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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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Pothoulaki, M., MacDonald, R., and Flowers, P. (2012). An interpretative phenomenological analysis of an improvisational music therapy program for cancer patients. J. Music Ther. 49, 45–67. doi: 10.1093/jmt/49.1.45

Sakamoto, M., Ando, H., and Tsutou, A. (2013). Comparing the effects of different individualized music interventions for elderly individuals with severe dementia. Int. Psychogeriatr. 25, 775–784. doi: 10.1017/s1041610212002256

Shimizu, N., Umemura, T., Matsunaga, M., and Hirai, T. (2018). Effects of movement music therapy with a percussion instrument on physical and frontal lobe function in older adults with mild cognitive impairment: a randomized controlled trial. Aging Ment. Health 22, 1614–1626. doi: 10.1080/13607863.2017.1379048

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Ueda, T., Suzukamo, Y., Sato, M., and Izumi, S. (2013). Effects of music therapy on behavioral and psychological symptoms of dementia: a systematic review and meta-analysis. Ageing Res. Rev. 12, 628–641. doi: 10.1016/j.arr.2013.02.003

Wang, X. Q., Peng, M. S., Weng, L. M., Zheng, Y. L., Zhang, Z. J., and Chen, P. J. (2019). Bibliometric study of the comorbidity of pain and depression research. Neural. Plast 2019:1657498. doi: 10.1155/2019/1657498

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

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

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

Reviewed by:

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

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

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

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

Impact of Music on Mental Health

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Learning More About Music Therapy

Amta published journals.

The American Music Therapy Association produces two scholarly journals where research in music therapy is published and shared:

• The Journal of Music Therapy is published by AMTA as a forum for authoritative articles of current music therapy research and theory. Articles explore the use of music in the behavioral sciences and include book reviews and guest editorials. An index appears in issue 4 of each volume.
• Music Therapy Perspectives is designed to appeal to a wide readership, both inside and outside the profession of music therapy. Articles focus on music therapy practice, as well as academics and administration.

Subscriptions to these journals, downloadable articles, and a limited number of open access articles are available on each respective journal's webpage (click the links above for more information).

AMTA Publications Catalog

AMTA publishes a number of monographs, textbooks and other resources about the profession of music therapy.  Please see our online bookstore for a complete listing of publications and products available.  Use the menu items to navigate to Bookstore>Visit the Bookstore.  Then you may choose to Shop for "Merchandise," Select Category, "Publications" and "Go" for a complete list of publications available.   Or click this link for the complete list of AMTA Publications.

Numerous databases are available that index and list citations and abstracts to journal articles on music therapy. Some of these databases include links to full text copies (usually for a fee) or provide article retrieval services through your local library (fees vary). Public university open access libraries generally allow persons to enter the library and conduct database searches on their computer terminals on site.

National Library of Medicine: MEDLINE

The Journal of Music Therapy is indexed in the MEDLINE database (NLM ID 0014162) sponsored by the National Library of Medicine (NLM). MEDLINE is the NLM's major bibliographic database covering the fields of medicine, nursing, dentistry, veterinary medicine, the health care system, and the preclinical sciences.  MEDLINE contains bibliographic citations and author abstracts from more than 4,800 biomedical journals published in the United States and 70 other countries. The database contains over 12 million citations dating back to the 1960’s. MEDLINE is searched through NLM’s search and browser tools called Entrez, a text-based search and retrieval system.

National Library of Medicine:  PUBMED

Also at NLM is PUBMED. PubMed is a service that includes over 16 million citations from MEDLINE and other life science journals for biomedical articles back to the 1950s. PubMed includes links to some full text articles and other related resources.

10 Tips for Researching Music Therapy

AMTA works tirelessly to advocate for music therapy and support the most up-to-date information in music therapy research.  To help your research of music therapy, take a look at these top tips and hacks to use:

• PUBMED is free:  PUBMED comprises more than 26 million citations for biomedical literature from MEDLINE, life science journals, and online books.  www.ncbi.nlm.nih.gov/pubmed
• Research database search - Know Your Boolean Operators:  While using PUBMED or other research databases, Boolean Operators are used to connect and define the relationship between search terms.  Use the connectors  AND, OR, NOT  to combine search terms.  Using AND indicates that all words must be found in the results (ex. music therapy AND premature AND infants), using OR indicates that at least one of the terms provided must be found in the results (ex. preterm OR premature), and NOT excludes results containing a particular term (ex. flute NOT piccolo).
• Research database search - Phrase Searching:  Use quotation marks around keyword phrases to indicate that these words be searched as a phrase, in the exact order you type them. Ex. “music therapy” OR “music-based interventions” will provide results with both of these exact phrases.
• Journal of Music Therapy  and  Music Therapy Perspectives  journal archives:  AMTA provides FREE access to all Journal of Music Therapy and Music Therapy Perspectives issues and archives to current members.  Login on the AMTA website and use the member access portal for the desired journal (Research>Music Therapy Journals & Publications) to access this content as a benefit of membership in AMTA.  For non-members, many libraries provide free access to these journals through their consortium programs.  Otherwise, you can browse abstracts for free and purchase single articles for download or subscribe to the whole year of issues. For more on music therapy journals and publications,  see our journals page.
• Citation Managers:  Is organizing your research articles becoming overwhelming?  Consider using Citation Manager software like Zotero, EndNote, or Mendeley
• Style Guides:  Need to write, reference, and/or cite using a specific style guide?  The online guides at the Purdue Owl offers APA, MLA, and Chicago style guides:  https://owl.english.purdue.edu/owl/section/2/
• Take a look at Arizona State University’s quick guide for PICOT examples:  http://libguides.asu.edu/c.php?g=263769&p=1762014
• Or take a look at this template to help create a PICOT question:  https://www.aaacn.org/sites/default/files/documents/misc-docs/1e_PICOT_Questions_template.pdf  
• Duke University library:  http://guides.mclibrary.duke.edu/c.php?g=158201&p=1036002
• Evidence-Based Behavioral Practice:  http://www.ebbp.org/
• JMT Instagram ( https://www.instagram.com/AMTA_JMT/ )
• JMT Twitter ( https://twitter.com/AMTA_JMT )
• MTP Twitter account ( https://twitter.com/AMTA_MTP )
• MTP releases periodic podcasts on the journal’s homepage ( https://academic.oup.com/mtp ).
• JMT and MTP joint facebook page: ( https://www.facebook.com/AMTAresearch/ )
• You are invited to follow, like, and share updates posted to the JMT and MTP Twitter, Instagram, blog, and Facebook accounts, and are encouraged to follow and use the hashtags #mtresearch, #AMTA_JMT, and #AMTA_MTP
• Post the article citation and the journal club discussion questions prior to each meeting.
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• Invite guests for special topics now and then.
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• DOI: 10.54097/ydnn6c74
• Corpus ID: 270647386

Application Of Orff Music Pedagogy in College Music Education

• Chunlei Zeng
• Published in Journal of Education… 1 April 2024

5 References

Music asylums: wellbeing through music in everyday life, computational systems for music improvisation, advanced competencies in music therapy, related papers.

Showing 1 through 3 of 0 Related Papers

• Introduction
• Conclusions
• Article Information

MRI indicates magnetic resonance imaging.

A, Shading indicates standard error. B, Dots represent individual participants; thick lines represent the group mean. C, Percentage of patients reporting pain scores of 0 or 1 of 10 (ie, pain-free or nearly pain-free) at posttreatment and at 1-year follow-up. PRT indicates pain reprocessing therapy.

A, Error bars show standard error. B, Coordinates and statistics for activations provided in eTable 7 in Supplement 2 ; analyses conducted within a mask of regions of interest; eFigure 1 in Supplement 2 . C, Decreased evoked pain-related activity was observed in anterior midcingulate (aMCC) and anterior prefrontal regions for PRT vs placebo and left anterior insula for PRT vs usual care. D, Error bars show standard error. E, PRT vs control conditions increased aPFC-seeded (red clusters) and aIns-seeded (green clusters) connectivity with primary somatosensory cortex (permutation test, P  < .05). Inset shows seed regions, derived from evoked pain analyses; magenta outlines, PRT vs placebo; black outlines, PRT vs usual care. F, PRT vs usual care increased connectivity between an aMCC seed (yellow; derived from evoked back pain analyses) and the precuneus (orange). Connectivity analyses were conducted within primary somatosensory cortex and medial default mode network masks.

a P  < .001.

b P  < .05.

Trial protocol

eDiscussion

eTable 1. Spinal anomalies among participants randomized to PRT

eTable 2. Treatment response rates

eTable 3. Secondary clinical outcomes measured only at pretreatment and posttreatment

eTable 4. Treatment satisfaction and patient global impression of change

eTable 5. Mediation results

eTable 6. Values for mediators at each timepoint

eTable 7. Evoked back pain localizer results

eTable 8. Regions showing pretreatment to posttreatment connectivity changes for PRT vs placebo or PRT vs usual care

eFigure 1. Evoked back pain localizer

eFigure 2. Target masks for seed connectivity analyses

eFigure 3. Individual trajectories of pain intensity for participants in the PRT, placebo and usual care groups

eFigure 4. Effects of PRT on pain-related fear and avoidance and beliefs that pain indicates injury

eFigure 5. Evoked back pain at pretreatment

eFigure 6. High vs low thumb pressure stimulation

eFigure 7. Histogram of quality control-functional connectivity correlations for spontaneous pain scans

eFigure 8. Continuous pain regressors for 4 randomly chosen sample individuals

eAppendix 1. Initial medical pain assessment and education session

eAppendix 2. Pain reprocessing therapy description

eAppendix 3. PRT treatment fidelity checklist

eReferences

Data sharing statement.

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Ashar YK , Gordon A , Schubiner H, et al. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain : A Randomized Clinical Trial . JAMA Psychiatry. 2022;79(1):13–23. doi:10.1001/jamapsychiatry.2021.2669

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Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain : A Randomized Clinical Trial

• 1 Department of Psychiatry, Weill Cornell Medical College, New York City, New York
• 2 Department of Psychology and Neuroscience, University of Colorado, Boulder
• 3 Institute of Cognitive Science, University of Colorado, Boulder
• 4 Pain Psychology Center, Los Angeles, California
• 5 Ascension Providence Hospital, Southfield, Michigan
• 6 Michigan State University College of Human Medicine, East Lansing
• 7 Panorama Orthopedics and Spine Center, Golden, Colorado
• 8 Department of Psychology, Northwestern University, Evanston, Illinois
• 9 Department of Philosophy, Washington University in Saint Louis, Saint Louis, Missouri
• 10 Johns Hopkins University Department of Biostatistics, Baltimore, Maryland
• 11 Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts
• 12 Department of Psychology, Emory University, Atlanta, Georgia
• 13 Renée Crown Wellness Institute, University of Colorado, Boulder
• 14 Department of Psychology, Wayne State University, Detroit, Michigan
• 15 Department of Psychological and Brain Sciences, Dartmouth College, Hanover, New Hampshire

Question   Can a psychological treatment based on the reappraisal of primary chronic back pain as due to nondangerous central nervous system processes provide substantial and durable pain relief?

