Literature Review

According to Leubner & Hinterberger (2017), depression is classified as one of the most grievous and frequent mental disorders globally affecting approximately 322 million people. The World Health Organization (WHO) predicted that by 2020 depression would become the leading cause of disability in the world. This prediction was based on the fact that the mood disorder can often lead to suicides with an estimated 800,000 suicidal deaths linked to the condition annually. In moderately common cases, depressed patients are often plagued with psychological, physical, emotional, and social impairments. The etiology of depression, as with most psychiatric conditions, is multi-factorial stemming from several factors including both genetic and environmental elements. Aalbers et al. (2017) state that current empirical and academic evidence supports the idea of a multi-faceted interaction between “neurotransmitter availability and receptor regulation within the brain.” The severity of this condition coupled with the ambiguity surrounding its etiology has resulted in a plethora of treatment and management plans aimed at alleviating the symptoms. One intervention that has proven invaluable in the treatment of depression is music therapy. This study seeks to determine the effectiveness of music therapy in alleviating the symptoms of depression through the conduction of a literature review.

Aalbers et al. (2017) defined Music therapy as the professional integration of music into treatment intervention to optimize and improve the quality of life of patients. This medical intervention is often delivered in several contexts ranging from developmental to educational. In psychiatry, the intervention is often delivered to individuals or groups with the former being exclusive to the patient and the latter being open to both new and recurring patients. The abstract nature of music therapy coupled with the nonfigurative characteristic of depression challenges the competent quantification of the relationship between the variables. Nonetheless, studies conducted in this field have used a combination of qualitative and quantitative research methods to define variables of depression that can be investigated for correlation to music therapy. Comparable treatment options for depression comprise of psychotherapy and pharmacological treatment options. However, studies have shown that common psychotropic medications, such as selective serotonin reuptake, and other adjunctive treatment options fail at addressing some symptoms of depression like anhedonia (Braun Janzen et al. 2019). Such symptoms are reward-based and characterized by variations in the ability of an individual to process primary and secondary rewards. The variation in treatment outcomes has influenced scholars and medical professionals alike to use music therapy to find an inclusive outcome that addresses the shortcomings of pharmacological options.

A literature review was conducted to systematically review and analyze current, evidence-based studies that contributed to the research topic. To determine the most relevant studies, the PICO tool was used to develop a research question that would guide the search. According to Brown (2020), this theoretical construct that is an acronym for Population, Intervention, Comparison, and Outcome is a conceptual framework that helps empirical studies formulates research questions that are concise and clearly articulated. The process is attached in Appendix A and resulted in the question how effective is music therapy in the treatment of depression in adult patients? The formulation of the research question was integral in determining keywords that would help in retrieving academic studies that were relevant to this study. This is because the search databases that were used have hundreds of thousands of studies that require a more refined strategy to retrieve reliable and relevant articles.

According to Qi et al. (2019), keywords are defined as significant words and phrases that form the basis of any study. Keywords are integral in literature research because they aid in the identification of articles that contain complementary information that will help support the study. The process of identifying keywords begins with isolation, the subsequent definition of the singularity, definition of sample, and population. This process helps in categorizing the research question into a niche/genre/discipline thereby narrowing the search. The identification of keywords is then followed by the establishment of synonyms that may be used as substitutes in the studies to broaden the search and capture all information needed. The consideration of spelling and punctuation helps capture all studies that may be important to this study. A Boolean search strategy is implemented alongside the keywords. This strategy refers to the use of specific keywords including AND/OR/NOT to combine keywords and retrieve studies specific to search operatives like geographical location (Ivchenko, 2017). The AND operator allows for a combination of keywords, the OR operator allows for substitution of terms, and the NOT operator allows for the exclusion of terms. The outcome of this search framework is attached in Appendix B.

A search through selected databases using varied keywords resulted in hundreds of thousands of articles. This made it difficult to retrieve relevant and valid academic studies that were applicable to this study. Consequently, an inclusion and exclusion criterion was formulated to help determine the studies that would be included or excluded. According to Patino & Ferreira (2018), an inclusion and exclusion criterion is important in a research methodology because it helps the researcher limit articles to valid and relevant ones. The criterion used in this study was formulated in conjunction with the PICO tool to ensure that all significant keywords were included in the search. this criterion can be found in Appendix D.

Specific databases were used to retrieve relevant academic studies. These databases were selected based on their relevance to the niche and included PubMed, Cinahl, Google Scholar, American Psychological Association (APA PsycNet). PubMed is a free research database that contains articles and journals on life sciences and biomedical topics; Cinahl is a paid nursing database accessed through free trial that contains full texts for journals for nursing and allied health professionals; Google Scholar is a free research database that contains academic studies, journals, and books across varied disciplines; and, American Psychological Association is a search database with paid and free versions containing full textbooks and peer-reviewed journals in psychology and behavioral science. The outcome of the search in these databases is attached in Appendix C.

