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- Published: 22 June 2021
Mental health and music engagement: review, framework, and guidelines for future studies
- Daniel E. Gustavson ORCID: orcid.org/0000-0002-1470-4928 1 , 2 ,
- Peyton L. Coleman ORCID: orcid.org/0000-0001-5388-6886 3 ,
- John R. Iversen 4 ,
- Hermine H. Maes 5 , 6 , 7 ,
- Reyna L. Gordon 2 , 3 , 8 , 9 &
- Miriam D. Lense 2 , 8 , 9
Translational Psychiatry volume 11 , Article number: 370 ( 2021 ) Cite this article
- Medical genetics
- Psychiatric disorders
Is engaging with music good for your mental health? This question has long been the topic of empirical clinical and nonclinical investigations, with studies indicating positive associations between music engagement and quality of life, reduced depression or anxiety symptoms, and less frequent substance use. However, many earlier investigations were limited by small populations and methodological limitations, and it has also been suggested that aspects of music engagement may even be associated with worse mental health outcomes. The purpose of this scoping review is first to summarize the existing state of music engagement and mental health studies, identifying their strengths and weaknesses. We focus on broad domains of mental health diagnoses including internalizing psychopathology (e.g., depression and anxiety symptoms and diagnoses), externalizing psychopathology (e.g., substance use), and thought disorders (e.g., schizophrenia). Second, we propose a theoretical model to inform future work that describes the importance of simultaneously considering music-mental health associations at the levels of (1) correlated genetic and/or environmental influences vs. (bi)directional associations, (2) interactions with genetic risk factors, (3) treatment efficacy, and (4) mediation through brain structure and function. Finally, we describe how recent advances in large-scale data collection, including genetic, neuroimaging, and electronic health record studies, allow for a more rigorous examination of these associations that can also elucidate their neurobiological substrates.
Music engagement, including passive listening and active music-making (singing, instrument playing), impacts socio-emotional development across the lifespan (e.g., socialization, personal/cultural identity, mood regulation, etc.), and is tightly linked with many cognitive and personality traits [ 1 , 2 , 3 ]. A growing literature also demonstrates beneficial associations between music engagement and quality of life, well-being, prosocial behavior, social connectedness, and emotional competence [ 4 , 5 , 6 , 7 , 8 ]. Despite these advances linking engagement with music to many wellness characteristics, we have a limited understanding of how music engagement directly and indirectly contributes to mental health, including at the trait-level (e.g., depression and anxiety symptoms, substance use behaviors), clinical diagnoses (e.g., associations with major depressive disorder (MDD) or substance use disorder (SUD) diagnoses), or as a treatment. Our goals in this scoping review are to (1) describe the state of music engagement research regarding its associations with mental health outcomes, (2) introduce a theoretical framework for future studies that highlight the contribution of genetic and environmental influences (and their interplay) that may give rise to these associations, and (3) illustrate some approaches that will help us more clearly elucidate the genetic/environmental and neural underpinnings of these associations.
Scope of the article
People interact with music in a wide variety of ways, with the concept of “musicality” broadly including music engagement, music perception and production abilities, and music training [ 9 ]. Table 1 illustrates the breadth of music phenotypes and example assessment measures. Research into music and mental health typically focuses on measures of music engagement, including passive (e.g., listening to music for pleasure or as a part of an intervention) and active music engagement (e.g., playing an instrument or singing; group music-making), both of which can be assessed using a variety of objective and subjective measures. We focus primarily on music engagement in the current paper but acknowledge it will also be important to examine how mental health traits relate to other aspects of musicality as well (e.g., perception and production abilities).
Our scoping review and theoretical framework incorporate existing theoretical and mechanistic explanations for how music engagement relates to mental health. From a psychological perspective, studies have proposed that music engagement can be used as a tool for encouraging self-expression, developing emotion regulation and coping skills, and building community [ 10 , 11 ]. From a physiological perspective, music engagement modulates arousal levels including impacts on heart rate, electrodermal activity, and cortisol [ 12 , 13 ]. These effects may be driven in part by physical aspects of music (e.g., tempo) or rhythmic movements involved in making or listening to music, which impact central nervous system functioning (e.g., leading to changes in autonomic activity) [ 14 ], as well as by personality and contextual factors (e.g., shared social experiences) [ 15 ]. Musical experiences also impact neurochemical processes involved in reward processing [ 10 , 13 , 14 , 16 , 17 , 18 ], which are also implicated in mental health disorders (e.g., substance use; depression). Thus, an overarching framework for studying music-mental health associations should integrate the psychological, physiological, and neurochemical aspects of these potential associations. We propose expanding this scope further through consideration of genetic and environmental risk factors, which may give rise to (and/or interact with) other factors to impact health and well-being.
Regarding mental health, it is important to recognize the hierarchical structure of psychopathology [ 19 , 20 ]. Common psychological disorders share many features and cluster into internalizing (e.g., MDD, generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD)), externalizing (e.g., SUDs, conduct disorder), and thought disorders (e.g., bipolar disorder, schizophrenia), with common variance shared even across these domains [ 20 ]. These higher-order constructs tend to explain much of the comorbidity among individual disorders, and have helped researchers characterize associations between psychopathology, cognition, and personality [ 21 , 22 , 23 ]. We use this hierarchical structure to organize our review. We first summarize the emerging literature on associations between music engagement and generalized well-being that provides promising evidence for associations between music engagement and mental health. Next, we summarize associations between music engagement and internalizing traits, externalizing traits/behaviors, and thought disorders, respectively. Within these sections, we critically consider the strengths and shortcomings of existing studies and how the latter may limit the conclusions drawn from this work.
Our review considers both correlational and experimental studies (typically, intervention studies; see Fig. 1 for examples of study designs). We include not only studies that examine symptoms or diagnoses based on diagnostic interviews, but also those that assess quantitative variation (e.g., trait anxiety) in clinical and nonclinical populations. This is partly because individuals with clinical diagnoses may represent the extreme end of a spectrum of similar, sub-clinical, problems in the population, a view supported by evidence that genetic influences on diagnosed psychiatric disorders or DSM symptom counts are similar to those for trait-level symptoms in the general population [ 24 , 25 ]. Music engagement may be related to this full continuum of mental health, including correlations with trait-level symptoms in nonclinical populations and alleviation of symptoms from clinical disorders. For example, work linking music engagement to subjective well-being speaks to potential avenues for mental health interventions in the population at large.
Within experimental studies, music interventions can include passive musical activities (e.g., song listening, music and meditation, lyric discussion, creating playlists) or active musical activities (e.g., creative methods, such as songwriting or improvisation and/or re-creative methods, such as song parody).
The goal of this scoping review was to integrate across related, but often disconnected, literatures in order to propose a comprehensive theoretical framework for advancing our understanding of music-mental health associations. For this reason, we did not conduct a fully systematic search or quality appraisal of documents. Rather, we first searched PubMed and Google Scholar for review articles and meta-analyses using broad search terms (e.g., “review” and “music” and [“anxiety” or “depression” or “substance use”]). Then, when drafting each section, we searched for additional papers that have been published more recently and/or were examples of higher-quality research in each domain. When giving examples, we emphasize the most recent and most well-powered empirical studies. We also conducted some targeted literature searches where reviews were not available (e.g., “music” and [“impulsivity” or “ADHD”]) using the same databases. Our subsequent framework is intended to contextualize diagnostic, symptom, and mechanistic findings more broadly within the scope of the genetic and environmental risk factors on psychopathology that give rise to these associations and (potentially) impact the efficacy of treatment efforts. As such, the framework incorporates evidence from review articles and meta-analyses from various literatures (e.g., music interventions for anxiety [ 26 ], depression [ 27 ]) in combination with experimental evidence of biological underpinnings of music engagement and the perspective provided by newly available methods for population-health approaches (i.e., complex trait genetics, gene–environment interactions).
Music engagement and well-being
A growing body of studies report associations between music engagement and general indices of mental health, including increased well-being or emotional competence, lending support for the possibility that music engagement may also be associated with better specific mental health outcomes. In over 8000 Swedish twins, hours of music practice and self-reported music achievement were associated with better emotional competence [ 5 ]. Similarly, a meta-ethnography of 46 qualitative studies revealed that participation in music activities supported well-being through management of emotions, facilitation of self-development, providing respite from problems, and facilitating social connections [ 28 ]. In a sample of 1000 Australian adults, individuals who engaged with music, such as singing or dancing with others or attending concerts reported greater well-being vs. those who engaged in these experiences alone or did not engage. Other types of music engagement, such as playing an instrument or composing music were not associated with well-being in this sample [ 4 ]. Earlier in life, social music experiences (including song familiarity and synchronous movement to music) are associated with a variety of prosocial behaviors in infants and children [ 6 ], as well as positive affect [ 7 ]. Thus, this work provides some initial evidence that music engagement is associated with better general mental health outcomes in children and adults with some heterogeneity in findings depending on the specific type of music engagement.
Music engagement and internalizing problems
MDD, GAD, and PTSD are the most frequently clustered aspects of internalizing psychopathology [ 19 , 24 , 29 , 30 ]. Experimental studies provide evidence for the feasibility of music intervention efforts and their therapeutic benefits but are not yet rigorous enough to draw strong conclusions. The most severe limitations are small samples, the lack of appropriate control groups, few interventions with multiple sessions, and publications omitting necessary information regarding the intervention (e.g., intervention fidelity, inclusion/exclusion criteria, education status of intervention leader) [ 31 , 32 , 33 ]. Correlational studies, by contrast, suggest musicians are at greater risk for internalizing problems, but that they use music engagement as a tool to help manage these problems [ 34 , 35 ].
Randomized controlled trials have revealed that music interventions (including both music therapies administered by board-certified music therapists and other music interventions) are associated with reduced depression, anxiety, and PTSD symptoms [ 26 , 27 , 33 , 36 ]. A review of 28 studies reported that 26 revealed significantly reduced depression levels in music intervention groups compared to control groups, including the 9 studies which included active non-music intervention control groups (e.g., reading sessions, “conductive-behavior” psychotherapy, antidepressant drugs) [ 27 ]. A similar meta-analysis of 19 studies demonstrated that music listening is effective at decreasing self-reported anxiety in healthy individuals [ 26 ]. A review of music-based treatment studies related to PTSD revealed similar conclusions [ 36 ], though there were only four relevant studies. More recent studies confirm these findings [ 37 , 38 , 39 ], such as one randomized controlled trial that demonstrated reduced depression symptoms in older adults following musical improvisation exercises compared to an active control group (gentle gymnastic activities) [ 39 ].
This work is promising given that some studies have observed effects even when compared to traditional behavior therapies [ 40 , 41 ]. However, there are relatively few studies directly comparing music interventions to traditional therapies. Some music interventions incorporate components of other therapeutic methods in their programs including dialectic or cognitive behavior therapies [ 42 ], but few directly compare how the inclusion of music augments traditional behavioral therapy. Still other non-music therapies incorporate music into their practice (e.g., background music in mindfulness therapies) [ 43 , 44 ], but the specific contribution of music in these approaches is unclear. Thus, there is a great need for further systematic research relating music to traditional therapies to understand which components of music interventions act on the same mechanisms as traditional therapies (e.g., developing coping mechanisms and building community) and which bolster or synchronize with other approaches (e.g., by adding structure, reinforcement, predictability, and social context to traditional approaches).
Aside from comparison with other therapeutic approaches, an earlier review of 98 papers from psychiatric in-patient studies concluded that promising effects of music therapy were limited by small sample sizes and methodological shortcomings including lack of reporting of adverse events, exclusion criteria, possible confounders, and characteristics of patients lost to follow-up [ 33 ]. Other problems included inadequate reporting of information on the source population (e.g., selection of patients and proportion agreeing to take part in the study), the lack of masking of interviewers during post-test, and concealment of randomization. Nevertheless, there was some evidence that therapies with active music participation, structured sessions, and multiple sessions (i.e., four or more) improved mood, with all studies incorporating these characteristics reporting significant positive effects. However, most studies have focused on passive interventions, such as music listening [ 26 , 27 ]. Active interventions (e.g., singing, improvising) have not been directly compared with passive interventions [ 27 ], so more work is needed to clarify whether therapeutic effects are indeed stronger with more engaging and active interventions.
Correlational studies have focused on the use of music in emotional self-regulation. Specifically, individuals high in neuroticism appear to use music to help regulate their emotions [ 34 , 35 ], with beneficial effects of music engagement on emotion regulation and well-being driven by cognitive reappraisal [ 45 ]. Music listening may also moderate the association between neuroticism and depression in adolescents [ 46 ], consistent with a protective effect.
A series of recent studies have used validated self-reported instruments that directly assess how individuals use music activities as an emotion regulation strategy [ 47 , 48 , 49 , 50 ]. In adults, the use of music listening for anger regulation and anxiety regulation was positively associated with subjective well-being, psychological well-being, and social well-being [ 50 ]. In studies of adolescents and undergraduates, the use of music listening for entertainment was associated with fewer depression and anxiety symptoms [ 51 ]. “Healthy” music engagement in adolescents (i.e., using music for relaxation and connection with others) was also positively associated with happiness and school satisfaction [ 49 ]. However, the use of music listening for emotional discharge was also associated with greater depression, anxiety, and stress symptoms [ 51 ], and “unhealthy” music engagement (e.g., ‘hiding’ in music to block others out) was associated with lower well-being, happiness, school satisfaction, and greater depression and rumination [ 49 ]. Other work has highlighted the role of valence in these associations, with individuals who listen to happier music when they are in a bad mood reporting stronger ability for music to influence their mood than those who listen to sad music while in a negative mood [ 52 , 53 ].
This work highlights the importance of considering individuals’ motivations for engaging with music in examining associations with well-being and mental health, and are consistent with the idea that individuals already experiencing depression, anxiety, and stress use music as a therapeutic tool to manage their emotions, with some strategies being more effective than others. Of course, these correlational effects may not necessarily reflect causal associations, but could be due to bidirectional influences, as suggested by claims that musicians may be at higher risk for internalizing problems [ 54 , 55 , 56 ]. It is also necessary to consider demographic and socioeconomic factors in these associations [ 57 ], for example, because arts engagement may be more strongly associated with self-esteem in those with higher education [ 58 ].
It is also necessary to clarify if musicians (professional and/or nonprofessional) represent an already high-risk group for internalizing problems. In one large study conducted in Norway ( N = 6372), professional musicians were higher in neuroticism than the general population [ 56 ]. Another study of musician cases ( N = 9803) vs. controls ( N = 49,015) identified in a US-based research database through text-mining of medical records found that musicians are at greater risk of MDD (Odds ratio [OR] = 1.21), anxiety disorders (OR = 1.25), and PTSD (OR = 1.13) [ 55 ]. However, other studies demonstrate null associations between musician status and depression symptoms [ 5 ] or mixed associations [ 59 ]. In N = 10,776 Swedish twins, for example, professional and amateur musicians had more self-reported burnout symptoms [ 54 ]. However, neither playing music in the past, amateur musicianship, nor professional musicianship was significantly associated with depression or anxiety disorder diagnoses.
Even if musicians are at higher risk, such findings can still be consistent with music-making being beneficial and therapeutic (e.g., depression medication use is elevated in individuals with depressive symptoms because it is a treatment). Clinical samples may be useful in disentangling these associations (i.e., examining if those who engage with music more frequently have reduced symptoms), and wider deployment of measures that capture emotion regulation strategies and motivations for engaging with music will help shed light on whether high-risk individuals engage with music in qualitatively different ways than others [ 51 , 57 ]. Later, we describe how also considering the role of genetic and environmental risk factors in these associations (e.g., if individuals at high genetic and/or environmental risk self-select into music environments because they are therapeutic) can help to clarify these questions.
Music engagement and externalizing problems
The externalizing domain comprises SUDs, and also includes impulsivity, conduct disorder, and attention-deficit hyperactivity disorder (ADHD), especially in adolescents [ 20 , 24 , 60 , 61 ]. Similar to the conclusions for internalizing traits, experimental studies show promising evidence that music engagement interventions may reduce substance use, ADHD, and other externalizing symptoms, but conclusions are limited by methodological limitations. Correlational evidence is sparce, but there is less reason to suspect musicians are at higher risk for externalizing problems.
Intervention studies have demonstrated music engagement is helpful in patients with SUDs, including reducing withdrawal symptoms and stress, allowing individuals to experience emotions without craving substance use, and making substance abuse treatment sessions more enjoyable and motivating [ 62 , 63 , 64 ] (for a systematic review, see [ 65 ]). Similar to the experimental studies of internalizing traits, however, these studies would also benefit from larger samples, better controls, and higher-quality reporting standards.
Music intervention studies for ADHD are of similar quality. Such interventions have been shown to reduce inattention [ 66 ], decrease negative mood [ 67 ], and increase reading comprehension for those with ADHD [ 68 ]. However, there is a great amount of variability among children with ADHD, as some may find music distracting while others may focus better in the presence of music [ 69 ].
Little research has been conducted to evaluate music engagement interventions for impulsivity or conduct disorder problems, and findings are mixed. For example, a music therapy study of 251 children showed that beneficial effects on communication skills (after participating in a free improvisation intervention) was significant, though only for the subset of children above age 13 [ 70 ]. Another study suggested the promising effects of music therapy on social skills and problem behaviors in 89 students selected based on social/emotional problem behaviors, but did not have a control group [ 71 ]. Other smaller studies ( N < 20 each) show inconsistent results on disruptive behaviors and aggression [ 72 , 73 ].
Correlational studies on externalizing traits are few and far between. A number of studies examined how listening habits for different genres of music relate to more or less substance use [ 74 , 75 , 76 , 77 ]. However, these studies do not strongly illuminate associations between music engagement and substance use because musical genres are driven by cultural and socioeconomic factors that vary over the lifespan. In the previously cited large study of American electronic medical records [ 55 ] where musicianship was associated with more internalizing diagnoses, associations were nonsignificant for “tobacco use disorder” (OR = 0.93), “alcoholism” (OR = 1.01), “alcohol-related disorders” (OR = 1.00), or “substance addiction and disorders” (OR = 1.00). In fact, in sex-stratified analyses, female musicians were at significantly decreased risk for tobacco use disorder (OR = 0.85) [ 55 ]. Thus, there is less evidence musicians are at greater risk for externalizing problems than in other areas.
Regarding other aspects of externalizing, some studies demonstrate children with ADHD have poor rhythm skills, opening a possibility that working on rhythm skills may impact ADHD [ 78 , 79 ]. For example, music might serve as a helpful scaffold (e.g., for attention) due to its regular, predictable rhythmic beat. It will be important to examine whether these associations with music rhythm are also observed for measures of music engagement, especially in larger population studies. Finally, musicians were reported to have lower impulsiveness than prior population samples, but were not compared directly to non-musicians [ 80 , 81 ].
Music engagement and thought disorders
Thought disorders typically encompass schizophrenia and bipolar disorder [ 20 ]. Trait-level measures include schizotypal symptoms and depression symptoms. Much like internalizing, music interventions appear to provide some benefits to individuals with clinical diagnoses, but musicians may be at higher risk for thought disorders. Limitations of both experimental and correlational studies are similar to those for internalizing and externalizing.
Music intervention studies have been conducted with individuals with schizophrenia and bipolar disorder. A recent meta-analysis of 18 music therapy studies for schizophrenia (and similar disorders) [ 82 ] demonstrated that music therapy plus standard care (compared to standard care alone) demonstrated improved general mental health, fewer negative symptoms of schizophrenia, and improved social functioning. No effects were observed for general functioning or positive symptoms of schizophrenia. Critiques echoed those described above. Most notably, although almost all studies had low risk of biases due to attrition, unclear risk of bias was evident in the vast majority of studies (>75%) for selection bias, performance bias, detection bias, and reporting bias. These concerns highlight the need for these studies to report more information about their study selection, blinding procedure, and outcomes.
More recent papers suggest similar benefits of music therapies in patients with psychosis [ 83 ] and thought disorders [ 84 ], with similar limitations (e.g., one study did not include a control group). Finally, although a 2021 review did not uncover more recent articles related to bipolar disorder, they argued that existing work suggests music therapy has the potential both to treat bipolar disorder symptoms and alleviate subthreshold symptoms in early stages of the disorder [ 85 ].
Much like internalizing, findings from the few existing studies suggest that musicians may be at higher risk for thought disorders. In the large sample of Swedish twins described earlier [ 54 ], playing an instrument was associated with more schizotypal symptoms across multiple comparisons (professional musicians vs. non-players; amateur musicians vs. non-players; still plays an instrument vs. never played). However, no associations were observed for schizophrenia or bipolar disorder diagnoses across any set of comparison groups. Another study demonstrated that individuals with higher genetic risk for schizophrenia or bipolar disorder were more likely to be a member of a creative society (i.e., actor or dancer, musician, visual artist, or writer) or work in a profession in these fields [ 86 ]. Furthermore, musician status was associated with “bipolar disorder” (OR = 1.18) and “schizophrenia and other psychotic disorders” (OR = 1.18) in US electronic health records (EHRs) [ 55 ].
There is promising evidence that music engagement is associated with better mental health outcomes. Music engagement is positively associated with quality of life, well-being, social connectedness, and emotional competence. However, some individuals who engage with music may be at higher risk for mental health problems, especially internalizing and thought disorders. More research is needed to disentangle these contrasting results, including clarifying how “healthy” music engagement (e.g., for relaxation or social connection) leads to greater well-being or successful emotion regulation, and testing whether some individuals are more likely to use music as a tool to regulate emotions (e.g., those with high neuroticism) [ 34 , 35 ]. Similarly, it will be important to clarify whether the fact that musicians may be an at-risk group is an extension of working in an artistic field in general (which may feature lower pay or lack of job security) and/or if similar associations are observed with continuous music engagement phenotypes (e.g., hours of practice). As we elaborate on later, genetically informative datasets can help clarify these complex associations, for example by tested whether musicians are at higher genetic risk for mental health problems but their music engagement mitigates these risks.
Music intervention studies are feasible and potentially effective at treating symptoms in individuals with clinical diagnoses, including depression, anxiety, and SUDs. However, it will be essential to expand these studies to include larger samples, random sampling, and active control groups that compare the benefits of music interventions to traditional therapies and address possible confounds. These limitations make it hard to quantify how specific factors influence the effectiveness of interventions, such as length/depth of music training, age of sample, confounding variables (e.g., socioeconomic status), and type of intervention (e.g., individual vs. group sessions, song playing vs. songwriting, receptive vs. active methods). Similarly, the tremendous breadth of music engagement activities and measures makes it difficult to identify the specific aspects of music engagement that convey the most benefits to health and well-being [ 87 ]. It is therefore necessary to improve reporting quality of studies so researchers can better identify these potential moderators or confounds using systematic approaches (e.g., meta-analyses).
Various mechanisms have been proposed to explain the therapeutic effects of music on mental health, including psychological (e.g., building communities, developing coping strategies) [ 10 , 11 ] and specific neurobiological drivers (e.g., oxytocin, cortisol, autonomic nervous system activity) [ 12 , 13 , 14 ]. However, it will be vital to conduct more systematic research comparing the effects of music interventions to existing therapeutic methods and other types of creative activities (e.g., art [ 88 ]) to quantify which effects and mechanisms are specific to music engagement. Music interventions also do not have to be an alternative to other treatments, but may instead support key elements of traditional interventions, such as being engaging, enjoyable, providing social context, and increasing structure and predictability [ 89 ]. Indeed, some music therapists incorporate principals from existing psychotherapeutic models [ 42 , 90 ] and, conversely, newer therapeutic models (e.g., mindfulness) incorporate music into their practice [ 43 , 44 ]. It is not yet possible to disentangle which aspects of music interventions best synergize with or strengthen standard psychotherapeutic practices (which are also heterogeneous), but this will be possible with better reporting standards and quality experimental design.
To encapsulate and extend these ideas, we next propose a theoretical framework that delineates key aspects of how music engagement may relate to mental health, which is intended to be useful for guiding future investigations in a more systematic way.
Theoretical framework for future studies
Associations between music engagement and mental health may take multiple forms, driven by several different types of genetic predispositions and environmental effects that give rise to, and interact with, proposed psychological and neurobiological mechanisms described earlier. Figure 2 displays our theoretical model in which potential beneficial associations with music are delineated into testable hypotheses. Four key paths characterize specific ways in which music engagement may relate to (and influence) mental health traits, and thus represent key research questions to be addressed in future studies.
Progression of mental health problems is based on a diathesis-stress model, where genetic predispositions and environmental exposures result in later problems (which can be remedied through treatment). Potential associations with music engagement include (Path 1; blue arrows) correlated genetic/environmental influences and/or causal associations between music engagement and trait-level mental health outcomes; (Path 2; red arrows) interactions between music engagement and risk factors to predict later trait-level or clinical level symptoms; and (Path 3; gold arrow) direct effects of music engagement on reducing symptoms or improving treatment efficacy. Path 4 (orange arrows) illustrates the importance of understanding how these potential protective associations are driven by neuroanatomy and function. MDD major depressive disorder, GAD generalized anxiety disorder, PTSD posttraumatic stress disorder, SUD substance use disorder(s).
Path 1: Music engagement relates to mental health through correlated genetic and environmental risk factors and/or causation
The diathesis-stress model of psychiatric disease posits that individuals carry different genetic liabilities for any given disorder [ 91 , 92 , 93 ], with disorder onset depending on the amount of negative vs. protective environmental life events and exposures the individual experiences. Although at first glance music engagement appears to be an environmental exposure, it is actually far from it. Twin studies have demonstrated that both music experiences and music ability measures are moderately heritable and genetically correlated with cognitive abilities like non-verbal intelligence [ 94 , 95 , 96 , 97 ]. Music engagement may be influenced by its own set of environmental influences, potentially including socioeconomic factors and availability of instruments. Thus, music engagement can be viewed as a combination of genetic and environmental predispositions and availability of opportunities for engagement [ 98 ] that are necessary to consider when evaluating associations with mental health [ 54 ].
When examining music-mental health associations, it is thus important to evaluate if associations are in part explained by correlated genetic or environmental influences (see Fig. 3 for schematic and explanation for interpreting genetic/environmental correlations). On one hand, individuals genetically predisposed to engage with music may be at lower risk of experiencing internalizing or externalizing problems. Indeed, music engagement and ability appear associated with cognitive abilities through genetic correlations [ 3 , 99 ], which may apply to music-mental health associations as well. On the other, individuals at high genetic risk for neuroticism or psychopathology may be more likely to engage with music because it is therapeutic, suggesting a genetic correlation in the opposite direction (i.e., increased genetic risk for musicians). To understand and better contextualize the potential therapeutic effects of music engagement, it is necessary to quantify these potential genetic associations, while simultaneously evaluating whether these associations are explained by correlated environmental influences.
Variance in any given trait is explained by a combination of genetic influences (i.e., heritability) and environmental influences. For complex traits (e.g., MDD or depression symptoms), cognitive abilities (e.g., intelligence), and personality traits (e.g., impulsivity), many hundreds or thousands of independent genetic effects are combined together in the total heritability estimate. Similarly, environmental influences typically represent a multitude of factors, from individual life events to specific exposures (e.g., chemicals, etc.). The presence of a genetic or environmental correlation between traits indicates that some set of these influences have an impact on multiple traits. A Displayed using a Venn diagram. Identifying the strength of genetic vs. environmental correlations can be useful in testing theoretical models and pave the way for more complex genetic investigations. Beyond this, gene identification efforts (e.g., genome-wide association studies) and additional analyses of the resulting data can be used to classify whether these associations represent specific genetic influences that affect both traits equally (i.e., genetic pleiotropy ( B )) or whether a genetic influence impacts only one trait which in turn causes changes in the other (i.e., mediated genetic pleiotropy ( C )). Environmental influences can also act pleiotropically or in a mediated-pleiotropy manner, but only genetic influences are displayed for simplicity.
Beyond correlated genetic and environmental influences, music engagement and mental health problems may be associated with one another through direct influences (including causal impacts). This is in line with earlier suggestions that music activities (e.g., after-school programs, music practice) engage adolescents, removing opportunities for drug-seeking behaviors [ 100 ], increasing their social connections to peers [ 101 ], and decreasing loneliness [ 41 ]. Reverse causation is also possible, for example, if experiencing mental health problems causes some individuals to seek out music engagement as a treatment. Longitudinal and genetically informative studies can help differentiate correlated risk factors (i.e., genetic/environmental correlations) from causal effects of music engagement (Fig. 2 , blue arrows) [ 102 ].
Path 2: Engagement with music reduces the impact of genetic risk
Second, genetic and environmental influences may interact with each other to influence a phenotype. For example, individual differences in music achievement are more pronounced in those who engage in practice or had musically enriched childhood environments [ 97 , 98 ]. Thus, music exposures may not influence mental health traits directly but could impact the strength of the association between genetic risk factors and the emergence of trait-level symptoms and/or clinical diagnoses. Such associations might manifest as decreased heritability of trait-level symptoms in musicians vs. non-musicians (upper red arrow in Fig. 2 ). Alternatively, if individuals high in neuroticism use music to help regulate their emotions [ 34 , 35 ], those who are not exposed to music environments might show stronger associations between neuroticism and later depressive symptoms or diagnoses than those engaged with music (lower red arrow in Fig. 2 ). Elucidating these possibilities will help disentangle the complex associations between music and mental health and could be used to identify which individuals would benefit most from a music intervention (especially preventative interventions). Later, we describe some specific study designs that can test hypotheses regarding this gene-environment interplay.
Path 3: Music engagement improves the efficacy of treatment (or acts as a treatment)
For individuals who experience severe problems (e.g., MDD, SUDs), engaging with music may reduce symptoms or improve treatment outcomes. This is the primary goal of most music intervention studies [ 27 , 33 ] (Fig. 2 , gold arrow). However, and this is one of the central messages of this model, it is important to consider interventions in the context of the paths discussed above. For example, if music engagement is genetically correlated with increased risk for internalizing or externalizing problems (Path 1) and/or if individuals at high genetic risk for mental health problems have already been using music engagement to develop strategies to deal with subthreshold symptoms (Path 2), then may be more likely to choose music interventions over other alternatives and find them more successful. Indeed, the beneficial aspects of music training on cognitive abilities appear to be drastically reduced in samples that were randomly sampled [ 103 ]. Therefore, along with other necessary reporting standards discussed above [ 32 , 33 ], it will be useful for studies to report participants’ prior music experience and consider these exposures in evaluating the efficacy of interventions.
