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Do music therapies reduce depressive symptoms and improve QOL in older adults with chronic disease?

Quach, Jenny BSN, RN; Lee, Jung-Ah PhD, RN

doi: 10.1097/01.NURSE.0000513604.41152.0c
Department: RESEARCH CORNER
Free

Using music therapy to reduce depressive symptoms in older adults

Jenny Quach is an RN in the telemetry unit at Garden Grove Hospital in Garden Grove, Calif. Jung-Ah Lee is an associate professor in the Sue and Bill Gross School of Nursing at the University of California–Irvine in Irvine, Calif.

Research Corner is coordinated by Ruth A. Mooney, PhD, MN, RN-BC, the former nursing research facilitator at Christiana Care Health System in Newark, Del.

The content in this article has received appropriate institutional review board and/or administrative approval for publication.

The authors have disclosed no financial relationships related to this article.

Abstract

Background: Chronic health disorders increase the risk of depression, a serious mental health issue for older adults. Medications used to treat depressive symptoms can be costly and cause drug-drug interactions. Literature has shown that music therapy can improve mood and behaviors in older adults with dementia. Objective: To examine the effect of different types of music therapy in improving depressive symptoms in older adults with chronic diseases. Methods: The systematic review of literature was conducted using CINAHL, PubMed, and PsycINFO. The key words used for the search included depression, mood, elderly, aged, older, geriatric, music, stroke, and pain. The search was limited to peer-reviewed articles published from 2006 through 2015 that were written in English. Approximately 65 articles were found for initial reviews, and then 13 studies were selected for thorough reviews. Results: Five randomized controlled trials and eight quasi-experimental studies were examined in this review. Eight of nine studies that specifically used a depression-measuring instrument showed significant decreases in depression. All studies reviewed showed some benefits of music therapy in improving emotional well-being in older adults with chronic diseases. Listening to music, playing an instrument, singing, or a combination of these was useful in relieving depression and improving overall mood. Limitation: The studies in this review were selected if the full texts were available through the university library. Conclusions and implications: Music therapy can reduce depressive symptoms in older adults with chronic diseases. Nurses and healthcare providers should be aware of the benefits of music therapies and consider incorporating them into patient care when feasible. Music therapy is often low cost and has much less risk of harmful adverse reactions than medications. Further research with large sample sizes is needed to support the effect of music therapy.

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Background

Depression is a serious concern for older adults. In the United States, 7.7% of adults age 50 and older reported currently being depressed, and 15.7% reported chronic depression.1 According to the National Council on Aging, 7 million older Americans are affected by depression and many do not receive the treatment they need.2 Preventive services are limited for them, so addressing possible mental health issues before they become more serious is difficult.2 Suicide rates are also higher in older adults compared with those of younger people, and these rates are closely tied to depression.3

Older adults are at an increased risk for depression due to chronic health disorders and are often misdiagnosed or undertreated for depression.4 About 92% of older adults have at least one chronic health disorder, such as heart disease, cancer, stroke, or diabetes, and 77% of older adults have at least two.2 Chronic illnesses compromise the quality of life (QOL) for older adults, both physically and emotionally. These diseases may make it more difficult for older adults to live independently and may keep them from pursuing activities.4

Psychotherapy and antidepressant medications are the most common and effective treatments available for older adults with depression.5 Although depression can be managed with medications, polypharmacy is a growing concern for older adults and additional medications may not be the best solution. Polypharmacy, defined as the use of multiple medications, is associated with drug-drug interactions and adverse reactions.6 According to statistics from the CDC from 2007 to 2008, 76% of older adults used two or more prescription drugs and 37% had used five or more in the past month.7 For these reasons, alternative therapies such as music therapy have been widely used to alleviate and prevent depression.

Many published studies acknowledge the benefits of music therapy and its positive effects on depression. It has been well established that music therapy is effective in older adults with dementia.8 One study showed that 6 weeks of music therapy could reduce agitation in persons with dementia compared with standard care alone.9 Another study showed that music can be effective in increasing exercise program participation in this population.10

A literature review supports the benefits of music therapy and reveals how it can produce positive effects in older adults with dementia, such as improved short-term behavior and mood.11 Overall, many studies show that music can improve depressive symptoms and behavior problems. However, little research has studied the effect of music therapy on depression in older adults who do not have dementia or other alterations in cognition.