Findings   In this randomized clinical trial, 33 of 50 participants (66%) randomized to 4 weeks of pain reprocessing therapy were pain-free or nearly pain-free at posttreatment, compared with 10 of 51 participants (20%) randomized to placebo and 5 of 50 participants (10%) randomized to usual care, with gains largely maintained through 1-year follow-up. Treatment effects on pain were mediated by reduced beliefs that pain indicates tissue damage, and longitudinal functional magnetic resonance imaging showed reduced prefrontal responses to evoked back pain and increased resting prefrontal-somatosensory connectivity in patients randomized to treatment relative to patients randomized to placebo or usual care.

Meaning   Psychological treatment focused on changing beliefs about the causes and threat value of primary chronic back pain may provide substantial and durable pain relief.

Importance   Chronic back pain (CBP) is a leading cause of disability, and treatment is often ineffective. Approximately 85% of cases are primary CBP, for which peripheral etiology cannot be identified, and maintenance factors include fear, avoidance, and beliefs that pain indicates injury.

Objective   To test whether a psychological treatment (pain reprocessing therapy [PRT]) aiming to shift patients’ beliefs about the causes and threat value of pain provides substantial and durable pain relief from primary CBP and to investigate treatment mechanisms.

Design, Setting, and Participants   This randomized clinical trial with longitudinal functional magnetic resonance imaging (fMRI) and 1-year follow-up assessment was conducted in a university research setting from November 2017 to August 2018, with 1-year follow-up completed by November 2019. Clinical and fMRI data were analyzed from January 2019 to August 2020. The study compared PRT with an open-label placebo treatment and with usual care in a community sample.

Interventions   Participants randomized to PRT participated in 1 telehealth session with a physician and 8 psychological treatment sessions over 4 weeks. Treatment aimed to help patients reconceptualize their pain as due to nondangerous brain activity rather than peripheral tissue injury, using a combination of cognitive, somatic, and exposure-based techniques. Participants randomized to placebo received an open-label subcutaneous saline injection in the back; participants randomized to usual care continued their routine, ongoing care.

Main Outcomes and Measures   One-week mean back pain intensity score (0 to 10) at posttreatment, pain beliefs, and fMRI measures of evoked pain and resting connectivity.

Results   At baseline, 151 adults (54% female; mean [SD] age, 41.1 [15.6] years) reported mean (SD) pain of low to moderate severity (mean [SD] pain intensity, 4.10 [1.26] of 10; mean [SD] disability, 23.34 [10.12] of 100) and mean (SD) pain duration of 10.0 (8.9) years. Large group differences in pain were observed at posttreatment, with a mean (SD) pain score of 1.18 (1.24) in the PRT group, 2.84 (1.64) in the placebo group, and 3.13 (1.45) in the usual care group. Hedges g was −1.14 for PRT vs placebo and −1.74 for PRT vs usual care ( P  < .001). Of 151 total participants, 33 of 50 participants (66%) randomized to PRT were pain-free or nearly pain-free at posttreatment (reporting a pain intensity score of 0 or 1 of 10), compared with 10 of 51 participants (20%) randomized to placebo and 5 of 50 participants (10%) randomized to usual care. Treatment effects were maintained at 1-year follow-up, with a mean (SD) pain score of 1.51 (1.59) in the PRT group, 2.79 (1.78) in the placebo group, and 3.00 (1.77) in the usual care group. Hedges g was −0.70 for PRT vs placebo ( P  = .001) and −1.05 for PRT vs usual care ( P  < .001) at 1-year follow-up. Longitudinal fMRI showed (1) reduced responses to evoked back pain in the anterior midcingulate and the anterior prefrontal cortex for PRT vs placebo; (2) reduced responses in the anterior insula for PRT vs usual care; (3) increased resting connectivity from the anterior prefrontal cortex and the anterior insula to the primary somatosensory cortex for PRT vs both control groups; and (4) increased connectivity from the anterior midcingulate to the precuneus for PRT vs usual care.

Conclusions and Relevance   Psychological treatment centered on changing patients’ beliefs about the causes and threat value of pain may provide substantial and durable pain relief for people with CBP.

Trial Registration   ClinicalTrials.gov Identifier: NCT03294148 .

Chronic pain affects 20% of people in the US, with an estimated annual cost of more than $600 billion. 1 , 2 The most common type is chronic back pain (CBP). In approximately 85% of cases, definitive peripheral causes of CBP cannot be identified, and central nervous system processes are thought to maintain pain. 3 - 7 For people with this type of CBP— often referred to as primary, nonspecific, nociplastic, or centralized pain—psychological and behavioral treatments are recommended. 8 - 10 Although these treatments can improve functioning, reductions in pain intensity are limited 11 , 12 and better treatments are needed.

Quiz Ref ID Advances in the neuroscience of pain 13 - 17 and interoception 18 - 21 suggest new directions for treatment development. In constructionist and active inference models, pain is a prediction about bodily harm, shaped by sensory input and context-based predictions. 18 , 19 , 22 - 26 Fearful appraisals of tissue damage can cause innocuous somatosensory input to be interpreted and experienced as painful. 22 , 24 , 27 , 28 Such constructed perceptions can become self-reinforcing: threat appraisals enhance pain, which is in turn threatening, creating positive feedback loops that maintain pain after initial injuries have healed. 27 , 29 - 31

As pain becomes chronic, it is increasingly associated with activity in the affective and motivational systems tied to avoidance and less closely tied to systems encoding nociceptive input. 14 , 32 - 34 Accordingly, brain regions serving allostasis and predictive control 18 , 23 —including the default mode network, somatosensory and insular cortices, amygdala, and nucleus accumbens—have been implicated in animal models 13 - 17 and human studies of chronic pain 22 , 25 , 32 , 33 , 35 , 36 and pain modulation. 24 , 25 , 28 , 37 - 39

We developed pain reprocessing therapy (PRT) based on this understanding of primary chronic pain. Leading psychological interventions for pain typically present the causes of pain as multifaceted and aim primarily to improve functioning and secondarily to reduce pain. PRT emphasizes that the brain actively constructs primary chronic pain in the absence of tissue damage and that reappraising the causes and threat value of pain can reduce or eliminate it.

In this study, we conducted the first test of PRT. In a randomized clinical trial with 1-year follow-up, we compared PRT with both open-label placebo and usual care control conditions. We tested hypothesized mechanisms of PRT with mediation analyses and longitudinal functional magnetic resonance imaging (fMRI) during spontaneously occurring and evoked back pain. fMRI provided objective correlates of treatment effects and identified potential neurobiological treatment mechanisms.

The trial was preregistered on ClinicalTrials.gov (Identifier: NCT03294148 ) and conducted from August 2017 to November 2018, with 1-year follow-up completed by November 2019. Clinical and fMRI data were analyzed from January 2019 to August 2020, after data collection at each follow-up timepoint was complete. Participants aged 21 to 70 years with back pain for at least half the days of the last 6 months and 1-week average pain intensity score of 4 of 10 or greater at screening were recruited from the community in Boulder, Colorado. We targeted primary CBP, excluding patients with leg pain worse than back pain (eMethods in Supplement 2 ). Power analysis targeted 80% power (α = .05) to detect a medium effect ( d  = 0.62) on pain intensity at the primary end point (eMethods in Supplement 2). Participants provided written informed consent as approved by the University of Colorado Institutional Review Board. The study followed the Consolidated Standards of Reporting Trials ( CONSORT ) reporting guideline for social and psychological intervention trials.

Participants completed an eligibility and consent session, followed by a baseline assessment session with fMRI. They were subsequently randomized to PRT, placebo, or usual care with equal probability, balancing on age, sex, baseline pain, and opioid use using an imbalance-minimization algorithm 40 (eMethods in Supplement  2 ). The primary end point (posttreatment fMRI session) occurred 1 month after the baseline fMRI. Participants completed online follow-up assessments at 1, 2, 3, 6, and 12 months after the primary end point ( Figure 1 ).

PRT seeks to promote patients’ reconceptualization of primary (nociplastic) chronic pain as a brain-generated false alarm. PRT shares some concepts and techniques with existing treatments for pain 41 - 48 and with the cognitive behavioral treatment of panic disorder. 66

Participants completed a 1-hour telehealth evaluation and education session with a physician (H.S.) assessing likely centralized vs peripheral contributions to pain, including a review of available preexisting spinal imaging. Assessment findings and centralized pain education were shared with the patient (eAppendix 1 in Supplement 2 ).

Quiz Ref ID Participants then completed 8 individual 1-hour therapy sessions with a therapist with extensive PRT experience (A.G. or C.U.) twice weekly for 4 weeks. Techniques included (1) providing personalized evidence for centralized pain; (2) guided reappraisal of pain sensations while seated and while engaging in feared postures or movements; (3) techniques addressing psychosocial threats (eg, difficult emotions) potentially amplifying pain; and (4) techniques to increase positive emotions and self-compassion. PRT followed the treatment protocol found in eAppendix 2 in Supplement 2 .

Treatment fidelity was assessed by independent raters coding audiorecordings of PRT sessions (eMethods and eAppendix 3 in Supplement 2 ). A mean (SD) of 4.93 (0.87) of 6 PRT elements were present in each session, and all sessions included at least 3 elements, indicating high treatment fidelity.

Participants watched 2 videos describing how placebo treatments can powerfully relieve pain even when known to be inert (eg, they can automatically trigger the body’s natural healing response). 49 A subcutaneous injection described as saline was administered by a physician (K.K.) at the site of greatest back pain during an empathic, validating clinical encounter at an orthopedic medical center. Open-label placebo treatments are as effective or nearly as effective as traditional (deceptive) placebos for CBP and other chronic symptoms when administered in this manner (eMethods in Supplement 2 ). 50 - 52 Participants in this group were also asked to continue their ongoing care as usual and not start other new treatments until after the study period.