Aalbers et al. (2017) conducted a study to determine the effects of music therapy for depression in comparison to other treatments like pharmacological and other psychological alternatives. The study conducted a meta-analysis on selected articles from relevant databases and used a selection criterion that limited the empirical studies to randomized controlled trials (RCTs) and controlled clinical trials (CCTs) (Aalbers et al. 2017). The articles were also limited to specific topics including psychological and pharmacological therapies, different forms of music therapies in the alleviation of depression symptoms, and other forms of therapies. The process for data collection and analysis involved two review authors who independently selected the studies, analyzed associated risk of bias, and extracted relevant data from all selected studies. Standard mean difference (SMD) for continuous data and odds ratios for dichotomous data limited to 95% confidence intervals were calculated (Aalbers et al. 2017). Heterogeneity was also assessed using I2 statistic. The study deduced that music therapy produced short-term benefits for people suffering from depression and was more effective when combined with treatment as usual (TAU) to alleviate symptoms associated with the condition (Aalbers et al. 2017). The study also deduced that music therapy showed efficacy in alleviating anxiety levels and improving the cognitive and neurological functions of the patients. Some limitations included an inadequate design and small sample for patients to consolidate findings. This study was important the defined research objective because it provides a positive correlation between music therapy and depression. Some weaknesses of this study include the lack of consideration for music therapy in a group or individual settings and the overall impact on the outcome.

Atiwannapat et al. (2016) conducted an RCT study to examine the impact of adjunctive group music therapy on depression. The defined objectives of the study included a comparison of active group music therapy and receptive group music therapy in the treatment of the major depressive disorder. The single-blinded randomized control trial was approved by the Institution Committee on Human Rights Related to Research Involving Human Subjects and included 14 MDD outpatients who were randomly assigned to a defined group therapy session in combination with their standard care (Atiwannapat et al. 2016). The study assessed the participants at baseline, 1 month (included 4 sessions), 3 months (end of intervention), and 6 months (post-study evaluation). The primary outcomes for the study were defined as depressive scores which were measured using the Montgomery-Åsberg Depression Rating Scale (MADRS) Thailand version (Atiwannapat et al. 2016). The secondary outcomes were assessed through self-rating depression scores on the patient’s quality of life. The study deduced that the patients in the therapy groups showed statistically non-significant reduction in MADRS in comparison to the control group at 1, 3, and 6 months. This reduction was greater in the active than the receptive group. The author deduced that group music therapy whether used actively or receptively is an integral adjunctive treatment option for outpatients with MDD (Atiwannapat et al. 2016). The study had several limitations that also served as weaknesses including a small sample size which affected the statistical power, the nature of interventions could not blind participants or therapists which may be a reason for bias, the sample had higher female to male ratio affecting the generalizability of the study, the participants were allowed to self-medicate during the study which means medication could have caused the changes, and the lack on consideration of non-modifiable confounders like stress relief that may affect outcomes. This study is important because it provides empirical evidence for the correlation between depressed patients and music therapy.

Braun Janzen et al. (2019) conducted an empirical study investigating the effect of music-based interventions on depression and associated symptoms. The study was an open-label one that focused on a single group with a pilot study conducted in collaboration with the Music and Health Research Collaboratory/University of Toronto and the Canadian Biomarker Integration Network in Depression (CAN-BIND) (Braun Janzen et al. 2019). The empirical study has 20 outpatients between the ages of 18 and 70 with a current diagnosis of MDD and who satisfied the DSM-5 (American Psychiatric Association, 2013) criterion for a Major Depressive Episode, as diagnosed by the clinician assessment. All participants had been experiencing depressive disorders for ≥3 months, with a Montgomery-Asberg Depression Rating Scale (MADRS) (Montgomery and Asberg, 1979) score of ≥15. This demonstrated mild to moderate symptoms. Participants were given music tracks with a low frequency between 30 and 70Hz with designed instrumental tracks in 30-minute session, 5 times every week through portable consumer devices. The study deduced that the patients experienced significant changes from bassline with quantified metrics including quality of sleep, life, and anhedonia. This discovery corroborates evidence that music therapy in conjunction with standard care is an effective adjunctive treatment for MDD (Braun Janzen et al. 2019). Some weaknesses and limitations include the absence of control conditions thereby not ruling out the possibility of change from passing time/Hawthorne effect and inability of study to exclude the influence of physical activities during treatment sessions. This study was important because it helped corroborate the hypothesis of a positive correlation between music therapy and depression.

