Five studies met the inclusion criteria for this review. Of these, four (Chen 1992; Hanser 1994; Hendricks 1999; Radulovic 1997) reported clinically significant positive effects. One (Zerhusen 1995) in which music therapy was used as a control treatment, showed no effect. Few studies provided sufficient numerical data to be included in a meta-analysis and marked heterogeneity resulting from differences in the type of intervention used and in the populations studied meant that quantitative synthesis would be inappropriate (Fletcher 2007).

The range of interventions included guided imagery to music; ‘prescribed’ music to induce particular emotional states, for example relaxation or motivation; reflective discussions around pre-composed music chosen by the patient or therapist; and joint music-making between therapist and participant(s). Two of the five studies describe a similar approach (Hanser 1994; Hendricks 1999), but Hendricks 1999 modifies the approach taken by Hanser 1994 with individual older adults, for groups of adolescents. Only one of the studies examined the effects of an active approach (Chen 1992). Despite a large body of qualitative research and theoretical papers on this subject, active approaches barely feature among the studies identified for this review (see Characteristics of included and excluded studies tables). Most of the studies we identified involved pre-recorded music ‘prescribed’ for alteration of mood states. This use of music may lend itself more easily to experimental research. It may also be that these approaches are more common in Europe where outcome research of psychological therapies is less developed than in the US.

Music therapy for depression
Music therapy has been used in a range of ways to treat depression. Approaches can be active or receptive: active techniques might be used when participants cannot articulate difficult feelings. Here the therapist uses clinical techniques to connect with the patient in an improvised dialogue, which can then act as a springboard to emotional awareness. Receptive techniques involve the use of pre-composed music for relaxation, reflection, guided reminiscence and change of mood state. We conducted a systematic review to find out whether music therapy is effective in reducing the symptoms of depression. Five studies met the inclusion criteria for the review. Marked variations in the interventions offered, the populations studied and the outcome measures used meant that quantitative data synthesis and meta-analysis were not appropriate. Four studies reported greater reductions in symptoms of depression among those randomised to music therapy. The fifth study reported no change in mental state among those receiving music therapy compared to those randomised to standard care alone. Findings from individual studies suggest that music therapy for people with depression is feasible and indicate a need for further research.

Description of condition
Depression is a common problem affecting about 121 million people world-wide and is characterised by persistent low mood, which leads to changes in appetite, sleep pattern and overall functioning (WHO 2000; Moussavi 2007). The disorder is characterised by a marked lowering of self-esteem and feelings of worthlessness and guilt. Symptoms further include anhedonia, fatigue and impaired concentration (WHO 1992). At its worst, depression can lead to suicide, which is associated with the loss of 1 million lives per year (WHO 2000; Moussavi 2007). Depression is projected to become the leading cause of disability and the second leading contributor to the global burden of disease by the year 2020 (WHO 2000, Moussavi 2007). It occurs in persons of all genders, ages, and backgrounds (WHO 2001). The huge personal and economic impact of depression implies a need for systematic reviews of the evidence for efficacy for all current treatment modalities.

Description of treatments for depression
Depression is commonly treated with either antidepressants or psychotherapy, or a combination of both (Hale 1997). Both tricyclic antidepressants and the more recent selective serotonin reuptake inhibitors (SSRIs) have been found to be effective in treating depression (Paykel 1992; Edwards 1992). However, a recent Cochrane review by Moncrieff 2003 found small differences only between antidepressant medications and active placebos, with the lowest effects found in inpatient trials. A variety of talking therapies have also been found to be helpful in treating depression, and two systematic reviews are currently in progress comparing psychological and pharmacological treatments (Churchill 2003a; Churchill 2003b). The evidence for treating depression in adolescent populations is equivocal: Hazell 2007 challenges recommendations by several health bodies that SSRIs should only be prescribed to moderate and severely depressed adolescents only, in combination with psychological therapy.

Depression is also one of the most common reasons for the use of complementary and alternative therapies. The reasons for this are complex and vary according to patient group. They may entail a lack of satisfaction with conventional treatments and/or a wish to avoid side-effects from medication or the stigma attached to seeking talking therapy (Hazell 2007). However, this is refuted by a US study of 1035 participants (Astin 1998) which concludes that the majority of alternative medicine users do so because it is felt to be more in line with their own values, beliefs and philosophical orientations, rather than because of dissatisfaction with conventional treatments. This view is consistent with recent findings in the UK and Australia that mental health literacy in the general population is reasonably poor which reduces the likelihood of the evidence based treatments being sought (Jorm 2000; Jorm 2006). User preferences are nevertheless important when treating mental illness. Recent evidence suggests that depressed young people prefer counselling to medication and active treatments over ‘watchful waiting’ (Jaycox 2006), both of which may be relevant to the use of active techniques in music therapy for this population.

How the intervention might work
Music therapy has been defined as ‘an interpersonal process in which the therapist uses music and all of its facets to help patients to improve, restore or maintain health’ (Bruscia 1991). Music therapy approaches across the world have emerged from diverse traditions such as behavioural, psychoanalytic, educational or humanistic models of therapy. While techniques used in music therapy are also diverse they can be broadly categorised as ‘Active’, in which people re-create, improvise or compose music, and ‘Receptive’, in which they listen to music (Bruscia 1998). Receptive or combined approaches are more prevalent in the US with active approaches being used more widely in Europe.

