLEGE,Madavpuram Meerut UP India

• Department of Higher Education Uttar Pradesh

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