Path 4: Music engagement influences brain structure and function
Exploring associations between music engagement and brain structure and function will be necessary to elucidate the mechanisms driving the three paths outlined above. Indeed, there are strong links between music listening and reward centers of the brain [ 104 , 105 ] including the nucleus accumbens [ 106 , 107 ] and ventral tegmental areas [ 108 ] that are implicated in the reward system for all drugs of abuse [ 109 , 110 , 111 , 112 ] and may relate to internalizing problems [ 113 , 114 , 115 ]. Moreover, activity in the caudate may simultaneously influence rhythmic sensorimotor synchronization, monetary reward processing, and prosocial behavior [ 116 ]. Furthermore, music listening may help individuals control the effect of emotional stimuli on autonomic and physiological responses (e.g., in the hypothalamus) and has been shown to induce the endorphinergic response blocked by naloxone, an opioid antagonist [ 18 , 117 ].
This work focusing on music listening and reward processing has not been extended to music making (i.e., active music engagement), though some differences in brain structure and plasticity between musicians and non-musicians have been observed for white matter (e.g., greater fractional anisotropy in corpus callosum and superior longitudinal fasciculus) [ 118 , 119 , 120 , 121 ]. In addition, longitudinal studies have revealed that instrument players show more rapid cortical thickness maturation in prefrontal and parietal areas implicated in emotion and impulse control compared to non-musician children/adolescents [ 122 ]. Importantly, because the existing evidence is primarily correlational, these cross-sectional and longitudinal structural differences between musicians and non-musicians could be explained by genetic correlations, effects of music training, or both, making them potentially relevant to multiple paths in our model (Fig. 2 ). Examining neural correlates of music engagement in more detail will shed light on these possibilities and advance our understanding of the correlates and consequences of music engagement, and the mechanisms that drive the associations discussed above.
New approaches to studying music and mental health
Using our theoretical model as a guide, we next highlight key avenues of research that will help disentangle these music-mental health associations using state-of-the-art approaches. They include the use of (1) genetic designs, (2) neuroimaging methods, and (3) large biobanks of EHRs.
Genetic designs provide a window into the biological underpinnings of music engagement [ 123 ]. Understanding the contribution of genetic risk factors is crucial to test causal or mechanistic models regarding potential associations with mental health. At the most basic level, twin and family studies can estimate genetic correlations among music ability or engagement measures and mental health traits or diagnoses. Genetic associations can be examined while simultaneously quantifying environmental correlations, as well as evaluating (bidirectional) causal associations, by testing competing models or averaging across different candidate models [ 102 , 124 ], informing Path 1.
By leveraging samples with genomic, music engagement, and mental health data, investigators can also examine whether individuals at higher genetic risk for psychopathology (e.g., for MDD) show stronger associations between music engagement measures and their mental health outcomes (Path 2). As a theoretical example, individuals with low genetic risk for MDD are unlikely to have many depressive symptoms regardless of their music engagement, so the association between depressive symptoms and music engagement may be weak if focusing on these individuals. However, individuals at high genetic risk for MDD who engage with music may have fewer symptoms than their non-musician peers (i.e., a stronger negative correlation). This is in line with recent work revealing the heritability of depression is doubled in trauma exposed compared to non-trauma exposed individuals [ 125 ].
Gene–environment interaction studies using polygenic scores (i.e., summed indices of genetic risk based on genome-wide association studies; GWAS) are becoming more common [ 126 , 127 ]. There are already multiple large GWAS of internalizing and externalizing traits [ 128 , 129 , 130 ], and the first large-scale GWAS of a music measure indicates that music rhythm is also highly polygenic [ 131 ]. Importantly, is not necessary to have all traits measured in the same sample to examine cross-trait relationships. Studies with only music engagement and genetic data, for example, can still examine how polygenic scores for depression predict music engagement, or interact with music engagement measures to predict other study outcomes. Figure 4 displays an example of a GWAS and how it can be used to compute and apply a polygenic score to test cross-trait predictions.
A GWAS are conducted by examining whether individual genetic loci (i.e., single-nucleotide polymorphisms, or SNPs, depicted with G, A, C, and T labels within a sample (or meta-analysis) differentiate cases from controls. The example is based on a dichotomous mental health trait (e.g., major depressive disorder diagnosis), but GWAS can be applied to other dichotomous and continuous phenotypes, such as trait anxiety, musician status, or hours of music practice. Importantly, rather than examining associations on a gene-by-gene basis, GWAS identify relevant genetic loci using SNPs from across the entire genome (typically depicted using a Manhattan plot, such as that displayed at the bottom of A ). B After a GWAS has been conducted on a given trait, researchers can use the output to generate a polygenic score (sometimes called a polygenic risk score) in any new sample with genetic data by summing the GWAS effect sizes for each SNP allele present in a participant’s genome. An individual with a z = 2.0 would have many risk SNPs for that trait, whereas an individual with z = −2 would have much fewer risk SNPs. C Once a polygenic score is generated for all participants, it can be applied like any other variable in the new sample. In this example, researchers could examine whether musicians are at higher (or lower) genetic risk for a specific disorder. Other more complex analyses are also possible, such as examining how polygenic scores interact with existing predictors (e.g., trauma exposure) or polygenic scores for other traits to influence a phenotype or predict an intervention outcome. Created with BioRender.com.
Finally, longitudinal twin and family studies continue to be a promising resource for understanding the etiology and developmental time-course of the correlates of mental health problems. Such designs can be used to examine whether associations between music and mental health are magnified based on other exposures or psychological constructs (gene-by-environment interactions) [ 132 ], and whether parents engaged with music are more likely to pass down environments that are protective or hazardous for later mental health (gene-environment correlations) in addition to passing on their genes. These studies also provide opportunities to examine whether these associations change across key developmental periods. The publicly available Adolescent Brain Cognitive Development study, for example, is tracking over 10,000 participants (including twin and sibling pairs) throughout adolescence, with measures of music engagement and exhaustive measures of mental health, cognition, and personality, as well as neuroimaging and genotyping [ 133 , 134 ]. Although most large samples with genomic data still lack measures of music engagement, key musical phenotypes could be added to existing study protocols (or to similar studies under development) with relatively low participant burden [ 135 ]. Musical questionnaires and/or tasks may be much more engaging and enjoyable than other tasks, improving volunteers’ research participation experience.
Another way to orient the design of experiments is through the exploration of neural mechanisms by which music might have an impact on mental health. This is an enormous, growing, and sometimes fraught literature, but there is naturally a great potential to link our understanding of neural underpinnings of music listening and engagement with the literature on neural bases of mental health. These advances can inform the mechanisms driving successful interventions and inform who may benefit the most from such interventions. We focus on two areas among many: (1) the activation of reward circuitry by music and (2) the impact music has on dynamic patterns of neural activity, both of which are likely vectors for the interaction of music and mental health and provide examples of potential interactions.
Music and reward
The strong effect of music on our emotions has been clearly grounded in its robust activation of reward circuitry in the brain, and motivational and hedonic effects of music listening have been shown to be specifically modulated by dopamine [ 16 , 105 , 136 ]. The prevalence of reward and dopaminergic dysfunction in mental illness makes this a rich area for future studies. For example, emotional responses to music might be used as a substitute for reward circuit deficiencies in depression, and it is intriguing to consider if music listening or music engagement could potentiate such function [ 137 , 138 ].
Music and brain network dynamics
The search for neuronally based biomarkers of aspects of mental illness has been a central thrust within the field [ 139 ], holding promise for the understanding of heterogeneity within disorders and identification of common mechanistic pathways [ 140 ]. A thorough review is beyond the scope of this paper, but several points of contact can be highlighted that might suggest neuro-mechanistic mediators of musical effects on mental health. For example, neurofeedback-directed upregulation of activity in emotion circuitry has been proposed as a therapy for MDD [ 141 ]. Given the emotional effects of music, there is potential for using musical stimuli as an adjuvant, or as a more actively patient-controlled output target for neurofeedback. Growing interest in measures of the dynamic complexity of brain activity in health and disease as measured by magnetic resonance imaging or magneto/electroencephalography (M/EEG) [ 142 ] provides a second point of contact, with abnormalities in dynamic complexity suggested as indicative of mental illness [ 143 ], while music engagement has been suggested to reflect and perhaps affect dynamic complexity [ 144 , 145 ].
The caveats identified in this review apply equally to such neuro-mechanistic studies [ 146 ]. High-quality experimental design (involving appropriate controls and randomized design) has been repeatedly shown to be critical to providing reliable evidence for non-music outcomes of music engagement [ 103 ]. For such studies to have maximal impact, analysis of M/EEG activity not at the scalp level, but at the source level, has been shown to improve the power of biomarkers, and their mechanistic interpretability [ 147 , 148 ]. Moreover, as with genetic influences that typically influence a trait through a multitude of small individual effects [ 149 ], the neural underpinnings of music-mental health associations may be highly multivariate. In the longer term, leveraging large-scale studies and large-scale data standardization and aggregation hold the promise of gleaning deeper cross-domain insights, for which current experimentalists can prepare by adopting standards for the documentation, annotation, and storage of data [ 150 ].
Biobanks and electronic health records
Finally, the use of EHR databases can be useful in quantifying associations between music engagement and mental health in large samples. EHR databases can include hundreds of thousands of records and allow for examination with International Statistical Classification of Diseases and Related Health Problems codes, including MDD, SUD, and schizophrenia diagnoses. This would allow for powerful estimates of music-mental health associations, and exploration of music engagement with other health outcomes.
The principal roadblock to this type of research is that extensive music phenotypes are not readily available in EHRs. However, there are multiple ways to bypass this limitation. First, medical records can be scraped using text-mining tools to identify cases of musician-related terms (e.g., “musician”, “guitarist”, “violinist”). For example, the phenome-wide association study described earlier [ 55 ] compared musician cases and controls identified in a large EHR database through text-mining of medical records and validated with extensive manual review charts. This study was highly powered to detect associations with internalizing and thought disorders (but showed null or protective effects for musicians for SUDs). Many EHR databases also include genomic data, allowing for integration with genetic models even in the absence of music data (e.g., exploring whether individuals with strong genetic predispositions for musical ability are at elevated or reduced risk for specific health diagnosis).
EHRs could also be used as recruitment tools, allowing researchers to collect additional data for relevant music engagement variables and compare with existing mental health diagnoses without having to conduct their own diagnostic interviews. These systems are not only relevant to individual differences research but could also be used to identify patients for possible enrollment in intervention studies. Furthermore, if recruitment for individual differences or intervention studies is done in patient waiting rooms of specific clinics, researchers can target specific populations of interest, have participants complete some relevant questionnaires while they wait, and be granted access to medical record data without having to conduct medical interviews themselves.
Music engagement, a uniquely human trait which has a powerful impact on our everyday experience, is deeply tied with our social and cultural identities as well as our personality and cognition. The relevance of music engagement to mental health, and its potential use as a therapeutic tool, has been studied for decades, but this research had not yet cohered into a clear picture. Our scoping review and framework integrated across a breadth of smaller literatures (including extant reviews and meta-analyses) relating music engagement to mental health traits and treatment effects, though it was potentially limited due to the lack of systematic literature search or formal quality appraisal of individual studies. Taken together, the current body of literature suggests that music engagement may provide an outlet for individuals who are experiencing internalizing, externalizing, or thought disorder problems, potentially supporting emotion regulation through multiple neurobiological pathways (e.g., reward center activity). Conducting more rigorous experimental intervention studies, improving reporting standards, and harnessing large-scale population-wide data in combination with new genetic analytic methods will help us achieve a better understanding of how music engagement relates to these mental health traits. We have presented a framework that illustrates why it will be vital to consider genetic and environmental risk factors when examining these associations, leading to new avenues for understanding the mechanisms by which music engagement and existing risk factors interact to support mental health and well-being.
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This work was supported by NIH grants DP2HD098859, R01AA028411, R61MH123029, R21DC016710, U01DA04112, and R03AG065643, National Endowment for the Arts (NEA) research lab grants 1863278-38 and 1855526-38, and National Science Foundation grant 1926794. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or National Endowment for the Arts. The authors would like to thank Navya Thakkar and Gabija Zilinskaite for their assistance.
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- Daniel E. Gustavson
Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN, USA
Daniel E. Gustavson, Reyna L. Gordon & Miriam D. Lense
Department of Otolaryngology – Head & Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
Peyton L. Coleman & Reyna L. Gordon
Swartz Center for Computational Neuroscience, Institute for Neural Computation, University of California, San Diego, La Jolla, CA, USA
John R. Iversen
Department of Human and Molecular Genetics, Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, VA, USA
- Hermine H. Maes
Department of Psychiatry, Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, VA, USA
Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
Vanderbilt Brain Institute, Vanderbilt University, Nashville, TN, USA
Reyna L. Gordon & Miriam D. Lense
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Gustavson, D.E., Coleman, P.L., Iversen, J.R. et al. Mental health and music engagement: review, framework, and guidelines for future studies. Transl Psychiatry 11 , 370 (2021). https://doi.org/10.1038/s41398-021-01483-8
Received : 23 November 2020
Revised : 03 June 2021
Accepted : 10 June 2021
Published : 22 June 2021
DOI : https://doi.org/10.1038/s41398-021-01483-8
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Effects of music therapy on anxiety: A meta-analysis of randomized controlled trials
- 1 Institute of Business, School of Business, Henan University, Jinming Avenue, Kaifeng, Henan, 475004, China.
- 2 Institute of Nursing and Health, College of Nursing and Health, Henan University, Jinming Avenue, Kaifeng, Henan, 475004, China.
- 3 Institute of Nursing and Health, College of Nursing and Health, Henan University, Jinming Avenue, Kaifeng, Henan, 475004, China. Electronic address: [email protected].
- PMID: 34365216
- DOI: 10.1016/j.psychres.2021.114137
This study aims to evaluate the efficacy of music therapy on anxiety from randomized controlled trials (RCTs). The following electronic databases were utilized for selecting eligible studies that were published from inception to March 2021: PubMed, Cochrane Library, PsycINFO, Medline, Web of Science, and Embase. Standard mean difference (SMD) with 95% confidence interval (CI) values were used to evaluate the efficacy of music therapy on anxiety. Thirty-two studies with 1,924 participants were included in the meta-analysis. Music therapy lasted an average of 7.5 sessions (range, 1-24 sessions), while the average follow-up duration was 7.75 weeks (range, 1-16 weeks). Music therapy significantly reduced anxiety compared to the control group at post-intervention (SMD = -0.36, 95% CI: -0.54 to -0.17, p < 0.05), but not at follow-up (SMD = -0.23, 95% CI: -0.53 to 0.08, p >0.05). Subgroup analysis found a significantly positive effect of music therapy on anxiety in < 60 and ≥ 60 age-group (SMD = -0.31, 95% CI: -0.52 to -0.09, p < 0.05; SMD = -0.45, 95% CI: -0.85 to -0. 05, p < 0.05), developed and developing country group (SMD = -0.28, 95% CI: -0.51 to -0.06, p < 0.05; SMD = -0.49, 95% CI: -0.80 to -0.17, p < 0.05), < 12 and ≥ 12 sessions group (SMD = -0.24, 95% CI: = -0.44 to -0.03, p < 0.05; SMD = -0.59, 95% CI: -0.95 to -0.22, p < 0.05), respectively. Our study indicated that music therapy can significantly improve anxiety during treatment. But given that only eight RCTs reported the effects of music therapy at follow-up and the duration of follow-up was inconsistent, further researches are needed on the lasting effects after the intervention is discontinued.
Keywords: Anxiety; Meta-analysis; Music Therapy.
Copyright © 2021. Published by Elsevier B.V.
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- Anxiety / therapy
- Anxiety Disorders
- Music Therapy*
- Randomized Controlled Trials as Topic
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39 Music Therapy Research: An Overview
Professor Barbara Wheeler, Professor Emerita, Montclair State University, USA
- Published: 05 May 2015
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Music therapy is a diverse field and music therapy research increasingly reflects that diversity. Many methods and approaches are used to examine the various facets of music therapy practice and theory. This chapter provides an overview of music therapy research, and provides basic information about how research is conducted in this field. Research methods in music therapy research are similar to those used in other healthcare disciplines. A range of methods are reviewed and presented including; experimental research and Randomized Controlled Trials, Participatory Action Research, Grounded Theory, and Phenomenological methods.
Music therapy is a diverse field and music therapy research increasingly reflects that diversity. Many methods and approaches are used to examine the various facets of music therapy practice and theory. This chapter provides an overview of music therapy research, and provides basic information about how research is conducted in this field.
Music therapy research is similar to research in other disciplines, but it has some unique aspects. It has the same definition and purposes, as described below, and most of the research methods that are employed are similar to those in other fields of health research. The focus on music is distinctive from most other types of health research. When the music, the therapist, and the client are included in the research process and outcomes a unique perspective is gained.
Definition of research
Bruscia (1995b) has defined research as “a systematic, self-monitored inquiry which leads to a discovery or new insight which, when documented and disseminated, contributes to or modifies existing knowledge or practice” (p. 21). Gfeller (1995) described research as “a disciplined or systematic inquiry” (p. 29). She has also pointed to the importance of the definition proposed by Phelps et al. (2005) that research is “a carefully organized procedure that can result in the discovery of new knowledge, the substantiation of previously held concepts, the rejection of false tenets, and the formal presentation of data collected” (p. 3).
Questions and types of research
Research comes from the questions of the researcher or research team. Once the question is developed and refined a research method or approach is chosen because of its suitability to answer the question. While some people begin their research with a particular research method in mind, it is more usual to begin with the question and to let the question determine the method. Some basic examples of questions that lead to research designs are presented here.
We might ask, “How does X influence our client during the process of therapy?” where X could be variations in the tempo, volume, tonality, or another aspect of an improvisation; type of instrument used; or things that are happening in the client’s life outside of music therapy. Examples of descriptive research in music therapy could include studies that are based on surveys and questionnaires, single subject designs that rely on numerical data to determine the results, and studies of groups of people that use quantitative measures of outcomes but do not include a control group for comparison.
We might ask, “Does X treatment work better than Y treatment?” X and Y could be music therapy and movement therapy or music therapy in combination with physical therapy versus music therapy alone. In experimental research, two or more treatment conditions are compared and participants are randomly assigned to conditions so that no variables outside of those that are being tested vary among conditions. Although it is not possible to achieve strict control outside of a laboratory, these designs do as much as possible to control all factors. These are standard experimental designs that answer questions about the effectiveness of music therapy and are often requested by those who determine what therapy should be supported or paid for.
In qualitative research, we might ask, “What do clients experience in music therapy?” Qualitative research examines how phenomena are experienced and constructed through description, analysis, and interpretation. It relies upon words, music, sounds, or pictures to report the results and can help us learn more about aspects of the therapeutic setting. Qualitative research encompasses a wide range of methods, some of which grew out of phenomenology, existentialism, and hermeneutics in the social sciences. It looks for meaning and understanding and allows phenomena to unfold over time.
Examples of music therapy research
The following sections provide an overview of music therapy research with reference to a variety of methods. Examples have been selected to represent good research using each design, and encompassing a variety of topics. Although most studies are selected to represent a single method, studies can frequently employ several methods.
Experimental research, including randomized control trials; exploratory trials; meta-analysis; survey research; quantitative single-case designs, including applied behavior analysis; and longitudinal research are examples of quantitative research and will be discussed here.
Experimental research/randomized control trials
A number of randomized control trials are currently available on various aspects of music therapy. The Journal of Music Therapy and the Nordic Journal of Music Therapy require authors to follow the CONSORT (Consolidated Standards of Reporting Trials) Statement ( Schulz et al. 2010 ), which provides guidelines for reporting randomized control trials (RCTs) and insures that the reported information is transparent. In a RCT, participants are randomly assigned to conditions, with random assignment meaning that each person has an equal opportunity of being assigned to each condition. This controls for confounding variables by insuring that the conditions or groups are equivalent.
Examples of RCTs include two studies by Ghetti. In one ( Ghetti 2011 ), of active music engagement with emotional-approach coping to improve well-being in liver and kidney transplant recipients, she evaluated the impact of music therapy under two conditions to which the patients were randomly assigned. One group received music therapy with an emphasis on emotional-approach coping, which uses emotional expression, awareness, and understanding to facilitate coping with significant life stressors, and the other group received music therapy without the emphasis on emotional-approach coping. In another RCT, Ghetti (2013) evaluated the use of music therapy emphasizing emotional-approach coping on preprocedural anxiety in adults receiving cardiac catheterization. Another RCT by Gattino et al. (2011) examined the effects of relational music therapy plus routine clinical activities compared with routine clinical activities alone on communication of children with autism.
Exploratory trials or studies
Exploratory trials ( Medical Research Council 2000 ) or exploratory studies allow the researcher to gather information on how an intervention works but without including random assignment to conditions. Some of these, sometimes called quasi-experimental designs ( Shadish et al. 2002 ), are similar to experimental designs such as the RCT but participants are not randomly assigned to groups.
One example is a study by Bensimon and Gilboa (2010) , who studied Musical Presentation (MP), a therapeutic tool in which members of a group present themselves through musical pieces of their choice in and receive feedback from their peers, with the aim of increasing their sense of purpose in life and self-consciousness. Rather than randomly assigning participants to experimental and control groups, the researchers assigned them to the groups based on the times at which they were available.
Nayak et al. (2000) investigated the use of music therapy as an aid in improving mood and social interaction among people who have had traumatic brain injuries or strokes. Although the original intention was to randomly assign participants to the different groups that included an experimental group who received music therapy, a control group who received art therapy, and a control group receiving standard care, this goal was not achieved due to problems finding enough participants who met the criteria and were willing to participate. The completed study compared music therapy to standard treatment, but the condition to which participants were assigned was based on their availability rather than random assignment. Without randomization of participants the study design is considered to be much weaker because of the risk of bias.
In another type of exploratory study, data are collected but there is no control condition. The information gathered can help to determine whether the intervention can be carried out as planned. Studies of this type are often shared in professional journals. It is important that those writing them make it clear that, because they do not include any type of control, it is impossible to say what caused the effects that are seen. These studies are similar if not identical to what many clinicians do when they collect data on their work about how their clients respond or change during and after therapy. It is important for those involved with these designs to be aware of the limitations of such designs, and also to consider the similarities with data collected in regular clinical work.
Two studies of the Sing and Grow program for young children and their parents in Australia used pre-experimental designs. Nicholson et al. (2008) assessed the impact of a 10-week program for marginalized parents and their children in promoting positive parenting and child development. Williams et al. (2012) explored the impact on parental well-being, parenting behaviors, and child development for parents of children with disabilities and their children. Another example is of a music therapy program for women coping with breast cancer ( Wheeler et al. 2010 ), while a fourth is the evaluation of a music therapy protocol to enhance swallowing training for people who have had strokes and have dysphagia ( Kim 2010 ). In all four studies, data were gathered on targeted responses at several points and an evaluation of changes was made, but none of them included a control group. The findings of such studies can be used to develop more robust experimental procedures for future studies.
In a meta-analysis the researcher calculates a standard effect size 1 for each study, giving an indication of the size and variability of the phenomenon under investigation and allowing the studies to then be compared among themselves across all measures and variables. Meta-analyses have provided important information on the efficacy of music and music therapy in medicine. Standley (2000) conducted the first of these in 1986 and subsequently updated it several times. Standley (2002) later performed meta-analyses on the effectiveness of music therapy with premature infants in neonatal intensive care units and of music versus no music conditions during medical treatment of pediatric patients ( Standley and Whipple 2003 ).
Dileo and Bradt (2005) completed a meta-analysis of 184 studies involving music in medical treatment. They included all studies that had been conducted with a control group that did not receive music. They included 47 dependent variables. The effects of music and music therapy were reported for each dependent variable, grouped according to 11 medical specialty areas: premature infants, fetal responses to music, pediatrics, obstetrics/gynecology, cardiology/intensive care, oncology and terminal illness, general hospital, surgery, rehabilitation, dementia, and dentistry.
Additional meta-analyses that have been conducted include an analysis of music education and music therapy objectives ( Standley 1996 ), dementia ( Koger et al. 1999 ), symptoms of psychosis ( Silverman 2003 ), children and adolescents with autism ( Whipple 2004 ), children and adolescents with psychopathology ( Gold et al. 2004 ), stress reduction ( Pelletier 2004 ), neurologic rehabilitation of upper and lower limbs ( Chandra 2005 ), endoscopy procedures ( Rudin et al. 2007 ), and several aspects of the treatment of people with Parkinson’s disease ( de Dreu et al. 2012 ). Meta-analyses are also part of some Cochrane reviews, discussed elsewhere in this chapter.
Survey research refers to:
the selection of a relatively large sample of people from a pre-determined population (the “population of interest”; this is the wider group of people in whom the researcher is interested in a particular study), followed by the collection of a relatively small amount of date from those individuals. The researcher therefore uses information from a sample of individuals to make some inference about the wider population. Kelley et al. 2003
Wigram (2005) divided music therapy survey research into three categories: (a) surveys of journals, (b) clinical surveys, and (c) surveys of training methods.
Surveys of journals, books, and other printed of web-based texts categorize the research and other articles according to the purpose of the survey. They can alert the profession to strengths and weaknesses, provide insight into where the research is happening, and determine how research is divided among clinical fields. Recent examples of this type of survey research include an analysis of music therapy journal articles by Brooks (2003) and analyses by Aigen of journals and books (2008a) and dissertations (2008b) . Roberts and McFerran (2008) utilized both quantitative and qualitative methods for a content analysis of how music therapy was reported in Australian print media over a 10-year period.
Clinical surveys consider aspects of clinical practice, attitudes from both professionals and clients, and information about where people work. Examples include such diverse topics as: a survey of the use of aided augmentative and alternative communication during music therapy sessions with persons with autism spectrum disorders ( Gadberry 2011 ); a survey of repertoire and music therapy approaches employed by Australian music therapists in working with older adults from culturally and linguistically diverse groups ( Baker and Grocke 2009 ); and a survey of the expectations of cancer and cardiac hospitalized cancer and cardiac patients regarding the medical and psychotherapeutic benefits of music therapy ( Bruscia et al. 2009 ). In an extension of traditional survey methods, Vega (2010) surveyed music therapists and also gave them a personality test and a test of burnout to examine possible relationships between personality, burnout level, longevity, and demographic variables among professional music therapists.
Surveys of training methods seek to learn more about music therapy practice, the experiences and attitudes of music therapy students, to assess the effectiveness of clinical training, and to explore competency requirements for music therapists. Researchers have sought information on a variety of topics. Stewart (2000) surveyed music therapists from the United Kingdom to assess personal qualities of music therapists, working models, support networks, and job satisfaction. Young (2009) surveyed music therapy internship directors to examine the extent to which multicultural issues were being addressed in internships in the United States and Canada; Gardstrom and Jackson (2011) surveyed music therapy program coordinators for information on personal therapy for undergraduate students; and Hahna and Schwantes (2011) surveyed music therapy educators regarding their views and use of feminist pedagogy and feminist music therapy.
Quantitative single-case designs and applied behavior analysis
Yin (2009) defines a case study as “an empirical inquiry that investigates a contemporary phenomenon in depth and within its real-life context, especially when the boundaries between phenomenon and context are not clearly evident” (p. 18). Smeijsters (2005) developed music therapy applications of case studies as single-case designs. Examples of quantitative single-case designs include a study of a preschooler with vision impairment in which the authors looked at the child’s participation through several different playground adaptations that include musical stations and staff interactions ( Kern and Wolery 2001 ); an examination of how girls with Rett syndrome make song choices ( Elefant 2002 , 2005 ); and a study of the emotional development of a client as reflected in improvisations ( Smeijsters 2005 ; Wosch and Frommer 2002 ). Each of these studies used evaluation measurements and either a single case or a series of single cases to gather information.
Applied behavior analysis ( Hanser 2005 ) can be considered a type of single-case design that includes specific designs and techniques, including reversal and multiple baseline designs. These designs are applied in behavioral research to test a hypothesis about the behavior of a single individual or group, examine the effect of a particular strategy, or examine intra-subject changes over time under different conditions. Wlodarczyk (2007) used a reversal design to examine the effect of music therapy on the spirituality of people in an in-patient hospice unit. Using a multiple baseline design, de Mers et al. (2009) looked at the effects of music therapy on challenging behaviors of young children in a special education setting. These designs have been used frequently in music therapy, as evidenced by Gregory’s (2002) finding of 96 examples of this design in an analysis of four decades of the Journal of Music Therapy .
Longitudinal research provides information over a period of time ( Ledger and Baker, 2005 ). According to Menard (2002) , longitudinal research is when: (a) data are collected for each individual unit for two or more distinct time periods; (b) the units are the same from one time period to the next; and (c) the analysis of collected data involves some comparison of data between or among time periods. The most commonly used longitudinal designs are: (a) repeated cross-sectional studies what are carried out regularly, each time using a different sample (or primarily different sample); (b) prospective (panel) studies that collect information from the same people repeatedly over a period of time (the preferred type); and (c) retrospective studies in which people are asked to remember and reconstruct events and aspects of their lives ( Ruspini 2002 ). Several methods may be combined.
An example of a longitudinal study in music therapy is Ledger and Baker’s (2007) investigation of the long-term effects of group music therapy on agitation levels of nursing home residents with Alzheimer’s disease. They tested residents at five time points over a year. Although they found short-term reductions in agitation for those who received weekly music therapy sessions, these positive effects did not continue over the year. Another example is Dingle et al.’s (2013) exploration of the personal experiences of choir members with various mental, physical, and intellectual disabilities in relation to their wellbeing using the interpretative phenomenological analysis method developed by Smith (2004) . Interviews with participants occurred at the inception of the choir, after six months, and after 12 months. This study is an example of a longitudinal study employing a qualitative research method.
Mixed methods research
Mixed methods research uses a range of research methods. This allows diverse perspectives, methods, and data to generate the information that is desired ( Bradt et al. 2013b ; Creswell and Clark 2011 ). These methods are relatively new and in their very early stages of development and expertise in music therapy research. Issues in combining methods occur on pragmatic and philosophical/paradigmatic levels and are the subject of numerous discussions and debates (K. Bruscia, personal communication, June 26, 2012; Johnson and Onwuegbuzie 2004 ; Teddlie and Tashakkori 2003 ).
Examples of mixed methods research in music therapy include a study by Grocke et al. (2009) in which they studied the effect of group music therapy on quality of life and social anxiety for people who had a severe and enduring mental illness. Quantitative data were gathered through several scales that measured the dependent variables, and qualitative data were gathered through focus group interviews and an analysis of lyric themes. Barry et al. (2010) studied the effects of creating a music CD on pediatric oncology patients’ distress and coping during their initial radiation therapy treatment. They collected numeric and textual data for quantitative and qualitative analyses. Ridder (2005 ; Ridder and Aldridge 2005 ) combined quantitative (including physiological measurements) and qualitative approaches, using therapeutic singing, in case studies of individuals with frontotemporal dementia.