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Objective

The purpose of this systematic review of literature was to examine the effect of different types of music therapies in reducing depressive symptoms and improving overall mood and QOL in older adults with chronic diseases. Because nurses are advocates for holistic healthcare, they focus on the whole patient, including both mental and physical health. Mental health needs more emphasis because depressive disorders are unfortunately often underdiagnosed and undertreated.1 Nurses should be aware that music therapy is a practical and effective method for treating depressive symptoms in older adults with chronic diseases.

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Methods

A systematic literature search was conducted using databases (CINAHL, PubMed, Medline, and PsycINFO). The key words were depression, mood, elderly, aged, older, geriatric, music, stroke, and pain. The initial search yielded 258 articles; 81 in CINAHL, 86 in PubMed, and 91 in PsycINFO were identified after the search was limited to peer-reviewed articles published from 2006 to 2015 and written in English. Studies that focused on older patients with dementia were excluded. The studies selected for review were either quasi-experimental or randomized controlled trials. (See Glossary of research terms.) A total of 65 studies met the inclusion criteria for abstract review. (See Process for selecting studies.)

Figure

Figure

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Results

The studies reviewed in this article examined the efficacy of music therapy in alleviating depressive symptoms in older adults with chronic diseases. The target population was older adults not affected by dementia.

  • Types and lengths of interventions studied. Of 13 studies eligible for full-text review, two were one-time interventions and the remaining studies were conducted over a set period, usually a few months. Five studies featured interventions that occurred once a week, two studies occurred two or three times a week, and three studies occurred at least four times a week. One study had varying numbers of sessions per week due to individualized patient treatments. The music interventions reviewed in this study lasted a minimum of 30 minutes, with the longest sessions being 120 minutes.

Only one study by Phipps et al. focused on the inpatient setting; the rest focused on community-dwelling or outpatient settings.12 Music interventions varied and included listening to music, playing an instrument, singing, or some combination of these three.

Visit Nursing2017.com for Description of music interventions, which provides additional details about individual studies.

  • Listening to music. Six studies found in the literature review featured listening to music as the main intervention. For one study lasting 3 months, Travers and Bartlett found that their radio program showed a significant improvement in both Geriatric Depression Scale-5 (GDS-5) scores and QOL scores, which were measured with the Quality of Life in Alzheimer's Disease (QOL-AD) scale and GDS-5.13 A study by Chan found significant differences after the intervention at weeks 4, 6, 7, and 8, with all results being statistically significant.14 Overall, in the music group at the end of the study, depression scores were reduced significantly. Depression was measured with the 15-item Geriatric Depression Scale (GDS-15).

In a study by Phipps et al., mood states were measured with the Profile of Mood States (POMS) questionnaire.12 The study showed significant reductions in anxiety, depression, and the overall mood score. A study by Särkämö et al. also used the POMS questionnaire, and baseline scores in the music group for depression were an average of 7.0 (S.D. = 7.3) out of the maximum score of 28.0 in the music group and 8.5 (S.D. = 7.4) in the control group.15 At the 3-month mark, researchers performed a post hoc test and results showed that the depression score was significantly lower in the music group compared with the control group. At the 6-month mark, additional post hoc tests showed that participants in the music group experienced less depressive tendencies than those in the control group, although this was not a statistically significant finding.

Table

Table

A study by Kim et al. featured patients who had experienced stroke.16 The researchers measured anxiety and depression with the Beck Anxiety Inventory and the Beck Depression Inventory, respectively. Although no statistically significant changes in participants' anxiety levels were noted, the change in depression levels in the music group, an average decrease of 2.3 points, was statistically significant.

In a study by Onieva-Zafra et al., depression was measured with both the Visual Analogue Scale for Pain and Depression (VAS) and the Beck Depression Inventory (BDI).17 Results showed an improvement in the music group when measured with the BDI, but not with the VAS. No significant differences were found in the control group compared with the experimental group when measured with the BDI or with the VAS.

