Research Rigour and Therapeutic Flexibility: Rationale for a Therapy Manual Developed for a Randomised Controlled Trial

Biological principles for music and mental health

Efforts to integrate music into healthcare systems and wellness practices are accelerating but the biological foundations supporting these initiatives remain underappreciated. As a result, music-based interventions are often sidelined in medicine. Here, I bring together advances in music research from neuroscience, psychology, and psychiatry to bridge music's specific foundations in human biology with its specific therapeutic applications. The framework I propose organizes the neurophysiological effects of music around four core elements of human musicality: tonality, rhythm, reward, and sociality. For each, I review key concepts, biological bases, and evidence of clinical benefits. Within this framework, I outline a strategy to increase music's impact on health based on standardizing treatments and their alignment with individual differences in responsivity to these musical elements. I propose that an integrated biological understanding of human musicality-describing each element's functional origins, development, phylogeny, and neural bases-is critical to advancing rational applications of music in mental health and wellness.

Group music therapy with songwriting for adult patients with long-term depression (SYNCHRONY study): a feasibility and acceptability study of the intervention and parallel randomised controlled trial design with wait-list control and nested process evaluation

BACKGROUND

Despite effective treatments, one fifth of patients develop chronic depression. Music therapy may offer a different approach. This study aimed to assess feasibility and acceptability of a music therapy intervention and trial methodology.

METHODS

A parallel two-arm randomised controlled trial with wait-list control, mixed feasibility/acceptability measures and nested process evaluation. Adults with long-term depression (symptom duration > 1 year) were recruited from community mental health services and computer randomised to 42 sessions of group music therapy with songwriting three times per week or wait-list control. Depression, social functioning, distress, quality of life, satisfaction and service use were assessed by blinded researchers at enrolment, 1 week and 3 and 6 months post-therapy. Outcomes were analysed descriptively, controlling for baseline covariates. Recruitment (number eligible, participation and retention rates) and intervention (fidelity, adherence) feasibility were assessed using pre-defined stop-go criteria. Attendance, adverse events, mood, relationship satisfaction and semi-structured interviews were analysed in a nested process evaluation.

RESULTS

Recruitment processes were feasible with 421 eligible, 12.7% participation and 60% (18/30) retention. Thirty participants were randomised to intervention (N = 20) and control (N = 10). Session attendance was low (mean 10.5) with four withdrawals. Music therapist adherence was good but changes to session frequency were suggested. Outcomes were available for 10/20 treatment and 9/10 wait-list participants. Depression increased in both arms post-therapy. Treatment depression scores fell below baseline 3 and 6 months post-therapy indicating improvement. Wait-list depression scores increased from baseline 3 and 6 months post-therapy. At 3 months, the treatment arm improved from baseline on all measures except satisfaction and functioning. At 6 months, quality of life, distress and functioning improved with reduction in health service contacts. High-attending participants improved more than low-attending. Seven adverse events (one serious) were reported.

LIMITATIONS

As this was a feasibility study, clinical outcomes should be interpreted cautiously.

CONCLUSION

A randomised controlled trial of group music therapy using songwriting is feasible with inclusion criteria and session frequency modifications, but further intervention development is required.

TRIAL REGISTRATION

ISRCTN18164037 on 26.09.2016.

Process-outcome relations in music therapy versus music listening for people with schizophrenia viewed through a mediational model: the role of the therapeutic alliance

Objectives

Examine whether change in clinical outcomes for patients with schizophrenia and negative symptoms randomized to either Music Therapy (MT) or Music Listening (ML) is associated to moderators and mediators, with focus on alliance, attendance and dropout.

Method

An exploratory post-hoc analysis of data from an original randomized controlled trial (RCT) investigating the effect of MT vs. ML for people with schizophrenia and negative symptoms. Inclusion to the study was implemented through screening of referred patients for symptoms of schizophrenia and negative symptoms. A total of 57 patients were randomly assigned, 28 to MT and 29 to ML. Session logs and notes were included in this study. Statistical analysis investigated moderator and mediator relation to outcome variables: Negative symptoms, functioning, quality of life, and retention to treatment.