Participants in this group were given no additional treatment. They agreed to continue their ongoing care as usual and not start new treatments before the posttreatment assessment. After the posttreatment assessment, they were given a chronic pain workbook 53 and access to http://www.unlearnyourpain.com .

The primary outcome was average pain over the last week on a numerical rating scale from 0 to 10 from the Brief Pain Inventory Short Form, assessed at the 1-month postbaseline session. We also calculated the proportion of participants reporting pain reduction of 30% or more, pain reduction of 50% or more, and a pain score of 0 or 1, indicating a pain-free or nearly pain-free state. Secondary outcomes included pain interference (Oswestry Disability Index); Patient-Reported Outcome Measurement Information System (PROMIS) short forms for depression, anxiety, anger, and sleep quality; and the Positive and Negative Affect Scale (measure details in the eMethods in Supplement 2 ).

We considered 3 measures of pain beliefs as potential mediators: (1) the Tampa Scale of Kinesiophobia (TSK-11), assessing belief that pain indicates injury and fear of movement; (2) the Pain Catastrophizing Scale (PCS); and (3) the Survey of Pain Attitudes Emotion subscale (SOPA-Emotion), assessing beliefs that stress and negative emotion increase pain. Adverse events were recorded when participants spontaneously reported them to study personnel. Baseline pain was computed as the average score from 2 prerandomization assessments (eligibility session and pretreatment fMRI session).

Structural T1 and multiband blood oxygenation level–dependent functional imaging was conducted on a 3-T Siemens Prisma Fit MRI scanner with standard fMRI preprocessing (eMethods in Supplement 2 ). During fMRI, participants completed (1) an evoked back pain task with a series of randomly ordered trials distending the back to 1 of 4 intensity levels and (2) a spontaneous pain scan in which participants rested and rated ongoing pain once per minute (design details in the eMethods in Supplement 2 ; fMRI data quality measures shown in eFigures 6 and 7 in Supplement 2 ). Participants rated pain during scanning on a visual analog scale from 0 (no pain) to 100 (worst pain imaginable).

Intent-to-treat analyses (including all randomized patients) were performed for the primary outcome with a mixed-effects model ( fitlme , MATLAB 2020a), including 2 group × time interactions (PRT vs placebo × posttreatment vs pretreatment and PRT vs usual care × posttreatment vs pretreatment), covariates for age and sex, and a random intercept per participant. Treatment response rates for 30% or greater reduction in pain, 50% or greater reduction in pain, and a pain-free or nearly pain-free state at posttreatment and 1-year follow-up were based on all randomized patients; those missing data were considered nonresponders. For follow-up time points and secondary outcomes, we calculated Hedges g for the PRT vs placebo and PRT vs usual care comparisons. Follow-up time points were analyzed individually, testing group differences in change from baseline to each time points. The placebo vs usual care comparison will be reported elsewhere.

To investigate psychological treatment mechanisms, we (1) correlated pretreatment to posttreatment changes in pain intensity with pretreatment to posttreatment changes in pain beliefs (TSK-11, PCS, and SOPA-Emotion) within each group and (2) tested pretreatment to posttreatment changes in pain beliefs as mediators of treatment effects on pain at follow-up timepoints (1 through 12 months posttreatment), controlling for baseline pain. PRT vs placebo and PRT vs usual care were tested in separate models. We also tested the reverse: whether pretreatment to posttreatment pain reductions mediated treatment effects on pain beliefs at follow-up, controlling for baseline pain beliefs (eMethods in Supplement 2 ). Correlational and mediation analyses were not prespecified in the trial protocol.

An evoked back pain localizer identified brain regions positively associated with evoked back pain intensity at baseline. The localizer was conducted within a mask of regions of interest (medial prefrontal, posteromedial, insula, cingulate, and somatosensory cortices; amygdala; and nucleus accumbens; eMethods and eFigure 1 in Supplement 2 ; localizer task design in eFigure 8 in Supplement 2 ). We tested for treatment effects (group × time interactions) in the average activity of clusters positively associated with evoked back pain using a mixed-effects (random-effects) model, applying a 1-tailed threshold of P  < .05 owing to directional hypotheses that PRT would reduce activity in pain-positive clusters.

Evoked pain analyses identified group × time interactions in the anterior insula, anterior midcingulate (aMCC), and a prefrontal region. We submitted these 3 regions as seeds to connectivity analyses in the spontaneous pain scan. We conducted permutation tests (threshold-free cluster-enhancement; eMethods in Supplement 2 ) testing for group × time interactions in connectivity between these seed regions and 2 areas most often demonstrating altered connectivity in chronic pain: (1) the midline default mode network, including the medial prefrontal and posteromedial cortex, and (2) primary somatosensory cortex (S1) 36 , 54 - 59 (masks in eFigure 2 in Supplement 2 ).

We randomized 151 participants (54% female; mean [SD] age, 41.1 [15.6] years; mean [SD] CBP duration, 10.0 [8.9] years). At baseline, patients reported low to moderate pain intensity scores (mean [SD], 4.10 [1.26]) to 4.41 [1.29]) and disability (mean [SD], 23.34 [10.12] on the Oswestry Disability Index), with similar pain and demographic characteristics across groups ( Table 1 ).

Of 50 participants randomized to PRT, 44 (88%) completed all treatment sessions and the posttreatment assessment. Five participants dropped out prior to initiating PRT and 1 had an unrelated medical emergency. Of 51 participants randomized to placebo, 44 (86%) received the treatment, all of whom completed the posttreatment assessment. Of the 50 participants randomized to usual care, 47 (94%) completed the posttreatment assessment ( Figure 1 ).

Twenty patients in the PRT group had preexisting spinal imaging, all of which showed at least 1 spinal anomaly (median of 4 findings per patient; eTable 1 in Supplement 2 ) assessed by a physician (H.S.) as not causal of pain (eMethods and eAppendix 1 in Supplement 2 ). 61

Quiz Ref ID Patients randomized to PRT reported substantial reductions in pain intensity at posttreatment compared with both control groups, with a mean (SD) pain score of 1.18 (1.24) in the PRT group, 2.84 (1.64) in the placebo group, and 3.13 (1.45) in the usual care group ( Figure 2 ; Table 2 ). Patients in the PRT group reported a pain reduction of 1.79 (on the 0 to 10 numerical rating scale) relative to placebo ( t 137.63  = 6.06; P  <  . 001; g , −1.14; 95% CI, −1.65 to −0.71) and reported a pain reduction of 2.40 relative to the usual care group ( t 135.69  = 8.13; P  <  . 001; g , −1.74; 95% CI, −2.28 to −1.32). A total of 33 of 50 patients randomized to PRT (66%), corresponding to 73% of the 45 patients who initiated PRT, were pain-free or nearly pain-free at posttreatment, compared with 10 of 51 patients (20%) in the placebo group and 5 of 50 patients (10%) in the usual care group. At 1-year follow-up, effects of PRT on pain remained large relative to both control groups, with a mean (SD) pain score of 1.51 (1.59) in the PRT group, 2.79 (1.78) in the placebo group, and 3.00 (1.77) in the usual care group. Hedges g was −0.70 for PRT vs placebo ( P  = .001) and −1.05 for PRT vs usual care ( P  < .001) ( Table 2 ; treatment response rates in eTable 2 in Supplement 2 ; individual patient pain trajectories in eFigure 3 in Supplement 2 ).

Analyses of secondary outcomes at posttreatment revealed significant reductions in disability and anger for PRT vs both controls ( g , −0.62 to −1.7; P  < .005) and improvements in sleep ( g , −0.56; P  = .009) and depression ( g , −0.63; P  = .003) relative to usual care ( Table 2 ). Treatment gains on secondary outcomes were largely maintained at 1-year follow-up ( Table 2 ). Significant PRT vs control effects were observed at posttreatment for positive affect (Positive and Negative Affect Schedule; g for PRT vs placebo, 0.63, g for PRT vs usual care, 0.59; P  < .005; eTable 3 in Supplement 2 ) but not for negative affect or alcohol, cannabis, or opioid use (eTable 3 in Supplement 2 ). Treatment satisfaction was high among participants in the PRT group (eTable 4 in Supplement 2 ).

Pretreatment to posttreatment reductions in TSK-11 and pain intensity scores were correlated among participants in the PRT group ( r 42  = 0.44; P  = .003; eFigure 4 in Supplement 2 ). This correlation was not significant for the placebo condition ( r 42  = 0.16; P  = .29) or usual care condition ( r 45  = 0.27; P  = .07). Pretreatment to posttreatment changes in PCS and SOPA-Emotion scores did not correlate with pain reductions within any group.

Pretreatment to posttreatment reductions in TSK-11 scores mediated PRT vs placebo and PRT vs usual care effects on pain intensity at most follow-up time points (eFigure 4 and eTables 5 and 6 in Supplement 2 ). The reverse was also true: pretreatment to posttreatment pain reductions mediated PRT vs placebo and PRT vs usual care effects on TSK-11 at follow-up. Pretreatment to posttreatment changes in PCS and SOPA-Emotion did not mediate PRT vs control effects at any follow-up time point. Treatment effects on TSK-11 were very large at posttreatment ( g for PRT vs placebo, −1.90; g for PRT vs usual care,−1.67; P  < .001).

Neither age nor sex moderated the treatment effect on pain intensity (eMethods in Supplement 2 ). No adverse events were reported for PRT.

At baseline, increased back distention led to increased pain (mean [SD] for distention level 1, 32.15 [18.57]; distention level 2, 37.91 [20.30]; distention level 3, 46.70 [21.71]; distention level 4, 52.73 [21.78]). There was a significant effect of distention level on pain (mean [SD] β for inflation, 7.05 [5.06]; t 95  = 13.64; P  < .001. Individual patient-evoked pain data are shown in eFigure 5 in Supplement 2 .

Patients receiving PRT reported significant pretreatment to posttreatment reductions in evoked back pain relative to placebo (β, −13.05 on a 101-point visual analog scale; t 122.85  = −2.82; P  = .006; g , −0.60; 95% CI, −1.06 to −0.16) and relative to usual care (β, −19.61; t 79.52  = −4.03; P  < .001; g , −0.99; 95% CI, −1.50 to −0.55; Figure 3 A). Among patients in the PRT group, pretreatment to posttreatment reductions in evoked back pain and 1-week average back pain intensity were correlated ( r 32  = 0.47; P  = .005).