Qualitative research is a broad term used to describe:
the varieties of social inquiry that have their intellectual roots in hermeneutics, phenomenological sociology, and the Verstehen tradition. Many scholars use the phrase qualitative inquiry as a blanket designation for all forms of social inquiry that rely primarily on qualitative data (i.e. data in the form of words)… To call a research activity qualitative inquiry may broadly mean that it aims at understanding the meaning of human action Schwandt 2007 , pp. 247–248.
Tesch (1990) listed 46 terms used to describe different types of research that is broadly considered as qualitative research in the social sciences. The terms include: action research, case study, clinical research, collaborative inquiry, content analysis, dialogical research, conversation analysis, Delphi study, descriptive research, discourse analysis, ecological psychology, ethnography, ethnomethodology, experiential psychology, field study, focus group research, grounded theory, hermeneutics, heuristic research, holistic ethnography, imaginal psychology, interpretive interactionism, life history study, naturalistic inquiry, oral history, participant observation, phenomenography, phenomenology, qualitative evaluation, symbolic interactionism, and transcendental realism (p. 58).
Interest in qualitative research in music therapy began in the mid-1980s, when some music therapists started to consider the limitations of quantitative research in capturing important aspects of the music therapy experience ( Wheeler and Kenny, 2005 ). All around the world music therapists started to explore the use of qualitative methods in their research. In the US, Aigen (1991) set the stage for the consideration of qualitative inquiry by music therapists in his doctoral dissertation, The Roots of Music Therapy: Towards an Indigenous Research Paradigm , as he considered historical influences on music therapy research from the philosophy and theory of science and critiqued what he called the received view from a position of process, clinical realities, creativity, and research methodologies ( Wheeler and Kenny 2005 ). In Australia in the early 1990s, O’Callaghan was researching the experience of palliative care patients using grounded theory method and content analysis by examining the text of their songs created in music therapy ( O’Callaghan 1996 ). Earlier in the US, Forinash (1992) used phenomenology to consider the experience of improvisation in Nordoff-Robbins music therapy sessions. In Germany at the same time Langenberg ( Langenberg et al. 1992 ) and her colleagues used hermeneutic inquiry to understand which aspects of the therapeutic process were helpful for the client. The First International Symposium for Qualitative Research in Music Therapy was held in 1994, offering music therapists who were using qualitative methods in their research an opportunity to share and collaborate ( Langenberg et al. 1996 ). This symposium was followed by similar gatherings, continuing until 2007.
Since the mid-1990s the number of qualitative studies has increased (see Aigen 2008a , b ). This chapter will focus on some of the qualitative research methods that have been used by music therapists.
Many qualitative studies use naturalistic inquiry ( Aigen 2005 ; Ely et al. 1991 ; Lincoln and Guba 1985 ), with the research being carried out in the settings that researchers want to understand, with the researcher’s self experience and observation as the primary vehicle for data-gathering and analysis. Although naturalistic inquiry is sometimes considered to be a type of qualitative research ( Aigen 2005 ), it is regarded in this chapter as a way of approaching the research and gathering information/data.
Phenomenology is defined as: “A philosophy or method of inquiry based on the premise that reality consists of objects and events as they are perceived or understood in human consciousness and not of anything independent of human consciousness” ( American Heritage Dictionary 2000/2009 ). Forinash and Grocke (2005) stated that “phenomenologists examine what is called the lived experience. This refers to experiences that we, as humans, have in relation to any event that we experience” (p. 321). Phenomenological inquiry is a frequently used method for music therapy researchers, probably because many of the questions of interest to music therapists are about people’s experiences. Reflexive phenomenology is a term used by Colaizzi ( Tesch 1990 ) for a form of phenomenology where the researcher uses his or her own experience as data. This is contrasted with empirical phenomenology, where data are gathered from others.
Examples of phenomenological inquiry in music therapy include Comeau’s (2004) examination of how music therapists experienced times of being effective and ineffective in their work; Cooper’s (2010) study of clinical-musical responses of Nordoff-Robbins music therapists during the process of clinical improvisation, which had a similar topic and some similar methods to an earlier phenomenological study of the lived experience of clinical improvisation by Nordoff-Robbins music therapists ( Forinash 1992 ); and Gardstrom’s (2004) study using descriptive phenomenology, as well as hermeneutic inquiry, to explore the experience of clinical improvisation with troubled adolescents.
Hermeneutics refers to the “art, theory, and philosophy of interpreting the meaning of an object” ( Schwandt 2001 , p. 115). The hermeneutic circle involves a constant analytic movement between the phenomena of interest and the structures (theories) developed in order to better understand the phenomenon. Theories are therefore tentative and evaluated against the data, further refined, and then reapplied to the data. The goal of hermeneutic research is to engage deeply in the circle of understanding in order to develop insightful and plausible interpretations of events.
Langenberg and her colleagues ( Langenberg 1988 ; Langenberg et al. 1992 , 1993 ) developed a psycho-analytically based method using what is called the resonator function to help observers gain access to the hidden meaning of an improvisation through a series of steps in which they listen to and respond to an improvisation by a client. Their system involves having a number of observers listen to a recording of a music therapy session and write down descriptions of the improvisation. They then follow a number of steps to compare and interpret the information and, finally, analyze the results in a process of hermeneutic circling in relation to clinical data from the client’s case history.
Rolvsjord (2007 , 2010 ) applied hermeneutic research to her study of a resource-oriented approach to music therapy, which intends to amplify the client’s strengths rather than to focus on reparation of symptoms or difficulties. Rolvsjord states:
According to the hermeneutic research tradition, understanding is arrived at through a process of dialogue between the researchers horizon and the texts that are studied. In my study, understanding and knowledge were generated through a similar reflexive and dialogical process between the empirical data and theory. This strategy for discovery has been labeled [by Alvesson and Sköldberg 2000] abduction. Rolvsjord 2007 , p. 50
Others who have used hermeneutic inquiry in music therapy research include Bonde (2005) , who employed a hermeneutic framework for understanding Bonny Method of Guided Imagery and Music (BMGIM) sessions; Gardstrom (2004) , who used phenomenological and hermeneutic inquiry to investigate meaning in clinical music improvisation with troubled adolescents; Luce (2008) , who studied music therapy students’ epistemological development and how that influences their education and clinical training; and Jackson (2010) , who explored responses to client anger in music therapy by examining cases, as units of data, through a process of hermeneutic phenomenological reflection.
Grounded theory is defined as:
a general approach of comparative analysis linked with data collection that uses a systematically applied set of methods to generate an inductive theory about a substantive area with the purpose of discovering theory from data. The researcher focuses on one area of study, gathers data from a variety of sources, and analyzes the data using coding and theoretical sampling procedure. Amir 2005
O’Callaghan (2012) presents a number of considerations and applications of grounded theory in music therapy.
Examples of grounded theory studies in music therapy include numerous studies by O’Callaghan, including one of the perceptions of a Chinese music therapy educator and students’ perceptions of their music project’s relevance for Sichuan earthquake survivors ( Gao et al. 2013 ); another on the effect of music therapy on oncologic staff bystanders ( O’Callaghan and Magill 2009 ); and one of the relevance of music for pediatric cancer patients ( O’Callaghan et al. 2011 ). Amir (1996 ; see also Amir 1992 ) studied how music therapists and music therapy clients experienced meaningful moments in the music therapy process; while a study by Bonde (2007) in which he used a grounded theory procedure to investigate how cancer survivors described the experience and perceived outcome of therapy using BMGIM.
First-person research is defined by Bruscia (2005b) as “any method in which researchers or participants gather data from themselves, using processes such as introspection, retrospection, self-perception, self-observation, self-reflection, self-inquiry, and so forth” (p. 379). One of the most well known types of first-person research is heuristic research ( Moustakas 1990 ), in which a person studies his or her own responses as a way of understanding a phenomena. Bruscia suggests that the following situations may occur in first-person research: the researcher studies self, the researcher studies self and participants, participants study themselves, and co-researchers study themselves.
Examples of first-person research include a study by Bruscia (1995a) of his shifts in awareness/consciousness as he guided a Guided Imagery with Music (GIM) session and a study by Wheeler (1999) of the various sources of pleasure experienced in working with children with severe disabilities. The study of flute improvising by Schenstead (2012) , described as a heuristic arts-based self-study (under arts-based research , below), is also an example of first-person research.
Participatory action research
Participatory action research is defined by Stige (2005b) as “… situated research advocating the primacy of the voices and goals of the participants themselves.” Stige lists four of the dimensions central to this tradition: (a) active lay participation in the research process; (b) empowerment of participants and sociocultural change as part of the research agenda; (c) linkage of theory, practice, and research; and (d) application of a broad conception of knowledge when evaluating research processes and outcomes.
Baines (2000) reported on a pilot study for a program to “develop a cost effective group music therapy program that prioritized the requests of the consumers as the process for development, thereby readily incorporating consumer concerns and hopefully meeting consumer needs” (p. 54). A survey to assess the program was jointly developed by staff and consumers (clients), thus incorporating elements of participatory action research. A later report ( Baines and Danko 2010 ) provided follow-up survey data supplemented by information from interviews with consumers.
Elefant’s (2010) research suggests the importance of considering empowerment and social change when designing research so as not to risk ignoring critical voices among participants and thus contributing to preserving the status quo. The participatory action research project, with individuals who were part of a choir for people with severe physical disabilities, was a way of helping them to make their voices heard.
There are varied examples of action or participatory action research in the music therapy literature. One is Stige’s (2002 , Chapter 4) research with Upbeat, a group of people with mental challenges who were involved in a collaborative process to develop a more inclusive life in the community. Another is by Baker (2007) , who used action research to evaluate a problem-based learning activity with students who were doing their first year of clinical training, emphasizing developing clinical reasoning skills. McFerran and Hunt (2008) used an action research process in a program to help adolescents cope with grief and loss in several situations. Rickson (2009) worked collaboratively with team members to facilitate their use of music with children who have special education needs and included action research in her consulting.
Ethnography and ethnographically informed research
Stige (2005a) stated: “Ethnography may be understood as a scholarly approach to the study of culture as lived, experienced, and expressed by a person or a group of people” (p. 392). There is an increasing amount of ethnographically informed research in music therapy.
Ledger (2010a) conducted an ethnographic study of service development in a health care organization. The ethnographic work revealed the inherent complexity of the researcher roles as she shifted between the identities of researcher, therapist, friend, and student while doing this research ( Ledger 2010b ).
Most of the case studies in the book about Community Music Therapy, Where Music Helps ( Stige et al. 2010 ), are ethnographically informed music therapy research exploring how the effects of music and musicking are linked to human interaction in context. Ansdell (2010) , explored what happens with a group of people in West London who get together to create and perform music. Pavlicevic (2010) documented the rich ethnographic context in and around a children’s choir in South Africa. Stige (2010) studied participation in a festival that was started by music therapists several decades ago. In each of these cases, the researcher employed ethnographic research methods to study the people, the events, and the process of collaborative music making.
Austin and Forinash (2005) have defined arts-based inquiry as “a research method in which the arts play a primary role in any or all of the steps of the research method. Art forms such as poetry, music, visual art, drama, and dance are essential to the research process itself and central in formulating the research question, generating data, analyzing data, and presenting the research results” (p. 458). Only a small number of arts-based research studies have been done in music therapy. Ledger and Edwards (2011) reviewed the arts based research conducted in music therapy and queried why music therapists have not engaged more enthusiastically in arts-based research. They suggested that music therapy researchers may be reluctant to adopt arts-based research practices due to a desire to insure that music therapy research is accepted as scientific and scholarly among other health care research. They also wondered whether music therapists may have used arts creation within their research approaches but have not highlighted this for various reasons, some of which might be related to the quest for recognition as a scientific and scholarly discipline.
Schenstead (2012) conducted a heuristic arts-based self-study through which she took an in-depth look at the intricacies of the personal improvisational process using her primary instrument, the flute. She improvised on stories and poetry that she had written and wrote about her experiences in a journal that became the main source of data. The journal was analyzed using an arts-based method and the findings took on the form of a performance piece in which she perform the stages of my process using a synthesis of poetry, artwork, music, and personal reflections. A final meta-reflection of the entire project presents a philosophy explaining the dynamics of the intrapersonal relationship.
Vaillancourt (2009 , 2011 ) used arts-based research to create an apprenticeship music therapy model. In the first phase of the research, a research group met for five sessions, using “discussions, instrumental and vocal improvizations, adapted group sessions of the Bonny Method of Guided Imagery and Music (BMGIM), mandala drawing, collective and individual writing, and poetry” to deepen their reflections on their mentoring needs. In the second phase, Vaillancourt used a phenomenological approach to investigate the lifeworlds of the participants regarding their work together, using the artistic data from the previous work together to structure the interview questions. The results of the study, the emerging themes and essences of the participants’ experiences, were reported through narratives and music, art, and poetry.
Evidence-based practice and music therapy
Evidence-based practice (EBP) is defined as “conscientious, explicit, and judicious use of current best evidence in making decisions about care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research” ( Sackett et al. 1996 , p. 71). EBP represents the combined use of (a) systematic reviews of the scientific literature, (b) practitioner experience and opinion, and (c) patient/client preferences and values for making clinical decisions and treatment/intervention planning.
EBP has received increased attention in music therapy as it has become apparent that by meeting the standards of EBP music therapy increases the opportunity to be accepted and funded. This is not without controversy and the issues surrounding the implementation of the evidence-based approach to music therapy have been elaborated ( Abrams 2010 ; Edwards 2005b ) The Cochrane Library and Cochrane reviews are an important source of information on EBP, and a number of Cochrane reviews have been done in music therapy, with the largest number in recent years.
The Cochrane Database of Systematic Reviews (< www.cochrane.org >) includes numerous reviews of various health care interventions. Cochrane reviews have been undertaken on music therapy for people with acquired brain injury ( Bradt et al. 2010b ), autistism spectrum disorder ( Geretsegger et al. 2014 ), dementia ( Vink et al. 2013 ), depression ( Maratos et al. 2008 ), end-of-life care ( Bradt and Dileo 2010 ), and for schizophrenia and schizophrenia-like disorders ( Mössler et al. 2011 ); music during Caeserian section ( Laopaiboon et al. 2009 ), for mechanically ventilated patients ( Bradt et al. 2010a ), improving psychological and physical outcomes in cancer patients ( Bradt et al. 2011 ), preoperative anxiety ( Bradt et al. 2013a ), and stress and anxiety reduction in coronary heart disease ( Bradt and Dileo 2009 ); and for singing for children and adults with cystic fibrosis ( Irons et al. 2010 ).
Other types of research
Research on music.
Bonde (2005) suggests that researching music includes “any method within music therapy in which researchers gather data concerning the relationship between music—improvised or composed, recorded or performed live—and client experiences and behavior” (p. 489) and that “the focus may be on material properties of music (stimulus or effect); on intentional properties of music (description, analysis, and interpretation of meaning); or on musical processes (interactions and relationships)” (p. 489). These may include studies of nonmusical or musical responses.
Studies that focuses on nonmusical responses include one by Elefant (2002 , 2005 ), who used a single case multiple baseline, time series, within-subjects design to investigate whether songs in music therapy intervention could enhance the communication skills of seven girls with Rett syndrome. Ridder’s research (2005 ; Ridder and Aldridge 2005 ) studied the use of therapeutic singing with individuals with frontotemporal dementia. This is presented under mixed methods research . They also viewed nonmusical responses, as do the examples of RCTs by Ghetti (2011 ; 2013 ) and Gattino et al. (2011) ; the exploratory studies by Bensimon and Gilboa (2010) ; Nayak et al. (2000) ; Williams et al. (2012) ; Wheeler et al. (2010) ; and Kim (2010) among others. The fact that so many examples of research on nonmusical responses have been presented in this chapter highlights that a great deal of music therapy research has focused on nonmusical responses or outcomes by music therapists.
There are also numerous examples of research on musical responses. The work on the resonator function , described under hermeneutic inquiry ( Langenberg 1988 ; Langenberg et al. 1992 , 1993 ), helped observers gain access to the hidden meaning of an improvisation. Bergstrøm-Nielsen (1993 , 1999 , 2010 ) developed a graphic notation as a tool for music therapists in notating and analyzing improvisations. Turry (2010) analyzed the relationship between words and music in clinically improvised songs with a woman with whom he had music therapy sessions for a number of years. Additional studies of musical responses that have been cited earlier in this chapter are by Cooper (2010) , Forinash (1992) , and Gardstrom (2004) .
Historical research is defined as “the systematic study of the past practices, materials, institutions, and people involved in therapeutic applications of music” ( Solomon and Heller 1982 ). Historical research is a way of preserving the history of music therapy that people in the future will know of what led to that point. Historical research topics cover a wide range.
Several studies of music therapy pioneers, including Ira Maximillian Altshuler ( Davis 2003 ), Willem van de Wall ( Clair and Heller 1989 ), and James Leonard Corning ( Davis 2012 ), have been published. Historical uses of music in hospitals, and the development of the profession of music therapy for hospital patients has been researched (e.g. Edwards 2007 , 2008 ; Taylor 1981 ). Reschke-Hernández (2011) examined the history of music therapy treatment interventions for children with autism.
Kim (2009) conducted an “Historical Investigation Regarding the Perception of Music Therapy Among Korean Medical Professionals as Seen in Medical Journal Articles,” which combines historical research with survey methods. In a narrative inquiry, Hadley (2001) explored connections between historical information and other aspects of Mary Priestley’s life and work. She conducted a similar study of the life of Clive Robbins ( Hadley 2003 ).
Philosophical inquiry and theory development
Bruscia (2005a) has said that a “theory is way of thinking about what we do or what we know” (p. 540) and that philosophy and theory “have the same aim: understanding.” Bruscia also suggested that “they relate to practice and research in the same way” and that “both involve thinking activities, such as reflection, reasoning, criticism, speculation, and intuition” (p. 541).
Theory development has always been a part of the research work in music therapy. Sears (1968) suggested three processes in music therapy: experience within structure, experience in self-organization, and experience in relating to others, still provides a basis for the thinking of many about what music therapy does. Kenny (1989 , 2006 ) organized her ideas into a formal theory and found a language to reflect her understanding of the music therapy process in what she termed The Field of Play .
Music therapy theory has continued to develop. Working to develop theory for the music therapy as procedural support for invasive medical procedures, Ghetti (2012) used qualitative document analysis to examine the literature in this field. She integrated findings from 19 primary sources to formulate a theoretically grounded working model. Robb (2012) suggests that music therapy research is moving from being outcomes-based to theory-based and that the attention that is now being paid to theory “offers one way to advance our understanding of the complex interactions between music, clients, and the education or health care environment” (p. 5).
In adaptations of theoretical research, Hadley (1999) compared philosophical premises underlying two approaches to music therapy, Creative Music Therapy, developed by Nordoff and Robbins (2007) , and Analytical Music Therapy, developed by Priestley (1994) . Mössler (2011) combined the development of theory and historical research as she examined the influence of theory construction on the formation of professional identity as it occurs in the Viennese School of Music Therapy.
Abrams (2011) has proposed that music is a temporal-aesthetic way of being. He proposed that music can be conceptualized as a phenomenon that transcends the concrete, physical medium of sound. In Abrams’s theory, while music may be expressed through sound, its essence is located in the ways that human thought, feeling, and action unfold aesthetically in time, allowing the music in music therapy to be not merely a means for promoting non-musical health but also a particular dimension of human health itself, manifesting as the temporal-aesthetic component of each health domain typically targeted within music therapy work.
Eight music therapy journals are published regularly in English, many by music therapy associations of their countries, and include varying amounts of research. In order of the dates on which they commenced publication (and which are listed), they are: Journal of Music Therapy 1964 (US); Canadian Journal of Music Therapy 1973; Music Therapy Perspectives 1982 (US); British Journal of Music Therapy 1987; Australian Journal of Music Therapy 1990; Nordic Journal of Music Therapy 1992 (representing all of the Nordic countries and now an international journal); New Zealand Journal of Music Therapy 1994; and Voices: A Worldwide Forum for Music Therapy 2001 (on-line: < www.voices.no >).
In addition to these journals published in English, the German journal, Musiktherapeutische Umshcau, has been published since 1980 and plays an important role in the development of German music therapy and thus music therapy internationally. Music Therapy: Journal of the American Association for Music Therapy was published from 1981–1996. The Arts in Psychotherapy, an international journal that covers all of the arts therapies, has been in publication since 1973, and includes a substantial amount of music therapy research. The Journal of the Association of Music and Imagery (AMI) , published since 1992, focuses on the Bonny Method of Guided Imagery and Music (BMGIM), which is closely related to music therapy. Music and Medicine: An Interdisciplinary Journal , published since 2009, includes current practices of music and medicine, including music therapy. Finally, many music therapy studies are published in journals of related disciplines.
Several people have reviewed music therapy research in the past decade, primarily through analyses of journal articles. Brooks (2003) examined 1521 articles from nine music therapy journals over a 37-year period, looking for trends and types of article and comparing them across journals. She tallied the numbers of research articles classified in the categories of quantitative, qualitative, clinical, historical, philosophical/theoretical, and professional. 2 The number of articles published in each of these journals is, of course, related to the length of time that the journal has been published and the number of issues a year. Brooks found quantitative research articles to be the predominant category across all journals, with 542 articles. She found 55 historical articles and 136 philosophical/theoretical articles.
Edwards (2005a) reviewed eight journals for content and trends, and also examined the number of articles from one journal that were referenced in other journals. This was in order to reveal the extent to which music therapists showed awareness of each others work across the international community. To examine how many articles from one journal were cited by authors writing in other journals, she reviewed papers from the Journal of Music Therapy (JMT) from 1964–2003 and the British Journal of Music Therapy (BJMT) from 1995–2003. She found no papers from either the New Zealand Journal of Music Therapy or the Canadian Journal of Music Therapy to have been cited in JMT during the publication period reviewed. Citations from the BJMT appeared in eight papers in JMT, five of which were authored by music therapists from countries outside the United States. The lack of awareness and citation of authors from other countries is a concern for the internationalization of the discipline of music therapy.
Aigen examined qualitative articles and chapters (2008a) and qualitative dissertations (2008b) published from 1987–2006. He found 92 articles and book chapters, 55 doctoral studies, and six books to have been published during that period. In the period from 1987–1990, two articles and chapters and two dissertations (or doctoral theses) were published; from 1991–1994, five articles and chapters and seven dissertations; from 1995–1998, 20 articles and chapters and seven dissertations; from 1999–2002, 31 articles and chapters and 13 dissertations; and from 2003–2006, 34 articles and chapters and 23 dissertations. This clearly represents a large increase in qualitative research in music therapy, beginning in the mid-1990s.
Issues and problems
As music therapists work to meet the demands of evidence-based practice, making it clear that RCTs need to be conducted to determine the efficacy of music therapy, there is much discussion about several areas. One of these is whether too much emphasis is being placed on RCTs. Many music therapists feel that the work that they do cannot be adequately investigated using RCTs and other quantitative approaches. Edwards (2005b) indicated some of these concerns and the ways they can be addresses in medical music therapy, and her suggestions can apply beyond medical areas. Bradt (2012) has emphasized that RCTs are not the only type of investigation that should be done about music therapy processes and outcomes. She wrote, “It is of great importance to the field of music therapy that multiple types of evidence contribute to its knowledge base and that the dialogue of clinical effectiveness is not dominated by the biomedical hierarchical model of evidence-based practice (EBP) in which meta-analytic reviews and randomized controlled trials reign” (p. 121).
Another discussion is about how well the requirements for rigorous control in conducting RCTs can match with what actually occurs in a music therapy session. As Bradt (2012) says, “One of the major concerns expressed by music therapists about the use of RCTs is the claim that the treatments used in RCTs suffer so severely from the required standardization that they become irrelevant to clinical practice” (p. 136). One way to address this concern is to use a treatment manual, which contains guidelines for the treatment approach being investigated but does not provide a rigid set of procedures to use. Rolvsjord et al. (2005) , who developed a manual for an RCT investigating resource oriented music therapy, say:
Our pragmatic solution… has been to produce a manual with open descriptions of principles that emphasize contextual and collaborative aspects. The manual thus focuses upon underlying assumptions and values informing a contextual approach to resource-oriented music therapy, rather than describing specific actions, techniques, or procedures. In this way we hope to have avoided that the manualization should limit the possibilities for each therapeutic process to be tailored to match the individual client. We also think that the principles, if practiced with competence and not only adherence, have left enough space for the collaborative therapeutic process to develop relatively freely. (p. 28)
Another issue is the quality of music therapy research. As research has been reviewed for Cochrane Reviews and the quality evaluated on a number of criteria, it has become apparent that many music therapy studies are not of high enough quality to be included. Bradt (2012) said, “Reviews of the music therapy research literature indicate a need for increased scientific rigor in the design and conduct of RCTs” (p. 146). “It is important that music therapists contributing to our evidence base through RCT research are prepared to design trials that meet current methodological standards and, equally important, are able to respond appropriately to those design aspects (e.g. blinding of the participants) that are not feasible in music therapy research” (p. 121).
The positive side of this is that it providing guidance for music therapy researchers in raising the quality of the studies, leading to more studies that meet criteria for inclusion. This applies primarily to RCTs, and it seems that the number of RCTs about music therapy research is increasing.
Another problem in experimental research in music therapy is enrolling enough participants for the research study, which generally requires a certain number of participants who meet the inclusion criteria for the study. Since many music therapy procedures require multiple sessions, the number of available participants can be further limited. One of the solutions for this problem is for researchers from several facilities to collaborate so that the research includes participants from several institutions. This was done, for example, in two hospitals with a study of the effects of music therapy for mood disturbance during hospitalization for autologous stem cell transplantation ( Cassileth et al. 2003 ), a multi-site study of the effects of parent-preferred melodies and entrained live rhythm and breath sounds on babies in neonatal intensive care units ( Loewy et al. 2013 ), and a multi-site study of the effects of active music engagement on children with cancer ( Robb et al. 2008 ) as well as a more recent study further investigating a therapeutic music video intervention ( Robb et al. 2014 ). Increasing international cooperation is making international multi-site studies possible, as exemplified by a study of improvisational music therapy ’ s effectiveness for children with autism spectrum disorders that aims to enroll 300 participants recruited from nine different countries ( Geretsegger et al. 2012 ; International Standard Randomized Controlled Trial Number Register 2013 ) and one of individual music therapy for mental health care clients with low therapy motivation that enrolled 144 adults from three countries ( Gold et al. 2013 ).
Challenges to music therapy research that are not specific to RCTs have to do with whether music therapy clinicians and others use the research that has been done. This has been an ongoing challenge for music therapy research (see Wheeler 2005 , p. 6). Waldon (2015) surveyed US music therapists for information on the extent to which they engage in research-related activities or whether they perceive barriers to integrating research into clinical. He found differences in how research is utilized as well as perceived barriers between music therapist whose primary job role is research and those in clinical positions. He says that “this suggests a divide between those generating knowledge about the profession (researchers and academicians) and those responsible for delivering treatment (clincians). Furthermore, reported utilization varies as a function of work setting (e.g. between rehabilitation/medical settings and others)” (p. 1). There are also questions about how qualitative research, an important portion of current music therapy research, is related to the demands of evidence-based practice. One way that this is being addressed is through synthesis of qualitative research, which combines and integrates qualitative research that addresses a similar topic, question or population ( Hannes and Lockwood 2012 ; Sandelowski and Barroso 2007 ).
Along with the challenges confronting music therapy research and researchers, there is a great deal of development and extension work that builds the profession and increases our knowledge within the profession as well as our visibility to others. Music therapy research draws from various traditions of inquiry, selecting the method as relevant to the questions being asked, and doing it with increasingly high quality. All of this brings music therapy closer to achieving an integral connection between theory, clinical practice, and research that Gaston (1968) suggested should form a tripod, each necessary in order for the other to stand.
An effect size is the difference between means in standardized units, or the number of standard deviations by which the means differ.
Since the focus of this chapter is music therapy research, clinical and professional articles are not included in this summary, although they were part of Brooks’ (2003) analysis.
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Music and Health: What the Science Says
Clinical Guidelines, Scientific Literature, Info for Patients: Music and Health
There is some evidence that music-based interventions may help to relieve pain associated with specific health conditions.
- A 2016 meta-analysis of 97 randomized controlled trials involving a total of 9,184 participants examined music-based interventions for acute or chronic pain associated with a variety of health problems and medical procedures. The overall evidence suggested that music-based interventions may have beneficial effects on both pain intensity and emotional distress from pain and may lead to decreased use of pain-relieving medicines.
- A 2017 systematic review and meta-analysis of 14 randomized trials (1,178 participants) examined music-based interventions for various types of chronic pain and found that the interventions reduced self-reported chronic pain and associated depressive symptoms, with a greater effect when the music was chosen by the participant rather than the researcher. The study participants had a variety of conditions that can cause chronic pain, including cancer, fibromyalgia, multiple sclerosis, or osteoarthritis, and most of the interventions involved listening to recorded music. Overall, the data suggested that as an adjuvant therapy, music reduces self-reported pain and common comorbidities associated with chronic pain.
- In recent studies, music-based interventions were helpful for pain associated with childbirth, platinum-based chemotherapy, shock wave lithotripsy, oocyte retrieval for in vitro fertilization, treatment of nose fractures, and sickle cell disease. However, music didn’t seem to be helpful for pain associated with loop electrosurgical excision, and the results of studies on pain during cystoscopy and pain during colonoscopy were inconsistent.
Music-based interventions have been evaluated for their effects on anxiety in a variety of disease conditions and health care settings. Most studies have had promising results.
- A 2013 Cochrane systematic review of 26 studies involving a total of 2,051 participants found that listening to recorded music significantly reduced anxiety in people who were waiting to have surgery. However, there was potential for bias in most of the studies because the investigators who performed the studies knew which participants had listened to music.
- A 2016 Cochrane systematic review of 17 studies involving a total of 1,381 participants evaluated the effect of music-based interventions on anxiety in adults with cancer. The findings from the review suggested that music-based interventions may have a large anxiety-reducing effect as well as beneficial effects on pain, fatigue, and quality of life in people with cancer. However, there was a high risk of bias in the studies.
- A 2015 systematic review and meta-analysis of 5 studies (290 participants) in people who were receiving incenter maintenance hemodialysis suggested that listening to music reduced anxiety. However, the studies included in the review have limitations because of their small size and high risk of bias.
It’s uncertain whether music-based interventions are helpful for people with ASD.
- A 2021 systematic review of 22 studies (850 participants) on music therapy for children with ASD was unable to reach any definite conclusions on whether adding music therapy to their care was beneficial, although some studies had promising results. For example, some studies of educational music therapy (involving techniques such as musical games) showed possible benefits on the children’s speech, and some studies of improvisational music therapy (in which children produce music) showed possible benefits on social functioning.