  • Playing a musical instrument. Five studies used playing a musical instrument either as the main intervention or as a component. In a study by Seinfeld et al., depression was measured with the BDI, and depression scores decreased in both intervention with piano practice and in control groups using different leisure activities.18 POMS showed a decrease in depression for the experimental group. For the control group, depression actually increased by the end of the study.

A study by Nakayama and Takeda measured mood states with the Mood Inventory scale.19 After music therapy, refreshment, shown by statements such as “I feel relaxed” or “I feel lively,” increased and depression and anxiety decreased, but results were not statistically significant.

  • Singing. A study by Tamplin et al. focused on the effects of singing on mood in patients after stroke.20 Participants were guided in vocal exercises and singing, but no formal training was given. Mood was measured with the Visual Analogue Mood Scale. Although participants reported that mood was improved before and after the singing performance, the overall results were not statistically significant, which could be due to the small sample size (N = 13).
  • Combination of methods. A study by Mohammadi, Shahabi, and Panah incorporated listening to music, playing an instrument, and singing into the music intervention.21 Depression was measured with the 21-item Depression Anxiety Stress Scale (DASS-21). At the end of the study, the music therapy intervention was found to be effective in reducing levels of anxiety, depression, and stress.

In a study by Jun, Roh, and Kim, participants were involved in music sessions that combined physical exercise and playing a musical instrument.22 Mood states were measured with a Korean version of the Profile of Mood States—Brief and depression was measured with The Center for Epidemiologic Studies Depression Scale. Mood states were shown to be improved in the intervention group compared with the control group, but depression scores did not show significant improvement in either group.

In a study by Gallagher et al., participants were involved with music therapy sessions that featured listening to music, singing, and playing a musical instrument.23 Mood was assessed with the Rogers' Happy/Sad Faces Assessment tool. Scores for anxiety, depression, and mood improved significantly.

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Discussion

The purpose of this review was to examine the literature analyzing the effectiveness of music therapy and its effects on depressive symptoms, mood, and QOL in older adults with chronic diseases. Overall, the studies reviewed support the use of music therapy and have shown that music can improve an individual's emotional well-being. Based on the results of these studies, music therapy can be a viable method of decreasing depressive symptoms in older adults with a chronic disease.

This literature review featured music therapies that varied in types of music therapy, length of intervention, and location of the intervention. The studies reviewed had positive results, with many of them showing reduction of depression symptoms, even though a few studies did not have statistically significant results. The fact that these music therapies varied considerably in methodology, yet all produced positive results, supports the practicality of implementing music therapy. Music therapy can be modified as needed for convenience and tailored to the person's needs, which will allow increased use of music therapy. Other advantages of music therapy are its low cost and lack of harmful adverse reactions.

The studies in this review varied greatly in study design and music intervention. Some programs were as short as a one-time session, but most of the studies ranged from 1 to 5 months. The music interventions also varied greatly and incorporated one or more of the following components: different types of music, instruments, and/or singing. However, all studies that measured changes in depressive symptoms13,14,16-18,21,22,24 showed improvement by the end of the study, although not all results were statistically significant.17,22 Many of these studies also featured populations with chronic diseases, such as stroke or chronic pain. These populations are at higher risk of depression because their chronic health disorders can be debilitating and may limit their physical activities. Strokes, for example, are a leading cause of long-term disability and reduce mobility in more than half of stroke survivors age 65 and older.25

Four studies by Jun et al., Kim et al., Särkämö et al., and Tamplin et al. in this review specifically evaluated the effect of music therapy on patients who had had strokes and found positive results.15,16,20,22 The studies of patients who had had strokes are relatively recent and their initial results are promising, warranting further research. Music can alleviate depressive symptoms, and the studies included in this review show that music can be beneficial in patients with chronic diseases. Music can be beneficial even if sessions are held for only a short period.

In one study by Phipps et al., the music session was merely a one-time intervention, but the results showed significant reductions in anxiety and depressive symptoms.12 Another study by Chan et al. found improvements as early as 4 weeks, but most of the studies did not measure depression until the conclusion of the study.14 Many of these studies did not measure the lasting effects of music therapy. For instance, do these beneficial effects remain 1 or 2 weeks later? Future studies should examine the long-term effects of music interventions.