Quiz Ref ID Localizer analyses identified 16 regions within the mask of interest positively associated with evoked pain intensity, including bilateral insula, cingulate, bilateral somatotopic back areas S1 and secondary somatosensory cortex, and prefrontal regions ( Figure 3 B; eFigure 1 and eTable 7 in Supplement 2 ). Relative to placebo, PRT reduced pain-related activity in aMCC ( t 133.48  = −1.73; P  = .04) and the anterior prefrontal cortex (aPFC; t 133.48  = −1.85; P  = .03). Relative to usual care, PRT reduced pain-related activity in the left anterior insula (aIns; t 120.1  = −2.34; P  = .01; Figure 3 C).

Patients receiving PRT reported reductions in spontaneous pain relative to placebo (β, −18.24 on a 101-point visual analog scale; t 140.66  = −4.59; P  < .001; g , −0.92; 95% CI, −1.44 to −0.47) and relative to usual care (β, −21.53; t 79  = −5.26; P  < .001; g , −1.11; 95% CI, −1.66 to −0.66; Figure 3 D).

We submitted the aMCC, aPFC, and aIns regions exhibiting treatment effects in evoked pain analyses as connectivity seed regions in the spontaneous pain task. Within S1, PRT vs placebo and PRT vs usual care led to increased aPFC- and aIns-seeded connectivity to 4 distinct S1 subregions (permutation test COPE-MAX, 3.55-3.91; P  < .05). Within the medial default mode network, PRT vs usual care increased aMCC-precuneus connectivity (permutation test COPE-MAX, 4.23; P  = .01; Figure 3 E; cluster coordinates and statistics in eTable 8 in Supplement 2 ). No group × time interactions were found for aPFC- or aIns-seeded connectivity to default mode network regions or for aMCC-seeded connectivity to S1.

PRT yielded large reductions in CBP intensity relative to open-label placebo and usual care control conditions in a community sample, with nearly two-thirds of randomized patients and 73% of those initiating PRT reporting they were pain-free or nearly pain-free at posttreatment. Large effects of PRT on pain continued at 1-year follow-up. PRT also reduced experimentally evoked back pain and spontaneous pain during fMRI with large effect sizes, and several secondary outcomes (eg, disability and anger) also improved for PRT relative to the control groups.

PRT targets primary (nociplastic) pain by shifting patients’ beliefs about the causes and threat value of pain. It presents pain as a reversible, brain-generated phenomenon not indicative of peripheral pathology, consistent with active inference and constructionist accounts of interoception and pain. 18 , 19 , 22 - 27 PRT builds on and extends existing psychological treatment models. Cognitive-behavioral, acceptance-based, and mindfulness-based interventions typically aim to improve functioning by decreasing pain catastrophizing, enhancing pain coping or acceptance, and promoting engagement in valued life activities. 41 , 44 , 46 , 48 , 62 Exposure-based treatments share with PRT an emphasis that painful activities are not injurious, 42 , 63 - 65 but do not emphasize reappraising pain sensations and reattributing the causes of pain. Some pain neuroscience education interventions present pain in a similar way as PRT, 43 though they typically lack guided exposure and reappraisal exercises.

Large reductions in pain are rarely observed in CBP psychological treatment trials. 11 , 12 Relatively unique components of PRT potentially contributing to the observed effects include (1) an in-depth medical and psychological assessment generating personalized evidence for centralized pain; (2) reattribution of pain to reversible learning- and affect-related brain processes rather than bodily injury; and (3) a unique combination of cognitive, somatic, and exposure-based techniques supporting pain reappraisal (eDiscussion in Supplement 2 ).

Correlational and mediational analysis results support changes in fear-inducing pain beliefs as a potential PRT mechanism. Effects of PRT on pain beliefs were also mediated by pain intensity reductions, perhaps because pain reductions promote beliefs in pain modifiability (eDiscussion in Supplement 2 ). Changes in pain beliefs are not unique to PRT, but PRT may more strongly change these beliefs compared with existing therapies (eTable 6 in Supplement 2 ).

These hypothesized mechanisms are consistent with extinction-based treatment approaches to anxiety disorders. 42 , 65 For example, 85% of patients became free of panic symptoms following treatment focused on reappraising somatic symptoms as caused by nondangerous central nervous system processes (eg, false alarms). 66

PRT reduced evoked pain-related activity in aPFC, aMCC, and aIns. The aPFC and adjacent dorsolateral prefrontal cortex (dlPFC) are implicated in the detection and inhibition of pain. 67 aPFC reductions following PRT suggest a potential reduction of pain-related signals or decreased prioritization of pain control. The aMCC and aIns are cortical convergence zones in the construction of negative affect in pain and other domains. 20 , 68 - 70 Cognitive pain regulation strategies, including mindful acceptance 38 , 39 and placebo analgesia, 24 , 25 , 28 have been found to reduce aMCC and aIns responses to pain, demonstrating parallels between experimental findings and our clinical findings. The aIns reductions in our study were not specific to PRT vs placebo and may reflect processes common to both these interventions.

PRT also increased aPFC and aIns connectivity to S1, aligning with previous findings that cognitive behavioral therapy for fibromyalgia 57 and acupuncture for CBP 55 increased aIns-S1 connectivity. Increased aPFC and aIns connectivity to S1 may reflect increased attention to somatosensory input in constructing pain. 71 This is congruent with mindfulness-based treatments promoting nonreactive attention to bodily sensations, reducing catastrophizing. 38 , 39 , 48 , 71 Yet, increased S1 connectivity has also been associated with increased clinical pain, 72 and the role of S1 connectivity remains unclear. 55 PRT vs usual care also increased aMCC-precuneus connectivity, with intermediate effects observed in participants receiving placebo treatment. Altered default mode connectivity has often been reported in chronic pain, although typically with heightened connectivity for patients vs controls (eDiscussion in Supplement 2 ). 36 , 54 , 56 , 58 , 59

Quiz Ref ID This study has limitations. The study sample was relatively well educated and active and reported long-standing low to moderate pain and disability at baseline. The physician and therapists were experts in the treatment model. Future studies should test generalizability to other patient populations, therapists, and treatment contexts (eDiscussion in Supplement 2 ). The fMRI effect sizes were modest, with some results not surviving whole-brain correction (eMethods in Supplement 2 ). Future trials should test PRT efficacy relative to leading psychological and medical treatments (eDiscussion in Supplement 2 ).

Overall, our findings raise key possibilities about the nature and treatment of primary CBP. Changing fear- and avoidance-inducing beliefs about the causes and threat value of pain may provide substantial, durable pain relief for people with primary CBP.

Accepted for Publication: July 27, 2021.

Published Online: September 29, 2021. doi:10.1001/jamapsychiatry.2021.2669

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2021 Ashar YK et al. JAMA Psychiatry .

Corresponding Author: Tor D. Wager, PhD, Department of Psychological and Brain Sciences, Dartmouth College, 352 Moore Hall, HB 6207, Hanover, New Hampshire 03755 ( [email protected] ); Yoni K. Ashar, PhD, Department of Psychiatry, Weill Cornell Medical College, 1300 York Ave, New York, NY 10065 ( [email protected] ).

Author Contributions : Drs Ashar and Wager had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design : Ashar, Gordon, Schubiner, Uipi, Knight, Geuter, Dimidjian, Wager.

Acquisition, analysis, or interpretation of data : Ashar, Gordon, Schubiner, Uipi, Knight, Anderson, Carlisle, Polisky, Geuter, Flood, Kragel, Lumley, Wager.

Drafting of the manuscript : Ashar, Gordon, Schubiner, Polisky, Lumley, Wager.

Critical revision of the manuscript for important intellectual content : All authors.

Statistical analysis : Ashar, Polisky, Geuter, Lumley, Wager.

Obtained funding : Gordon, Schubiner, Flood, Wager.

Administrative, technical, or material support : Ashar, Uipi, Knight, Anderson, Carlisle, Polisky, Kragel, Dimidjian, Lumley, Wager.

Supervision : Ashar, Gordon, Wager.

Conflict of Interest Disclosures: Dr Ashar reports grants from the National Institutes of Health during the conduct of the study and personal fees from UnitedHealth Group, Lin Health, Inc, Pain Reprocessing Therapy Center, Inc, and Mental Health Partners of Boulder County outside the submitted work. Mr Gordon is a consultant with UnitedHealth Group, director of the Pain Psychology Center and the Pain Reprocessing Therapy Center, and is the author of the book The Way Out . Dr Schubiner is the co-owner of Freedom From Chronic Pain, Inc, earns book royalties for Unlearn Your Pain, Unlearn Your Anxiety and Depression and Hidden From View ; serves as a consultant with UnitedHealth Group, Karuna Labs, and Curable Health; and receives personal fees from OVID Dx outside the submitted work. Mrs Uipi serves as a consultant for UnitedHealth Group. Dr Dimidjian reports being a co-founder of Mindful Noggin, Inc, and received royalties from Guilford Press and Wolters Kluwer as well as funding from The National Institutes of Health. Dr Lumley reports personal fees from CognifiSense, Inc, outside the submitted work. Dr Wager reports grants from the National Institutes of Health and the Foundation for the Study of the Therapeutic Encounter, and funding to support trainees from the Radiological Society of North America and the German Research Foundation; he is on the Scientific Advisory Board of Curable Health. No other disclosures were reported.

Funding and Support: This study was funded by National Institutes of Health grants R01 DA035484 (Dr Wager), R01 MH076136 (Dr Wager), National Center for Advancing Translational Sciences grant TL1-TR-002386 (Dr Ashar), Radiological Society of North America (Dr Flood), German Research Foundation grant GE 2774/1-1 (Dr Geuter), the Psychophysiologic Disorders Association, the Foundation for the Study of the Therapeutic Encounter, and community donations.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 3 .

Additional Information: Deidentified demographic and clinical outcomes data and subject-level functional magnetic resonance imaging statistical parameter maps for evoked pain and seed connectivity are provided here: https://figshare.com/s/1840dc4c0e236a7072ca

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Long Covid feels like a gun to my head

By Rachel Hall-Clifford June 18, 2024

I have spent my career studying infectious diseases that fall under the heading of neglected tropical diseases . Now I have a neglected disease — long Covid — an incurable (for now and for me) disease.

As a medical anthropologist working in global health, I thought I understood the despair of poor health. I didn’t. I join 7% of the U.S. adult population — or about 18 million Americans — who have experienced long Covid. Diagnosis of long Covid remains uncertain and contested , and treatments, ranging from repurposed drugs to hyperbaric oxygen, are even more so.