- A 2017 randomized controlled trial of improvisational music therapy for children with ASD (which was included in the review described above) was a multinational trial involving 364 children from 9 countries. It is the largest study completed so far, and its design was especially rigorous. In this study, the severity of symptoms related to difficulties in social communication did not differ between children who received improvisational music therapy along with standard care and those who received standard care alone.
There is some limited evidence that music-based interventions may be helpful for shortness of breath, anxiety, and sleep quality in adults with COPD.
- A 2021 systematic review of 12 studies (812 participants) showed that music-based interventions (i.e., listening to music or a combination of listening and singing) were helpful for shortness of breath, anxiety, and sleep quality in adults with COPD but were not helpful for depression. Because the studies were brief (several days to 12 months) and because researchers measured effects in different ways in different studies, there is some uncertainty about the conclusions.
Much research is being done on the potential benefits of music-based interventions for people with cognitive impairment or various types of dementia, such as Alzheimer’s disease. Limited evidence suggests that music-based interventions may improve emotional well-being, behavioral challenges, and quality of life in people with these conditions. Whether the interventions have benefits for cognitive functioning is unclear; effects might depend on the population studied or the type of intervention used.
- A 2018 Cochrane systematic review evaluated 22 studies (1,097 participants) of music-based interventions for people with dementia who were living in institutions. Some of the interventions were receptive (listening to music), some were active (singing, playing instruments, moving to music, etc.), and some were a combination of the two. The evidence from these studies indicated that music-based interventions probably reduce depressive symptoms and improve overall behavioral problems, but effects differ for different behavior problems. They may also improve emotional well-being and quality of life and reduce anxiety. However, the interventions may have little or no effect on agitation, aggression, or cognitive function.
- A 2021 systematic review and meta-analysis analyzed 21 studies involving 1,472 participants with either mild cognitive impairment or mild or moderate dementia for potential effect sizes and intervention activities. Nine of the studies (495 participants) were included in a quantitative analysis of effects on cognitive functioning This analysis indicated that the music-based interventions had a small beneficial effect on cognitive functioning for older adults with probable mild cognitive impairment or dementia. There was also some evidence for beneficial effects on mood and quality of life.
There is some evidence that adding music-based interventions to usual treatment may improve depressive symptoms when compared with usual treatment alone. There is also some evidence that music-based interventions may help decrease anxiety levels and improve functioning in people with depression.
- A 2017 Cochrane systematic review looked at 9 studies (421 participants) of music-based interventions in adults or adolescents with depression. There was moderate-quality evidence that adding music-based interventions to usual treatment saw improvement based on clinician‐rated and patient‐reported measures of depression when compared with usual treatment alone. Music-based interventions also helped decrease anxiety levels and improve functioning of people with depression (for example, their ability to maintain involvement in work, activities, and relationships).
Findings from several studies suggest that music-based interventions may be beneficial for coordination, balance, some aspects of gait and walking, emotional status, and pain in people with MS.
- A 2021 systematic review of music-based interventions for people with multiple sclerosis (10 trials, 429 participants) found consistent evidence overall that the music-based therapies were better than conventional care or no intervention for fatigue level, fatigability, coordination, balance, some aspects of gait and walking, emotional status, and pain, but no effect was observed for mental fatigability or memory. The music-based therapy came from one of four different modalities: (1) Rhythmic auditory; (2) Playing musical instruments; (3) Dance strategy; and (4) Neurological music therapy.
There is some limited evidence that rhythmic auditory stimulation may significantly improve gait speed and stride length in people with PD. There is some evidence that music-based movement therapy may improve motor function, balance, freezing of gait, walking speed, and mental health. In addition, a few studies have found some evidence that singing may have a beneficial effect on speech in people with PD.
- Rhythmic auditory stimulation. A 2021 systematic review and meta-analysis of 5 studies (209 total participants) showed significant improvements in gait speed and stride length in people with PD who participated in rhythmic auditory stimulation. However, the quality of evidence was low, and the number of studies and participants was small.
- Music-based movement therapy. A 2021 systematic review and meta-analysis of 17 studies (598 participants) of music-based movement therapy showed evidence of improvements in motor function, balance, freezing of gait, walking speed, and mental health but not gait cadence, stride length, or quality of life in people with PD.
- Singing. The potential benefits of singing for people with PD have been studied primarily in terms of effects on speech. In a 2016 systematic review of 7 studies (102 participants), 5 studies found some evidence of a beneficial effect on speech.
Results of studies have been mixed as to whether music-based interventions can be helpful for sleep problems.
- A 2021 systematic review of 16 studies involving 812 older adults with sleep problems found mixed results; some studies suggested that the music interventions were helpful, while others did not.
- 2015 Cochrane systematic review of 6 studies involving a total of 314 participants with insomnia found that music-based interventions may be effective for improving subjective sleep quality in adults with insomnia.
Music-based interventions, particularly music therapy, may be helpful for improving physical and psychological markers associated with stress, according to two related reviews.
- A 2020 systematic review and two meta-analyses of 104 studies (9,617 participants), analyzed the effects of a variety of music-based interventions on measures associated with stress, including both physiological measures (heart rate, blood pressure, and levels of stress-related hormones) and psychological measures (anxiety, nervousness, restlessness, and feelings of worry). The music-based interventions had a small-to-medium sized beneficial effect on the physiological measures and a medium-to-large beneficial effect on the psychological measures.
- A 2022 systematic review and meta-analysis of 47 studies (2,747 participants) of music therapy (excluding other music-based interventions) found an overall medium-to-large beneficial effect on stress-related outcomes. The effects were greater than those seen in the larger review. The investigators who performed the review suggested that the opportunity for music therapists to tailor interventions to the needs of individual patients might account for the difference.
There is evidence that music-based interventions may be helpful in the rehabilitation of people who have had a stroke.
- A 2019 systematic review of 27 studies (730 participants) found positive effects on physical status (upper-limb activity, various aspects of walking, balance), cognition (paying attention, communication), and mood in people who had a stroke. In particular, rhythmic auditory stimulation had beneficial effects on gait and balance, and receptive music therapy was helpful for mood and some aspects of cognitive function (i.e., verbal memory, focused attention).
- In general, research studies of music-based interventions do not show any negative effects. However, listening to music at too high a volume can contribute to noise-induced hearing loss. You can find out about this type of hearing loss on the National Institute on Deafness and Other Communication Disorders website .
- Because music can be associated with strong memories or emotional reactions, some people may be distressed by exposure to specific pieces or types of music.
- Music-based interventions that involve exercise or other types of movement could lead to injury if appropriate safety precautions are not taken.
- Aalbers S, Fusar-Poli L, Freeman RE, et al. Music therapy for depression . Cochrane Database of Systematic Reviews. 2017;(11):CD004517.
- Barnish J, Atkinson RA, Barran SM, Barnish MS. Potential benefit of singing for people with Parkinson’s disease: a systematic review . Journal of Parkinson’s Disease. 2016;6(3):473-484.
- Bradt J, Dileo C, Magill L, et al . Music interventions for improving psychological and physical outcomes in cancer patients . Cochrane Database of Systematic Reviews. 2016;(8):CD006911. Accessed at https://www.cochranelibrary.com on October 29, 2021.
- Bradt J, Dileo C, Shim M. Music interventions for preoperative anxiety . Cochrane Database of Systematic Reviews. 2013;(6):CD006908. Accessed at https://www.cochranelibrary.com on October 29, 2021.
- Buglione A, Saccone G, Mas M, et al. Effect of music on labor and delivery in nulliparous singleton pregnancies a randomized clinical trial . Archives of Gynecology and Obstetrics . 2020;310(3):693-698.
- Burrai F, Apuzzo L, Zanotti R. Effectiveness of rhythmic auditory stimulation on gait in Parkinson disease. A systematic review and meta-analysis . Holistic Nursing Practice. June 11, 2021. [Epub ahead of print].
- Burrai F, Magavern EF, Micheluzzi V, et al. Effectiveness of music to improve anxiety in hemodialysis patients. A systematic review and meta-analysis . Holistic Nursing Practice. 2020;34(6):324-333.
- Cakmak O, Cimen S, Tarhan H, et al. Listening to music during shock wave lithotripsy decreases anxiety, pain, and dissatisfaction. A randomized controlled study . Wiener Klinische Wochenscrift. 2017;129:687-691.
- Çelebi D, Yılmaz E, Şahin ST, et al. The effect of music therapy during colonoscopy on pain, anxiety and patient comfort: a randomized controlled trial . Complementary Therapies in Clinical Practice. 2020;38:101084.
- Chantawong N, Charoenkwan K. Effects of music listening during loop electrosurgical excision procedure on pain and anxiety: a randomized trial . Journal of Lower Genital Tract Disease. 207;21(4):307-310.
- Cheung CWC, Yee AWW, Chan PS, et al. The impact of music therapy on pain and stress reduction during oocyte retrieval – a randomized controlled trial . Reproductive Biomedicine Online. 2018;37(2):145-152.
- Çift A, Benlioğlu C. Effect of different musical types of patient’s relaxation, anxiety and pain perception during shock wave lithotripsy: a randomized controlled study . Urology Journal. 2020;17(1):19-23.
- de Witte M, da Silva Pinho A, Stams G-J, et al. Music therapy for stress reduction: a systematic review and meta-analysis . Health Psychology Review. November 27, 2020. [Epub ahead of print].
- de Witte M, Spruit A, Van Hooren S, et al. Effects of music interventions on stress-related outcomes: a systematic review and two meta-analyses . Health Psychology Review. 2020;14(2):294-324.
- Dorris JE, Neely S, Terhorst L, et al. Effects of music participation for mild cognitive impairment and dementia: a systematic review and meta-analysis . Journal of the American Geriatrics Society. 2021;69(9):2659-2667.
- Garza-Villareal EA, Pando V, Vuust P, et al. Music-induced analgesia in chronic pain conditions: a systematic review and meta-analysis . Pain Physician. 2017;20(7):597-610.
- Huang J, Yuan X, Zhang N, et al. Music therapy in adults with COPD . Respiratory Care. 2021;66(3):501-509.
- Jespersen KV, Koenig J, Jennum P, et al. Music for insomnia in adults . Cochrane Database of Systematic Reviews. 2015;(8):CD010459. Accessed at https://www.cochranelibrary.com on October 29, 2021
- Ko SY, Leung DYP, Wong EML. Effects of easy listening music intervention on satisfaction, anxiety, and pain in patients undergoing colonoscopy: a pilot randomized controlled trial . Clinical Interventions in Aging . 2019;14:977-986.
- Le Perf G, Donguy A-L, Thebault G. Nuanced effects of music interventions on rehabilitation outcomes after stroke: a systematic review . Topics in Stroke Rehabilitation. 2019;26(6):473-484.
- Lee JH. The effects of music on pain: a meta-analysis . Journal of Music Therapy. 2016;53(4):430-477.
- Lopes J, Keppers II. Music-based therapy in rehabilitation of people with multiple sclerosis: a systematic review of clinical trials . Arquivos de Neuro-psiquiatria. 2021;79(6):527-535.
- Mayer-Benarous H, Benarous X, Vonthron F, et al. Music therapy for children with autistic spectrum disorder and/or other neurodevelopmental disorders: a systematic review . Frontiers in Psychiatry. 2021;12:643234.
- McClintock G, Wong E, Mancuso P, et al. Music during flexible cystoscopy for pain and anxiety – a patient-blinded randomized control trial . BJU International. 2021;128 Suppl 1:27-32.
- Mumm J-N, Eismann L, Rodler S, et al. Listening to music during outpatient cystoscopy reduces pain and anxiety and increases satisfaction: results from a prospective randomized study . Urologia Internationalis . 2021;105(9-10):792-798.
- Ortega A, Gauna F, Munoz D, et al. Music therapy for pain and anxiety management in nasal bone fracture reduction: randomized controlled clinical trial . Otolaryngology—Head and Neck Surgery. 2019;161(4):613-619.
- Perković R, Dević K, Hrkać A, et al. Relationship between education of pregnant women and listening to classical music with the experience of pain in childbirth and the occurrence of psychological symptoms in puerperium . Psychiatria Danubina . 2021;33(Suppl 13):260-270.
- Petrovsky DV, Ramesh P, McPhillips MV, et al. Effects of music interventions on sleep in older adults: a systematic review . Geriatric Nursing. 2021;42(4):869-879.
- Rodgers-Melnick SN, Matthie N, Jenerette C, et al. The effects of a single electronic music improvisation session on the pain of adults with sickle cell disease: a mixed methods pilot study . Journal of Music Therapy . 2018;55(2):156-185.
- Tang H, Chen L, Wang Y, et al. The efficacy of music therapy to relieve pain, anxiety, and promote sleep quality, in patients with small cell lung cancer receiving platinum-based chemotherapy . Supportive Care in Cancer. 2021;29(12):7299-7306.
- van der Steen JT, Smaling HJA, van der Wouden JC, et al. Music-based therapeutic interventions for people with dementia . Cochrane Database of Systematic Reviews. 2018;(7):CD003447. Accessed at cochranelibrary.com on October 29, 2021.
- Zhou Z, Zhou R, Wei W, et al . Effects of music-based movement therapy on motor function, balance, gait, mental health, and quality of life for patients with Parkinson’s disease: a systematic review and meta-analysis . Clinical Rehabilitation. 2021;35(7):937-951.
Information for Your Patients
- Music and the Brain: Report on an NIH/Kennedy Center Workshop
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Music Therapy Journals and Publications
Click to go directly to: Opt-in to Receive Printed Journal Copies! The Journal of Music Therapy Journal of Music Therapy - AMTA Member Access Portal Music Therapy Perspectives Music Therapy Perspectives - AMTA Member Access Portal Steps to Access Your Online Member Subscription to Research Journals Music Therapy Matters Monthly Other Publications from AMTA Imagine, early childhood newsletter 2010, 2011 & 2012 Back Issues of AMTA Journals Music Therapy - 1981-1996 journal Advertising in AMTA Publications
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Journal of Music Therapy webpage at Oxford University Press
Journal of music therapy amta member access portal.
A forum for authoritative articles of current music therapy research and theory, including book reviews and guest editorials. An index appears in issue four of each volume. ISSN #0022-2917
Subscriptions to the Journal of Music Therapy are now available for the current and upcoming year. For subscription rate information and to subscribe to the Journal of Music Therapy , please contact AMTA's partner in publishing, Oxford Universtiy Press, https://academic.oup.com/jmt/subscribe
The Journal of Music Therapy (JMT) is a forum for authoritative articles of current music therapy research and theory, including book reviews and guest editorials. Its mission is as follows:
The Journal of Music Therapy seeks to advance research, theory, and practice in music therapy through the dissemination of scholarly work. Its mission is to promote scholarly activity in music therapy and to foster the development and understanding of music therapy and music-based interventions. To this end, the journal publishes all types of research, including quantitative, qualitative, historical, philosophical, theoretical, and musical, and may include discipline, profession, and foundational research topics. The journal strives to present a variety of research approaches and topics, to promote critical inquiry, and to serve as a resource and forum for researchers, educators, and clinicians in music therapy and related professions.
The Journal of Music Therapy publishes only the very best of what is submitted and includes articles concerning the psychology of music, applied music therapy techniques, perception of music, and effects of music on human behavior. All papers for publication are selected on the basis of their quality and contribution to existing knowledge. About 30% of submitted manuscripts are accepted for publication and include but are not limited to qualitative, quantitative, and mixed methodologies; historical, descriptive, philosophical, or experimental designs; and integrative reviews, meta-analysis or meta-synthesis. Individual case studies or studies with very small numbers of subjects are rarely published; however, an extremely innovative case study may be accepted due to its unique contribution to knowledge. Conversely, articles of any type which do not advance the science and practice of music therapy are not accepted.
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Journal of Music Therapy Online Member Access
AMTA's journals are available to subscribers and current AMTA members who may access and search the online journals. At times, articles may be published online as open access for a limited number of weeks. For member access to articles that are not open access, go to www.musictherapy.org and log in in the upper right with your current member personal email address and password. Once logged into your personal member account, then go to Research>Music Therapy Journals and Publications and select the "Member Access Portal" link for your desired journal. This is the member portal to AMTA's music therapy journals at Oxford University Press. Just one more click on the link in the access portal and you will be directed to the journal page. Once you are there, you may begin browsing the journals. You will see the unlocked padlocked icon next to articles that you are able to access and the AMTA Members account in the upper right. This means you are logged into your online subscription and are able to browse the journal and its archives. Alternatively (for fewer steps), you can use the Quick Links for each journal on the AMTA home page after you initially log in.
Contributions to the Journal of Music Therapy
Please submit manuscripts and submission letters electronically using AMTA's online submission program at the URL/link below. AMTA's online submission system is ScholarOne located at: http://mc.manuscriptcentral.com/jmt Please review all Instructions for Authors before submitting. Should you have any difficulties with your online submission, please contact via email:
Blythe LaGasse, PhD, MT-BC Editor, Journal of Music Therapy Colorado State University College of Liberal Arts, UCA 145D Fort Collins, CO 80523-1701 [email protected]
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- The complaint or concern is raised, preferably in an email to the editorial office, including specific and detailed evidence to support the claim.
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- The editor will notify the AMTA’s journal business manager and/or CEO, and journal publisher, and work with them to seek out all applicable industry guidelines concerning matters of research integrity and publication ethics (including those of the Committee on Publication Ethics), case examples, and AMTA Bylaws.
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- The editor will provide written explanation of the decision to the complainant. Journal of Music Therapy Email: [email protected]
Music Therapy Perspectives
Music therapy perspectives webpage at oxford university press, music therapy perspectives - amta member access portal, advertising in music therapy perspectives.
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. ISSN #0734-6875
Subscriptions to Music Therapy Perspectives are now available for the current and upcoming year! For subscription rate information and to subscribe to Music Therapy Perspectives , please contact AMTA's partner in publishing, Oxford University Press, https://academic.oup.com/mtp/subscribe
Music Therapy Perspectives seeks to promote the development of music therapy clinical practice through the dissemination of scholarly work. It publishes all forms of reports that have implications for music therapy practice including clinically-focused research reports, innovative developments, case studies, educational research, and theoretical articles. With a focus on clinical benefits of music therapy, Music Therapy Perspectives strives to serve as a resource and forum for music therapists, music therapy students and educators, and those in related professions.
Music Therapy Perspectives seeks to:
- Speak to the direct clinical and professional experiences of practicing music therapists, and in so doing advance the profession.
- Include information useful to music therapists, music therapy students, and professionals interested in the therapeutic uses of music.
- Address issues related to the supervision of music therapy students and the supervision of music therapists in both professional and advanced practice.
- Include articles addressing the education and training of music therapists.
- Address ethical concepts and issues as they pertain to music therapy education, training, research and professional practice.
Music Therapy Perspectives focuses on scholarly articles in the following areas:
- Music therapy models, methods and practices that reflect broad theoretical perspectives reflective of the AMTA Standards of Clinical Practice (professional and advanced).
- Information useful to clinical training directors, educators and administrators
- Discussions, commentaries and analyses of professional issues related to music therapy practice, such as ethics and licensure.
- Qualitative research consistent with the mission and objectives of the journal.
- Quantitative research, consistent with the mission and objectives of the journal, with small sample sizes that may serve as a foundation for larger research studies suitable for the Journal of Music Therapy and other relevant music therapy journals.
- Pilot projects that reflect new areas of clinical practice.
- Case Studies.
- Analyses of literature that expand clinical practice knowledge.
- Book Reviews.
Music Therapy Perspectives Online Member Access
Contributions to music therapy perspectives.
Please submit manuscripts and submission letters electronically using AMTA's online submission program at the URL/link below. AMTA's online submission system is ScholarOne located at: http://mc.manuscriptcentral.com/mtp Please review all Instructions for Authors before submitting. Should you have any difficulties with your online submission, please contact via email:
Laura Beer, PhD, MT-BC (she, her) Editor, Music Therapy Perspectives Associate Professor, Music Therapy Colorado State University Campus Delivery 1778 Fort Collins, CO 80523-1778 [email protected]
- The editor will provide written explanation of the decision to the complainant. Music Therapy Perspectives Email: [email protected]
Music Therapy was the official publication of the American Association for Music Therapy (AAMT) and was published annually from 1981 to 1996. The goal of the journal Music Therapy was to reflect a wide diversity of clinical, research and educational issues concerning the profession of music therapy during the years it was published. Now provided here for archival purposes, contributors to Music Therapy were practicing clinicians, music therapy educators, and professionals deeply involved in their organizations and dedicated to the enhancement of the music therapy profession.
Music Therapy Matters Monthly
This e-newsletter is provided to all current AMTA members as a benefit of membership in AMTA and published on the AMTA website under " Latest News ." An abridged version is sent directly to the primary email address of record for each individual member. For information on membership or subscribing, please contact the AMTA National Office at (301) 589-3300 or [email protected] .
Archives of past issues can be found in the AMTA Member Toolkit on the AMTA website . AMTA members joining after a specific issue was e-mailed out may check the Member Toolkit for access to all previous issues.
Music Therapy Matters Monthly Submission Guidelines
Music Therapy Matters is a monthly e-publication that welcomes article submissions from AMTA members.
Article submissions will be reviewed by the Editor and AMTA Executive Director and considered for inclusion based on available space and relevance to the music therapy profession and circulation of Music Therapy Matters Monthly .
Please note that while every effort will be made to include submissions received, they will be published on a space-available basis. Submissions may be edited for content, grammar and length. Publication dates are subject to change, but generally happen around the 15th of each month. To contact the Music Therapy Matters Monthly Editor, please email [email protected] or call 301-589-3300. Currently, Music Therapy Matters Monthly does not accept advertising.
In addition to research journals and newsletters, AMTA publishes a variety of other publications including texts and monographs such as the monograph series Effective Clinical Practice in Music Therapy, Music in Special Education, and Music Therapy and Premature Infants or Music Therapy in Pediatric Healthcare . AMTA also produces videos such as Music Therapy & Medicine: Partnerships in Care . Back issues of music therapy journals are available as well as products and informational brochures about the music therapy profession.
AMTA's complete publications catalog can be found in the AMTA online store. Simply hover over the "Bookstore" menu item above and select "Visit the Bookstore." Then, under "Shop for," choose "Merchandise" and "Select Category," choose "Publications" and click "Go." You'll find a list of all books and publications AMTA offers or click this link to go directly there .
AMTA welcomes book and publication proposals on music therapy. Music therapy professionals and academics are encouraged to consider donating manuscripts for publication consideration with AMTA. See the menu item Bookstore> Publish with AMTA for more information.
Imagine , early childhood newsletter 2010, 2011 & 2012
Click here to explore and read archived issues.
Browse the imagine archive using an innovative viewing mode. Learn about our AMTA early childhood network opportunities, international perspectives on early childhood music therapy, and the "imagine" editorial team. Be part of future issues by reading the guidelines for authors and submitting your paper.
Back Issues of AMTA Journals
Back issues of any of the Journal of Music Therapy and Music Therapy Perspectives can be found on the respective journal's website and may be downloaded for a fee. Please see link for each journal above and click on "Browse the Archives."
Copyright © 1998-2023. American Music Therapy Association® and its logo are registered trademarks with the U.S. Patent and Trademark office. Information, files, graphics, and other content on this site are the property of the American Music Therapy Association® and may not be used, reprinted or copied without the express written permission of the American Music Therapy Association.
The American Music Therapy Association® is a 501(c)3 non-profit organization and accepts contributions which support its mission. Contributions are tax deductible as allowed by law.
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How music heals us, even when it’s sad – by a neuroscientist leading a new study of musical therapy
Professor of Cognitive-Neuroscience , Department of Psychology, Northumbria University, Newcastle
Leigh Riby does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
Northumbria University, Newcastle provides funding as a member of The Conversation UK.
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When I hear Shania Twain’s You’re Still The One , it takes me back to when I was 15, playing on my Dad’s PC. I was tidying up the mess after he had tried to [take his own life]. He’d been listening to her album, and I played it as I tidied up. Whenever I hear the song, I’m taken back – the sadness and anger comes flooding back.
There is a renewed fascination with the memory-stimulating and healing powers of music. This resurgence can primarily be attributed to recent breakthroughs in neuroscientific research, which have substantiated music’s therapeutic properties such as emotional regulation and brain re-engagement. This has led to a growing integration of music therapy with conventional mental health treatments.
Such musical interventions have already been shown to help people with cancer , chronic pain and depression . The debilitating consequences of stress, such as elevated blood pressure and muscle tension, can also be alleviated through the power of music .
Across the world, we’re seeing unprecedented levels of mental illness at all ages, from children to the very old – with huge costs to families, communities and economies. In this series , we investigate what’s causing this crisis, and report on the latest research to improve people’s mental health at all stages of life.
As both a longtime music fan and neuroscientist, I believe music has a special status among all the arts in terms of the breadth and depth of its impact on people. One critical aspect is its powers of autobiographical memory retrieval – encouraging often highly personal recollections of past experiences. We can all recount an instance where a tune transports us back in time, rekindling recollections and often imbuing them with a range of powerful emotions.
But enhanced recollection can also occur in dementia patients, for whom the transformative impact of music therapy sometimes opens a floodgate of memories – from cherished childhood experiences and the aromas and tastes of a mother’s kitchen, to lazy summer afternoons spent with family or the atmosphere and energy of a music festival.
One remarkable example is a widely shared video made by the Asociación Música para Despertar , which is thought to feature the Spanish-Cuban ballerina Martha González Saldaña (though there has been some controversy about her identity). The music of Swan Lake by Tchaikovsky appears to reactivate cherished memories and even motor responses in this former prima ballerina, who is moved to rehearse some of her former dance motions on camera.
In our laboratory at Northumbria University, we aim to harness these recent neuroscience advances to deepen our understanding of the intricate connection between music, the brain and mental wellbeing. We want to answer specific questions such as why sad or bittersweet music plays a unique therapeutic role for some people, and which parts of the brain it “touches” compared with happier compositions.
Advanced research tools such as high-density electroencephalogram (EEG) monitors enable us to record how the brain regions “talk” to each other in real-time as someone listens to a song or symphony. These regions are stimulated by different aspects of the music, from its emotional content to its melodic structure, its lyrics to its rhythmic patterns.
Of course, everyone’s response to music is deeply personal, so our research also necessitates getting our study participants to describe how a particular piece of music makes them feel – including its ability to encourage profound introspection and evoke meaningful memories.
Ludwig van Beethoven once proclaimed: “Music is the one incorporeal entrance into the higher world of knowledge which comprehends mankind, but which mankind cannot comprehend.” With the help of neuroscience, we hope to help change that.
A brief history of music therapy
Music’s ancient origins predate aspects of language and rational thinking. Its roots can be traced back to the Paleolithic Era more than 10,000 years ago, when early humans used it for communication and emotional expression. Archaeological finds include ancient bone flutes and percussion instruments made from bones and stones, as well as markings noting the most accoustically resonant place within a cave and even paintings depicting musical gatherings .
Music in the subsequent Neolithic Era went through significant development within permanent settlements across the world. Excavations have revealed various musical instruments including harps and complex percussion instruments, highlighting music’s growing importance in religious ceremonies and social gatherings during this period – alongside the emergence of rudimentary forms of music notation, evident in clay tablets from ancient Mesopotamia in western Asia.
Ancient Greek philosophers Plato and Aristotle both recognised music’s central role in the human experience. Plato outlined the power of music as a pleasurable and healing stimulus, stating: “Music is a moral law. It gives soul to the universe, wings to the mind, flight to the imagination.” More practically, Aristotle suggested that: “Music has the power of forming the character, and should therefore be introduced into the education of the young.”
Throughout history, many cultures have embraced the healing powers of music. Ancient Egyptians incorporated music into their religious ceremonies, considering it a therapeutic force. Native American tribes, such as the Navajo, used music and dance in their healing rituals, relying on drumming and chanting to promote physical and spiritual wellbeing. In traditional Chinese medicine, specific musical tones and rhythms were believed to balance the body’s energy (qi) and enhance health.
During the Middle Ages and the Renaissance, the Christian church was pivotal in popularising “music for the masses”. Congregational hymn singing allowed worshippers to engage in communal music during church services. This shared musical expression was a powerful medium for religious devotion and teaching, bridging the gap for a largely non-literate population to connect with their faith through melody and lyrics. Communal singing is not only a cultural and religious tradition, but it has also been recognised as a therapeutic experience .
In the 18th and 19th centuries, early investigations into the human nervous system paralleled the emergence of music therapy as a field of study. Pioneers such as American physician Benjamin Rush , a signatory of the US Declaration of Independence in 1776, recognised the therapeutic potential of music to improve mental health.
Soon afterwards, figures such as Samuel Mathews (one of Rush’s students) began conducting experiments exploring music’s effects on the nervous system , laying the foundation for modern music therapy. This early work provided the springboard for E. Thayer Gaston , known as the “father of music therapy”, to promote it as a legitimate discipline in the US. These developments inspired similar endeavours in the UK, where Mary Priestley made significant contributions to the development of music therapy as a respected field.
The insights gained from these early explorations have continued to influence psychologists and neuroscientists ever since – including the late, great neurologist and best-selling author Oliver Sacks, who observed that:
Music can lift us out of depression or move us to tears. It is a remedy, a tonic, orange juice for the ear.
The ‘Mozart effect’
Music was my profession, but it was also a special and deeply personal pursuit … Most importantly, it gave me a way to cope with life’s challenges, learning to channel my feelings and express them safely. Music taught me how to take my thoughts, both the pleasant and the painful ones, and turn them into something beautiful.
Studying and understanding all the brain mechanisms involved in listening to music, and its effects, requires more than just neuroscientists. Our diverse team includes music experts such as Dimana Kardzhieva (quoted above), who started playing the piano aged five and went on to study at the National School of Music in Sofia, Bulgaria. Now a cognitive psychologist, her combined understanding of music and cognitive processes helps us delve into the complex mechanisms through which music affects (and soothes) our minds. A neuroscientist alone might fall short in this endeavour.
The starting point of our research was the so-called “Mozart effect” – the suggestion that exposure to intricate musical compositions, especially classical pieces, stimulates brain activity and ultimately enhances cognitive abilities . While there have been subsequent mixed findings as to whether the Mozart effect is real , due to the different methods employed by researchers over the years, this work has nonetheless triggered significant advances in our understanding of music’s effect on the brain.
In the original 1993 study by Frances Rauscher and colleagues , participants experienced enhancement in spatial reasoning ability after just ten minutes of listening to Mozart’s Sonata for Two Pianos in D.
In our 1997 study , which used Beethoven’s second symphony and rock guitarist Steve Vai’s instrumental track For the Love of God , we found similar direct effects in our listeners – as measured both by EEG activity associated with attention levels and the release of the hormone dopamine (the brain’s messenger for feelings of joy, satisfaction and the reinforcement of specific actions). Our research found that classical music in particular enhances attention to how we process the world around us, regardless of one’s musical expertise or preferences.