Results

On average, participants in MT attended 18.86 sessions (SD = 7.17), whereas those in ML attended 12.26 (SD = 9.52), a statistically significant difference (p = 0.0078). Dropout at 25 weeks was predicted by intervention, with dropout being 2.65 (SE = 1.01) times more likely in ML than in music therapy (p = 0.009). Helping alliance score at weeks was explained by intervention, with mean score being 0.68 (SE = 0.32) points lower in ML than in MT (p = 0.042). The number of sessions attended was also explained by intervention, with participants in ML attending on average 6.17 (SE = 2.24) fewer sessions than those randomized to MT (p = 0.008). Though both groups improved significantly, improvements in negative symptoms, depression, and functioning tended to be higher in ML, whereas improvements in alliance and quality of life tended to be higher in MT.

Conclusion

The analysis could not detect a direct link between helping alliance score and outcome variables. However, the analysis documented a stronger alliance developed in the MT group, a lower dropout rate, as well as higher attendance in treatment.Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02942459.

Music, families and interaction (MUFASA): a protocol article for an RCT study

Background

General mental health and interpersonal skills of families are crucial to children's development and future. Research suggests a link between participation in music activities and individuals' own sense of mental health, as well as an effect in objective measures of health such as quality of life, social skills, and rehabilitation of various kinds. However, in Denmark there are not many services for families with school-aged children (7–12 years) that focus on prevention and strengthening family interaction hereby minimising the risk of children not thriving and developing optimally in terms of social and emotional skills and competences. The purpose of this study is to investigate the effect of shared music activities on family interaction, parental stress, and child well-being.

Methods

The study is a controlled effect study where 40 family dyads from Aalborg and Aarhus are randomized into 4 different groups including music therapy activities, community music, family concerts and a control group. Measurements of family interaction (Assessment of Parent Child Interaction, APCI) and mental health (Parental Stress Scale, PSS, and the Strengths and Difficulties Questionnaire, SDQ) will be made at baseline/pre intervention, at post intervention and a follow-up measurement 12 month after baseline (month 1, 3 and 12) 3 times in total. Furthermore, data about the family dyad’s regular participation in music events as part of every-day life at the same measure points (month 1, 3 and 12). Since this is a planned prospective study, results are not yet available, but clinical experience from a feasibility study in 2021 were promising and expected challenges and changes are discussed in the article.

Discussion

Findings of this study will be relevant for all fields where music is applied for families, such as education, mental health, social work and for basic research on the study of music and interaction. Music used as a resource for families is crucial in understanding how different modalities can influence the family interaction including emotional communication and attachment.

Trial registration: ISRCTN, ISRCTN17290015, Registered 03 March 2022, https://www.isrctn.com/ISRCTN17290015

Date and protocol version

July 2022, version 1. Protocol is planned to be updated after finalized recruitment during second data collection point and again after the third and last data collection point (see Additional file 1: SPIRIT Checklist).

Observing Music Therapy in Dementia: Repeated Single-case Studies Assessing Well-being and Sociable Interaction

OBJECTIVES

This study compared behavioral expressions of momentary well-being and sociable behavior toward significant others during music therapy and regular social interaction.

METHODS

A 10-week active music therapy intervention was provided for people living with dementia and family caregivers. A bi-phasic AB single-case design was replicated for three sessions per dyad and coded using the Observable Well-being in Living with Dementia-Scale (OWLS) and the Verbal and Nonverbal Sociable Interaction Scale-Care Receiver (VNVIS-CR). Effect sizes (Log Response Ratio) were calculated for each session and analyzed with robust cluster meta-analysis.

RESULTS

Eleven dyads were included, and 32 sessions analyzed (2102 observations). Within sessions we found a 48% increase in well-being, and a 32% increase in sociable interaction during music therapy. Heterogeneity was high. Dementia severity predicted an increase in nonverbal sociable interaction (93% for moderate dementia). Depression and time did not predict any change.

CONCLUSION

The potential of music therapy to increase well-being and sociable interactions toward significant others calls for further investigation of heterogeneity and covariates. Single-case designs are demonstrated to be feasible for these investigations.

CLINICAL IMPLICATIONS

Preference-based music therapy may alleviate some of the individual and relational consequences of living with dementia, facilitating positive emotions and connection to significant others.