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I was infected with SARS-CoV2 during the Omicron wave of January 2022. It crashed through my kid’s kindergarten class and swept our household along with it. We had none of the “ underlying conditions ” that may indicate increased risks of poor outcomes from Covid (and which have been used throughout the pandemic to allay fears that dangerous outcomes would only happen to “others”). My acute infection wasn’t scary: I had fever, aches, and chills for about four days. My initial Covid aches and pains were nothing in comparison to when I had dengue fever, known as “bone break fever,” while working in Guatemala’s remote mountains.

And then I just never got better . It took a couple of months for me to realize that. I developed crushing chest pain and a heart rate that would rival a hummingbird’s. I couldn’t walk around my block without stopping to catch my breath. I was often dizzy, and my arms and legs felt like leaden sausages that had grown too big for their casings.

Related: Listen: Why Long Covid can feel scarier than a gun to the head

Like many of my global health colleagues, I love a good adventure and don’t mind flirting with danger a little. I’ll go anywhere and talk to anyone. I once talked a Guatemalan street gang out of harming my small research team as they held a Kalashnikov to our heads during a robbery. It was scary, but I didn’t fear for my life. I knew it wasn’t the end of my story. But I have thought that long Covid might be: At its worst, I wrote letters to my children in fear that I wouldn’t survive the night.

More than two years in, I’m among the luckiest of those living with long Covid. My symptoms are managed, though imperfectly. I have the academic background to follow the latest research findings and access to brilliant colleagues doing some of that work. I have the money, insurance, and health care providers that have enabled me to try several treatments.

Here’s a bit of what I’ve tried so far, all shots in the dark: A beta blocker controls my chest pain and high heart rate. A 3-month course of powerful blood thinners improved numbness and pain in my limbs. Constant use of electrolyte fluids like Gatorade and Pedialyte (ironically what I studied in graduate school) improves my dizziness and is essential for propping myself up to teach a class in a lecture hall or get through a day of Zoom meetings. My iliac vein has completely collapsed in my left leg, and my cardiologist wants me to get a stent.

I wouldn’t be able to hold down the jobs in warehouses, factories, and farms that many in my family have had.

Though my world has gotten small, and I’m not able to travel for my work as I once did, most days I feel like I just got off a long-haul flight and live in a permanent state of jet lag . I have one of those pill organizers stuffed full of medications and supplements that I hope will help at least a little. (I still struggle to reconcile my self-identity with this new reality.)

Related: NIH documents show how $1.6 billion long Covid initiative has failed so far to meet its goals

I was able to take a 15-day course of the antiviral Paxlovid , and it was the best I’ve felt in two years. For many people, the side effects of this medicine are terrible, but I never wanted its hallmark metallic tang to end. About two days after my course of Paxlovid ended, though, my symptoms crept back. Recent findings of viral persistence came as no surprise to me, and new results from a clinical trial investigating a 15-day course of Paxlovid in long Covid patients has shown no benefit .

I am now taking (at great cost) maraviroc , an antiviral used to treat HIV, which helps partially control my symptoms. I recently slid into the whirring tomb of an MRI machine to try to find an explanation for persistent post-Covid migraines in my brain, but that was a dead end. Nothing was found, and I don’t know whether to be disappointed or relieved.

I admit I am scared. This is not a funny story I will tell colleagues over drinks later. There’s no gangland drug lord to negotiate with this time. Instead, I spend a lot of my time lying in the dark (I’m here now, even as I type this) negotiating with god and science to make me — and all of us suffering with long Covid and other post-viral illnesses — better. It’s surprisingly been the short periods when I have felt better that are the most upsetting, as they highlight how terrible I feel most of the time.

So I fake it. I need the pretense of being my old, fearless self. I need to discuss interesting things with colleagues and teach and run my lab. I need to take the snacks to soccer and help my kids with homework. That’s what makes me who I am, even as I playact a poor facsimile of my healthy self that requires hours (sometimes days) of recovery time afterwards.

I will continue to bargain with the universe to get to live the life I have worked to build for myself. I want that for everyone. My work in global health has shown me both the fragility of life but also the value of fighting for everyone’s right to a full and healthy life.

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I understand that no one cares much about Covid anymore. It’s been a long haul for all of us, even those who aren’t “long haulers.” I hope everyone who hasn’t experienced long Covid never really understand what I’m talking about — what others with chronic illness and disability have tried to teach us — that our abled bodies are only temporary. Long Covid and the SARS-CoV-2 infections that cause it are harsh teachers.

I am inspired by the work of the long Covid Patient-Led Research Collaborative and the research being done to uncover the causes of and cures for long Covid. But it’s not enough. Given the widespread burden of disease and the losses to the economy and social fabric it is causing in the U.S. and around the globe, the U.S. government must act quickly and decisively to curb long Covid. The Long Covid Moonshot is a collective advocating for $1 billion in annual research funding for long Covid, akin to the Operation Warp Speed that enabled the first generation of Covid-19 vaccines. U.S. Senator Bernie Sanders (D-Vt.) recently released a Long Covid Moonshot legislative proposal . Bipartisan support for long Covid is essential so that someday no one needs to care about Covid and its lasting effects.

Long Covid feels like living with a gun to my head. Please pull the trigger on the moonshot.

Rachel Hall-Clifford, Ph.D., is an assistant professor of global health, human health, and sociology at Emory University in Atlanta.

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A Systematic Review of Music Therapy Practice and Outcomes with Acute Adult Psychiatric In-Patients

Catherine carr.

1 Unit for Social and Community Psychiatry, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom

Helen Odell-Miller

2 Music and Performing Arts Department, Anglia Ruskin University, Cambridge, United Kingdom

Stefan Priebe

Conceived and designed the experiments: CEC HOM SP. Performed the experiments: CEC. Analyzed the data: CEC HOM SP. Wrote the paper: CEC HOM SP.

Associated Data

Background and objectives.

There is an emerging evidence base for the use of music therapy in the treatment of severe mental illness. Whilst different models of music therapy have been developed in mental health care, none have specifically accounted for the features and context of acute in-patient settings. This review aimed to identify how music therapy is provided for acute adult psychiatric in-patients and what outcomes have been reported.

Review Methods

A systematic review using medical, psychological and music therapy databases. Papers describing music therapy with acute adult psychiatric in-patients were included. Analysis utilised narrative synthesis.

98 papers were identified, of which 35 reported research findings. Open group work and active music making for nonverbal expression alongside verbal reflection was emphasised. Aims were engagement, communication and interpersonal relationships focusing upon immediate areas of need rather than longer term insight. The short stay, patient diversity and institutional structure influenced delivery and resulted in a focus on single sessions, high session frequency, more therapist direction, flexible use of musical activities, predictable musical structures, and clear realistic goals. Outcome studies suggested effectiveness in addressing a range of symptoms, but were limited by methodological shortcomings and small sample sizes. Studies with significant positive effects all used active musical participation with a degree of structure and were delivered in four or more sessions.

Conclusions

No single clearly defined model exists for music therapy with adults in acute psychiatric in-patient settings, and described models are not conclusive. Greater frequency of therapy, active structured music making with verbal discussion, consistency of contact and boundaries, an emphasis on building a therapeutic relationship and building patient resources may be of particular importance. Further research is required to develop specific music therapy models for this patient group that can be tested in experimental studies.

Introduction

Acute in-patient care is offered when a patient is in severe crisis to provide a “safe and therapeutic setting for service users in the most acute and vulnerable stage of their illness” [1] . Admissions may be voluntary or through compulsory legal detention. Reasons for admission may be for assessment, treatment of acute symptoms or relapse prevention with the aim for patients to recover to a point where they are able to return to the community. Length of admission varies, however within the United Kingdom (UK), it has reduced to an average of less than 4 weeks [2] , and is continuing to decrease.

Whilst the evidence base for music therapy in the treatment of serious mental disorders is growing [3] - [7] , little attention has been paid to the delivery of music therapy in acute in-patient treatment. Research to date suggests many more sessions are required for clinically meaningful effects than may be accessed in hospital [4] and there has been little distinction between interventions offered in acute stages of illness, and those offered long-term [8] , [9] . A number of models and methods of music therapy have developed in mental health care, yet specific approaches to account for the acute in-patient context have not been systematically examined [10] - [14] . Against this background, we conducted a systematic review addressing the following questions:

• 1. What are the clinical aims and considerations for music therapy with acute adult psychiatric patients in acute hospital settings?
• 2. How is music therapy provided in these settings in terms of frequency, duration and methods used?
• 3. What are the findings from outcome studies conducted in these settings?

A systematic review was conducted utilising narrative synthesis [15] - [17] . Methods were specified in advance in a protocol [ Supporting information S1 ].

Eligibility Criteria

Definition of intervention.

Music therapy is a systematic intervention that uses music experiences and the relationships that develop through these to promote health [18] . Music may be actively produced by patient and therapist (for example, improvisation on musical instruments), or receptive, such as listening to pre-recorded music. The type of musical interaction, level of structure and amount of verbal discussion may vary depending upon the music therapist’s approach, client characteristics and diagnosis. Interventions can take the form of group or individual therapy and aims will vary according to the specific needs of the patient.

Papers were included if they described music therapy as the main component of treatment with adult in-patients (ages 18+) admitted for treatment of acute symptoms in psychiatric hospitals. Interventions used active and/or receptive musical activities as the primary treatment component in conjunction with the relationships formed through these activities to promote health [18] . Papers were excluded if a) music was not the primary focus of the intervention, for example, dance movement psychotherapy might use music within the intervention, but the focus is upon the physical use of body and movement; b) music was provided without a focus upon relationships, for example use of background music to alter the surrounding environment, music for private listening without therapist involvement, or provision of instruments for patients to access in their own time on the ward; c) the primary aim of the intervention was not to promote health, for example, music lessons with the aim of increasing musical knowledge or skill. Interventions delivered by non-music therapists were included if the intervention met the above criteria.

Papers describing both in-patient and out-patient treatment were included but only features of in-patient work were extracted. Papers focusing upon patients with an organic mental illness (ICD F00-09) were excluded. Data on diagnosis-specific and general symptoms, motivation, attendance, musical engagement, musical preference, social and behavioural changes were extracted. There were no restrictions on study design, publication year or language.