Krauss (2019) conducted a review of the literature published between 2014 and 2019 to determine the effectiveness of music therapy in clinical settings. The review focused on using music therapy as a treatment option for depression. 18 empirical studies were reviewed and deductions made based on the consolidation of outcomes. The studies that were reviewed included the effect of music therapy on several psychological disorders including depression, bipolar disorder, and trauma-related disorders (Krauss, 2019). The study deduced that music therapy is an effective treatment method for depression and other psychological disorders regardless of its use with other options like pharmacotherapy. The review also incorporated an analysis of conceptual frameworks that postulated the neurological impact of music therapy. An insightful inference was made that rhythmic entertainment was an emergent and positive intervention for neurological and motor disorders and more specifically and debilitating aspects of psychiatric issues like memory loss and dissociation (Krauss, 2019). Some weaknesses of this study include inability to consider the impact of music therapy in individual setting and inability to address the literature gaps posed by the reviewed studies.

Leubner & Hinterberger (2017) conducted a review of empirical research trials that used music therapy as an intervention for people suffering from depression. The selected studies were based on guidelines recommended by the Cochrane Centre on a systematic literature search. The study incorporated both randomized controlled and longitudinal studies which resulted in 28 studies with a total sample of 1810 (Leubner & Hinterberger, 2017). The study discovered that in 26 studies, there existed statistical significant decline in depression levels in empirical music intervention groups in comparison to control groups. Senior patients particularly exhibited impressive improvements in musical intervention trials. This study was relevant because it used empirical evaluation to postulate positive correlation between depression and music therapy. However, it failed at considering secondary influences amongst control samples like extraneous activities, spirituality sessions like yoga, and familial influence.

Erkkilä et al. (2019) conducted a 2 × 2 factorial randomized controlled trial on 68 adults diagnosed with depression in Finland. The study exposed the participants to 6 weeks of biweekly integrative improvisational music therapy (IIMT) to determine its impact on symptoms of depression. Primary outcomes were measured using the Montgomery–Åsberg Depression Rating Scale (MADRS) at 6 weeks while secondary outcomes were depressive symptoms measured after 6 months (Erkkilä et al. 2019). The study revealed a therapeutic enhancement and alleviation of symptoms in short and long terms sessions. The study deduced that music contributes to memory retention which is integral in long term reduction of symptoms because they enabled the expression of unexpressed sentiments through the creation of non-cognitive bypass. While this study provided empirical corroboration for the hypothesis of a positive relationship between music therapy and depression it failed to clarify the clinical technique that created the outcome.

The reviewed studies corroborated the hypothesis that music therapy has a positive influence on patients suffering from depression by alleviating the intensity of the symptoms. Most of the studies examined or conducted empirical studies in randomized controlled settings that applied various music therapy designs in group settings. This had a significant impact on the outcome because it created room for exploration of the possibility of either improved or declined results when applied in individual settings. The studies used music mediums that ranged from low-frequency sounds to specific choices favored by the patients. Even though there were divergent mediums used across the studies, the impact was standard across all studies. Atiwannapat et al. (2016), Braun Janzen et al. (2019), and Erkkilä et al. (2019) conducted empirical studies based on randomized controlled designs while Aalbers et al. (2017), Krauss (2019), and Leubner & Hinterberger (2017) conducted meta-analysis and literature reviews. The studies base don medical studies found significantly higher correlations than those based on literature reviews between musical therapy and alleviation of symptoms of depressed patients. Additionally, the empirical trials had improved statistical significance for inferences than the literature reviews.

The empirical studies all used the Montgomery-Åsberg Depression Rating Scale (MADRS) that eliminates range for conceptual rating frameworks. The sole usage of this scale limits the generalizability of the study. On the other hand, the literature reviews incorporated studies with both present and older academic studies. While academic studies conducted in previous years/decades have contributing elements for the current studies, they limit the applicability of deductions in modern settings. This is because of the propagation and introduction of new and improved treatment options for depression. Krauss (2019) reviewed the application of music therapy across a range of psychological disorders including depression corroborating the inference that this form of intervention is critical in alleviating symptoms of depression. Aalbers et al. (2017), Atiwannapat et al. (2016), Braun Janzen et al. (2019), and Erkkilä et al. (2019) all deduced that music therapy was more effective when implemented in combination with other treatment plans like pharmacotherapy; Krauss (2019) refuted this claim and concluded that music therapy was more effective when implemented without any accompanying treatment options; and Leubner & Hinterberger (2017) did not address the impact of implementing music therapy with other treatment options. In conclusion, the studies all postulated a positive correlation between music therapy and depression implying a positive effect manifested through alleviation and eventual elimination of symptoms of depression. These studies validated the inference that music therapy is equally effective as pharmacotherapy in the treatment of depression.

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