Music therapy for autistic people

BACKGROUND

Social interaction and social communication are among the central areas of difficulty for autistic people. Music therapy uses music experiences and the relationships that develop through them to enable communication and expression, thus attempting to address some of the core problems of autistic people. Music therapy has been applied in autism since the early 1950s, but its availability to autistic individuals varies across countries and settings. The application of music therapy requires specialised academic and clinical training which enables therapists to tailor the intervention to the specific needs of the individual. The present version of this review on music therapy for autistic people is an update of the previous Cochrane review update published in 2014 (following the original Cochrane review published in 2006).

OBJECTIVES

To review the effects of music therapy, or music therapy added to standard care, for autistic people.

SEARCH METHODS

In  August 2021, we searched  CENTRAL, MEDLINE, Embase, eleven other databases and two trials registers. We also ran citation searches, checked reference lists, and contacted study authors to identify additional studies.

SELECTION CRITERIA

All randomised controlled trials (RCTs), quasi-randomised trials and controlled clinical trials comparing music therapy (or music therapy alongside standard care) to 'placebo' therapy, no treatment, or standard care for people with a diagnosis of autism spectrum disorder were considered for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Four authors independently selected studies and extracted data from all included studies. We synthesised the results of included studies in meta-analyses. Four authors independently assessed risk of bias (RoB) of each included study using the original RoB tool as well as the certainty of evidence using GRADE.   MAIN RESULTS: We included 16 new studies in this update which brought the total number of included studies to 26 (1165 participants). These studies examined the short- and medium-term effect of music therapy (intervention duration: three days to eight months) for autistic people in individual or group settings. More than half of the studies were conducted in North America or Asia. Twenty-one studies included children aged from two to 12 years. Five studies included children and adolescents, and/or young adults. Severity levels, language skills, and cognition were widely variable across studies. Measured immediately post-intervention, music therapy compared with 'placebo' therapy or standard care was more likely to positively effect global improvement (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.06 to 1.40; 8 studies, 583 participants; moderate-certainty evidence; number needed to treat for an additional beneficial outcome (NNTB) = 11 for low-risk population, 95% CI 6 to 39; NNTB = 6 for high-risk population, 95% CI 3 to 21) and to slightly increase quality of life (SMD 0.28, 95% CI 0.06 to 0.49; 3 RCTs, 340 participants; moderate-certainty evidence, small to medium effect size). In addition, music therapy probably results in a large reduction in total autism symptom severity (SMD -0.83, 95% CI -1.41 to -0.24; 9 studies, 575 participants; moderate-certainty evidence). No clear evidence of a difference between music therapy and comparison groups at immediately post-intervention was found for social interaction (SMD 0.26, 95% CI -0.05 to 0.57, 12 studies, 603 participants; low-certainty evidence); non-verbal communication (SMD 0.26, 95% CI -0.03 to 0.55; 7 RCTs, 192 participants; low-certainty evidence); and verbal communication (SMD 0.30, 95% CI -0.18 to 0.78; 8 studies, 276 participants; very low-certainty evidence). Two studies investigated adverse events with one (36 participants) reporting no adverse events; the other study found no differences between music therapy and standard care immediately post-intervention (RR 1.52, 95% CI 0.39 to 5.94; 1 study, 290 participants; moderate-certainty evidence).  AUTHORS' CONCLUSIONS: The findings of this updated review provide evidence that music therapy is probably associated with an increased chance of global improvement for autistic people, likely helps them to improve total autism severity and quality of life, and probably does not increase adverse events immediately after the intervention. The certainty of the evidence was rated as 'moderate' for these four outcomes, meaning that we are moderately confident in the effect estimate. No clear evidence of a difference was found for social interaction, non-verbal communication, and verbal communication measured immediately post-intervention. For these outcomes, the certainty of the evidence was rated as 'low' or 'very low', meaning that the true effect may be substantially different from these results. Compared with earlier versions of this review, the new studies included in this update helped to increase the certainty and applicability of this review's findings through larger sample sizes, extended age groups, longer periods of intervention and inclusion of follow-up assessments, and by predominantly using validated scales measuring generalised behaviour (i.e. behaviour outside of the therapy context). This new evidence is important for autistic individuals and their families as well as for policymakers, service providers and clinicians, to help in decisions around the types and amount of intervention that should be provided and in the planning of resources. The applicability of the findings is still limited to the age groups included in the studies, and no direct conclusions can be drawn about music therapy in autistic individuals above the young adult age. More research using rigorous designs, relevant outcome measures, and longer-term follow-up periods is needed to corroborate these findings and to examine whether the effects of music therapy are enduring.