Information Sources and Search Strategy

Databases were identified and searched based on existing guidance and reviews [4] , [19] , [20] . Relevant journals, library catalogues and conference proceedings were then hand-searched. The full database and journal list can be found in the supporting information [ Supporting information S2 ]. References were inspected for further relevant literature, and a forward citation search performed using ISI Web of Science. The search was repeated after 10 months and completed on 30 th March 2012.

The following search terms were employed:

[* musi* or musi* or * sound* or sound* or * acou* or acou* or gim 1 in title, abstract, index terms of REFERENCE] or [music* in interventions of STUDY] and [psychiatr* or mental* or schizophreni* or psychosis or psychotic].

The search term ‘gim’ was included to find papers relating to Guided Imagery in Music – a specific approach used by music therapists involving receptive listening with the therapist guiding the patient through images evoked.

Study Selection

Detailed citations (title and abstract) were screened by the author (CC) and marked as include; exclude or uncertain. Full papers were retrieved and those marked as uncertain were reviewed against the inclusion criteria. Five authors were contacted for further information. All responded, and three provided references to a further five papers. Searches were managed and saved using Reference Manager (v.12, Thomson Reuters).

Data Extraction

Details of research design and method, country, diagnosis, group/individual, frequency, length, number of sessions offered and attended, duration of therapy, music therapy approaches and techniques, theories informing rationale, client and setting specific features, reported experiences and prospective study results were entered into an excel spreadsheet which was then imported into NVivo (v.18, QSR International) for qualitative analysis [ Supporting information S3 ]. For clinical outcome studies, sample size, mean scores and standard deviations for each time point were extracted along with statistical tests of significance. Twenty-five percent of the included papers were checked for accuracy of inclusion, coding and quality assessment by a second researcher (SO). Third and fourth researchers (SP and HO-M) were available for further discussion and resolution.

Assessment of Risk of Bias

As this review combined clinical, theoretical and research papers, the EPPI “weight of the evidence” (WoE) approach was employed [21] , [22] . In this approach, papers are rated not only on their methodological quality (WoEA), but also on the relevance of the study design to the review question (WoEB) and overall relevance to the review question as a whole (WoEC). These ratings are combined to provide an overall “weight of the evidence”(WoED). For research methodology (WoEA), Downs & Black’s [23] checklist was selected for prospective quantitative studies.

For qualitative studies, the “Quality Framework” [24] was used by scoring each area as either present (1) or absent (0). Finally, for practitioner based papers (such as expert opinion or clinical theoretical papers), guidelines from the Social Care Institute for Excellence were employed [25] . Scores were averaged to make an overall score (WoED) and classified as Low (0–0.35), Medium (0.36–0.69) or High (0.7-1). Any papers with a low overall (WoED) or methodological score (WoEA) are reported in the results but were excluded from all analyses. To examine publication and selective reporting bias, study protocols and outcomes reported in the method were compared with published results.

Synthesis used elements and tools from guidance for the narrative synthesis of mixed types of data and followed three stages of 1. Developing a preliminary synthesis, 2. Exploring relationships within and between studies and 3. Assessing the robustness of the synthesis [15] - [17] . Preliminary synthesis (step 1) for objectives 1 and 2 employed tools of thematic synthesis and vote counting of themes within papers [26] . Papers were coded line by line for each area of extraction and grouped thematically. A thematic framework was tabulated and organized by sub-groups of country, approaches, interventions, research design and outcomes. This was then developed into a conceptual map of ‘analytical themes’ to synthesize setting-specific features and approaches [26] . Clinical aims, modifications to practice and reasons for this were grouped into similar features. For objective 3, experimental group pre-post differences and differences between groups post-intervention were converted to standardised mean differences and tabulated.

Relationships between studies (step 2) were explored using tabulation and vote counting. In the thematic analysis, similar features specific to acute inpatient work were grouped together, along with their impact upon therapy and approaches taken to address them. Vote counting was used to check coverage of themes and these were stratified by year of publication, country and length of stay to explore any potential patterns or influences. Experimental results were tabulated and grouped by outcome. Vote counting was used to rank outcomes according to the size and direction of standardized mean differences and statistical significance. Outcomes were then compared by intervention, number of sessions received and study quality.

Robustness of the synthesis product (step 3) was assessed through quality assessment, Doctoral supervision with a music therapist (HO-M) and psychiatrist (SP) and presentations to a mental health research group consisting of Psychologists and Psychiatrists within the authors’ institution and to music therapists at an international music therapy conference.

Ninety-eight papers [4] , [10] , [12] , [13] , [27] - [120] , were identified for inclusion in the review [PRISMA diagram, Figure 1 ]. Of these, 57 covered acute work specifically, whilst 41 included acute work as part of a wider discussion of practice in mental health. The majority of papers came from the USA (N = 32) and UK (N = 17) and were clinical theoretical discussions or case studies (N = 63), whilst research and service evaluations comprised 35 of the included papers. Two papers were rated as low quality and therefore excluded from the main thematic analysis [42] , [92] . Paper characteristics are shown in the supporting information [ Supporting information S4 ].

Thematic Synthesis

Clinical aims.

Clinical aims were conceptualized as building of interpersonal relationships, self-expression and personal resources [Table S5]. Immediate and short-term aims were most prominent, with priority given to establishing the therapeutic engagement of patients. Initial engagement aims related specifically to making contact and building a therapeutic relationship, active involvement of patients in either activity or therapy (both as in and out-patient) (N = 34) and fostering motivation and volition (N = 22). Immediate aims focused upon the reduction of anxiety, management of emotional arousal, building internal and external organization and providing reality orientation. Once engagement was established, goals then focused upon short term features to address the patient’s immediate situation within hospital. These included work on coping skills (N = 21), building musical resources, defences and boundaries (N = 39), prevention of relapse and exploration of issues that led to hospitalization (N = 13). Interpersonal processes focused upon making nonverbal contact with others, building awareness of how one interacts with others, building and improving relationships, teamwork and socialisation. Related to this was communication (N = 50) where aims focused upon encouragement of nonverbal expression, self-expression and verbal communication with others. Emotional aims (N = 47) focused upon management of arousal, self-expression and building awareness and naming of affective states whilst cognitive aims (N = 33) focused upon sustaining and increasing attention and organizing patients’ physical actions, behaviours and thoughts. Papers from the USA, UK and Denmark noted setting specific aims of helping patients to deal with hospitalization, such as decreasing hospital and discharge anxiety (N = 24), and changing the atmosphere on the ward, such as improving patient staff integration (N = 16).

Aims relating to symptoms were less frequently mentioned (N = 20). They focused upon reality orientation in psychosis and the reduction of depression and anxiety. Papers varied in opinion regarding the extent to which music therapy should aim to address specific symptoms and problems directly. Three papers stated specifically that this was not a goal of therapy [30] , [65] , [106] . Both Solli [65] and Leite [106] suggested that complete elimination of symptoms or problems may be unrealistic given the short time-frame of work and therefore suggest building of patient strengths and resources to help them cope with their current situation. Solli & Rolvsjord [110] suggested four features of music therapy that might assist in addressing symptoms of psychosis: motivation, structure, emotional expression and social participation. Nine papers, all informed by Yalom’s model of in-patient therapy [122] , proposed aims oriented towards supporting and reinforcing strengths and skills rather than longer term insight [13] , [49] , [76] , [79] , [107] - [109] , [118] , [119] . Mössler et al. [76] linked this to Storz’s [112] ‘potential orientation’ and ‘resource orientation’ found in other short term psychotherapies. Similarly psychodynamic and psychoanalytically informed approaches focused upon building and strengthening defence structures [52] , [65] , [119] , aiming at “containing action and delineating boundaries” [65] rather than opening up of emotions or deep connection with others.

Characteristics of Delivery

Service characteristics are shown in Table 1 , and content and structure of sessions in Table 2 . Music therapy was offered to patients with a range of diagnoses. Twenty-six papers focused upon specific diagnoses, usually schizophrenia or psychosis, 13 of which were individual case studies and 8 were for research or service evaluation.

The duration of in-patient stay ranged from 3 days to 75 weeks. Duration of therapy upon acute wards ranged from a single session to 38 weeks. The mode frequency of therapy was twice a week, and ranged from fortnightly to 6 sessions per week. Therapists working in hospitals with a short length of stay tended to offer a greater frequency of sessions, particularly in the USA. Open ward groups were the predominant form of delivery. Smaller semi-open or closed groups were run to meet specific needs or levels of functioning. Group and individual work was also combined (N = 29), whilst other reports focused on individual work only (N = 17) or included outpatient work (N = 22).

Features impacting upon the delivery of music therapy can be found in supporting information S5 and S6 [ Supporting information S5 ] [ Supporting information S6 ]. Setting characteristics included the institutional model and structure, communication with the multi-disciplinary team, ward environment, high patient turnover and shorter time-frame to work. The diversity of patients in terms of symptom severity, functioning levels, reaction to hospitalization, previous therapy experiences, and motivation to enter into therapy similarly impacted upon therapy delivery.

The integration of music therapy within the models and systems of the institutional setting meant prioritization of multidisciplinary team communication, provision of clear information to both patients and staff, and provision of a programme to maximize patient access and staff support [34] , [40] , [75] , [91] , [104] . Solli [108] suggests therapists tailor their work at different individual, group, ward and hospital levels. Work may also extend to links with the community through sessions accessible to outpatients eg. [48] , [86] or direction of patients to community resources eg. [13] , [48] , [64] , [108] , [109] , although barriers such as continuity of service and ability to follow-up patients were identified [40] , [116] .

Attendance and engagement were key challenges due to symptom severity, high patient turnover and short lengths of stay. Low attendance was generally experienced negatively by patients [50] , [91] and impacted upon the group dynamic [117] . Access to sessions was limited by mental state, external events or by institutional barriers such as the time taken for referral and assessment and ongoing demands upon the patient whilst in hospital [34] , [52] . Talwar et al. [116] also observed that uptake of outpatient attendance was rare unless several in-patient sessions were attended.

Engagement of patients in therapy itself was noted as a difficult process either due to anxiety in use of the medium [29] , [39] , [59] , [62] , [65] , [76] , [82] , [85] , [90] , [95] , [111] , lack of motivation [39] , [56] , [57] , [66] , [77] , [87] or damage in previous relationships [79] . Attendance for the duration of the session could also be challenging [29] , [59] , [62] . Coercion to attend was seen by some to have a negative impact, resulting in disruption, focus on authority, or resistance to participating and being involved in the group [27] , [38] , [59] . Arnason [29] also suggested that some may not feel that they need therapy or may hold ambivalence towards attending as they fear missing visitors, clinical appointments or wish to return home. Patients may attend in order to ‘play the system’ to obtain early discharge [87] and it may be that the idea of making music itself may be more motivating for patients than that of psychological change [76] , [108] . Cullen [39] , noted resistance may take many forms including resistance to choice, personal expression, focus on the here and now, criticism, breaking the mood of the group and intellectualization.