Besides improving depression, music therapy improved overall mood and QOL for the participants. QOL is an important measurement that focuses on patients and how their disease affects their physical, emotional, and social well-being. Eight studies in this review measured changes in QOL and/or mood, and all of these studies found positive effects, although not all of the results were statistically significant.19,20

Travers et al. and Seinfeld et al. measured QOL in their research. These studies found significant improvements in QOL, but no conclusions can be made from only two studies.13,18 However, music therapy has been shown to potentially increase QOL, so more research is warranted to create a more solid evidence base to support the use of music therapy for this purpose.

Seven studies measured mood changes that resulted from music interventions. All findings of these studies showed improvement of mood, but these improvements were statistically significant in only four of the seven studies. In addition, two studies conducted by Travers et al. and Tamplin et al. qualitatively analyzed participants' responses to music therapy.13,20 Both of these reviews recorded anecdotal evidence of participant satisfaction with the music intervention. Many results from the studies showed improvements in anxiety, depression, and overall mood, which support the use of music therapy.

Several factors affect the internal validity of the studies. In all studies examined for this review, the staff member conducting the music intervention received training to standardize procedures. This strengthens the fidelity of the study and prevents results from being affected by the interventionist. Additionally, the type of music intervention affected the participant drop-out rate. Studies that focused on listening to music, such as those by Chan et al. and Travers et al.,13,14 had much lower drop-out rates compared with studies that involved singing and playing an instrument, such as those by Seinfeld et al. and Tamplin et al.18,20 One probable reason for this outcome is that listening to music requires less effort for the participant, increasing the chances of the participant remaining in the study. These two particular studies were also the longest in duration compared with the rest of the studies reviewed, which could have contributed to higher participant drop-out rate.

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Limitations

Several limitations were found in the studies reviewed. The most common limitation across most of the studies was a small sample size; 10 studies consisted of 55 participants or fewer, which prevents the study results from being generalizable. For most studies, the difficulty of achieving large sample sizes was due to the limited number of participants available at the location where the study was being conducted. Therefore, the results of the studies are less generalizable, and they may not apply to the overall population. Several of these studies were pilot studies and will probably be expanded in the future.

Several of the studies did not include a control group of participants who did not receive the intervention. The lack of a control group prevents researchers from attributing mental health improvements solely to the intervention. Participants' mood may have improved for other reasons, such as due to their own hobbies and activities.

Finally, some of the studies recruited participants solely through volunteering, and convenience sampling may lead to selection bias. Participants who volunteered may be more outgoing or more motivated to change their current health state, which could have increased their chances of having positive results from the intervention.

This literature review also has some limitations. Most of the studies reviewed were conducted outside the United States, and replicating these studies may produce vastly different results due to differences in culture and opinions about alternative therapies. Most of the studies included in this literature review focused on mainly listening to music so the other types of music therapy did not have as much evidence to support it. Ideally, having the same number of studies for each type of intervention would provide equal levels of evidence. However, because listening to music is easier to implement than either singing or playing a musical instrument, more studies were done about that particular topic, which influenced the types of studies included in this review. In addition, the studies chosen for this review were not all randomized controlled trials, so the results do not necessarily provide the strongest evidence supporting the use of music therapy.

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Conclusions

Nurses and caregivers of older adults may be able to use music interventions to prevent or relieve depressive symptoms. Healthcare providers and nurses should remain knowledgeable about music and other alternative therapies because they are often more affordable and cause little or no adverse reactions compared with medications. Music therapy can be practical and easily applied, especially because music can be incorporated in many ways. Weighing the numerous potential benefits that music therapy has to offer against negligible risks, clinicians should consider including music in a patient's care. More rigorous studies that include a control group and larger sample sizes should be conducted to provide stronger evidence to examine the efficacy of music therapy in older adults with chronic diseases.

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RESOURCE

National Council on Aging. Healthy aging. 2014. http://www.ncoa.org/assets/files/pdf/FactSheet_HealthyAging.pdf.

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