Long-Term Effects of Short-Term Music Therapy for Prison Inmates: Six-Year Follow-Up of a Randomized Controlled Trial

For most interventions to reduce criminal recidivism, long-term effects are uncertain. Music therapy has shown effects on possible precursors of recidivism, but direct evidence on long-term effects is lacking. In an exploratory parallel randomized controlled trial, 66 inmates in a Norwegian prison were allocated to music therapy or standard care and followed up over a median of 6 years, using state registry data. Median time to relapse was 5 years, with no differences between the interventions. The imprisonment of most participants was too short to provide a sufficient number of therapy sessions. Sufficiently powered studies are needed to examine the long-term effects of appropriate doses of therapy.

The Resilience Songwriting Program for Adolescent Bereavement: A Mixed Methods Exploratory Study

Music therapy research with youth who are grieving often reports on a combination of interventions, such as lyric analysis, improvisation, and/or songwriting. Unfortunately, the lack of theoretical transparency in how and why these interventions affect targeted outcomes limits interpretation and application of this important research. In this exploratory study, the authors evaluated the impact of an 8-session, theory-driven group songwriting program on protective factors in adolescent bereavement, and also sought to better understand adolescents' experiences of the program. Using a single-group, pretest-posttest convergent mixed methods design, participants were enrolled from three study sites and included 10 adolescents (five girls and five boys), ages 11-17 years, who self-identified as grieving a loss. Outcomes measured included grief, coping, emotional expression, self-esteem, and meaning making. Qualitative data were captured through in-session journaling and semi-structured interviews. There were no statistically significant improvements for grief, self-esteem, coping, and meaning making. Individual score trends suggested improvements in grief. The majority of the participants reported greater inhibition of emotional expression, and this was statistically significant. Thematic findings revealed that the program offered adolescents a sense of togetherness, a way to safely express grief-related emotions and experiences verbally and nonverbally, and opportunities for strengthening music and coping skills. These findings suggest that engaging in collaborative therapeutic songwriting with grieving peers may decrease levels of grief, enhance creative expression, and provide social support. More research is needed on measuring self-esteem, emotional expression, coping, and meaning making outcomes in ways that are meaningful to adolescents.

Facilitated music listening: Music therapy in an invasive cardiac procedure

This article presents and discusses a clinical music therapy protocol for use during an invasive cardiac procedure and the theoretical rationale behind it. The protocol was developed for a specific invasive cardiac procedure performed transvenously with local anaesthesia: cardiac implantable electronic device lead extraction. The music listening intervention presented in the protocol aims to optimise stress and pain management for patients through patient involvement, communication, individualised music listening and relaxation techniques. The Music Therapist remains present throughout the peri-operative phase (in the operating theatre during the operation). The music is chosen from a limited set of prepared playlists through a process involving assessment and patient preference. Biological, psychological and social components are integrated into the protocol, which is also informed by the theory of music therapy as procedural support, the neuromatrix theory of pain and receptive music therapy techniques. The protocol was developed to be standardised for implementation into the existing medical procedure, yet flexible enough to meet individual patient needs. It is the cornerstone of the research protocol of an ongoing randomised controlled trial at the Department of Cardiology at Oslo University Hospital Ulleval. Results of the randomised controlled trial, focussing on quantitative efficacy outcomes, are expected in 2020.

Accumulating Evidence for Dance/Movement Therapy in Cancer Care

This review offers a discussion of the state of dance/movement therapy (DMT), research with people living with cancer. The vast majority of extant studies published in the English language are with women with breast cancer. An examination of challenges facing DMT researchers in this area is provided, and recommendations for research foci, and priorities are outlined. These include qualitative syntheses, integration of implementation evidence with qualitative synthesis, and formal process evaluation studies.