The beauty of EEG methodology lies in its capacity to track brain processes with millisecond accuracy – allowing us to distinguish unconscious neural responses from conscious ones. When we repeatedly showed simple shapes to a person, we found that classical music sped up their early (pre-300 millisecond) processing of these stimuli. Other music did not have the same effect – and nor did our subjects’ prior knowledge of, or liking for, classical music. For example, both professional rock and classical musicians who took part in our study improved their automatic, unconscious cognitive processes while listening to classical music.
But we also found indirect effects related to arousal. When people immerse themselves in the music they personally enjoy, they experience a dramatic shift in their alertness and mood. This phenomenon shares similarities with the increased cognitive performance often linked to other enjoyable experiences.
In a further study, we explored the particular influence of “ program music ” – the term for instrumental music that “carries some extramusical meaning”, and which is said to possess a remarkable ability to engage memory, imagination and self-reflection. When our participants listened to Antonio Vivaldi’s Four Seasons, they reported experiencing a vivid representation of the changing seasons through the music – including those who were unfamiliar with these concertos. Our study concluded, for example, that:
Spring – particularly the well-recognised, vibrant, emotive and uplifting first movement – had the ability to enhance mental alertness and brain measures of attention and memory.
What’s going on inside our brain?
Music’s emotional and therapeutic qualities are highly related to the release of neurochemicals. A number of these are associated with happiness, including oxytocin, serotonin and endorphins. However, dopamine is central to the enhancing properties of music.
It triggers the release of dopamine in regions of the brain devoted to reward and pleasure , generating sensations of joy and euphoria akin to the impact of other pleasurable activities such as eating or having sex. But unlike these activities, which have clear value related to survival and reproduction, the evolutionary advantage of music is less obvious.
Its strong social function is acknowledged as the main factor behind music’s development and preservation in human communities. So, this protective quality may explain why it taps into the same neural mechanisms as other pleasurable activities.
This article is part of Conversation Insights The Insights team generates long-form journalism derived from interdisciplinary research. The team is working with academics from different backgrounds who have been engaged in projects aimed at tackling societal and scientific challenges.
The brain’s reward system consists of interconnected regions, with the nucleus accumbens serving as its powerhouse. It is situated deep within the subcortical region, and its location hints at its significant involvement in emotion processing, given its proximity to other key regions related to this.
When we engage with music, whether playing or listening, the nucleus accumbens responds to its pleasurable aspects by triggering the release of dopamine. This process, known as the dopamine reward pathway, is critical for experiencing and reinforcing positive emotions such as the feelings of happiness, joy or excitement that music can bring.
We are still learning about the full impact of music on different parts of the brain, as Jonathan Smallwood, professor of psychology at Queen’s University, Ontario, explains:
Music can be complicated to understand from a neuroscience perspective. A piece of music encompasses many domains that are typically studied in isolation – such as auditory function, emotion, language and meaning.
That said, we can see how music’s effect on the brain extends beyond mere pleasure. The amygdala , a region of the brain renowned for its involvement in emotion, generates and regulates emotional responses to music, from the heartwarming nostalgia of a familiar melody to the exhilarating excitement of a crescendoing symphony or the spine-tingling fear of an eerie, haunting tune.
Research has also demonstrated that, when stimulated by music, these regions can encourage us to have autobiographical memories that elicit positive self-reflection that makes us feel better – as we saw in the video of former ballerina Martha González Saldaña.
Read more: How to solve our mental health crisis
Our own research points to the hippocampus , crucial for memory formation, as the part of the brain that stores music-related memories and associations. Simultaneously, the prefrontal cortex , responsible for higher cognitive functions, closely collaborates with the hippocampus to retrieve these musical memories and assess their autobiographical significance. During music listening, this interplay between the brain’s memory and emotion centres creates a powerful and unique experience, elevating music to a distinctive and pleasurable stimulus.
Visual art, like paintings and sculptures, lacks music’s temporal and multisensory engagement, diminishing its ability to form strong, lasting emotional-memory connections. Art may evoke emotions and memories but often remains rooted in the moment. Music – perhaps uniquely – forms enduring, emotionally charged memories that can be summoned with the replaying of a particular song years later.
Music therapy can change people’s lives in profound ways. We have had the privilege of hearing many personal stories and reflections from our study participants, and even our researchers. In some cases, such as the memories of a father’s attempted suicide elicited by Shania Twain’s You’re Still The One, these are profound and deeply personal accounts. They show us the power of music to help regulate emotions, even when the memories it triggers are negative and painful.
In the face of severe physical and emotional challenges, another participant in our study explained how they had felt an unexpected boost to their wellbeing from listening to a favourite track from their past – despite the apparently negative content of the song’s title and lyrics:
Exercise has been crucial for me post-stroke. In the midst of my rehab workout, feeling low and in pain, an old favourite, What Have I Done To Deserve This? by the Pet Shop Boys, gave me an instant boost. It not only lifted my spirits but sent my heart racing with excitement – I could feel the tingles of motivation coursing through my veins.
Music can serve as a cathartic outlet, a source of empowerment, allowing individuals to process and cope with their emotions while supplying solace and release. One participant described how a little-known tune from 1983 serves as a deliberate mood inducer – a tool to boost their wellbeing:
Whenever I’m down or in need of a pick me up, I play Dolce Vita by Ryan Paris . It is like a magic button for generating positive emotions within myself - it always lifts me up in a matter of moments.
As each person has their own tastes and emotional connections with certain types of music, a personalised approach is essential when designing music therapy interventions, to ensure they resonate with individuals deeply. Even personal accounts from our researchers, such as this from Sam Fenwick, have proved fruitful in generating hypotheses for experimental work:
If I had to pick a single song that really strikes a chord, it would be Alpenglow by Nightwish . This song gives me shivers. I can’t help but sing along and every time I do, it brings tears to my eyes. When life is good, it triggers feelings of inner strength and reminds me of nature’s beauty. When I feel low, it instils a sense of longing and loneliness, like I am trying to conquer my problems all alone when I could really use some support.
Stimulated by such observations, our latest investigation compares the effects of sad and happy music on people and their brains, in order to better understand the nature of these different emotional experiences. We have found that sombre melodies can have particular therapeutic effects, offering listeners a special platform for emotional release and meaningful introspection.
Exploring the effects of happy and sad music
Drawing inspiration from studies on emotionally intense cinematic experiences, we recently published a study highlighting the effects of complex musical compositions, particularly Vivaldi’s Four Seasons, on dopamine responses and emotional states. This was designed to help us understand how happy and sad music affects people in different ways.
One major challenge was how to measure our participants’ dopamine levels non-invasively. Traditional functional brain imaging has been a common tool to track dopamine in response to music – for example, positron emission tomography (PET) imaging. However, this involves the injection of a radiotracer into the bloodstream, which attaches to dopamine receptors in the brain. Such a process also has limitations in terms of cost and availability.
In the field of psychology and dopamine research, one alternative, non-invasive approach involves studying how often people blink, and how the rate of blinking varies when different music is played.
Blinking is controlled by the basal ganglia , a brain region that regulates dopamine. Dopamine dysregulation in conditions such as Parkinson’s disease can affect the regular blink rate. Studies have found that individuals with Parkinson’s often exhibit reduced blink rates or increased variability in blink rates , compared with healthy individuals. These findings suggest that blink rate can serve as an indirect proxy indicator of dopamine release or impairment.
While blink rate may not provide the same level of precision as direct neurochemical measurements, it offers a practical and accessible proxy measure that can complement traditional imaging techniques. This alternative approach has shown promise in enhancing our understanding of dopamine’s role in various cognitive and behavioural processes.
Our study revealed that the sombre Winter movement elicited a particularly strong dopamine response, challenging our preconceived notions and shedding light on the interplay between music and emotions. Arguably you could have predicted a heightened response to the familiar and uplifting Spring concerto , but this was not the case.
Our approach extended beyond dopamine measurement to gain a comprehensive understanding of the effects of sad and happy music. We also used EEG network analysis to study how different regions of the brain communicate and synchronise their activity while listening to different music. For instance, regions associated with the appreciation of music, the triggering of positive emotions and the retrieval of rich personal memories may “talk” to each other. It is like watching a symphony of brain activity unfold, as individuals subjectively experienced a diverse range of musical stimuli.
In parallel, self-reports of subjective experiences gave us insights into the personal impact of each piece of music, including the timeframe of thoughts (past, present, or future), their focus (self or others), their form (images or words), and their emotional content. Categorising these thoughts and emotions, and analysing their correlation with brain data, can provide valuable information for future therapeutic interventions.
Our preliminary data reveals that happy music sparks present and future-oriented thoughts, positive emotions, and an outward focus on others. These thoughts were associated with heightened frontal brain activity and reduced posterior brain activity. In contrast, sad tunes caused self-focused reflection on past events, aligning with increased neural activity in brain areas tied to introspection and memory retrieval.
So why does sad music have the power to impact psychological wellbeing? The immersive experience of sombre melodies provides a platform for emotional release and processing. By evoking deep emotions, sad music allows listeners to find solace, introspect, and effectively navigate their emotional states.
This understanding forms the basis for developing future targeted music therapy interventions that cater to people facing difficulties with emotional regulation, rumination and even depression. In other words, even sad music can be a tool for personal growth and reflection.
What music therapy can offer in the future
While not a panacea, music listening offers substantial therapeutic effects, potentially leading to increased adoption of music therapy sessions alongside traditional talk therapy. Integrating technology into music therapy, notably through emerging app-based services, is poised to transform how people access personalised, on-demand therapeutic music interventions, providing a convenient and effective avenue for self-improvement and wellbeing.
And looking even further ahead, artificial intelligence (AI) integration holds the potential to revolutionise music therapy. AI can dynamically adapt therapy interventions based on a person’s evolving emotional responses. Imagine a therapy session that uses AI to select and adjust music in real-time, precisely tailored to the patient’s emotional needs, creating a highly personalised and effective therapeutic experience. These innovations are poised to reshape the field of music therapy , unlocking its full therapeutic potential.
In addition, an emerging technology called neurofeedback has shown promise. Neurofeedback involves observing a person’s EEG in real-time and teaching them how to regulate and improve their neural patterns. Combining this technology with music therapy could enable people to “map” the musical characteristics that are most beneficial for them, and thus understand how best to help themselves.
In each music therapy session, learning occurs while participants get feedback regarding the status of their brain activity. Optimal brain activity associated with wellbeing and also specific musical qualities – such as a piece’s rhythm, tempo or melody – is learned over time. This innovative approach is being developed in our lab and elsewhere .
As with any form of therapy, recognising the limitations and individual differences is paramount. However, there are compelling reasons to believe music therapy can lead to new breakthroughs. Recent strides in research methodologies , driven partly by our lab’s contributions, have significantly deepened our understanding of how music can facilitate healing.
We are beginning to identify two core elements: emotional regulation, and the powerful link to personal autobiographical memories. Our ongoing research is concentrated on unravelling the intricate interactions between these essential elements and the specific brain regions responsible for the observed effects.
Of course, the impact of music therapy extends beyond these new developments in the neurosciences. The sheer pleasure of listening to music, the emotional connection it fosters, and the comfort it provides are qualities that go beyond what can be solely measured by scientific methods. Music deeply influences our basic emotions and experiences, transcending scientific measurement. It speaks to the core of our human experience, offering impacts that cannot easily be defined or documented.
Or, as one of our study participants so perfectly put it:
Music is like that reliable friend who never lets me down. When I’m low, it lifts me up with its sweet melody. In chaos, it calms with a soothing rhythm. It’s not just in my head; it’s a soul-stirring [magic]. Music has no boundaries – one day it will effortlessly pick me up from the bottom, and the next it can enhance every single moment of the activity I’m engaged in.
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Music Therapy and Other Music-Based Interventions in Pediatric Health Care: An Overview
1 Department of Music Therapy, University of Music and Performing Arts Vienna, 1030 Vienna, Austria; ta.ca.wdm@m-anatems
2 WZMF—Music Therapy Research Centre Vienna, University of Music and Performing Arts Vienna, 1010 Vienna, Austria; ta.ca.wdm@couq-nahp (E.P.Q.); ta.ca.wdm@ldeir (H.R.)
3 GAMUT—The Grieg Academy Music Therapy Research Centre, NORCE, 5008 Bergen, Norway; on.hcraeserecron@egom
Eva Phan Quoc
Hannah riedl, monika smetana.
Background: In pediatric health care, non-pharmacological interventions such as music therapy have promising potential to complement traditional medical treatment options in order to facilitate recovery and well-being. Music therapy and other music-based interventions are increasingly applied in the clinical treatment of children and adolescents in many countries world-wide. The purpose of this overview is to examine the evidence regarding the effectiveness of music therapy and other music-based interventions as applied in pediatric health care. Methods: Surveying recent literature and summarizing findings from systematic reviews, this overview covers selected fields of application in pediatric health care (autism spectrum disorder; disability; epilepsy; mental health; neonatal care; neurorehabilitation; pain, anxiety and stress in medical procedures; pediatric oncology and palliative care) and discusses the effectiveness of music interventions in these areas. Results: Findings show that there is a growing body of evidence regarding the beneficial effects of music therapy, music medicine, and other music-based interventions for children and adolescents, although more rigorous research is still needed. The highest quality of evidence for the positive effects of music therapy is available in the fields of autism spectrum disorder and neonatal care. Conclusions: Music therapy can be considered a safe and generally well-accepted intervention in pediatric health care to alleviate symptoms and improve quality of life. As an individualized intervention that is typically provided in a person-centered way, music therapy is usually easy to implement into clinical practices. However, it is important to note that to exploit the potential of music therapy in an optimal way, specialized academic and clinical training and careful selection of intervention techniques to fit the needs of the client are essential.
Music therapy is an evidence and art-based health profession which uses music experiences within a therapeutic relationship to address clients’ physical, emotional, cognitive, and social needs [ 1 ]. A recent worldwide survey among professional members of organizations affiliated with the World Federation of Music Therapy ( n = 2495) revealed that music therapists mainly worked in mental health settings, schools, geriatric facilities, and private practice [ 2 ]. About half of the respondents reported working with children/preteens (50.6%), and teens (45.7%), whereas 38.2% indicated working with infants/children. In the ranking of specific populations served, autism spectrum disorder, developmental disabilities, and depressive disorder are amongst the top three. Although music therapy with children and adolescents constitutes a huge and important part of music therapy practice since the beginnings of the profession, there is a dearth of scientific evidence—particularly when compared to music therapy with adults—and more rigorous research is needed.
The purpose of this overview is to examine the evidence regarding the effectiveness of music therapy and other music-based interventions as applied in pediatric health care.
This overview defines and contrasts three music-based approaches used in health care: music medicine, music therapy, and other music-based interventions (see Figure 1 ).
Types of music-based interventions in health care.
In addition to the definition by the American Music Therapy Association (see above), music therapy (MT) can be described as “a systematic process of intervention wherein the therapist helps the client to promote health, using music experiences and the relationships that develop through them as dynamic forces of change” [ 3 ]. With these tailored music experiences provided by credentialed music therapists, music therapy can be contrasted to interventions which are “categorized as ’music medicine’ when passive listening to pre-recorded music is offered by medical personnel” [ 4 ], especially before, during and/or after medical interventions, and other music-based interventions such as musically-based activities like choir singing or playing drums that are provided by musicians or health professionals other than credentialed music therapists.
In MT, four main methods are usually distinguished which overlap in clinical practice or may be combined: improvising, listening, recreating, and composing [ 5 ]. Depending on the underlying MT model (see Section 1.2 .), the spontaneous creation of music by means of the voice, body, or simple musical instruments may be seen as the ‘via regia’ to the unconscious and may facilitate contact, communication, and emotional expression. Receptive methods (listening to music and responding verbally or in another modality) typically aim to activate or relax a client, to evoke specific body responses, memories, and fantasies, or to stimulate self-knowledge and reflection. Recreating methods encompasses any kind of pre-composed music that the client learns to play or sing. Composition means that the therapist helps the client to create (and to record or perform) music such as instrumental pieces, lyrics, and songs.
1.2. Fields of Application and Music Therapy Approaches
The first documentation of MT in children and adolescents comes from shortly after the Second World War, when pioneers in the USA, and from the late 1950s onwards also in Europe, started to use music for treating mentally ill people within various clinical fields [ 6 ].
Apart from various clinical areas (see Section 3 ), MT for children and adolescents is currently also applied in other health care fields such as chronic illness, as well as in non-medical and community contexts such as schools (special education, prevention) or refugee centers (integration, migration, trauma).
Music therapy is especially indicated when verbal language is not, or only limitedly, available or when music as a non-verbal medium enables access to one’s own feelings in cases where improved processing of emotions may help to decrease symptoms. Music therapy can also help to regulate activity and tension and positively influence mood and motivation. In music interventions, it is not necessary for clients to have any musical background such as musical talent, the ability to play an instrument, or to read music; it is one’s individual engagement with the music experience which is a key factor.
Functional and behavioristic approaches typically use the activating or relaxing effects of music for stimulation or calming, and to enhance learning of specific skills and behaviors. Humanistic approaches (represented by pioneers such as Juliette Alvin [ 7 ], or Paul Nordoff and Clive Robbins [ 8 ]) emphasize creativity and expression of the self within improvisational music making and the development of positive relationships by allowing the child to find his or her own musical way without fixed rules. Analytically-oriented MT (pioneered by Mary Priestley [ 9 ]) employs the symbolic content of improvised music in order to connect with emotions, thoughts, images, or bodily sensations that cannot be verbalized.
In addition to individual and group therapy settings, family-based approaches have been increasingly used in MT with children and adolescents within the last couple of years [ 10 ].
To evaluate the current evidence for the effectiveness of MT, music medicine, and other music-based interventions in selected fields of pediatric health care, we conducted database searches for systematic reviews published within the last five years (November 2013 to October 2018) using PubMed/Medline, Cinahl, PsycINFO, Scopus, and Web of Science. The following search terms were used: (1) music therapy/music intervention/music-based intervention or arts-based therapy combined with (2) children/pediatrics and with (3) respective fields of application as listed in Section 3 of this article. Based on screening of titles and abstracts, we retrieved eligible systematic reviews. We included those systematic reviews where full-texts were available in English. Findings from systematic reviews and meta-analyses are briefly presented along with a descriptions of assumed working mechanisms and specific goals of music interventions in the Results section.
Included articles were assessed regarding their quality and validity using AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews) guidelines [ 11 ]. AMSTAR 2 is a critical appraisal tool for systematic reviews that include randomized or non-randomized studies of healthcare interventions, or both. It includes 16 items on domains such as “adequacy of the literature search”, “justification for excluding individual studies”, “appropriateness of meta-analytical methods”, and “consideration of risk of bias when interpreting the results of the review”. Based on a scheme for interpreting weaknesses detected in critical and non-critical items, the overall confidence in the results of the review can then be categorized as “high”, “moderate”, “low”, or “critically low”. All of the systematic reviews and meta-analyses included in our overview were assessed and rated independently by two of the authors. Any disagreements were discussed further in order to reach mutual consent between the two authors.
We included a total of 13 systematic reviews/meta-analyses—published within the last five years—across the following fields of pediatric health care (in alphabetical order; in parentheses; number of systematic reviews included): autism spectrum disorder (2); disability (1); epilepsy (1); mental health (2); neonatal care (3); neurorehabilitation (1); pain, anxiety, and stress in medical procedures (2); pediatric oncology and palliative care (1). Key characteristics of the studies and an assessment of quality according to the AMSTAR 2 guidelines are summarized in Table 1 .
Key characteristics and ratings of overall confidence in the results (based on AMSTAR 2) of included systematic reviews.
* MT = music therapy; MM = music medicine; MBI = other music-based interventions. 1 In some of the included studies, the numbers of participants were not indicated or unclear. 2 In two of the nine publications [ 35 , 36 ], adolescent patients were studied (total n = 82). 3 Number of infant participants; in addition, 286 parent participants were included. 4 According to the selection criteria of the review, “studies that included people older than 16 years of age” were examined; based on the information given in the review it is not possible to indicate how many adolescents were included; most of the studies report a mean age > 50 years of age. 5 Eight of the 50 studies involved pediatric participants (total n = 705). 6 Five of the 52 publications were conducted in pediatric patients (total n = 201).
3.1. Autism Spectrum Disorders
Music therapy has been applied in the field of autism since the mid-1940s [ 12 ]. The latest update of a Cochrane review on music therapy for people with autism spectrum disorders (ASD) [ 13 ] summarizes results from 10 studies examining the short- and medium-term effect of MT interventions (one week to seven months) with a total of 165 participants who were all between two and nine years of age. Findings provide evidence for moderate to large effects of MT as compared to ‘placebo’ therapy or standard care in outcome areas constituting the core of the condition such as social interaction, non-verbal communicative skills, initiating behavior, and social–emotional reciprocity. Music therapy may also help to improve verbal communication, social adaptation, joy, and the quality of parent–child relationships. Due to low numbers of study participants and other study design issues, the quality of the evidence was assessed as moderate to low. Therefore, the review authors suggest that future studies need to be larger, more rigorous, and should also evaluate outcomes for people with ASD above nine years of age. Based on AMSTAR 2 criteria, the confidence in these results can be assessed as “high” (i.e., the SR provides an accurate and comprehensive summary of the results of the available studies).
Another meta-analysis that focused on randomized controlled trials (RCTs) published in Chinese [ 14 ] also came to favorable conclusions regarding MT for ASD, but only reached a rating of “low” confidence according to AMSTAR 2 (i.e., it has a critical methodological flaw and may not provide an accurate and comprehensive summary of the available studies). Summarizing the findings of six studies with a total of 300 children with autism, the authors found significant effects of MT (six weeks to three months) as compared to other forms of therapy on mood, language, sensory perception, behavior, and social skills. The risk of bias for all six included studies was assessed as moderate.
The potential of MT as an intervention within ASD, where difficulties with social interaction and communication are at the core by definition, is explained by processes that naturally occur in musical interactions within the relationship between client and therapist, where music is used as an expressive and communicative means. Behaviors necessary for social engagement such as joint attention, eye contact, and turn-taking are characteristic events in shared, active music making and therefore inherent components of MT processes. Structures in improvised or pre-composed music also provide opportunities to experience both predictability and flexibility, and attention and enjoyment typically increase in individuals when presented with musical as opposed to verbal stimuli. Music therapy for individuals with ASD is often provided as individual therapy, but there are also group-based, peer-mediated and family-based forms [ 13 ].
In MT, work with children and adolescents with disabilities is one of the traditional fields of application [ 6 ]. Children with ASD, trisomy 21, Rett syndrome, or Williams syndrome are known to be very responsive to music listening and musical activities. Thus, MT is applied for assessment as well as for fostering communication, social competencies, emotional regulation, and motor skills [ 15 , 16 ]. Although MT is a quite common approach in special education, there is still a dearth of research, in particular with respect to effectiveness studies.
Only one SR met our inclusion criteria [ 17 ]. This publication on “music research in inclusive school settings” covered the period from 1975 to 2013 and found evidence that music-based interventions in preschool settings positively influence reading/literacy outcomes in children with and without disabilities. Due to the high level of heterogeneity in study methodologies and outcomes, no other summary statements could be made. As a conclusion, the authors stress the necessity to conduct more studies in inclusive music settings. Due to several critical flaws in the review, the confidence in its results was rated as “critically low” according to AMSTAR 2 criteria, which means that it should not be relied upon to provide an accurate and comprehensive summary of the included studies.
Musicogenic epilepsy, i.e. epileptic seizures induced by music, has been known of since at least the late 1930s, as Oliver Sacks mentions in his book “Musicophilia” [ 18 ]. At the same time, music has the potential to reduce seizure activity: “The dichotomous effect of music on seizures may be explained by modification of dopaminergic circuitry or counteractive cognitive and sensory input in ictogenesis” [ 19 ]. In a recent systematic review [ 20 ], eight publications were identified in which the influence of music by W.A. Mozart on seizures in children was studied. Although there is some substantial and serious doubt about the existence of a ‘Mozart effect’ as such, classical pieces of the ‘Wunderkind’ are still very popular stimuli in this type of research. Noteworthily, seven of the eight included studies were from the same research group in Taiwan. Brackney and Brooks [ 20 ] summarize their findings: “The evidence for the efficacy of the Mozart Effect on seizure activity in children is promising but not conclusive”. According to AMSTAR 2 criteria, the confidence in the systematic review’s results is rated as “critically low”. Seven of the studies were classified as “quasi-experimental”. In the only RCT [ 21 ], the treatment group ( n = 24) listened to Mozart’s sonata for two pianos in D major K.448 daily before bedtime for six months, while the control group ( n = 24) received treatment as usual (patients were between 8 and 13 years of age). Results showed that during the follow-up period of approximately one and a half years on average, eight of the 22 patients in the treatment group suffered seizure recurrence, while 18 of the 24 patients in the control group had seizure recurrence. Further, significant decreases in epileptiform discharges after one, two, and six months compared with EEGs before listening to music have been observed in the treatment group.
3.4. Mental Health
Mental health care for children and adolescents is one of the main clinical fields of music therapists. Music therapy with children and adolescents can include active methods such as improvisation or working with songs (song writing, performing of pre-composed songs) as well as receptive methods such as listening to pre-recorded music [ 5 ].
A Cochrane review on music therapy for depression [ 22 ]—for which the AMSTAR 2 level of confidence in the results was rated as “high”—included nine RCTs (total n = 421), of which two studied the effectiveness of “music therapy techniques” in high school students [ 23 , 24 ]. However, as it was not clear whether a trained music therapist was providing the interventions [ 22 ], these studies are categorized as music-based intervention studies according to our definitions provided above. Findings from these two studies suggest that the group music intervention in comparison to cognitive behavioral therapy is significantly more effective as measured by self-rating (Beck Depression Inventory).
The findings of a recent meta-analysis [ 25 ] on different music-based interventions (including MT, music medicine, and other music-based interventions) to reduce internalizing symptoms in children and adolescents also suggest that these interventions are beneficial, but due to a relatively small sample size (only five trials with a combined sample size of n = 100), the authors draw these implications with caution. The confidence in the results according to AMSTAR 2 criteria was estimated as “low”.
3.5. Neonatal Care
Music therapy and music interventions are of growing importance in neonatal intensive care units (NICUs) as documented by two recent publications: a systematic review of RCTs on various music-based interventions by van der Heijden and colleagues [ 26 ], and a meta-analysis on music therapy for infants and their parents by Bieleninik, Ghetti, and Gold [ 27 ]. Progress in medicine and new technical developments allow for higher survival rates in preterm newborns. However, the survival of preterm babies who are more premature and vulnerable also calls for better and more efficient integrated care as early as possible. This explains why there is a growing awareness for environmental factors influencing the newborn’s health and well-being, e.g. acoustic stimuli in the NICU. Van der Heijden and colleagues state: “Where unpredictable noise adversely affects sleep and physiologic stability, meaningful auditory stimulation, such as music, might contribute to the neurodevelopment of premature infants” [ 26 ].
Summarising the main findings of the two reviews—based on RCTs only, and both assessed as justifying “moderate” confidence in their findings according to AMSTAR 2 (i.e., they include weaknesses, but no critical flaws, so that they may provide an accurate summary of the results of included studies)—MT and other music-based interventions in NICUs lead to a reduction in heart and respiratory rate, improve the infant’s sleep and food intake, and reduce the anxiety of mothers [ 26 , 27 ]. Interestingly, not only from an economical point of view, a recent systematic review of RCTs [ 28 ] found that length of stay can be significantly reduced through music therapy interventions. In addition, O’Toole et al. [ 28 ] reported that music medicine interventions yield positive effects of pain management in preterm infants. However, the confidence in this review’s results had to be rated as “critically low” according to AMSTAR 2 criteria due to several critical flaws in its methodology.
Regardless of whether live or pre-recorded music is played, the ‘golden rules’ of music interventions in the NICU are “less is more”, and “minimal change, minimal range”. The former being true for duration and the number of musical instruments used, the latter applies to all musical parameters: “minimal change” in rhythm, harmony, dynamics, and volume, and “minimal range” in melody and pitch range—“like a lullaby” [ 29 ]. Thus, in live interventions, music therapists primarily use their voice (infant directed singing), accompanied maybe by a harp, a guitar or a small percussion instrument. For recorded acoustic interventions, music or the mother’s voice is played softly through loudspeakers inside or outside of the incubator.
A recent Cochrane review on MT for acquired brain injury came to the following conclusion: “The results suggest that music interventions using rhythm may be beneficial for improving walking in people with stroke, and this may improve quality of life. (…) Music interventions that use a strong beat within music may be more effective than interventions where a strong beat is used without music. Treatment delivered by a trained music therapist might be more effective than treatment delivered by other professionals” [ 30 ]. The quality of the evidence was assessed as “generally low” by the review authors [ 30 ]. The confidence in these results can be assessed as “high” based on AMSTAR 2 criteria. In the context of our focus on pediatric health care, it has to be noted however that it was not possible to determine the number of adolescents who were included based on the information given in the review. According to the selection criteria of the review, “studies that included people older than 16 years of age” were examined. Most of the studies report a mean age of more than 50 years of age, so the applicability of the review’s results to children and adolescents remains unclear.
3.7. Pain, Axiety, and Stress in Medical Procedures
A systematic review by Yinger and Gooding [ 31 ] on music-based interventions for procedural support identified 50 studies meeting the inclusion criteria, but only eight of them included children and adolescents. The confidence in the results of this systematic review according to AMSTAR 2 criteria was rated as “moderate”, i.e., it includes weaknesses, but no critical flaws, so that it may provide an accurate summary of the results of included studies. The authors came to the conclusion that the majority of studies (84%) were at high risk of bias and revealed limitations in adequate intervention reporting. Interestingly, two of the eight studies with a low or moderate risk of bias were music therapy studies involving pediatric participants [ 32 , 33 ], with significant effects for the reduction of pain and anxiety.
In a systematic review from 2016, Kim and Stegemann [ 34 ] searched the literature of the last 35 years with regard to music listening as an intervention for children and adolescents. The authors identified 36 studies of which 18 were from the field of pediatrics, encompassing 12 studies with pediatric patients undergoing either surgery or needle insertion procedures. Accordingly, pain, anxiety, and stress were the main outcome measures.
Pain perception in the context of medical procedures was investigated in 12 RCTs, of which nine found a significant decrease of pain in the music condition compared to the non-music condition or treatment as usual. In most of the studies, the music condition included recorded music (e.g., lullabies, classical music, pop) presented via loudspeaker or earphones. The largest effect sizes were reported in a study by Nguyen and colleagues [ 35 ] who investigated the reduction of pain and anxiety in children with cancer undergoing lumbar puncture (LP). Pain, heart and respiratory rates were significantly reduced in the music group during and after the LP (pain reduction: d = 1.53 (huge effect) during and d = 1.08 (large effect) after the LP).
