Music Therapy May Strike the Right Note for Schizophrenia

Pauline Anderson

June 16, 2017

Music therapy may provide something drugs or other treatments don't for patients with schizophrenia, results of a new Cochrane Review article show.

Investigators found that when used in conjunction with standard care, music therapy improved global state, mental state, social functioning, and quality of life for patients with schizophrenia or schizophrenialike disorders, at least on a short- to medium-term basis.

However, the effects were inconsistent across studies and depended on the number of music therapy sessions as well as the quality of the therapy.

"Moderate- to low-quality evidence suggests that music therapy as an addition to standard care improves the global state, mental state (including negative and general symptoms), social functioning, and quality of life of people with schizophrenia or schizophrenia-like disorders," the investigators, led by Monika Geretsegger, PhD, the Grieg Academy Music Therapy Research Centre, Uni Research Health, Bergen, Norway, write.

The article was published online May 31 in the Cochrane Database of Systematic Reviews.

Participation Critical

Research suggests music therapy can have unique motivational and relationship-building effects and can enhance emotionally expressive qualities that may help patients who do not benefit from verbal therapy.

Music therapy is becoming more established as a profession and is a state-registered profession in some countries, although its availability varies greatly. A German survey cited by the authors showed that music therapy was used in 37% of all psychiatric and psychosocial clinics in Germany.

Approaches to music therapy can be "active," whereby clients play music or sing, or "receptive," whereby they listen to music played by the therapist or to recorded selections of music. The therapy often employs several of these techniques.

Music therapy must involve a client-therapist relationship and can be provided in either an individual or small group setting. Active participation is crucial for the success of the therapy, but patients do not need to have musical skills.

Researchers searched the literature for randomized controlled trials that compared music therapy with standard care, placebo therapy, or no treatment. Their review included 18 trials that lasted from 1 to 6 months; the trials included a total of 1215 participants.

Ten studies examined the short-term effects of music therapy during a period of about 1 to 1.5 months. Seven trials investigated medium-term effects during a period of 3 to 4 months. Two studies examined the long-term effects of music therapy during a period of 6 to 9 months.

Most studies investigated music therapy in hospital settings and included primarily inpatients and some outpatients. The number of therapy sessions ranged from seven to 240.

There is currently no consensus as to what should be the primary outcomes for music therapy among people with schizophrenia. Symptom-related outcomes are most commonly measured in research studies.

For the review, the primary outcomes included global state; mental state (general mental state and negative symptoms); and functioning (general functioning and social functioning).

Although there were data from only two studies regarding effects of music therapy on global state, the results suggest that music therapy has a strong effect in the medium term. The number needed to treat for an additional beneficial outcome (NNTB) is small (n = 133; NNTB, 2; 95% confidence interval [CI], 2 - 4). The results seem to be mediated by the number of sessions.

"This is an important result that should be replicated," the authors write.

Benefit Takes Time

The studies used various measurements to assess mental state, including the Positive and Negative Symptoms Scale (PANSS) and the Brief Psychiatric Rating Scale (BPRS) for general mental state, the Scale for the Assessment of Negative Symptoms (SANS) for negative symptoms, the Scale for the Assessment of Positive Symptoms (SAPS) for positive symptoms, the Self-Rating Depression Scale (SDS) and the Hamilton Depression (HAM-D) rating scale for depression, and the Self-Rating Anxiety Scale (SAS) for anxiety.

The review found significant results on five of the seven scales. Effects tended to increase over time and were clearly seen in the medium term.

Music therapy showed large effects (standardized mean difference (SMD) > 0.80) on general mental state (PANSS: total n = 159; SMD, -0.97; 95% CI, -1.31 to -0.63; BPRS: total n = 70; SMD, -1.25; 95% CI, -1.77 to -0.73) and medium-sized effects (SMD, 0.50) on negative symptoms (SANS: total n = 177; SMD, -0.55; 95% CI, -0.87 to -0.24).

Short-term effects of medium size were seen for negative symptoms (total n = 319; SMD, -0.50; 95% CI, -0.73 to -0.27).

For other aspects of mental state (general mental state, positive symptoms, depression, and anxiety), interpretation was complicated by the use of different scales, different number of sessions, and variations in the quality of the music therapy.

Data on long-term effects were available from one study and were strongly in favor of music therapy.

"It clearly takes time for the effects of music therapy to unfold. This can be seen not only from the tendency of effects to increase over time, but also from examining the numbers of sessions provided in each of the studies. The strongest effects were found in studies that provided long-term, high-frequency music therapy."

Inasmuch as music therapy addresses problems related to emotion and social interaction, experts have speculated that it may be particularly well suited to treat negative symptoms, which are related to problems in that area. Examples of such problems include affective flattening and bluntness, poor social interaction, and a general lack of interest.

"However, the present review update suggests that effects on general mental state are at least as strong as those on negative symptoms," the authors note.

Dose-Dependent Effect

Effects on general functioning were significant and large for "high-dose" music therapy, both in the medium and long term. In contrast, low-dose music therapy (involving fewer than 20 sessions) did not affect general functioning.

As for social functioning, effects were in favor of music therapy in the short, medium, and long term, with effect sizes ranging from medium to large.

Results for cognitive functioning were mixed, with some scales suggesting benefit and others suggesting no effect.

Overall, music therapy may affect social functioning more quickly than general functioning, say the authors. "This appears plausible, given the focus of especially active music therapy on social interaction."

General functioning may be harder to change and may require more music therapy sessions and more time to affect functioning, say the authors.

Usable data on the effects of music therapy on behavior were limited but did suggest large effects of high-dose therapy in the medium term, similar to mental state and functioning. High-dose music therapy also had beneficial effects on quality of life in the short to medium term.

No effects on patient satisfaction with care could be identified. Data were too sparse to draw any conclusions.

Although the minimum number of sessions required for clinical results is difficult to determine, the results of the review "suggest that at least 20 sessions may be needed to reach clinical significant effects," the authors note. But they add that this probably varies from patient to patient.

The included studies were of moderate quality and were characterized by a moderate risk for bias. All studies stated explicitly that randomization was used, but concealment of allocation was unclear in most studies. Blinding of assessment was reported in only a minority of studies. The training level of music therapists was unclear in about half of the included studies.

Further research is needed to confirm the positive effects of music therapy. Research is particularly needed on long-term effects of music therapy, the dose-effect relationship, and on the effects of therapy delivered outside hospital settings, the authors note.

The review was supported by the University of Bergen, Uni Research, and the Research Council of Norway.The authors have disclosed no relevant financial relationships.

Cochrane Database Syst Rev. Published online May 29, 2017. Abstract

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