A Conceptual Framework: The Musical Self as a Unique Pathway to Outcomes in the Acute Pediatric Health Setting

This article reports on a project at the Royal Children's Hospital Melbourne in which the music therapy team synthesized their practice and related theories to propose a new conceptual framework for music therapy in their acute pediatric setting. The impetus for the project was the realization that in the process of producing key statements about the non-musical benefits of music therapy, the cost was often the suppression of information about the patient's unique musical potential as the major (mediating) pathway from referral reason, to music therapy, and to effective outcomes. The purpose of the project was to articulate how this team of clinicians conceive of the patient's musical self as the major theoretical pathway for music therapy in an evidence-based acute medical setting. The clinicians' shared reflexive process across six months involved robust directed discussion, annotation of shared reading, and documentation of all engagement in words and diagrams. The outcome was a consensus framework including three constructs: the place of music in the life of the infant, child, and young people, Culture and Context, and Musical Manifestations. The constructs were tested in a clinical audit, and found to be robustly inclusive. In addition to the conceptual framework, this project serves to demonstrate a process by which clinical teams may reflect on their individual practice and theory together to create a consensus stance for the overall service they provide in the one setting.

Feasibility and acceptability of group music therapy vs wait-list control for treatment of patients with long-term depression (the SYNCHRONY trial): study protocol for a randomised controlled trial

BACKGROUND

Depression is of significant global concern. Despite a range of effective treatment options it is estimated that around one in five diagnosed with an acute depressive episode continue to experience enduring symptoms for more than 2 years. There is evidence for effectiveness of individual music therapy for depression. However, no studies have as yet looked at a group intervention within an NHS context. This study aims to assess the feasibility of conducting a randomised controlled trial of group music therapy for patients with long-term depression (symptom durations of 1 year or longer) within the community.

METHODS

This is a single-centre randomised controlled feasibility trial of group music therapy versus wait-list control with a nested process evaluation. Thirty participants will be randomised with unbalanced allocation (20 to receive the intervention immediately, 10 as wait-list controls). Group music therapy will be offered three times per week in a community centre with a focus on songwriting. Data will be collected post-intervention, 3 and 6 months after the intervention finishes. We will examine the feasibility of recruitment processes including identifying the number of eligible participants, participation and retention rates and the intervention in terms of testing components, measuring adherence and estimation of the likely intervention effect. A nested process evaluation will consist of treatment fidelity analysis, exploratory analysis of process measures and end-of-participation interviews with participants and referring staff.

DISCUSSION

Whilst group music therapy is an option in some community mental health settings, this will be the first study to examine group music therapy for this particular patient group. We will assess symptoms of depression, acceptability of the intervention and quality of life. We anticipate potential challenges in the recruitment and retention of participants. It is unclear whether offering the intervention three times per week will be acceptable to participants, particularly given participants' enduring symptoms and impact upon motivation. This study will provide data to inform both development of the intervention and to assess and inform the design of a full trial.

TRIAL REGISTRATION

ISRCTN.com, ISRCTN18164037 . Registered on 26 September 2016.

Evidence and Effectiveness in Music Therapy

Adopting a knowledge-based controversy perspective, this article considers critically the ‘fit’ or appropriateness of the so-called ‘gold standard’ of assessment – the Randomised Controlled Trial. It sets the growing dominance of this method within music therapy in the contexts of medical work and the changing social relations of medical expertise, the importance of local practice in music therapy (and healthcare more widely), and the politics of representation as they apply to medical modes of accounting and measurement. I then consider what is overlooked when experimental models are used as the prime mode of perceiving the music therapeutic process and suggest that they may not provide a good or appropriate way of observing, accounting for and assessing music therapy. I suggest that they are not amenable to the observation and documentation of temporal and local craft practices and that these practices provide the active ingredients of music therapy's effectiveness. I conclude that music therapy is poised to highlight the radical performative and social features of health status and that these features have far-reaching implications for our concepts of illness and the aetiology of illness and, most importantly, for the ways in which we conceptualise and implement therapeutic procedures of all kinds.

Whose Power of Music?

This article considers questions concerning the ontology of music in relation to music therapy. Contemporary musicology emphasises the cultural context of music and the role of individual experience and interpretation. The concepts of musical affordance and musical appropriation offer a representation of music centred around the contextually situated individual without neglecting the aesthetic qualities inherent in musical structure and performance. This article considers music as a potential health resource that can be accessed and used in multiple ways, linking this with a contextual approach to therapy. Political implications are discussed in relation to the accessibility and power of music in music therapy.