Besides pain, anxiety plays a major role as a stressor for children in medical procedures. The effect of music listening in reducing anxiety was measured in 11 studies, of which seven favored the music condition while four studies found no significant difference between groups. Effect sizes for anxiety reduction ranged between d = 0.61 (medium effect) and d = 1.5 (huge effect). Kristjánsdóttir and Kristjánsdóttir [ 36 ] studied the effect of a specific music medicine intervention (a musical distraction strategy) in adolescents receiving immunization. They found the odds of participants experiencing “no pain” during the immunization if listening to music to be approximately 2.8 times higher than those of participants receiving standard nursing care. The authors concluded that musical distraction, pre-immunization fear and anxiety, and expected immunization pain were significant predictors of adolescent immunization pain sensation.
The effects of music listening on stress perceived by children and adolescents during painful medical procedures were measured by observational parameters (e.g., video analysis) as well as physiological parameters (e.g., heart rate, blood pressure, respiratory rate). The majority of the studies (four out of seven) were in favor of the music condition, while the other three studies found no significant differences. Results of an earlier RCT by Malone [ 37 ] who used live music interventions with children in a preoperative setting revealed that participants in the music condition showed significantly shorter duration of stress signs with a large effect size ( d = 1.01).
Only two of the 36 studies reviewed by Kim and Stegemann [ 30 ] were categorized as “relatively low risk of bias”; both of these studies [ 35 , 38 ] showed strong results in favor of the music medicine intervention. The confidence in the results of this systematic review by Kim and Stegemann [ 30 ] according to AMSTAR 2 criteria was also rated as “moderate”.
3.8. Pediatric Oncology and Palliative Care
In several countries, music therapy services are well-established in the field of pediatric oncology, and some treatment guidelines include creative arts therapies for this specific client population, as for instance in Germany [ 39 ]. Music therapists in pediatric oncology and palliative care have to deal with various somatic and psychological symptoms of their patients and often, therapy is provided for children together with their family members. Due to ethical concerns and feasibility issues regarding such vulnerable times in life, RCTs are scarce in this field, particularly within palliative care.
A Cochrane review by Bradt and colleagues [ 40 ]—for which the AMSTAR 2 level of confidence in the results was assessed as “high”—on music interventions for improving psychological and physical outcomes in cancer patients included studies with children, but only five of the 52 reviewed studies were conducted in pediatric fields. Outcomes of these studies varied from impact on immune system functioning [ 41 ] through to anxiety and pain management [ 35 , 42 ] and children´s coping behavior [ 43 , 44 ]. Due to the low number of studies in pediatrics, no overall conclusions were drawn. Findings from single studies indicate some benefits of MT and music-based interventions, particularly on anxiety, pain, and coping behaviors.
According to the results from systematic reviews and meta-analyses, the evidence for the effectiveness of music therapy and other music-based interventions in areas relevant to pediatric health care can be summarized as displayed in Table 2 .
Summary of findings regarding evidence for the effectiveness of music therapy (MT), music medicine (MM) and other music-based interventions (MBI) in selected fields of applications relevant to pediatric health care.
Music therapy (MT) and other music-based interventions are applied and have shown to be beneficial in a broad variety of fields and seem effective especially in combination with other treatment forms and within a multimodal therapy approach—but they are certainly not the ‘magic bullet’ working for everyone at any time.
The growing body of evidence for MT and other music-based interventions (including music medicine) in childhood and adolescence indicates that MT is particularly effective in improving mood and affect regulation, communication, social skills, and quality of life; music medicine approaches are successfully applied in medical settings to alleviate pain, anxiety, and stress. As documented by meta-analyses, the best evidence regarding the effectiveness of MT today is reported in neonatal care and in children with autism spectrum disorders. In other fields, especially in children with disabilities, there is a clear need for more and better-quality research—which is of course not only a challenge for MT but holds true for medical and special education interventions in childhood and adolescence in general.
“Where words fail, music speaks”, as the writer Hans Christian Andersen put it. Thus, music-based interventions can open doors, especially for people who are not capable of communicating through spoken language. The communication beyond words is a unique feature of arts therapies such as MT—this may be one reason why MT works in NICUs and for people with ASD.
Music therapy can be considered a safe and generally well-accepted intervention in pediatric health care to alleviate symptoms and improve quality of life. None of the included systematic reviews reported adverse effects of music-based interventions for children and adolescents. This is in line with the findings of a study on the acceptance of specific complementary and alternative medicine modalities, where acceptance was highest for music therapy [ 45 ].
As an individualized intervention that is typically provided in a person-centered way, music therapy is usually easy to implement into clinical practices. In addition, it is important to note that to exploit the potential of music therapy in an optimal way, specialized academic and clinical training and careful selection of intervention techniques to fit the client’s needs are essential. More rigorous research on MT, music medicine, and other music-based interventions is still needed to determine what types of interventions work best for whom and under which circumstances.
T.S. took the initiative for the study and coordinated study activities; T.S., M.G., and M.S. developed the concept and methodology; H.R. and E.P.Q. helped to revise the concept and methodology; T.S., M.G., and M.S. drafted the initial manuscript; H.R. and E.P.Q. conducted literature searches and helped in revising the manuscript. M.S., H.R., and E.P.Q. rated the systematic reviews according to AMSTAR 2 criteria. All authors extracted and analyzed data from eligible search results, summarized and interpreted findings, and approved the final version of the manuscript.
This research received no external funding.
Conflicts of Interest
The authors declare that the article was written in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All authors are clinically trained music therapists.
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Music listening and stress recovery in healthy individuals: A systematic review with meta-analysis of experimental studies
Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Visualization, Writing – original draft
* E-mail: [email protected]
Affiliation Behavioural Science Institute, Radboud University, Nijmege, Netherlands
Roles Conceptualization, Methodology, Supervision, Writing – review & editing
Affiliations Behavioural Science Institute, Radboud University, Nijmege, Netherlands, Donders Institute for Brain, Cognition, and Behaviour, Radboud University, Nijmege, Netherlands
- Krisna Adiasto,
- Debby G. J. Beckers,
- Madelon L. M. van Hooff,
- Karin Roelofs,
- Sabine A. E. Geurts
- Published: June 17, 2022
- Peer Review
- Reader Comments
Effective stress recovery is crucial to prevent the long-term consequences of stress exposure. Studies have suggested that listening to music may be beneficial for stress reduction. Thus, music listening stands to be a promising method to promote effective recovery from exposure to daily stressors. Despite this, empirical support for this opinion has been largely equivocal. As such, to clarify the current literature, we conducted a systematic review with meta-analysis of randomized, controlled experimental studies investigating the effects of music listening on stress recovery in healthy individuals. In fourteen experimental studies, participants ( N = 706) were first exposed to an acute laboratory stressor, following which they were either exposed to music or a control condition. A random-effects meta-regression with robust variance estimation demonstrated a non-significant cumulative effect of music listening on stress recovery g = 0.15, 95% CI [-0.21, 0.52], t (13) = 0.92, p = 0.374. In healthy individuals, the effects of music listening on stress recovery seemed to vary depending on musical genre, who selects the music, musical tempo, and type of stress recovery outcome. However, considering the significant heterogeneity between the modest number of included studies, no definite conclusions may currently be drawn about the effects of music listening on the short-term stress recovery process of healthy individuals. Suggestions for future research are discussed.
Citation: Adiasto K, Beckers DGJ, van Hooff MLM, Roelofs K, Geurts SAE (2022) Music listening and stress recovery in healthy individuals: A systematic review with meta-analysis of experimental studies. PLoS ONE 17(6): e0270031. https://doi.org/10.1371/journal.pone.0270031
Editor: Urs M. Nater, Universitat Wien, AUSTRIA
Received: July 14, 2021; Accepted: June 2, 2022; Published: June 17, 2022
Copyright: © 2022 Adiasto 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 materials relevant to our review, including: (a) the pre-registered study protocol; (b) an outline of the search strategy; (c) a list of screened articles with rationales for exclusion; (d) the meta-analysis data set with extracted data; and, (e) R code to replicate the analysis, are available on the Open Science Framework ( https://osf.io/9pxhj/?view_only=0f2f28db4adf4a2492aa57e5e003cc9f ).
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
The prevalence of stress-related diseases worldwide has seen no decrease over the previous decade [ 1 , 2 ], as stress has become so pervasive in daily life that our physiological systems are under constant pressure to cope with various stressors [ 3 ]. Stress recovery has been introduced as a process which may mitigate the adverse consequences of frequent stress exposure [ 4 , 5 ]: effective stress recovery on a daily basis may prevent the occurrence of blunted or exaggerated stress responses that over time develop into various physiological and psychological disorders, such as cardiovascular and cerebrovascular disease, hypertension, burnout, and depression [ 2 , 5 – 8 ].
Given the importance of effective stress recovery from exposure to daily stressors, research on potential means to promote stress recovery has experienced significant growth [ 5 ]. Various activities have been proposed that may lead to better stress recovery, one among them being music listening. Music listening may have a modulatory effect on the human stress response [ 9 ]. Furthermore, given that music is readily available through online streaming services, music listening stands to be a time- and cost-effective method to facilitate daily stress recovery. Indeed, a recent meta-analysis of 104 randomized controlled trials on the effects of music concluded that music-based interventions have a positive impact on both physiological ( d = .380, 95% CI [0.30–0.47]) and psychological ( d = .545, 95% CI [0.43–0.66]) stress-related outcomes [ 10 ]. However, a large proportion of studies included in this meta-analysis were conducted in medical or therapeutic settings, and the included music-based interventions encompassed not only music listening but also music therapy. Thus, a more specific review to determine whether music listening alone is beneficial for the recovery of healthy individuals outside medical and therapeutic settings seemed justified.
To expand on the above considerations: stressors in medical or therapeutic settings (e.g., treatment anxiety, pregnancy, and labor) and their subsequent stress recovery processes can be difficult to generalize to more daily settings [ 10 – 13 ]. Next, with regards to music-based interventions, music listening simply involves listening to a particular song, while music therapy is characterized by the presence of a therapeutic process and use of personal music experiences, and thus must be performed by a trained music therapist [ 14 ]. In practice, music therapy may not only involve music listening, but also music playing, composing, songwriting, and interaction with music [ 10 , 14 ]. The effects of music therapy on stress appear to be more consistent compared to music listening [ 10 , 15 , 16 ]. Studies on music listening and stress recovery in healthy individuals are indeed equivocal: though music listening is considered beneficial for physiological stress recovery, several studies have reported no differences in heart rate, heart rate variability, respiration rate, blood pressure, or cortisol recovery between participants who listened to music and those who either sat in silence or listened to an auditory control [ 17 – 20 ]. Similarly, although music is notable for its anxiolytic effects, several studies have reported no significant differences in post-stressor anxiety between participants who listened to music and those who did not [ 3 , 18 , 21 ]. Taken together, it is currently difficult to draw definite conclusions about the effects of music listening on stress recovery in healthy individuals, particularly outside medical and therapeutic settings [ 15 , 22 ].
Therefore, to expand on previous reviews, we opted to conduct a systematic review with meta-analysis on experimental studies in healthy individuals, focusing specifically on the role of music listening in stress recovery. In our review, we focus specifically on experimental studies, under the assumption that greater control over study variables would help reduce between-study heterogeneity. Furthermore, considering the crucial role of stress recovery in preventing the long-term consequences of stress exposure [ 5 , 23 ], we believe the acute stress responses elicited by laboratory stressors would more closely approximate typical stress responses in daily life. The aim of our review was two-fold: through systematic review, we provide a comprehensive account of experimental studies examining the effect of music listening on stress recovery. Through meta-analysis, we assess the reliability of the effect of music listening on stress recovery, including the extent and impact of publication bias, and weigh-in on outstanding discussions within existing literature.
The stress response
The stress response can be conceptualized as a compensatory reaction aimed at mitigating the potential consequences of a stressor [ 24 , 25 ]. The stress response is best illustrated by the archetypal ‘fight-flight-freeze’ reaction: in the presence of a stressor, the brain initiates an elegant synergy of neuroendocrine, physiological, and psychological processes that serve to mobilize energy resources and direct attention towards prominent stimuli, with the aim of promoting appropriate and rapid action [ 26 , 27 ]. During a stress response, the autonomic nervous system (ANS) suppresses parasympathetic activity and promotes sympathetic exertion, resulting in marked increases in heart rate, respiration rate, systolic and diastolic blood pressure, and salivary secretion of the dietary enzyme, alpha-amylase [ 27 – 31 ]. These changes are mediated by neuropeptides (e.g., corticotropin-releasing factor) and catecholamines (e.g., norepinephrine, dopamine) [ 24 , 25 ]. Simultaneous with ANS activity, the hypothalamic-pituitary-adrenocortical (HPA) axis begins a process which leads to a surge of cortisol production in the adrenal cortex [ 24 , 25 ]. Cortisol acts as a regulator of the stress response, whose effects occur in a temporally specific manner due to variations in corticosteroid receptor affinity and distribution throughout the body [ 24 , 26 , 32 ]. Cortisol may require up to 45 minutes to reach peak concentration levels, during which it binds to high-affinity corticosteroid receptors [ 24 ]. This process enables rapid, non-genomic effects that sustain ANS-mediated changes for the duration of the stressor, while suppressing immune system function [ 32 – 34 ]. This suppression is visible through lower concentrations of immunoglobulins, such as salivary immunoglobulin-A (s-IgA) [ 35 ].
The physiological changes triggered by the ANS and HPA axis are supplemented by psychological changes that motivate adaptive behaviours required to cope with the stressor [ 25 , 27 ]. For example, the unpleasant feeling one gets when experiencing anxiety and negative affect in response to a stressor is thought to prompt behaviours aimed at reducing these unpleasant states. Since psychological reactions to stressors are contingent on how individuals perceive, evaluate, and react to threats and challenges [ 36 ], self-reported measures of stress, anxiety, arousal, and emotion are common in psychological research on stress and its consequences [ 18 , 37 – 39 ].
The stress response is considered adaptive when it is short-lived and immediately followed by a period of recovery following stressor cessation. In this period, ANS- and HPA-mediated changes that have occurred in response to a stressor revert to pre-stress baselines [ 24 , 25 , 27 ]. Therefore, stress recovery may be conceptualized as the process of unwinding that is opposite to the neuroendocrine, physiological, and psychological activation that occurs during the stress response [ 4 , 5 ]. Following a stress response, ANS-mediated changes quickly revert to pre-stress levels within 30 to 60 minutes [ 26 ]. This manifests as a restoration of parasympathetic activity, marked by a deceleration of heart rate and respiration rate, lower systolic and diastolic blood pressure, and less activity of salivary alpha-amylase [ 4 , 28 – 31 ]. This restoration of parasympathetic activity typically precedes any decline in cortisol. Instead, during the same window of time, cortisol levels will have just reached their peak, activating low-affinity corticosteroid receptors [ 40 ]. This process is thought to signal the termination of the stress response, as the binding of cortisol to low-affinity receptors inhibits further autonomic activation [ 24 , 26 ]. As cortisol levels begin to decrease, slow, cortisol-mediated genomic changes are initiated, which directly oppose the rapid effects of catecholamines and the non-genomic effects of cortisol [ 24 , 26 ]. Following a stressor, these genomic changes may take up to one hour to commence and may continue for several hours [ 24 , 26 ].
At a psychological level, stress recovery is typically experienced as a reduction of unpleasant states, which is often reflected by lower ratings of self-reported stress, anxiety, and negative affect, along with higher ratings of relaxation and positive affect [ 5 , 15 , 18 ]. However, it is worth noting that persistent, ruminative thoughts about a stressor may delay stress recovery by prolonging the physiological activation that occurs during the stress response [ 41 – 45 ]. Indeed, participants who reported higher rumination following a stress task demonstrated poorer heart rate, systolic blood pressure, diastolic blood pressure, and cortisol recovery compared to participants who did not [ 41 , 42 , 44 , 46 , 47 ].
Music listening and stress recovery
Within the current literature, music listening has frequently been related to various neuroendocrine, physiological, and psychological changes that are considered beneficial for stress recovery [ 10 , 11 , 15 , 22 ]. For example, music listening has been associated with lower heart rate [ 48 – 50 ], systolic blood pressure [ 21 , 49 , 51 ], skin conductance [ 17 , 19 , 52 , 53 ], and cortisol [ 54 , 55 ] compared to silence or an auditory control condition. Furthermore, music listening has been associated with higher parasympathetic activity [ 56 ] compared to silence [ 3 , 37 ]. Together, these findings suggest that music listening may generate beneficial changes in ANS and HPA axis activity that should be conducive to the stress recovery process [ 27 , 57 , 58 ]. Furthermore, studies have demonstrated that listening to music may influence mood [ 59 , 60 ]. Indeed, music listening has been associated with lower negative affect [ 37 ], higher positive affect [ 18 , 61 ], and fewer self-reported depressive symptoms [ 37 ] compared to silence or an auditory control condition. Music listening has also been associated with lower subjective stress [ 53 , 54 ], lower state anxiety [ 37 , 48 , 49 ], and higher perceived relaxation [ 17 , 48 , 62 ].
The exact mechanisms underlying the effects of music listening on stress recovery remain to be elucidated. Music-evoked positive emotions are thought to be particularly beneficial for stress recovery, as they may help undo the unfavourable changes wrought by negative emotions during stress, ultimately aiding the stress recovery process [ 63 ]. Alternatively, music-evoked emotions may promote a more robust, and thus more adaptive, stress response [ 61 ], which may be followed by an equally robust period of stress recovery. Next, it has been theorized that music may act as an anchor that draws attention away from post-stressor ruminative thoughts or negative affective states, thus preventing a lengthening of physiological activation, and facilitating a more regular stress recovery process [ 45 , 64 ]. Finally, physiological rhythms in our body, such as respiration, cardiovascular activity, and electroencephalographic activity, may become fully or partially synchronized with rhythmical elements perceived in music [ 65 – 68 ]. This rhythmic entrainment process is thought to occur via a bottom-up process that originates in the brainstem: salient musical features, such as tempo, pitch, and loudness, are continuously tracked by the brainstem, generating similar changes in ANS activity over time [ 69 , 70 ]. Indeed, studies have demonstrated that changes in a song’s musical envelope, which represents how a song unfolds over time, are closely followed by proportional changes in blood pressure and skin conductance [ 52 , 65 ]. Similarly, incremental changes in musical tempo, which represents the speed or pace of a song, were predictive of similar changes in heart rate, blood pressure, and respiration rate [ 71 – 73 ]. It is further hypothesized that the physiological changes resulting from rhythmic entrainment may evoke any number of associated emotions via proprioceptive feedback mechanisms [ 66 , 69 , 70 ]. Indeed, higher self-reported entrainment predicted increased positive affect, along with other self-reported emotional responses, such as transcendence, wonder, power, and tenderness [ 66 ].
Which music works best?
There are several ongoing discussions about potential moderating effects in the relationship between music listening and stress recovery. We briefly describe these effects below, and later contribute to the discussion through moderator analyses.
Classical music vs. other genres.
Classical music is considered the golden standard in many stress management efforts. Indeed, a copious amount of ‘anti-stress’ playlists often feature some selection of classical pieces. To discern which music best promotes stress recovery, studies have contrasted the effects of classical music with other musical genres, including rock [ 48 ], jazz and pop [ 21 ], and heavy metal [ 17 ]. We compare the effects of different musical genres in our moderator analysis.
Instrumental vs. lyrical.
It is commonly believed that instrumental, as opposed to lyrical music, would better promote stress recovery. However, several studies have argued that lyrics may act as a stronger distractor compared to the sound of instruments. Thus, lyrical music may be more effective than instrumental music in preventing the prolonged physiological activation that may occur due to ruminative thoughts [ 17 , 18 , 74 ]. We compare the effects of instrumental and lyrical music in our moderator analysis.
Self- vs. experimenter selected.
Studies on the effects of music often fail to consider the differential effects of self-selected (i.e., chosen by participants) and experimenter selected (i.e., chosen for participants by the experimenter) music [ 15 ]. It is hypothesized that allowing participants to select their own music may be more helpful to promote stress recovery due to a restoration of perceived control [ 15 ]. It has also been argued that individuals select music in service of personal self-regulatory goals [ 64 , 75 , 76 ], meaning that individuals know precisely which music to select for them to effectively recover from stress [ 38 , 77 ]. Furthermore, previous studies have found that listening to self-selected music may help elicit stronger and more positive emotional responses regardless of a song’s valence (positive or negative) and arousal (high or low), possibly due to increased preference and familiarity towards the self-selected music [ 78 – 80 ]. In theory, self-selected music should thus be more beneficial compared to experimenter-selected music for the purpose of stress recovery. We compare the effects of self- and experimenter selected music in our moderator analysis.
Fast vs. slow tempo.
Several studies have investigated whether listening to music with slower tempo will better facilitate stress recovery compared to music with faster tempo. For example, while listening to an instrumental song, proportional increases and decreases in tempo resulted in similar changes in participants’ heart rate [ 73 ]. Similarly, sequential decreases in tempo predicted greater increases in parasympathetic activity compared to sequential increases in tempo [ 71 ]. We investigate whether slower tempi differentially influence the effect of music listening on stress recovery in our moderator analysis.
The present review was designed following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines [ 81 ]. All materials relevant to this review, including: (a) the pre-registered study protocol; (b) an outline of the search strategy; (c) a list of screened articles with rationales for exclusion; (d) the meta-analysis data set with extracted data; and, (e) R code to replicate the analysis reported in this review, are available on the Open Science Framework ( https://osf.io/9pxhj ).
The study selection process is summarized in Fig 1 . In April 2021, we conducted a comprehensive literature search for experimental studies on the effect of music listening on stress recovery. The search was conducted using RUQuest, the electronic search system of Radboud University library, which accesses several notable bibliographic databases, including MEDLINE, Wiley Online Library, ScienceDirect, SpringerLink, Taylor and Francis, and JSTOR. The results of this primary search were supplemented with three additional electronic searches in the publication databases of Web of Science, PsycINFO, and PubMed. Appendix A provides a complete description of our search terms. Together, this first step resulted in 3124 articles.
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Next, the first author (KA) screened all titles and abstracts for studies examining the effects of music listening on stress recovery. If there was any doubt about the eligibility of an article, it was retained for further review. During this initial screening, 3008 articles were excluded. KA then scanned the reference lists of the 116 remaining articles for potentially relevant studies, resulting in an additional three articles. Together, this second step resulted in 119 full-text reports to be assessed for eligibility.
Lastly, KA used the following criteria to assess full-text reports for eligibility:
First, to minimize between-study heterogeneity, and to ensure that included studies investigated the effects of music listening on stress recovery as precisely as possible, studies must employ an experimental design including stress induction, with random assignment of participants to experimental and control conditions. Quasi-experimental studies were included only when they incorporated a control or comparison group. Second, studies should compare music listening to silence or an auditory stimulus (e.g., white noise, audiobooks). To ensure that included studies tested the immediate effect of music listening on stress recovery, exposure to music, silence, or auditory stimuli must occur after the stress induction procedure. Third, to demonstrate this effect, studies must include at least one measure of neuroendocrine (e.g., cortisol), physiological (e.g., heart rate, blood pressure), or psychological (e.g., subjective stress, positive and negative affect) stress recovery outcome. Fourth, given that stress reactivity and recovery responses differ between children and adults, and with consideration to the potential role of music in the prevention of stress-related diseases in adults, studies must include healthy, adult, human participants. Fifth, to improve the generalization of our results in the context of daily stress recovery, studies where stress recovery occurred within a medical or therapeutic context, such as a hospital or operating room, were excluded. Finally, for the purpose of the meta-analysis, means and standard deviations of stress recovery outcomes following stressor cessation must be available. Corresponding authors were contacted when this information was not available. When authors did not or could not provide the required information (e.g., due to data no longer being accessible), outcomes were dropped from the meta-analysis. Following attempts to obtain missing information, the final sample for our review consisted of 14 studies.
Methodological moderators of interest
Several methodological differences were identified between included studies that may moderate the effect of music listening on stress recovery:
Stress induction procedures.
Studies utilized a diverse array of stress induction procedures. These include mental arithmetic tasks [e.g., 21 ], adaptations of the Trier Social Stress Task [e.g., 3 ], impromptu presentations [ 49 , e.g., 50 ], unpleasant stimuli [e.g., 82 ], cognitive tests [e.g., 48 ], or a CO 2 stress task [ 61 ]. Stress induction procedures may generally be classified based on the inclusion of a social-evaluative threat (SET) component, which are designed to induce psychosocial stress and have been shown to elicit greater cardiovascular and cortisol responses [ 83 ]. In the event of a greater stress response, the effects of music listening on stress recovery may be larger, since there may be a larger window for the stress recovery process to occur. We examined this possibility in our moderator analysis.
Stress induction checks.
Stress induction procedures in included studies were not always successful. Given that successful stress induction procedures are crucial to ensure that participants experience some physiological or psychological change they may recover from, in our moderator analysis we examined whether the effect of music listening on stress recovery differed based on the outcome of a study’s stress induction check (manipulation check).
Type of outcome.
Studies adopted numerous outcome measures as indicators of stress recovery. These include indicators related to ANS and HPA axis activity, such as heart rate [e.g., 49 ], heart rate variability [e.g., 3 ], blood pressure [e.g., 84 ], respiration rate [e.g., 17 ], skin conductance [ 58 ], salivary cortisol [e.g., 54 ], salivary alpha-amylase (sAA) [e.g., 38 ], and salivary immunoglobulin-A (sIgA) [e.g., 85 ], as well as indicators for psychological consequences of the stress response, such as subjective stress [e.g., 18 ], perceived relaxation [e.g., 17 ], state anxiety [e.g., 21 ], rumination [e.g., 18 ], and affect [e.g., 37 ]. In our moderator analysis, we examined whether the effects of music listening on stress recovery differed across general (neuroendocrine, physiological, psychological) and specific outcome types.
Duration of music.
Studies differed with regards to how long participants listened to music following stressor cessation. This duration ranged from two minutes [e.g., 53 ] to forty-five minutes [e.g., 54 ]. We examined whether the effect of music listening on stress recovery differed based on duration of music listening.
Data extraction, moderator coding, and quality assessment
KA extracted means, standard deviations, and total participants per condition for each stress recovery outcome. When these statistics were not included in text, but informative graphs were provided, KA used an open-source program to extract data from the graphs [ 86 ]. Coding criteria for each moderator can be found in Table 1 . The ‘141–160 bpm’, ‘unsuccessful’, ‘salivary IgA’, and ‘salivary alpha-amylase’ moderator levels were ultimately not included in the meta-analysis due to unavailable information.
Next, KA assessed the quality of included studies using the revised Cochrane risk of bias tool for randomized trials (RoB 2) [ 87 ]. Based on criteria in the RoB 2, studies with low risk of bias were considered high quality, while those with some concerns and high risk of bias were considered moderate and low quality respectively. Fig 2 summarizes the results of the quality assessment procedure.
All studies were of overall moderate quality due to little-to-no information on pre-specification of analysis plans, making it difficult to fully rule out any bias that may occur due to selection of reported results.
Based on the RoB 2, all included studies were of moderate quality due to unavailable information on pre-specification of analysis plans. Thus, it was difficult to completely rule out bias that may have occurred due to a selection of reported results. Since the quality of included studies was homogenous, study quality was thus not included in our moderator analysis. An exploratory analysis with less stringent criteria, where potential risk of bias from selection of reported results is not included in our quality assessment procedure, is reported in Appendix B.
Data extraction, moderator coding, and quality assessment were conducted by KA in coordination with DB and MvH. Disagreements were resolved through face-to-face discussions, or through consultation with SG and KR when no consensus could be reached.
Effect size index..
We calculated Hedges’ g for each comparison using the escalc function of the metafor package [ 88 ] in R 3.6.3 [ 89 ]. In the present study, a Hedges’ g of zero indicates the effect of music listening on stress recovery is equivalent to silence or an auditory control. Conversely, a Hedges’ g greater than zero indicates the degree to which music listening is more effective than control, while a g less than zero indicates the degree to which music listening is less effective than control. The effect sizes are reported in Table 2 .
Due to use of multiple stress recovery outcomes, eleven out of fourteen studies included in the meta-analysis contributed multiple effect sizes of interest. To deal with the statistical dependency caused by the inclusion of multiple effect sizes from the same study, we use a combination of multivariate meta-regression [ 90 ] and robust variance estimation (RVE) [ 91 ] to estimate overall effect sizes and conduct moderator analyses. Although we believe our approach using RVE was the most suitable for our data, we also calculated overall effect sizes using the aggregation method outlined in Borenstein et al. [ 92 ], and random-effects meta-analyses without correcting for dependencies. These yielded estimates that were nearly identical to those generated by our approach and were therefore not reported.
Currently, methods to identify outliers in meta-regression models with RVE are not yet available. Therefore, we first fit a random-effects meta-regression model without correcting for dependencies between effect sizes. Values for influential case diagnostics (e.g., covariance ratios, Cook’s distance, studentized residuals) were subsequently requested using the ‘influence’ function of the ‘metafor’ package [ 88 ]. As this approach does not fully consider the nature of dependencies between effect sizes from each study, the results of this analysis were treated as a sensitivity analysis for the estimated overall effect of music listening on stress recovery. All extracted effect sizes were retained in further analyses.
Test of overall effect and moderators.
To estimate the overall effect of music listening on stress recovery, we fit an intercept-only, random-effects meta-regression model with RVE using the ‘robu’ function of the ‘robumeta’ package [ 93 ]. The intercept estimated by this model can be interpreted as the precision-weighted overall effect size which has been corrected for dependencies. We used a similar approach to estimate cumulative effect sizes at each level of each moderator. For cases where a level of a moderator had too few observations for the RVE approach, we calculated cumulative effect sizes by fitting a random-effects meta-regression using the ‘rma.mv’ function of the ‘metafor’ package [ 88 ].
Prior to conducting moderator analyses, categorical moderators (e.g., ‘Genre’) were dummy coded, while the continuous moderator ‘Duration’ was left as is. For cases where the categorical moderator only had two levels, moderator variables were entered into separate meta-regression equations using the RVE approach. The significance test of the regression coefficient for the predictor variable in the meta-regression equation was interpreted as a test of whether the variable was a significant moderator. We used the same approach to test the effect of continuous moderators. For cases where the categorical moderator had more than two levels, moderator variables were entered into separate random-effects meta-regression models. This yielded QM and QE statistics: the QM statistic indicated whether there was a significant difference among all levels of the tested moderator, while the QE statistic indicated whether there were significant amounts of residual heterogeneity after accounting for the effect of the moderator [ 94 ].