The putative mechanism of action of receptive music therapy is that different types of musical stimulus directly induce physical and emotional changes. Receptive forms are more likely to be influenced by cognitive-behavioural or humanistic traditions and may involve an adjunctive activity performed whilst listening to live or recorded music, such as relaxation, meditation, movement, drawing or reminiscing. It has been suggested that this form of music therapy can help reduce stress, sooth pain, and energise the body (Bruscia 1991; Standley 1991). Most music therapy trainings of this sort in the US are at Bachelors level, and graduates can practice professionally by attaining Board Certification after a number of hours clinical practice.

In active approaches the therapist uses clinical improvisation techniques to stimulate or guide or respond to the patient who may use his/her voice or any musical instrument of choice within his/her capability (such as percussion). Patients may also bring songs written by themselves or others, or sheet music to play with the therapist. These models are often primarily improvisational and many are psycho-analytically informed. The putative mechanism of action here is that the co-created musical relationship between the therapist and the patient enables the latter to experience him or herself differently and/or to gain insight into his or her relational and emotional problems through talking about the musical dialogue (Nordoff 1977; Odell-MIller 1995). Trainings in these approaches are either at Masters level (e.g. all UK trainings) or they are extended undergraduate degrees.

More recently specialisms have evolved in particular areas, for example Neurologic Music Therapy is the specific application of music to cognitive, sensory and motor dysfunctions in neurological rehabilitation (Thaut 1999). Often, a combination of different techniques is used in the same therapy. The choice of approach tends to be based upon the person’s needs, the therapist’s training and the context (Drieschner 2001; Wigram 2002).

Music therapy is delivered over a range of time periods from a few weeks to several years. Intensity of treatment also varies from daily to weekly to monthly sessions. People may be seen in groups or individually, they may drop in to an open group (for example in a psychiatric ward setting) or have been referred and assessed by the music therapist before being placed in individual treatment or a closed group.

Why it is important to do this review
Although the music therapy profession in some countries originated in psychiatric rehabilitation, and music therapy is offered to people with mental disorders across the world, the evidence base of music therapy for depression has not yet been examined. Proponents of music therapy have suggested that it may be particularly beneficial for people who experience mental distress (e.g., Hadsell 1974; Benenzon 1981). For example, one observational study concluded that music therapy may have beneficial effects for people experiencing depression (Reinhardt 1982), a finding which was subsequently supported by a small randomised control trial of music therapy vs waiting list control among older adults with depressive disorders (Hanser 1994). However, a preliminary scan of the few systematic attempts at experimental research in this field highlights a number of difficulties. In particular, all RCTs have suffered from small sample sizes, making outcomes difficult to gauge accurately. In addition, patient groups are often heterogeneous (Radulovic 1997) and as mentioned above, types of music therapy vary. However, as music therapy is being sought and accessed for the treatment of depression as a complement or alternative to pharmacological or other psychological therapies, there is a need for a systematic review of the available evidence to understand its effectiveness with this patient group. There is also a case for comparing different music therapy approaches in order to develop a better understanding of the relationship between process and outcomes in different contexts.

Background
Depression is a highly prevalent disorder associated with reduced social functioning, impaired quality of life, and increased mortality. Music therapy has been used in the treatment of a variety of mental disorders, but its impact on those with depression is unclear.

Objectives
To examine the efficacy of music therapy with standard care compared to standard care alone among people with depression and to compare the effects of music therapy for people with depression against other psychological or pharmacological therapies.

Search strategy
CCDANCTR-Studies and CCDANCTR-References were searched on 7/11/2007, MEDLINE, PsycINFO, EMBASE, PsycLit, PSYindex, and other relevant sites were searched in November 2006. Reference lists of retrieved articles were hand searched, as well as specialist music and arts therapies journals.

Selection criteria
All randomised controlled trials comparing music therapy with standard care or other interventions for depression.

Data collection and analysis
Data on participants, interventions and outcomes were extracted and entered onto a database independently by two review authors. The methodological quality of each study was also assessed independently by two review authors. The primary outcome was reduction in symptoms of depression, based on a continuous scale.

Main results
Five studies met the inclusion criteria of the review. Marked variations in the interventions offered and the populations studied meant that meta-analysis was not appropriate. Four of the five studies individually reported greater reduction in symptoms of depression among those randomised to music therapy than to those in standard care conditions. The fifth study, in which music therapy was used as an active control treatment, reported no significant change in mental state for music therapy compared with standard care. Dropout rates from music therapy conditions appeared to be low in all studies.

Authors’ conclusions
Findings from individual randomised trials suggest that music therapy is accepted by people with depression and is associated with improvements in mood. However, the small number and low methodological quality of studies mean that it is not possible to be confident about its effectiveness. High quality trials evaluating the effects of music therapy on depression are required.

AS Maratos, C Gold, X Wang, MJ Crawford

Cochrane Database of Systematic Reviews 2008 Issue 1 (Status: New)

DOI: 10.1002/14651858.CD004517.pub2   This version first published online: 23 January 2008 in Issue 1, 2008
Date of Most Recent Substantive Amendment: 3 September 2007

This record should be cited as: Maratos AS, Gold C, Wang X, Crawford MJ. Music therapy for depression. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD004517. DOI: 10.1002/14651858.CD004517.pub2.