The papers described the therapist as highly active in identifying, informing and establishing relationships with patients both prior to, during and between sessions. Interest and willingness to work with music, level of risk and ability to function in a group were common indication criteria. Acute psychosis was seen as a contraindication by some therapists, whilst others utilized individual sessions or specific targeted groups to engage and work with this patient group. Consistency in therapeutic boundaries of environment, time, place, session structure and behaviour were seen to be of importance but could be difficult to ensure due to the availability of space and fluctuating atmosphere on the ward. When patients were unable to access the group (for example due to ward confinement), therapists would visit the patient, hold sessions on the ward, or provide taped music (either of the group session [62] , or for relaxation [29] to maintain consistency of contact. Due to rapid discharge, some offered outpatient work (N = 22), or home visits where this was not possible eg. [78] . Therapists also noted the importance of preparing the groups for change or breaks.

Music therapists described greater participation and direction of the sessions. The level at which patients could influence the group process was determined by therapist approach and level of functioning of patients. Overall, papers described an approach led by patients, but structured by the therapist at the beginning and end of sessions. Opening events were used to orientate new members and closing events used for reflection. Due to the high turnover of patients, 14 papers viewed sessions as standalone sessions [29] , [40] , [59] , [65] , [79] , [95] , [96] , [99] , [100] - [103] , [106] , [107] , [117] , often influenced by the work of Yalom [121] . A range of music interventions was used. Most emphasised active musical participation, predominantly through structured improvisation and singing/playing pre-composed music. Receptive methods were used either in groups where active music making was deemed too challenging, or for higher functioning patients using a modified form of the Bonny Method of Guided Imagery in Music [31] , [52] , [72] , [73] . Across all forms of music making, musical components of importance were described as having a clear structure, predictability, and tonal and harmonic simplicity. Musical boundaries and ground rules were employed to address behaviour within groups. Verbal reflection was described in all papers and was used to clarify and encourage communication. Discussions focused upon concrete events within the here and now with minimal interpretation.

Stratification by year, duration of stay and country

Year of publication and length of in-patient stay were inspected to explore whether changes to psychiatric services could have influenced the derived themes. Thirty-eight papers published between 1973 and 2011 reported lengths of stay of less than 3 months. Sixteen papers described durations over 3 months. These were published from 1995 onwards and originated from Belgium (N = 2), Denmark (N = 2), Germany (N = 3), Israel (N = 1), Norway (N = 4), and USA (N = 3). These papers all considered acute cases, but the exact length of the acute phase of treatment was not specified.

All themes covered a range of publication years and countries. Analysis of themes by publication year suggested that symptom specific aims (Aim A6) and patient turnover (Theme S4) might be more recent concerns, although it should be noted that short lengths of stay (Theme S5) covered papers published between 1975-present and there were no papers representing the years 1977–1985. Papers from Germany did not mention patient turnover as a theme of work and a single case study from Israel [94] did not mention any setting specific features of work although this may be due to the paper’s focus upon the process of therapy in relation to grief and mourning.

Outcome Studies

Of the 35 research papers identified in this review, 10 evaluated clinical outcomes ( Table 3 ). Of these, 8 used a randomised controlled trial design [37] , [74] , [84] , [100] , [102] , [103] , [116] , [118] , although only one utilised a reliable randomisation method [116] . Various outcomes were assessed, which were mostly social/interpersonal, mood and symptom domains.

Risk of bias within studies

Six studies were evaluated as medium quality (37%–62.9%) [37] , [73] , [84] , [96] , [102] , [103] and four as high (70.4%–88.9%) [74] , [100] , [116] , [118] ( Table 4 ). Studies were strong in reporting, but had significant shortcomings in four areas: Information regarding adverse events was reported in only one study [73] ; six did not outline explicit exclusion criteria [37] , [84] , [96] , [100] , [102] , [103] ; four did not provide a description of principle confounders [37] , [84] , [96] , [103] and three did not report characteristics of patients lost to follow-up [37] , [96] , [100] . External validity was difficult to assess as only two studies provided adequate information regarding the source population, selection of patients and the proportion of those invited who agreed [74] , [116] . Internal validity was limited by a lack of blinding of subjects, outcome assessors, and concealment of randomisation with only one study adequately addressing these [74] .

Risk of bias across studies

In terms of missing studies, one protocol was identified which did not have ensuing published data [122] . It was unclear whether this study involved acute in-patients [122] . Only one study protocol was available to examine selective reporting bias [83] , of which all outcomes were reported in the final publication [84] . One study [103] reported outcomes not explicitly outlined in the method whilst Cassity [37] did not provide tabulated data for measures of peer acceptance and interpersonal relationships.

Clinical Outcomes

Comparisons of clinical outcomes are shown in Table 5 . Direction and size of pre- post- change in the intervention group, post intervention differences between groups and statistical significance were examined to compare the strength of evidence between studies. Reductions in positive and negative symptoms [74] , [116] , [118] , psychiatric symptoms [74] and increased interpersonal functioning [118] were significantly more favourable in patients receiving music therapy compared to controls, although the size of the effects were small. All used active music-making methods with a degree of structure and delivered between 4–12 sessions over 2 weeks to 3 months. These studies were of a higher methodological quality than most of the studies in this review. However, studies were limited by lack of blinding of interviewers, small sample sizes (N = 12–81), and few used an active control.

Vote count coding key: Positive outcomes suggesting a trend towards the intervention but not significant when compared to controls included patient behaviour on the ward (NOSIE-30), patient experienced anxiety and stress (DASS-21) [74] , global functioning (GAF), satisfaction with music therapy (CSQ) [116] and quality of life (SPG) [118] . Three randomised controlled trials by Silverman [99] , [102] , [103] examined the effect of psychoeducational music therapy interventions upon psychoeducational knowledge , coping skills, satisfaction with life and appraisal of music therapy after a single session. Sessions were based on a psychoeducational framework with the aim to educate patients with knowledge and skills to manage their mental illness. Interventions included lyric analysis, songwriting and music games, with themes of relapse prevention, management of mental illness, active coping strategies for common problems faced, leisure skills and improving mental health knowledge. The active control followed the same psychoeducational script but did not employ music activities. Patients demonstrated greater psychoeducational knowledge in the music therapy group compared to the control in all three studies but these were not statistically significant. Effects may have been limited by assessment of a single session and use of an active control.

Outcomes for depression were mixed. Morgan et al. [74] found treatment group BPRS scores significantly decreased compared to the control. However, reduction was not significant compared to the control when assessed on the Calgary Interview Guide for Depression whereas scores on the DASS-21 suggested a trend towards the control. Other outcomes with a trend towards the control group were irritability and interaction subscales of the NOSIE-30, [74] and ratings of comfort after a single session of psychoeducational lyric analysis [99] .

Odell-Miller et al’s study [84] on the effectiveness of arts therapies (music, dance movement and art therapy) compared 10 patients receiving an arts therapy intervention, to 15 patients receiving treatment as usual at three time points. Patients in the treatment group reduced in anxiety and depression but this was not significant and the group difference favoured the control. Individual global distress reduced in both treatment and control, but increased in the final assessment for the treatment group. Life skills increased for the control, but decreased in the treatment group. Despite its rigorous design, the authors noted the problems inherent in assessing a range of interventions, diagnoses, and small number of participants.

Subjective outcomes

Five papers sought patient evaluations of music therapy. Reker [90] , Heaney [60] and Dye [44] used questionnaire-based surveys. Silverman [101] combined a questionnaire and interview to ascertain patient perceptions of different interventions, whilst Ansdell & Meehan [28] conducted in-depth idiographic interviews.

Reker [90] designed a 25 item questionnaire for patients to rate their experience of active music therapy utilising structured music making, and 30 patients completed the questionnaire. Patients rated music therapy positively, particularly in terms of enjoyment, safety relaxation and improvement in mood. Patients noted that it was anxiety provoking to play, although only 5 respondents partly felt that the music made them uneasy or frightened. Patients found it difficult to speak about the music although all rated that it was important to speak about the music after playing. Dye [44] found patients rated both a singing and listening group highly, with slightly higher ratings for the singing group. Out of 39 responses, all but one were able to suggest a song that was meaningful for them during the session. Dye notes the consensus between individuals for favoured songs in the group, although personal reasons given as to why these songs were favoured varied between individuals. In his comparison of music therapy to other group therapies, Heaney [60] examined ratings from 27 patients. He found music therapy consistently gained the most positive appraisals, and was significantly more pleasurable than other groups, whilst there were no significant differences in importance and success ratings. Heaney found a relationship approaching significance for age, but no significant relationships between overall ratings and length of admission or previous hospitalisation.

When assessing patient perceptions of 5 psychoeducational interventions (individual game, team game, singalong session, lyric analysis, songwriting), Silverman [101] found patients rated the team game as most enjoyable and individual games least. However, the individual game had highest helpfulness ratings and lyric analysis the lowest. Whilst patients could recall events in the group, they were not always able to state what the purpose of the group had been. All stated they would attend another session.

Ansdell and Meehan’s study [28] revealed in greater depth the experiences of patients who had significantly engaged in music therapy for a minimum of 10 individual sessions. The study met all but two of the qualitative framework criteria (attention to (12c) and explanation of (14d) negative cases, outliers or exceptions) [24] . Nine themes were defined: 1. Benefit is broader than symptomatic change; 2. Music therapy often involves reconnecting with a previous relationship to music; 3. Music therapy elicits and works with patients’ “music-health-illness” narrative; 4. Qualities of ‘musical’ and ‘therapeutic’ are often experienced as a unity; 5. Aspects of musical process in music therapy are experienced as distinctive; 6. The therapist is experienced as an equal ‘musical companion’; 7. Music therapy is experienced as distinctive in relation to other therapies; 8. Overall benefits are characterised as compensatory or alleviatory in relation to illness experiences; 9. A key benefit of music therapy is its ability to mobilise “music’s hope”. They suggest that the “music-health-illness” narrative forms 3 parts whereby patients have a previous positive relationship and history with music, which is lost when becoming ill, leading to loss of music as a helping resource. The authors suggest that the accounts indicate music therapy enables this relationship to be re-established, thus providing patients with a means of seeking help from music themselves again.