The most common method to assess publication bias in meta-analytic data sets with dependent effect sizes is to aggregate individual effect sizes from the same study, and subsequently perform standard publication bias tests on the aggregated estimates. Therefore, we first aggregated individual effect sizes using the ‘agg’ function of the ‘MAd’ package [ 95 ]. The ‘agg’ function calculates aggregated effect size and variance estimates using formulas specified in Borenstein et al. [ 92 ]. These aggregated estimates were then used to assess publication bias by means of: (a) Egger’s regression of funnel plot asymmetry [ 96 ]; (b) a trim-and-fill analysis [ 97 ]; and (c) PET-PEESE models [ 98 ].
Overall, the analyses comprised s = 14 studies, from which k = 90 effect sizes were calculated. The cumulative sample size of these studies was N = 706, while individual sample sizes ranged from 12–143 participants, with a mean of approximately 68 participants per study.
Based on a meta-regression with RVE, the estimated overall effect of music listening on stress recovery was g = 0.15, 95% CI [-0.21, 0.52], t (13) = 0.92, p = 0.374. This estimate suggests that, taking all variations in music and outcomes into consideration, the effect of music listening on stress recovery is equivalent to silence or an auditory control.
Using the ‘influence’ function of the ‘metafor’ package [ 88 ], one influential outlier in the negative direction was detected [ 18 ]. The overall effect of music listening on stress recovery with outlier removed was g = 0.18, 95% CI [-0.18, 0.54], t (13) = 1.08, p = 0.300. The full meta-analytic data set was retained in subsequent analyses.
There was significant heterogeneity of effect sizes ( T 2 = 0.71, I 2 = 89.29) from each study, which suggests that meaningful differences may exist among studies that could be further explored through moderator analyses. Cumulative effect size estimates at each level of each moderator, along with their respective significance tests, are reported in Table 3 .
Our results suggest that the effect of music listening on stress recovery may differ across musical genres, QM (4) = 27.19, p < .001. Despite this, it is difficult to further elaborate on these differences as the individual estimated effects of pop ( g = 0.317, 95% CI [0.09, 0.53], p = .025) and jazz music ( g = 0.137, 95% CI [0.00, 0.27], p = .049) were derived from single studies, while the estimates for classical ( g = 0.431, 95% CI [-0.03, 0.88], p = .059) and heavy metal music ( g = -0.076, 95% CI [-0.64, 0.48], p = .619), along with music collapsed into the ‘unspecified’ category ( g = 0.067, 95% CI [-0.42, 0.56], p = .765), were non-significant. Residual heterogeneity was statistically significant, QE (67) = 1147.43, p < .001.
The effects of music listening on stress recovery did not differ between lyrical music ( g = 0.159, 95% CI [-1.13, 1.45], p = .362), instrumental music ( g = 0.194, 95% CI [-0.22, 0.65], p = .273), and music with ‘unspecified’ lyrical presence ( g = 0.151, 95% CI [-0.46, 0.78], p = .581), QM (2) = 3.44, p = .179. Residual heterogeneity was statistically significant, QE (69) = 1171.95, p < .001.
Our results suggest that there may be differences in magnitude between the effect of self-selected, pseudo self-selected, and experimenter selected music on stress recovery, QM (2) = 19.13, p < .001. However, these differences were difficult to expand on since the estimated effect of pseudo self-selected music (i.e., self-selected music from a list composed by experimenters) was derived from only one study ( g = 0.377, 95% CI [0.27, 0.48], p = .004), while the estimated effects of self-selected ( g = 0.336, 95% CI [-0.29, 0.96], p = .226) and experimenter selected music ( g = 0.030, 95% CI [-0.33, 0.45], p = .874) were non-significant. Residual heterogeneity was statistically significant, QE (69) = 1139.39, p < .001.
Our results suggest that the effects of music listening on stress recovery may differ in magnitude based on musical tempo, QM (5) = 43.66, p < .001. However, little can be said about these differences since the estimated effects of music at 80 bpm or below ( g = 0.084, 95% CI [-0.06, 0.23], p = .086), 81–100 bpm ( g = 0.497, 95% CI [-0.62, 1.62], p = .197), 101–120 bpm ( g = -0.260, 95% CI [-11.3, 10.8], p = .815), 121–140 bpm ( g = 0.067, 95% CI [-1.58, 1.71], p = .696), 161 bpm and above ( g = -0.020, 95% CI [-1.33, 1.29], p = .870), and ‘unspecified’ tempo ( g = 0.235, 95% CI [-0.26, 0.73], p = .301) were non-significant. Residual heterogeneity was statistically significant, QE (67) = 1128.90, p < .001.
Stress induction procedure.
There were no significant differences in the effects of music listening on stress recovery between studies whose stress induction procedures included SET ( g = 0.319, 95% CI [-0.15, 0.79], p = .154) and those without SET ( g = -0.141, 95% CI [-0.90, 0.62], p = .636), β 1 = -0.450, p = .218.
There were no significant differences in the effects of music listening on stress recovery for studies with successful ( g = 0.173, 95% CI [-0.26, 0.61], p = .399) and unreported ( g = 0.062, 95% CI [-0.08, 0.20], p = .115) stress induction checks, β 1 = -0.108, p = .661.
Our results suggest that the effects of music listening on stress recovery may differ between neuroendocrine, physiological, and psychological outcomes QM (2) = 164.22, p < .001. These differences were challenging to further expand on since the estimated effects of music listening for neuroendocrine ( g = -0.004, 95% CI [-14.6, 14.6], p = .794), physiological ( g = 0.135, 95% CI [-0.39, 0.67], p = .585), and psychological ( g = 0.298, 95% CI [-0.11, 0.71], p = .127) stress recovery outcomes were not statistically significant. We noted a similar pattern when comparing the effects of music listening between specific stress recovery outcomes: the magnitude of the effect of music listening may vary across stress recovery outcomes, QM (18) = 545.09, p < .001, but estimated effects per outcome were non-significant ( Table 3 ). Residual heterogeneity was statistically significant despite the inclusion of general outcome type ( QE (69) = 1018.57, p < .001) and specific outcome measure ( QE (53) = 629.144, p < .001) as moderators.
There was no evidence that the effect of music listening on stress recovery may differ depending on how long participants were exposed to music, β 1 = -0.005, p = .870 ( range duration = 2–45 minutes).
To further illustrate the methodological heterogeneity among experimental studies on the effect of music listening on stress recovery, we provide a more extensive, qualitative overview of the included studies in Appendix C. A summary of this overview is presented in Table 4 .
To visually assess the extent of publication bias, the aggregated effect size estimates in our meta-analytic data set were first used to create a plot of the estimates and their standard errors. In the absence of publication bias, this pattern should resemble a funnel, where effect size estimates with smaller standard errors cluster around the mean effect size, while effect size estimates with larger standard errors spread out in both directions. A common pattern which suggests publication bias is asymmetry in the bottom of the plot. Fig 3 presents the funnel plot of the aggregated effect sizes.
The small number of studies renders it difficult to visually inspect asymmetry, and thus precludes an accurate assessment of publication bias.
Given the limited number of studies included in the meta-analysis ( n = 14), an accurate visual assessment of asymmetry was difficult. Thus, to supplement our visual inspection of the funnel plot, we conducted a trim-and-fill analysis, which trims the values of extreme estimates that may lead to asymmetry in the funnel plot and imputes values to balance out the distribution. No studies were imputed by the trim-and-fill analysis. Additionally, an Egger’s regression for funnel plot asymmetry using the aggregated effect sizes failed to detect significant evidence of publication bias ( t (12) = 1.26, p = 0.231). Lastly, both PET ( β 1 = 2.63, p = 0.311) and PEESE ( β 1 = 3.87, p = 0.356) models were not statistically significant. Taken together, based on the aggregated effect sizes, the different methods of publication bias detection suggest that there is no evidence of publication bias. However, considering the small number of included studies and the significant heterogeneity of our meta-analytic data set, firm conclusions about the extent of publication bias within the current literature on the effects of music listening and stress recovery are difficult to make.
Music listening has the potential to fulfill the promise of effective stress recovery in healthy individuals. However, cumulative evidence from 17 experimental studies suggests that support for the beneficial effect of music listening on stress recovery is currently lacking: for healthy individuals, the effect of music listening on stress recovery may be equivalent to that of other auditory stimuli, or even merely sitting in silence. Furthermore, the effect of music listening on stress recovery is heterogeneous, and moderator analyses suggest the effect may differ in magnitude according to musical genre, whether music is self-selected, musical tempo, and type of stress recovery outcome. Despite this, the limited number of available studies makes it difficult to draw further conclusions from these analyses.
Overall effects of music listening on stress recovery
The results of our review contrast those of previous meta-analyses, which underscore the relevance of music-based interventions for stress-reduction [ 10 , 11 ]. While previous reviews suggest that music-based interventions may be moderately beneficial for stress-related outcomes, particularly in medical and therapeutic settings, our results suggest that the magnitude of this effect outside of these settings, particularly for healthy individuals under acute, experimentally induced stress, may be more modest. We presume that one of the principal reasons for this difference was our decision to exclude studies conducted in medical and therapeutic settings. In previous reviews, randomized controlled trials of the effects of music-based interventions within medical and therapeutic settings constituted a large portion of included studies: 67 of 79 (85%) studies in de Witte et al. [ 10 ], and 15 of 22 (68%) studies in Pelletier [ 11 ], making it more likely that overall effect sizes were derived from studies conducted within these settings. Tentatively, the effects of music listening may be more prominent for the stress recovery of individuals in medical or therapeutic contexts, compared to that of individuals under acute stress in an experimental context. Whereas the time course of stress responses and stress recovery in experimental settings can be considered relatively brief [ 24 , 26 , 40 , 83 ], the time course of stress responses and stress recovery within medical and therapeutic settings may be significantly more protracted [ 12 , 13 ]. Thus, within medical and therapeutic settings, music may be exerting its influence on neuroendocrine, physiological, and psychological processes that have been subjected to longer periods of strain [ 27 , 99 ].
Furthermore, the difference in overall estimated effect sizes may be attributed to differences in the breadth of music activities encompassed by our review and that of de Witte et al. [ 10 ]: whereas we included studies in which participants merely listened to music following a stressor, de Witte et al. [ 10 ] also included music therapy, along with other unspecified music activities. We speculate that the effect of music on stress recovery may differ depending on whether music is merely listened to, performed, or used within a music therapy setting. However, studies comparing the stress recovery effects of these various music activities are rare [ 15 , 58 ]. Thus, future investigations into the differential effect of these music activities may therefore provide a more comprehensive picture of the effects of music on stress recovery.
Potential moderating effects
Our review highlights the considerable methodological variety between studies investigating the effects of music listening on stress recovery. This is particularly concerning given the modest number of experimental studies on music listening and stress recovery in current literature. Although we investigated the impact of these methodological differences through moderator analyses, many of the estimated effects at each level of each moderator were either non-significant or originated from single studies. Taken together, meaningful interpretations for these moderating effects are difficult to make. Therefore, for each significant moderator, we instead provide several recommendations for future research, which we believe may help delineate the effects of these potential moderators.
Although comparisons between musical genres seem relatively straightforward, investigating the differential effects of musical genres may be particularly challenging: the conceptualization of musical genres, along with the songs they encompass, tends to be somewhat arbitrary [ 69 , 75 , 100 , 101 ]. Indeed, studies display considerable variation in musical stimuli, even within the same genre ( Table 4 ). A notable example of this is the study by Sandstrom and Russo [ 53 ], which utilized four ‘classical’ songs, each at different extremes of valence and arousal. It should also be considered that new music is continuously being released which may not completely fit with the definition of any existing genre [ 9 ].
As such, an alternative approach to the investigation of musical genre involves describing these genres according to their musical features, such as tempo, timbre, and loudness, and subsequently investigating the effects of these individual musical features on stress recovery [ 9 , 101 ]. For example, classical music may be described as rhythmically complex, with mellow timbre and fluctuating loudness. Comparatively, though equally rhythmically complex, heavy metal possesses sharper timbre and more pronounced loudness. Investigating the differential effects of these musical features on stress recovery may provide relevant insight into the differential effects of listening to various musical genres on stress recovery.
Self- versus experimenter selection.
In investigating the effects of self- versus experimenter selected music on stress recovery in healthy individuals, studies typically request participants to select music they consider ‘relaxing’ prior to an experiment [ 3 , 17 , 18 ]. Although this approach is viable, it precludes the potential role of perceived control in the relationship between music listening and stress recovery, since allowing participants to self-select their own music may already be helpful for stress recovery due to a restoration of perceived control [ 15 ]. Our results were not able to provide a significant contribution to this discussion, as hardly any experimental studies in our review have attempted to account for the potential effects of perceived control. As such, when contrasting the effects of self- and experimenter selected music on stress recovery, future studies may benefit from the inclusion of perceived control as an additional variable in their theoretical models.
It should also be noted that allowing participants to self-select their own music will result in a considerable variety of musical stimuli. Given that each of these musical stimuli may possess a different combination of musical features, the use of self-selected music may generate confounding effects that should preferably be accounted for. Arguably, self-selected music may produce consistent effects on stress-recovery regardless of underlying musical features, given that individuals tend to select music in service of personal self-regulatory goals [ 64 , 75 , 76 ]. However, given that variations in specific musical features, such as tempo, pitch, and loudness have been related to various physiological (e.g., heart rate) [ 73 ] and psychological stress recovery outcomes (e.g., positive and negative affect) [ 100 – 102 ], future studies may benefit from ensuring that musical features are consistent between self- and experimenter selected musical stimuli. This may be done, for instance, by comparing expert ratings of musical features [ 18 ]. Alternatively, there may be value in allowing participants to self-select music from a list provided by experimenters [ 21 ], as this would allow experimenters to standardize musical features a-priori, which may further help disentangle the effects of music listening from that of perceived control.
The comparison of musical features between self-selected and experimenter selected music may also offer a more nuanced perspective on the role of preference and familiarity. Specifically, preferences and familiarity towards certain songs could be described in terms of specific (combinations of) musical features. For example, an individual may prefer music with slow tempo, mellow timbre, and moderate loudness. This approach is often leveraged by music recommender systems, such as those implemented by music streaming platforms (e.g., Spotify, Deezer, Apple Music, etc.), with the goal of recommending songs that listeners are likely to engage with. Future studies could investigate the extent to which preference and familiarity might differ between self-selected and experimenter selected music with similar combinations of musical features, to further clarify the role of selection in the relationship between music listening and stress recovery.
The systematic review portion of our results demonstrates that no studies have directly compared the effect of different musical tempi on stress recovery in healthy individuals. As such, the most straightforward approach to delineate the effects of musical tempo on stress recovery would be to adopt procedures in which participants listen to the same musical stimulus post-stressor, which is then varied in tempo across experimental conditions. Furthermore, even when the goal of a particular study on music listening and stress recovery is not to clarify the effects of musical tempo, we suggest that tempo values for each musical stimulus should be noted down and reported, as this would facilitate the comparison of the differential effects of musical tempo on stress recovery in future meta-synthesis of the literature.
Alternatively, the notion that music with slow tempo is more beneficial for stress recovery compared to music with fast tempo is supported by the assumption that physiological parameters will entrain to musical rhythms [ 63 , 68 ]. As such, a more accurate approach to investigate the effects of musical tempo on stress recovery would be to leverage the dynamic, temporal nature of both music and physiological parameters through use of non-linear analyses of continuous data [ 52 , 103 ]. For example, cross-recurrence quantification analysis (CRQA) [ 104 , 105 ] may enable future studies to quantify the magnitude and duration of rhythmic entrainment for each participant. These indexes of magnitude and duration could then be compared between different musical tempi. Studies have utilized CRQA to investigate cardiac entrainment between participants of collective rituals [ 106 ] and the entrainment of an audience’s heart rate to a live musical performance [ 107 ]. This analytical approach may therefore yield a more nuanced understanding of the effect of musical tempo on the recovery of autonomic parameters.
Stress recovery outcomes.
During short-term stress responses, catecholamine- and cortisol-mediated stress responses follow temporally specific patterns: catecholamines rapidly exert their influence on ANS activity, and these changes tend to normalize within 30–60 minutes [ 26 ]. Meanwhile, decreases in cortisol that may be attributed to stress recovery will only become noticeable after recovery-related changes in autonomic activity have begun to occur [ 24 ]. As such, to further clarify the effect of music listening on various stress recovery outcomes, we recommend future studies to be more sensitive towards the innate, intricate, and temporally specific changes of each stress recovery outcome.
Furthermore, multiple studies included in our review have opted to analyze continuous data by means of multivariate analyses of variance, after averaging participants’ observed stress recovery outcomes at multiple time points (e.g., pre-stress, post-stress, post-recovery). Although this approach is practical, doing so may over-simplify the complex changes that may occur during the stress response and subsequent stress recovery, such as the temporal dynamics of different physiological responses [ 52 ] and emotion regulation strategies [ 108 ]. As such, we again suggest future studies to utilize non-linear analyses of data when appropriate, particularly when investigating the effects of music listening on the recovery of autonomic activity post-stressor. The idea of using non-linear analyses, such as time-series analysis, to investigate the stress recovery process is not new [ 5 ]. However, few studies on music listening and stress recovery have utilized this analytical approach.
Two studies with unreported stress induction procedures were still included in the review [ 17 , 84 ], as reported means for certain recovery outcomes still suggested an increase from baseline that participants could recover from. For example, with the information reported in Gan et al. [ 84 ], assuming a correlation of 0.5 between baseline and post-stressor measures of state anxiety, we estimated that their stress induction procedure elicited a significant increase in state anxiety in their sedative music ( t (34) = 5.87, p < .001, m diff = 8.17, SD diff = 8.24), stimulative music ( t (34) = 8.21, p < .001, m diff = 12.42, SD diff = 8.95), and control ( t (34) = 13.15, p < .001, m diff = 15.83, SD diff = 7.12) conditions. As the overall estimated effect of music listening on the recovery process of healthy individuals following laboratory stressors may be relatively modest, it becomes particularly important to ensure that a sufficient stress response is elicited, to provide a larger window of opportunity in which the effect of music listening may be exerted on participants’ recovery processes. We thus encourage future studies to adopt validated, (variations of) well-known stress tasks, such as the TSST [ 109 ], SECPT [ 110 ], or CO2 stress task [ 111 ], which have been demonstrated to consistently elicit marked physiological and psychological stress-related responses in laboratory settings. Furthermore, we remind future studies to candidly report the results of their stress induction procedures to facilitate subsequent meta-syntheses of the effects of music listening on stress recovery.
As the current review focused on the effects of music listening after a stressor, studies where music was played before or during a stressor were omitted from our analyses. However, several studies suggest that the timing at which music is played (i.e., before, during, or after a stressor) may influence its effects on stress recovery. For example, in Burns et al. [ 48 ], participants who listened to classical music while anticipating a stressful task exhibited lower post-music heart rate compared to participants who anticipated the stressor in silence. Similarly, concentrations of salivary cortisol were lower for participants who watched a stressful visual stimulus while listening to music compared to those who watched the same stimulus without music [ 112 ]. Together, these findings hint that, when listened during a stressor, music may attenuate cortisol responses [ 9 , 113 ], thus reducing the subsequent need for recovery. On the other hand, Thoma et al. [ 9 ] reported that participants who listened to music prior to a stressor exhibited higher post-stressor cortisol compared to participants who listened to an audio control. Interestingly, despite the stronger stress response, Thoma et al. [ 9 ] noted a trend for quicker ANS recovery among participants who listened to music, particularly with regards to salivary alpha-amylase activity. This pattern of findings is consistent with the notion forwarded by Koelsch et al. [ 61 ], in that music listening may promote a more adaptive stress response, thus facilitating subsequent stress recovery processes. To date, research on timing differences in the context of music listening and stress recovery is scarce. Thus, future studies could further examine the influence of such timing differences to better understand their role in the relationship between music listening and stress recovery.
Given the pervasiveness of stress, Ecological Momentary Assessment (EMA) studies may provide a more intimate outlook on the dynamics of daily music listening behaviour, particularly for the purpose of stress recovery. For example, through an ambulatory assessment study, Linnemann et al. [ 38 ] revealed that music produced the most notable reductions in physiological and psychological stress outcomes when it was listened to for the purpose of ‘relaxation’, compared to other reasons such as ‘distraction’, ‘activation’, and ‘reducing boredom’. Indeed, given their high ecological validity, EMA studies may provide further insight into important contextual variables in the relationship between music listening and stress recovery. For example, in an EMA study, listening to music in the presence of others was related to decreased subjective stress, attenuated cortisol secretion, and higher activity of salivary alpha-amylase [ 55 ]. Furthermore, physiological responses to music may co-vary between members of a dyad when music is listened to by couples [ 114 ]. Thus, given the benefits of EMA studies, we invite future studies to continue exploring the dynamics and contextual factors of music listening behaviour for stress recovery in daily life.
Lastly, we encourage studies to support open science research practices, and to clearly report statistical information that may be relevant for meta-syntheses (e.g., means and standard deviations per time point, per experimental condition, etc.). Additionally, based on our assessment of study quality using the RoB 2, pre-registration of analysis plans can be helpful to ensure that the conducted study is of overall high quality. Next, we encourage studies to note down which specific musical stimuli were used, particularly those self-selected by participants [ 69 , 99 ], as this enables future exploratory analyses of structural commonalities between different musical stimuli. Musical features from individual songs may be extracted by means of audio information extraction packages, such as MIRtoolbox [ 115 ]. Alternatively, individual song titles may be used to query related meta-data from online databases of various music streaming platforms. This meta-data can subsequently be used to obtain additional insight into the effects of music listening on stress recovery.
Limitations of the current review
To our knowledge, our review is the first to comprehensively investigate the effect of music listening on stress recovery within healthy individuals. Given the explicit focus of our review, our meta-analytic data set excluded the more prominent effects of music listening in both medical and therapeutic settings [ 12 , 13 ], allowing us to obtain results that are tentatively more representative of daily stress recovery processes. Despite this, the present review is not without its limitations:
First, although the specific focus of our review has allowed us to obtain a portrait of the effects of music listening on stress recovery in well-controlled experimental settings, the results of our review may be difficult to generalize to situations in which individuals experience prolonged stress responses. Stress induction procedures in experimental studies are designed to elicit acute stress responses that are meant to subside upon conclusion of an experiment [ 83 ]. Although we believe these procedures provide a suitable approximation of typical stressors in daily life, certain stressors in daily life may also persist for a longer time. The manner and magnitude in which music listening influences prolonged stress responses may potentially differ from the way music influences acute, laboratory-induced stress responses [ 18 , 45 ]. However, studies investigating the effect of music listening on stress recovery in the long-term are particularly rare.
Next, despite our best efforts to obtain relevant meta-analytic information from all studies selected for our review, our meta-analytic data set was ultimately constructed from a subset of fourteen studies. Although the subset allowed us to extract sufficient information to estimate an overall effect of music listening on stress recovery, several estimated effects at moderator level were derived from merely one or two studies (see Table 3 ). This precluded us from drawing further, meaningful conclusions about the results of our moderator analyses.
Finally, despite our clear focus on the effects of music listening on stress recovery within healthy individuals, there was substantial heterogeneity in our meta-analytic data set that could not be fully explained by the inclusion of moderators. Although the systematic review portion of our results highlighted potential additional sources of between-study heterogeneity, these additional sources could not be evaluated in our meta-analytic data set. We note, for example, that all studies utilized different musical stimuli to investigate the effect of music listening on stress recovery (see Table 4 ). The differential effects of these musical stimuli were difficult to account for in our meta-analysis, given the limited number of included studies. Overall, the significant heterogeneity in our meta-analytic data set suggests that our moderator analyses should be interpreted with caution.
Studies commonly suggest that listening to music may have a positive influence on stress recovery. Based on cumulative evidence from 90 effect sizes in 14 studies, it may be premature to firmly conclude whether music listening is beneficial for the stress recovery of healthy individuals. The present review underscores the necessity for further and finer research into the effects of music, bearing the potential role of various moderators, such as musical genre, self-selection, musical tempo, and different stress recovery outcomes, to fully comprehend the nuanced effects of music listening on short-term stress recovery.
Using the advanced search feature within RUQuest, Web of Science, and PsycINFO, the following syntax was used so that the search returned results if keywords were found within the title, abstract, or keywords of relevant publications:
ti: ( music * OR “ music listening ”) AND (( stress * OR strain OR recover * OR relax * OR fatigue OR “ heart rate ” OR “ heart rate variability ” OR “ blood pressure ” OR cardiovascular OR physiological OR cortisol OR “ perseverative cognition ” OR ruminat * OR detachment OR distract * OR worry * OR emotion * OR affect * OR mood OR burnout OR depress *) NOT ( patient OR disease OR surgery OR operating OR theat ?? OR disorder OR clinical OR stroke OR animal OR dent* OR material OR recogni* OR recommend *))
ab: ( music * OR “ music listening ”) AND (( stress * OR strain OR recover * OR relax * OR fatigue OR “ heart rate ” OR “ heart rate variability ” OR “ blood pressure ” OR cardiovascular OR physiological OR cortisol OR “ perseverative cognition ” OR ruminat * OR detachment OR distract * OR worry * OR emotion * OR affect * OR mood OR burnout OR depress *) NOT ( patient OR disease OR surgery OR operating OR theat ?? OR disorder OR clinical OR stroke OR animal OR dent* OR material OR recogni* OR recommend *))
kw: ( music * OR “ music listening ”) AND (( stress * OR strain OR recover * OR relax * OR fatigue OR “ heart rate ” OR “ heart rate variability ” OR “ blood pressure ” OR cardiovascular OR physiological OR cortisol OR “ perseverative cognition ” OR ruminat * OR detachment OR distract * OR worry * OR emotion * OR affect * OR mood OR burnout OR depress *) NOT ( patient OR disease OR surgery OR operating OR theat ?? OR disorder OR clinical OR stroke OR animal OR dent* OR material OR recogni* OR recommend *))
Exploratory moderator analysis with study quality
Based on the RoB 2, all studies in the meta-analysis were of moderate quality, since the lack of pre-specified analysis plans from included studies made it difficult to completely rule out bias from the selection of reported results. Exploratorily, we conducted a less stringent assessment of study quality assuming all studies contained no bias due to selection of results. Based on this assessment, 7 (50%) of the included studies were high quality, while the remaining were moderate quality.
Following our procedure for moderator analyses, we conducted an additional random-effects meta-regression with RVE to test whether the estimated effect of music listening on stress recovery was stable across studies of different quality. The meta-regression suggests that study quality is a significant moderator of the effect of music listening on stress recovery, QM (1) = 41.95, p < .001. The estimated effect of music listening on stress recovery in high quality studies was g = 0.178, 95% CI [0.00, 0.35], p = .046, while the estimated effect of music in moderate quality studies was g = 0.102, 95% CI [-0.14, 0.35], p = .041.
Stress induction procedures
In our meta-analysis, we generally distinguished between stress induction procedures with- or without a socio-evaluative threat component. However, specific stress induction procedures varied considerably between studies, as described below:
Four studies utilized arithmetic tasks to induce stress in participants. These tasks included single- and double-digit mental arithmetic operations [ 17 ], mental arithmetic operations “with harassment” [ 18 , 21 ], and standardized mathematic tests [ 84 ].
Trier Social Stress Task (with modifications).
One study [ 54 ] followed the standard administration protocol of the Trier Social Stress Task (TSST) [ 109 , 116 ]. Two studies modified the TSST [ 109 ] by having participants prepare and deliver their presentations in front of a camera instead of a panel of judges [ 3 , 37 ], while the subsequent mental arithmetic task was replaced by the Paced Auditory Serial Addition Test (PASAT) [ 117 ], administered through a laptop. One study administered the TSST with a shorter mental arithmetic component [ 118 ], while two studies omitted the TSST’s speech delivery component [ 119 , 120 ].
One study made use of anticipation to induce stress [ 50 ], where participants were asked to prepare an impromptu presentation that would be videotaped at the end of a preparation period. Participants were eventually not required to deliver the prepared presentation.
Two studies exposed participants to unpleasant stimuli as a means of inducing stress. These unpleasant stimuli were either auditory [ 82 ] or visual [ 19 ] in nature.
CO 2 stress task.
One study utilized the CO 2 Stress Task [ 61 ]. In this task, as a an acute physiological stressor, participants were instructed to take a single, vital-capacity breath of air containing 35% carbon dioxide and 65% oxygen [ 111 ].
The duration of each stress induction procedure varied according to procedure category. The longest stress induction procedures (15 minutes) typically involved (variations of) the TSST (e.g., [ 37 ]. Conversely, the shortest procedure (90 seconds) was the exposure to unpleasant noise in Nakajima et al. [ 82 ], as their experimental design involved repeated presentation of the stressor to participants. Finally, it is also worth noting that among studies which reported successful stress induction procedures (see Table 2 ), the magnitude of resulting stress responses was often not reported.
Selection of musical stimuli
All studies held a general assumption that ‘relaxing’ music would best promote stress recovery. However, studies utilized different strategies in selecting ‘relaxing’ music, resulting in considerable variation in musical stimuli between studies. These strategies are listed below:
Sampling from available music.
Four studies utilized a relatively straightforward strategy in selecting music—musical stimuli were sampled from songs commonly found on ‘relaxing’, either from their inclusion in anti-stress cassettes [ 21 , 54 ], coverage in popular media [ 120 ], or the researcher’s opinion [ 118 ].
Referencing prior studies.
Three studies selected music that, in prior studies, seemed to have positive effects on heart rate, respiration rate, perceived arousal, and perceived relaxation. One study made reference to pilot studies [ 82 ], while the remaining two cited previous published work by the same authors [ 19 , 50 ].
Two studies attempted to theoretically conceptualize which music would be ‘relaxing’, and selected their musical stimuli accordingly. De la Torre-Luque et al. [ 3 ] utilized Melomics, a computational system for the automatic composition of music, to create songs that would be considered ‘relaxing’. These songs were slow-paced, instrumental pieces, which contained no sudden or abrupt changes in melody. Gan et al. [ 84 ] distinguished between stimulative and sedative (‘relaxing’) music based on musical tempo—the speed or pace of a given song, and dynamic range—the difference between the quietest and loudest parts of a song [ 121 ]. In their study, stimulative music was characterized by fast tempo and broad dynamic range, while sedative music was characterized by slow tempo and narrow (soft) dynamic range.
Six studies allowed participants to select and listen to their own ‘relaxing’ music. In four studies, participants were instructed to bring a list of ‘preferred’ relaxing music, which they would have the opportunity to listen to during the study [ 18 , 37 , 54 , 66 , 119 ]. In one study, participants selected ‘relaxing’ music from a list created by the experimenters ( pseudo self-selection) [ 21 ]. The specific musical stimuli chosen by participants in studies allowing self-selection were often not reported.