This review has identified a wide variety of ways in which music therapists work within acute adult psychiatric settings. Therapists respond to the challenges of the setting and system, as well as the diverse and individual needs of the patients. Initial engagement of patients with therapy is a core aim and emphasis is placed upon immediate presenting emotional, interpersonal and behavioural issues. Whilst papers describing clinical practice have some shared features which may be of importance for work in these settings, it is clear that as yet, no clearly defined model exists to accommodate the challenges of providing music therapy in acute adult mental health care.

Patient and Setting Challenges

The short period of in-patient stay has been a challenge for music therapists working to models that assume a longer period of work. Combined with the severity and range of symptoms, attendance and engagement were of particular concern. Adaptations to address this include increased session frequency, viewing sessions as standalone, targeted groups for particular function levels or needs and service diversification to incorporate the wider hospital, outpatients and community.

There is mixed evidence concerning attendance and engagement of patients in music therapy. The outcome studies suggest that adherence to music therapy is high, although this is contrasted with the difficulties in managing rapid patient turnover and fostering initial engagement. Despite the acknowledged difficulties in fostering group processes due to high turnover, few papers have fully examined the impact of this upon engagement in therapy. The early stages of group development described by Hara [59] , Jensen [64] and Hannibal [57] fit with those described within acute verbal psychotherapy groups [123] and the early stages of wider music therapy mental health groups [124] . Further research into the impact of group processes and music therapy techniques upon engagement in music therapy is therefore required.

Aims focus upon fostering therapeutic engagement with patients, building interpersonal relationships and immediate effects such as reduction in arousal or relaxation, which were suggested to be of immediate benefit both to individuals, and the ward environment as a whole. Patients within acute settings were noted to be in crises, and interventions therefore focused upon management of symptoms and interpersonal relationships in the ‘here and now’ rather than long term insight or understanding.

The lack of clear indication criteria and diagnostic focus is problematic for therapists working in acute settings as evidenced by the difficulties in communicating the value and purpose of music therapy to the multi-disciplinary team. This has been a wider issue for some time in music therapy mental health work [125] - [127] . The findings suggest that the patient’s interest and willingness to work with music, level of risk and ability to function in a group were core criteria. Music therapists may need to articulate their aims and criteria for referral with an emphasis upon immediate and short term benefits, along with ways in which patients might access and benefit from medium and longer term services.

Despite the heterogenous delivery of music therapy, different processes may be apparent for distinct diagnoses. Within this review, de Backer [10] , Jensen [64] and Solli & Rolvsjord [110] suggest distinct ways of working with acute psychosis, which was seen by some other authors as a contraindication for wider mixed groups. In the wider mental health literature, distinct patterns and processes within musical co-improvisation have been identified in depression and schizophrenia but this does not appear to have been explored any further within acute clinical practice [128] . In contrast, those utilizing resource-oriented principles, use methods to support and strengthen patient engagement in music and argue against a purely diagnostic focus.

Diversity of Practice

Approaches to music therapy were diverse, influenced by training and predominating models of their country. Previous reviews have also noted the diversity of practice and approaches in mental health [4] , [6] , [7] , [9] . Music therapy approaches often conflicted with the changing institutional models and structure. For example, within the UK, two early music therapists, Fenwick and Priestley [48] , [86] , describe services that offered music therapy to the whole hospital as an institution, such as open ensembles for staff, in- and outpatients. Later work by Grandison [54] and Odell-Miller [12] , [82] details the challenges faced as hospitals moved from therapeutic communities, conducive to group work models of music therapy on acute admission wards, to shorter term individually delivered medical models. A similar situation is seen in the work of Silverman in the USA, whereby approaches were adapted to fit with the institution’s psycho-educational and short term model.

Later papers in this review suggest that patient and setting specific models are beginning to evolve. Papers from the 1980s onwards are influenced by Yalom’s application of group psychotherapy to in-patient settings [121] , [129] , whilst therapists working within psychoanalytic and psychodynamic approaches have adapted their models to focus more upon the immediate interpersonal processes (influenced by the work of Daniel Stern [130] , [131] ) than upon interpretation of transference dynamics. In Norway, the concept of resource orientation in mental health care is also developing [13] , [76] , [107] - [110] .

Few studies have rigorously evaluated the effectiveness of music therapy specifically for acute psychiatric in-patients. The studies in this review provide some evidence suggesting that active music therapy can be effective in reducing psychiatric, positive and negative symptoms and improving interpersonal interaction although the length of time evaluated in these studies is generally much greater than typical lengths of in-patient stay. Studies of shorter durations suggest minor improvements, but these are not sustained at follow-up. Morgan et al. [74] note that the short time frame of therapy (2 weeks) might explain the lack of significant findings in their study. Similarly, studies of the immediate effects of psychoeducational music therapy [99] , [102] , [103] suggest minor improvements in a range of areas including coping skills, but these were not significant after 3 months. These findings are in line with the suggested dose-effect response [4] yet it remains unclear as to what role the immediate effects of primarily active music making and frequency of sessions may have upon processes and outcomes for this patient group.

Structured active music production, such as structured improvisation or active playing of pre-composed music plays a dominant role in music therapy for this patient group and was supported in the findings from outcome studies. Whilst active techniques were dominant across all countries, 11 papers observed that playing music actively could provoke high anxiety in patients. Therapists attempted to alleviate this by providing information and reassurance prior to the group, structured activities, and music familiar to patients. A recent study of music therapy techniques as predictors of change in individual work with adults with severe mental health problems and low motivation [132] found that use of music reproduction techniques, such as playing precomposed music or tuition of basic musical skills was associated with gains in relational competencies. The authors suggested that the pre-formed musical structure in music reproduction (ie. actively playing pre-composed music) can support patients who find it difficult to express or create their own music. Similarly, in her study of art and dance movement therapy, Dokter [133] found that young adults in a longer term therapeutic community setting valued active participation, but therapists had to carefully manage structure, discussions and arts activities to counter initial anxiety, meet individual needs and the stage of the group. It may be that use of familiar musical structures and styles assists in alleviating anxiety and builds the confidence to nonverbally further explore emotions and relationships in music [13] , [108] , [132] .

If both engagement and clinical improvement are dependent on 20 or more sessions [4] , [58] one might still question what value music therapy in acute settings may have in the treatment process. Whilst some papers cited the importance of fostering therapeutic engagement for longer term work in the community, this review identified difficulties in the linkup between in-patient and outpatient services, and the lack of continuation when outpatient work was offered. It is unclear to what extent patients are able to access further therapy after discharge and what impact this might have upon outcomes. Small benefits can be seen after a single session, but do not reach statistical significance. However, studies which incorporated patient feedback provided evidence of positive appraisals of music therapy with emphasis on improvement in mood, relationships and fostering of motivation.

Implications for Future Research

This review has identified clinical practice spanning 40 years across a range of countries in acute in-patient settings. Despite this large body of work, very little research exists to qualify the evidence base for practice in acute settings. One possible model of music therapy may be to offer a high intensity of sessions. However, whilst evidence suggests a greater number of sessions is required to achieve clinically significant benefits, no research has yet assessed whether increasing the frequency of therapy is accepted by patients. An alternative or adjunctive model may be to focus on brief interventions lasting only a few or even a single session although this would require consideration of clinical aims and outcomes that might be possible to achieve in such a short amount of time. Future research needs to disentangle the processes of music therapy for this population in order to better define indications and the types of outcomes that may be achieved. Development of models with consistent aims, theoretical concept and delivery is required if feasibility and effectiveness of music therapy within these settings is to be tested in systematic research including randomized controlled trials. Such developments would assist in defining the role, purpose and effective clinical practice of music therapy in acute in-patient settings.

Strengths and Limitations

To our knowledge this is the first systematic review of clinical practice of music therapy in acute adult psychiatry. The review employed a rigorous methodology, with a wide search strategy and systematic quality appraisal. The range of identified papers was large and the use of thematic synthesis ensured that the analysis was fully grounded in the data presented. Core themes within the analytic framework of clinical considerations and aims are represented internationally, indicating robustness of the synthesis, although the manner in which therapists adapted practice varied according to approach and country.

Despite the rigorous methodology, there are a number of limitations. Whilst the scope was wide to detect variations in clinical practice, the small number of research papers and inclusion of low quality research designs means that little can be concluded regarding effectiveness. Meekams & Daniels [134] note the challenges in combining quantitative and qualitative data within thematic synthesis. The majority of papers identified in this review came from secondary searches performed after searching of electronic databases. The review only identified four studies that would meet more rigorous criteria for meta-analysis of clinical outcomes, each of which employed diverse music therapy methods, and outcome measures. Within an acute in-patient setting, evaluation of music therapy as only one part of treatment is problematic given that patients are treated within the whole institution and are seen to improve rapidly to a point where they can be discharged. Given the extremely wide nature of the review, the full depth of papers, particularly within case studies is not covered. Papers from the Far East and Asia were under-represented with 3 of the unobtainable papers originating from these countries, and this review may have missed other important and potentially different ways of working.

The review suggests that currently there is no agreed, well researched and evidenced, clearly defined model of music therapy that accommodates the challenges of acute adult psychiatric in-patient settings. Changes to service setup have resulted in a need to modify existing models of music therapy to focus upon immediate and short term aims. Features of music therapy which may play an important role for this context include the frequency of therapy, active structured music making with verbal discussion, consistency of contact and boundaries, an emphasis on building a therapeutic relationship and building patient resources. Further research is now needed to develop clear models and aims, which take into account the acute in-patient context and provide information on the varying processes and outcomes. Such a model would provide greater clarity on the role and purpose of music therapy for acute adult in-patients and would provide a better defined framework of practice which can be tested in clinical trials.

Supporting Information

Information s1.

Review protocol.

Information S2

Search sources and example of search strategy.

Information S3

Data extraction form.

Information S4

Paper characteristics.

Information S5

Coverage of themes.

Information S6

Analysis of client and setting characteristics.

Acknowledgments

Stavros Orfanos, for assistance in screening, data extraction and quality assessment.

Funding Statement

Catherine Carr is funded by the National Institute for Health Research Clinical Doctoral Research Fellowship for Allied Health Professionals: CAT-CDRF 10-006; www.nihrtcc.nhs.uk . This paper presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.