Effects of music listening on stress recovery
Studies utilized a variety of outcomes to investigate the effects of music listening on stress recovery. To expand upon the results of our meta-analysis, we detail the findings reported for each of these outcomes below. Given that three studies included in the systematic review could not be included in the meta-analysis due to incomplete reported data, the number of studies per outcome reported in this section may differ from the number of studies per outcome in the meta-analysis ( Table 3 ).
Scheufele [ 50 ] reported that participants who listened to classical music demonstrated lower post-stressor heart rate (HR) compared to participants in a comparable control group. By contrast, six studies reported no significant differences in post-stressor HR between participants who listened to music and those who did not [ 3 , 18 , 19 , 21 , 66 , 84 ]. In summary, only one study out of seven provides evidence in support of a positive effect of music listening on post-stressor HR recovery.
Heart rate variability.
Four studies utilized various heart rate variability (HRV) indices as a means to assess stress recovery. Two studies reported higher post-stressor HF band power in participants who listened to music compared to those who sat in silence [ 3 , 37 ]. In Nakajima et al. [ 82 ], this difference was more pronounced for participants who listened to music with boosted high frequencies. Contrarily, in Sokhadze [ 19 ], participants who listened to peaceful music demonstrated lower post-stressor HF band power compared to those who sat in silence. Two studies reported that post-stressor sample entropy was higher for participants who listened to music compared to silence [ 3 , 37 ]. This difference was taken as indicator which suggested that the physiological parameters of participants in the music condition were more ready to change compared to those in the silence condition [ 3 ]. No studies reported significant differences in RMSSD, LF band power, and LF/HF ratio between participants who listened to music and those who did not [ 3 , 19 , 37 , 82 ]. Overall, three of four studies provide support for a positive effect of music listening on post-stressor HRV recovery, but these effects seem to vary across HRV indices.
Four studies assessed the impact of music listening on stress recovery through changes in systolic blood pressure (SBP) and diastolic blood pressure (DBP). Chafin et al. [ 21 ] reported that the post-stressor SBP approached baseline values more quickly for participants who listened to experimenter-selected classical music compared to participants who sat in silence. On the other hand, three studies reported no significant differences in post-stressor SBP between participants who listened to music and those who did not [ 18 , 84 , 120 ]. Instead, compared to participants sitting in silence, post-stressor SBP recovery in participants who listened to either happy or relaxing music was delayed [ 18 ]. With regards to DBP, none of the above studies reported significant differences in post-stressor DBP between their respective experimental conditions. In summary, one study out of four provides support for a beneficial effect of music listening on post-stressor SBP recovery, while no studies provide support for a beneficial effect of music listening on DBP recovery.
One study reported no significant differences in post-stressor respiration rate (RR) between participants listening to different musical genres and silence [ 17 ]. As such, there is currently no evidence to suggest that music listening is beneficial for post-stressor RR recovery.
In Sokhadze [ 19 ], participants’ SC was lower while listening to pleasant music compared to during the stressor. In Fallon et al. [ 118 ], participants who listened to self-selected music experienced lower SC compared to those in the control condition during the recovery session of the study. In a post-hoc analysis, Labbé et al. [ 17 ] reported that post-stressor SC recovery was greater for the classical and self-selected music groups, compared to the heavy metal or no music groups. Collectively, three studies provide evidence for a positive effect of music listening on post-stressor SC recovery.
Two studies utilized cortisol to examine the effect of music listening on stress recovery. Khalfa et al. [ 54 ] reported that post-stressor cortisol decreased more rapidly for participants who listened to experimenter-selected classical music, compared to participants who sat in silence. Contrarily, Koelsch et al. [ 61 ] reported that music listening delayed cortisol recovery, as cortisol concentrations were higher for participants who listened to music post-stressor compared to silence. As such, only one study out of two provides support for a beneficial effect of music listening on post-stressor cortisol recovery.
In Groarke & Hogan [ 119 ], participants who listened to self-selected music reported lower subjective stress post-stressor compared to those who listened to a radio documentary. By comparison, in Radstaak et al. [ 18 ], there were no differences in post-stressor subjective stress between participants listening to happy music, relaxing music, an audiobook, and silence. Thus, only one study out of two provides support for a beneficial effect of music listening on post-stressor subjective stress.
In Labbé et al. [ 17 ], post-stressor perceived relaxation was higher for participants who listened to classical music compared to heavy metal, but not compared to silence. There were no significant differences in post-stressor perceived relaxation between participants listening to the various musical genres in Chafin et al. [ 21 ], and between participants listening to classical music or silence [ 50 ]. Thus, no studies provide conclusive evidence that music listening is beneficial for post-stressor perceived relaxation. However, the effects of music listening on perceived relaxation may differ depending on genre.
Three studies reported that music listening reduced post-stressor state anxiety compared to silence [ 17 , 37 , 119 ]. Furthermore, Gan, Lim, and Haw [ 84 ] reported that post-stressor changes in mathematics-related anxiety were significantly higher for participants who listened to sedative music compared to those who did not. Despite this, three studies reported no significant differences in post-stressor state anxiety between their respective experimental groups [ 3 , 19 , 21 ]. Thus, four of seven studies provide support for a beneficial effect of music listening on post-stressor state anxiety.
Two studies looked at the presence and/or severity of depressive symptoms in order to assess whether or not music facilitated psychological recovery [ 19 , 37 ]. However, only de la Torre-Luque et al. [ 37 ] reported significant positive differences in post-stressor depressive symptoms between participants who listened to music and those who did not.
Two studies measured rumination as an indicator of psychological stress recovery, and both reported no significant differences in post-stressor rumination between participants in their respective experimental conditions [ 18 , 21 ]. As such, there is currently no evidence to suggest that music listening is beneficial for post-stressor rumination.
Positive and negative affect.
De la Torre-Luque et al. [ 37 ] noted that participants who listened to music reported higher positive affect scores and lower negative affect scores post-stressor compared to the control group. Similarly, Radstaak et al. [ 18 ] reported that participants who listened to happy or relaxing music reported higher post-stressor positive affect compared to participants who did not listen to music, but found no significant differences in post-stressor negative affect. Two studies utilized the Profile of Moods Scale (POMS) to assess post-stressor changes in affect. Koelsch et al. [ 61 ] noted that participants who listened to music demonstrated higher post-stressor POMS scores (suggesting higher positive affect) compared to those who sat in silence. On the other hand, Scheufele [ 50 ] reported no significant differences in post-stressor POMS scores between experimental groups. Two studies [ 118 , 119 ] measured affect by asking participants to report whether they felt various emotions (e.g., calmness, nervousness) throughout the study. Fallon et al. [ 118 ] reported that music listening did not have differential effects on affect compared to silence, while Groarke and Hogan [ 119 ] noted that participants who listened to music demonstrated less negative affect (as indicated by lower scores on the various emotions that participants were asked to rate) compared to those who did not. Collectively, the effect of music listening on post-stressor positive and negative affect seemed to be mixed. Three studies provide support for the beneficial role of music listening on post-stressor positive affect, and two studies provide support for the beneficial effect of music listening for negative affect.
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- Published: 24 February 2021
Music Therapy in Autism Spectrum Disorder: a Systematic Review
- Amparo V. Marquez-Garcia ORCID: orcid.org/0000-0001-7356-6660 1 ,
- Justine Magnuson 1 ,
- James Morris 2 ,
- Grace Iarocci 3 ,
- Sam Doesburg 1 &
- Sylvain Moreno 4
Review Journal of Autism and Developmental Disorders volume 9 , pages 91–107 ( 2022 ) Cite this article
Individuals with autism spectrum disorder (ASD) can experience difficulties functioning in society due to social communication deficits and restrictive and repetitive behaviors. Music therapy has been suggested as a potential intervention used to improve these deficits in ASD. The current systematic literature review focuses on two methods of music therapy: improvisational music therapy (IMT) and singing/listening to songs. We review the extant literature and the associated methodological limitations, and we propose a framework to assess the effectiveness of music therapy as an intervention in ASD. We suggest the creation of a standardized framework that should utilize neuroimaging tools as an objective marker of changes induced by music therapy as well as a combination of functional and behaviourial outputs, rather than assessment methods addressing a broad range of functional and behavioural outputs, rather than only the main symptoms. The methodological limitations found in the current literature prevent us from making a strong statement about the effects of music therapy in autism. We consider treatment fidelity assessments as the key to successful future attempts to truly understand music therapy effects in ASD.
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Amparo V. Marquez-Garcia, Justine Magnuson & Sam Doesburg
School of Medicine, University College Dublin, Dublin, Ireland
Department of Psychology, Simon Fraser University, Burnaby, Canada
Department of School of Interactive Art and Technology, Simon Fraser University, Surrey, Canada
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Marquez-Garcia, A.V., Magnuson, J., Morris, J. et al. Music Therapy in Autism Spectrum Disorder: a Systematic Review. Rev J Autism Dev Disord 9 , 91–107 (2022). https://doi.org/10.1007/s40489-021-00246-x
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Published : 24 February 2021
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DOI : https://doi.org/10.1007/s40489-021-00246-x
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Editorial article, editorial: the impact of music on human development and well-being.
- 1 Department of Culture, Communication and Media, University College London, London, United Kingdom
- 2 Department of Philosophy, Sociology, Education and Applied Psychology, University of Padua, Padua, Italy
- 3 School of Humanities and Communication Arts, Western Sydney University, Penrith, NSW, Australia
- 4 Melbourne Conservatorium of Music, University of Melbourne, Melbourne, VIC, Australia
Editorial on the Research Topic The Impact of Music on Human Development and Well-Being
Music is one of the most universal ways of expression and communication for humankind and is present in the everyday lives of people of all ages and from all cultures around the world ( Mehr et al., 2019 ). Hence, it seems more appropriate to talk about musics (plural) rather than in the singular ( Goble, 2015 ). Furthermore, research by anthropologists as well as ethnomusicologists suggests that music has been a characteristic of the human condition for millennia (cf. Blacking, 1976 ; Brown, 1999 ; Mithen, 2005 ; Dissanayake, 2012 ; Higham et al., 2012 ; Cross, 2016 ). Nevertheless, whilst the potential for musical behavior is a characteristic of all human beings, its realization is shaped by the environment and the experiences of individuals, often within groups ( North and Hargreaves, 2008 ; Welch and McPherson, 2018 ). Listening to music, singing, playing (informally, formally), creating (exploring, composing, improvising), whether individually and collectively, are common activities for the vast majority of people. Music represents an enjoyable activity in and of itself, but its influence goes beyond simple amusement.
These activities not only allow the expression of personal inner states and feelings, but also can bring about many positive effects in those who engage in them. There is an increasing body of empirical and experimental studies concerning the wider benefits of musical activity, and research in the sciences associated with music suggests that there are many dimensions of human life—including physical, social, educational, psychological (cognitive and emotional)—which can be affected positively by successful engagement in music ( Biasutti and Concina, 2013 ). Learning in and through music is something that can happen formally (such as part of structured lessons in school), as well as in other-than-formal situations, such as in the home with family and friends, often non-sequentially and not necessarily intentional, and where participation in music learning is voluntary, rather than mandated, such as in a community setting (cf. Green, 2002 ; Folkestad, 2006 ; Saether, 2016 ; Welch and McPherson, 2018 ).
Such benefits are evidenced across the lifespan, including early childhood ( Gerry et al., 2012 ; Williams et al., 2015 ; Linnavalli et al., 2018 ), adolescence ( McFerran et al., 2018 ), and older adulthood ( Lindblad and de Boise, 2020 ). Within these lifespan perspectives, research into music's contribution to health and well-being provides evidence of physical and psychological impacts ( MacDonald et al., 2013 ; Fancourt and Finn, 2019 ; van den Elzen et al., 2019 ). Benefits are also reported in terms of young people's educational outcomes ( Guhn et al., 2019 ), and successful musical activity can enhance an individual's sense of social inclusion ( Welch et al., 2014 ) and social cohesion ( Elvers et al., 2017 ).
This special issue provides a collection of 21, new research articles that deepen and develop our understanding of the ways and means that music can impact positively on human development and well-being. The collection draws on the work of 88 researchers from 17 different countries across the world, with each article offering an illustration of how music can relate to other important aspects of human functioning. In addition, the articles collectively illustrate a wide range of contemporary research approaches. These provide evidence of how different research aims concerning the wider benefits of music require sensitive and appropriate methodologies.
In terms of childhood and adolescence, for example, Putkinen et al. demonstrate how musical training is likely to foster enhanced sound encoding in 9 to 15-year-olds and thus be related to reading skills. A separate Finnish study by Saarikallio et al. provides evidence of how musical listening influences adolescents' perceived sense of agency and emotional well-being, whilst demonstrating how this impact is particularly nuanced by context and individuality. Aspects of mental health are the focus for an Australian study by Stewart et al. of young people with tendencies to depression. The article explores how, despite existing literature on the positive use of music for mood regulation, music listening can be double-edged and could actually sustain or intensify a negative mood.
A Portuguese study by Martins et al. shifts the center of attention from mental to physical benefits in their study of how learning music can support children's coordination. They provide empirical data on how a sustained, 24-week programme of Orff-based music education, which included the playing of simple tuned percussion instruments, significantly enhanced the manual dexterity and bimanual coordination in participant 8-year-olds compared to their active control (sports) and passive control peers. A related study by Loui et al. in the USA offers insights into the neurological impact of sustained musical instrument practice. Eight-year-old children who play one or more musical instruments for at least 0.5 h per week had higher scores on verbal ability and intellectual ability, and these correlated with greater measurable connections between particular regions of the brain related to both auditory-motor and bi-hemispheric connectivity.
Younger, pre-school children can also benefit from musical activities, with associations being reported between informal musical experiences in the home and specific aspects of language development. A UK-led study by Politimou et al. found that rhythm perception and production were the best predictors of young children's phonological awareness, whilst melody perception was the best predictor of grammar acquisition, a novel association not previously observed in developmental research. In another pre-school study, Barrett et al. explored the beliefs and values held by Australian early childhood and care practitioners concerning the value of music in young children's learning. Despite having limited formal qualifications and experience of personal music learning, practitioners tended overall to have positive attitudes to music, although this was biased toward music as a recreational and fun activity, with limited support for the notion of how music might be used to support wider aspects of children's learning and development.
Engaging in music to support a positive sense of personal agency is an integral feature of several articles in the collection. In addition to the Saarikallio team's research mentioned above, Moors et al. provide a novel example of how engaging in collective beatboxing can be life-enhancing for throat cancer patients in the UK who have undergone laryngectomy, both in terms of supporting their voice rehabilitation and alaryngeal phonation, as well as patients' sense of social inclusion and emotional well-being.
One potential reason for these positive findings is examined in an Australian study by Krause et al. . They apply the lens of self-determination theory to examine musical participation and well-being in a large group of 17 to 85-year-olds. Respondents to an online questionnaire signaled the importance of active music making in their lives in meeting three basic psychological needs embracing a sense of competency, relatedness and autonomy.
The use of public performance in music therapy is the subject of a US study by Vaudreuil et al. concerning the social transformation and reintegration of US military service members. Two example case studies are reported of service members who received music therapy as part of their treatment for post-traumatic stress disorder, traumatic brain injury, and other psychological health concerns. The participants wrote, learned, and refined songs over multiple music therapy sessions and created song introductions to share with audiences. Subsequent interviews provide positive evidence of the beneficial psychological effects of this programme of audience-focused musical activity.
Relatedly, McFerran et al. in Australia examined the ways in which music and trauma have been reported in selected music therapy literature from the past 10 years. The team's critical interpretive synthesis of 36 related articles led them to identify four different ways in which music has been used beneficially to support those who have experienced trauma. These approaches embrace the use of music for stabilizing (the modulation of physiological processes) and entrainment (the synchronization of music and movement), as well as for expressive and performative purposes—the fostering of emotional and social well-being.
The therapeutic potential of music is also explored in a detailed case study by Fachner et al. . Their research focuses on the nature of critical moments in a guided imagery and music session between a music therapist and a client, and evidences how these moments relate to underlying neurological function in the mechanics of music therapy.
At the other end of the age span, and also related to therapy, an Australian study by Brancatisano et al. reports on a new Music, Mind, and Movement programme for people in their eighties with mild to moderate dementia. Participants involved in the programme tended to show an improvement in aspects of cognition, particularly verbal fluency and attention. Similarly, Wilson and MacDonald report on a 10-week group music programme for young Scottish adults with learning difficulties. The research data suggest that participants enjoyed the programme and tended to sustain participation, with benefits evidenced in increased social engagement, interaction and communication.
The role of technology in facilitating access to music and supporting a sense of agency in older people is the focus for a major literature review by Creech , now based in Canada. Although this is a relatively under-researched field, the available evidence suggests that that older people, even those with complex needs, are capable of engaging with and using technology in a variety of ways that support their musical perception, learning and participation and wider quality of life.
Related to the particular needs of the young, children's general behavior can also improve through music, as exampled in an innovative, school-based, intensive 3-month orchestral programme in Italy with 8 to 10-year-olds. Fasano et al. report that the programme was particularly beneficial in reducing hyperactivity, inattention and impulsivity, whilst enhancing inhibitory control. These benefits are in line with research findings concerning successful music education with specific cases of young people with ADHD whose behavior is characterized by these same disruptive symptoms (hyperactivity, inattention, and impulsivity).
Extra-musical benefits are also reported in a study of college students (Bachelors and Masters) and amateur musicians in a joint Swiss-UK study. Antonini Philippe et al. suggest that, whilst music making can offer some health protective effects, there is a need for greater health awareness and promotion among advanced music students. Compared to the amateur musicians, the college music students evaluated their overall quality of life and general and physical health more negatively, as did females in terms of their psychological health. Somewhat paradoxically, the college students who had taken part in judged performances reported higher psychological health ratings. This may have been because this sub-group were slightly older and more experienced musicians.
Music appears to be a common accompaniment to exercise, whether in the gym, park or street. Nikol et al. in South East Asia explore the potential physical benefits of synchronous exercise to music, especially in hot and humid conditions. Their randomized cross-over study (2019) reports that “time-to-exhaustion” under the synchronous music condition was 2/3 longer compared to the no-music condition for the same participants. In addition, perceived exertion was significantly lower, by an average of 22% during the synchronous condition.
Comparisons between music and sport are often evidenced in the body of existing Frontiers research literature related to performance and group behaviors. Our new collection contains a contribution to this literature in a study by Habe et al. . The authors investigated elite musicians and top athletes in Slovenia in terms of their perceptions of flow in performance and satisfaction with life. The questionnaire data analyses suggest that the experience of flow appears to influence satisfaction with life in these high-functioning individuals, albeit with some variations related to discipline, participant sex and whether considering team or individual performance.
A more formal link between music and movement is the focus of an exploratory case study by Cirelli and Trehub . They investigated a 19-month-old infant's dance-like, motorically-complex responses to familiar and unfamiliar songs, presented at different speeds. Movements were faster for the more familiar items at their original tempo. The child had been observed previously as moving to music at the age of 6 months.
Finally, a novel UK-based study by Waddington-Jones et al. evaluated the impact of two professional composers who were tasked, individually, to lead a 4-month programme of group composing in two separate and diverse community settings—one with a choral group and the other in a residential home, both funded as part of a music programme for the Hull City of Culture in 2017. In addition to the two composers, the participants were older adults, with the residential group being joined by schoolchildren from a local Primary school to collaborate in a final performance. Qualitative data analyses provide evidence of multi-dimensional psychological benefits arising from the successful, group-focused music-making activities.
In summary, these studies demonstrate that engaging in musical activity can have a positive impact on health and well-being in a variety of ways and in a diverse range of contexts across the lifespan. Musical activities, whether focused on listening, being creative or re-creative, individual or collective, are infused with the potential to be therapeutic, developmental, enriching, and educational, with the caveat provided that such musical experiences are perceived to be engaging, meaningful and successful by those who participate.
Collectively, these studies also celebrate the multiplicity of ways in which music can be experienced. Reading across the articles might raise a question as to whether or not any particular type of musical experience is seen to be more beneficial compared with another. The answer, at least in part, is that the empirical evidence suggests that musical engagement comes in myriad forms along a continuum of more or less overt activity, embracing learning, performing, composing and improvising, as well as listening and appreciating. Furthermore, given the multidimensional neurological processing of musical experience, it seems reasonable to hypothesize that it is perhaps the level of emotional engagement in the activity that drives its degree of health and well-being efficacy as much as the activity's overt musical features. And therein are opportunities for further research!
The editorial was drafted by GW and approved by the topic Co-editors. All authors listed have made a substantial, direct and intellectual contribution to the Edited Collection, and have approved this editorial for publication.
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.
We are very grateful to all the contributing authors and their participants for their positive engagement with this Frontiers Research Topic, and also for the Frontiers staff for their commitment and support in bringing this topic to press.
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Keywords: music, wider benefits, lifespan, health, well-being
Citation: Welch GF, Biasutti M, MacRitchie J, McPherson GE and Himonides E (2020) Editorial: The Impact of Music on Human Development and Well-Being. Front. Psychol. 11:1246. doi: 10.3389/fpsyg.2020.01246
Received: 12 January 2020; Accepted: 13 May 2020; Published: 17 June 2020.
Copyright © 2020 Welch, Biasutti, MacRitchie, McPherson and Himonides. 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: Graham F. Welch, firstname.lastname@example.org ; Michele Biasutti, email@example.com
This article is part of the Research Topic
The Impact of Music on Human Development and Well-Being
DeepMind and YouTube release Lyria, a gen-AI model for music, and Dream Track to build AI tunes
Back in January, Google made some waves — soundwaves, that is — when it quietly released some research on AI-based music creation software that built tunes based on word prompts. Today, its sister business Google DeepMind went several steps further — it has announced a new music generation model called Lyria that will work in conjunction with YouTube , and two new toolsets it’s describing as “experiments” built on Lyria: Dream Track lets you create music for YouTube Shorts, and Music AI is a set of tools that it says are aimed at helping with the creative process (for example, building a tune out of a snipped that a creator might hum). Alongside these, DeepMind said it’s adapting SynthID — used to mark AI images — to watermark AI music, too.
The new tools are being released at a time when AI continues to court controversy in the world of creative arts. It was a key subject at the heart of the Screen Actors Guild strike (which finally ended this month). And in music, while everyone knew Ghostwriter used AI to mimic Drake and The Weeknd, the question you have to ask is whether AI creation will become more of the norm in the future.
With the new tools getting announced today, the first priority for DeepMind and YouTube appears to be creating tech that helps AI music stay credible, both as a complement to creators today, but also just in the most aesthetic sense of sounding like music.
As Google’s past efforts have shown, one detail that often emerges is that the longer one listens to AI-generated music, the more distorted and surreal it starts to sound, moving further from the intended outcome. As DeepMind explained today, that’s in part because of the complexity of information that is going into music models, covering beats, notes, harmonies and more.
“When generating long sequences of sound, it’s difficult for AI models to maintain musical continuity across phrases, verses or extended passages,” DeepMind noted today. “Since music often includes multiple voices and instruments at the same time, it’s much harder to create than speech.”
It’s notable, then, that some of the first applications of the model are appearing in shorter pieces.
Dream Track is initially rolling out to a limited set of creators to build 30-second AI-generated soundtracks in the “voice and musical style of artists including Alec Benjamin, Charlie Puth, Charli XCX, Demi Lovato, John Legend, Sia, T-Pain, Troye Sivan, and Papoose.”
The creator enters a topic, choosing an artist; a track with lyrics, backing tracks and the voice of the selected musician are used to create the 30-second piece, which is intended to be used with Shorts. Here’s an example of a Charlie Puth track:
YouTube and DeepMind are clear to point out that these artists are involved in the project, helping test the models and giving other input.
Lyor Cohen and Toni Reed, respectively head of music for YouTube and its VP of emerging experiences and community projects, note that the set of Music AI tools that are getting released are coming out of the company’s Music AI Incubator, a group of artists, songwriters and producers working on testing and giving feedback on projects.
“It was clear early on that this initial group of participants were intensely curious about AI tools that could push the limits of what they thought possible,” they note. “They also sought out tools that could bolster their creative process.”
While Dream Track is getting a limited release today, the Music AI tools are only going to get rolled out later this year, they said. DeepMind teased three areas that they will cover: creating music in a specified instrument, or creating a whole set of instrumentation, based on humming a tune; using chords that you build on a simple MIDI keyboard to create a whole choir or other ensemble; and building backing and instrumental tracks for a vocal line that you might already have. (Or, in fact, a combination using all three of those, starting just with a simple hum.)
In music, Google and Ghostwriter are, of course, not alone. Among others that are rolling out tools, Meta open sourced an AI music generator in June; Stability AI launched one in September; and startups like Riffusion are also raising money for their efforts in the genre. The music industry is scrambling to prepare, too .
New research advances understanding of cancer risk in gene therapies
Medical research has shown promising results regarding the potential of gene therapy to cure genetic conditions such as sickle cell disease and the findings of this study, published in Nature Medicine , offer important new insights into processes happening in the body after treatment.
The present study looked at samples from six patients with sickle cell disease who were undergoing gene therapy as part of a major clinical trial at Boston Children's Hospital. The research brought together an international team of experts, to take a closer look at the genetic changes in the stem cells of patients before and after gene therapy and compare the cells that were modified with the therapy to those that weren't.
The study highlights the importance of long-term and in-depth monitoring of stem cell samples from patients with genetic conditions to track mutations that could lead to blood cancer, the researchers say.
Co-senior author of the study Professor David Kent from the Department of Biology and York Biomedical Research Institute said: "Think of the gene therapy process like clearing a forest and planting new seedlings. If you imagine that some seedlings are red and some are green, then the 'selection' we are observing is akin to having the forest regrow red trees preferentially.
"Our research indicates that gene therapy imposes a selection on different blood stem cells, the 'seed' cells of our blood and immune system. After gene therapy, the treatment might favour growth of stem cells with certain mutations, and this in turn could potentially lead to expansion of blood cells containing these mutations. In other settings, such expansions have been associated with development of blood cancers, particularly in older individuals, but the relationship of this study's findings to the risk of blood cancers is not yet fully understood."
The researchers used new technologies in genome science that allow blood cells to be tracked and compared in patients, a new approach which could substantially influence gene therapy trials in the future.
Co-senior author of the study Dr David Williams from Boston Children's Hospital and Harvard Medical School noted: "Gene therapy holds immense potential to cure genetic conditions such as sickle cell disease, and understanding how the process influences blood stem cell growth in the long run is crucial for safety. Notably, our study revealed that younger patients, with fewer genetic mutations in their stem cells, didn't exhibit strong signs of mutations post-therapy. This suggests that treating patients with gene therapy at a younger age could be both safer and more effective, but substantial work needs to be done to test this formally."
Sickle cell disease, an inherited genetic disorder, alters the natural round and flexible shape of red blood cells into a sickle or crescent shape, leading to severe health issues and putting patients at higher risk of developing blood cancer. Though approximately 100 million people carry the sickle cell trait worldwide, the disease only occurs if a child inherits the trait from both parents. In regions where the trait is prevalent, such as parts of sub-Saharan Africa, up to 20 percent of the population can be affected.
However, recent advances in gene therapy offer hope. This innovative approach involves modifying a patient's own stem cells outside the body, correcting the faulty gene responsible for the abnormal cell shape. These corrected cells are reintroduced into the patient, aiming to replace the problematic cells with healthy, normal-shaped ones.
The study, funded by the Bill and Melinda Gates Foundation, reveals that the gene therapy treatment itself is not the likely cause of new DNA mutations in blood stem cells. Instead, the process of genetically modifying these stem cells outside the body and re-transplanting them back into the patient makes blood stem cells that already have these mutations more prominent, thereby increasing their influence on the blood and immune systems.
The research team say the findings also suggest that younger patients may have acquired fewer stem cell mutations in their lifetime, which may inform the optimal age for gene therapies in this and other diseases in the future.
Co-lead author of the paper, Dr Alyssa Cull from the Department of Biology and York Biomedical Research Institute, emphasised the need for further research: "We now require more in-depth studies to uncover the precise connections behind specific mutations and the gene therapy procedure. There are pressing questions regarding how we can refine gene therapy to avoid stem cells that might contain mutations that affect blood cell growth. Determining whether mutations within a sample of cells are dangerous in the long run remains challenging though and substantial further research is needed."
Co-lead author Michael Spencer-Chapman from the Wellcome Sanger Institute echoes the need for longer term follow-up of patients saying: "Our research revealed that both gene-therapy modified and unaltered stem cells from sickle cell patients sometimes contained cancer-associated mutations leading to accelerated growth through the gene therapy procedure. Continuously tracking these mutations and gaining a deeper understanding of these processes will profoundly impact the future well-being of sickle cell patients around the world."
- Gene Therapy
- Sickle Cell Anemia
- Immune System
- Personalized Medicine
- Medical Topics
- Diseases and Conditions
- Embryonic stem cell
- Gene therapy
- Adult stem cell
- Alzheimer's disease
- Stem cell treatments
Materials provided by University of York . Note: Content may be edited for style and length.
Journal Reference :
- Michael Spencer Chapman, Alyssa H. Cull, Marioara F. Ciuculescu, Erica B. Esrick, Emily Mitchell, Hyunchul Jung, Laura O’Neill, Kirsty Roberts, Margarete A. Fabre, Nicholas Williams, Jyoti Nangalia, Joanne Quinton, James M. Fox, Danilo Pellin, Julie Makani, Myriam Armant, David A. Williams, Peter J. Campbell, David G. Kent. Clonal selection of hematopoietic stem cells after gene therapy for sickle cell disease . Nature Medicine , 2023; DOI: 10.1038/s41591-023-02636-6
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Biostatistics Graduate Program
Max rohde is first author on new gene therapy research paper.
Posted by cullum1 on Wednesday, November 15, 2023 in News .
PhD candidate Max Rohde is first author on “ Practical and Statistical Considerations for the Long Term Follow-Up of Gene Therapy Trial Participants ” published recently in Clinical Pharmacology & Therapeutics . The paper outlines “some of the key considerations for designing long term follow-up protocols in the gene therapy setting” and offers “guidance for innovative operational and statistical methods that can help assess the safety profile and durability of response for these novel therapeutics.” Co-authors include Seoan Huh (Pfizer), Vanessa D’Souza (Google), Steven Arkin (Pfizer), Erika Roberts (ELR Lab Services), and Avery McIntosh (Pfizer).
Max’s research interests include adaptive clinical trial design, reproducible research, and statistics education. He was the 2022 winner of the Distinguished Teaching Assistant award .
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