Randomized Trial of Group Music Therapy With Chinese Prisoners: Impact on Anxiety, Depression, and Self-Esteem

This study investigated the effects of group music therapy on improving anxiety, depression, and self-esteem in Chinese prisoners. Two-hundred male prisoners were randomly assigned to music therapy (n = 100) or standard care (n = 100). The music therapy had 20 sessions of group therapy compared with standard care. Anxiety (State and Trait Anxiety Inventory [STAI]), depression (Beck Depression Inventory [BDI]), and self-esteem (Texas Social Behavior Inventory [TSBI], Rosenberg Self-Esteem Inventory [RSI]) were measured by standardized scales at baseline, mid-program, and post-program. Data were analyzed based on the intention to treat principle. Compared with standard care, anxiety and depression in the music therapy condition decreased significantly at mid-test and post-test; self-esteem improved significantly at mid-test (TSBI) and at post-test (TSBI, RSI). Improvements were greater in younger participants (STAI-Trait, RSI) and/or in those with a lower level of education (STAI-State, STAI-Trait). Group music therapy seems to be effective in improving anxiety, depression, and self-esteem and was shown to be most beneficial for prisoners of younger age or with lower education level.

Concepts of context in music therapy

In contemporary music therapy as well as in related interdisciplinary fields, the importance of context in relation to theory, research, and practice has been emphasized. However, the word context seems to be used in several different ways and conceptualizations of contextual approaches vary too. The objective of this theoretical article is to clarify traditions of language use in relation to context in music therapy. In reviewing and discussing the literature, we focus on the field of mental health care. When discussing issues related to context, this literature partly focuses on the surroundings of music therapy practice, partly on the ecology of reciprocal influences within and between situations or systems. On this basis, three types of context awareness in music therapy are identified: music therapy in context; music therapy as context; and music therapy as interacting contexts. The identified types of context awareness are exemplified through references to music therapy literature and then discussed in relation to two very different metaphors, namely context as frame and context as link. Implications for practice, research, and theory development in music therapy are suggested.

Music therapy for prisoners: pilot randomised controlled trial and implications for evaluating psychosocial interventions

Mental health problems are common among prison inmates. Music therapy has been shown to reduce mental health problems. It may also be beneficial in the rehabilitation of prisoners, but rigorous outcome research is lacking. We compared group music therapy with standard care for prisoners in a pilot randomised controlled trial that started with the establishment of music therapy services in a prison near Bergen in 2008. In all, 113 prisoners agreed to participate. Anxiety (STAI-State [State-Trait Anxiety Inventory], STAI-Trait), depression (HADS-D [Hospital Anxiety and Depression Scale]), and social relationships (Quality of Life Enjoyment and Satisfaction Questionnaire [Q-LES-Q]) were assessed at baseline; every 2 weeks in the experimental group; after 1, 3, and 6 months in the control group; and at release. No restrictions were placed on the frequency, duration, or contents of music therapy. Duration of stay in the institution was short (62% stayed less than 1 month). Only a minority reached clinical cutoffs for anxiety and depression at baseline. Between-group analyses of effects were not possible. Music therapy was well accepted and attractive among the prisoners. Post hoc analysis of within-group changes suggested a reduction of state anxiety after 2 weeks of music therapy (d = 0.33, p = .025). Short sentences and low baseline levels of psychological disturbance impeded the examination of effects in this study. Recommendations for planning future studies are given, concerning the careful choice of participants, interventions and settings, comparison condition and design aspects, choice of outcomes, and integration of research approaches. Thus, the present study has important implications for future studies evaluating interventions for improving prisoners' mental health.

TRIAL REGISTRATION

ISRCTN22518605.

Music therapy for people with autism spectrum disorder

BACKGROUND

The central impairments of people with autism spectrum disorder (ASD) affect social interaction and communication. Music therapy uses musical experiences and the relationships that develop through them to enable communication and expression, thus attempting to address some of the core problems of people with ASD. The present version of this review on music therapy for ASD is an update of the original Cochrane review published in 2006.

OBJECTIVES

To assess the effects of music therapy for individuals with ASD.

SEARCH METHODS

We searched the following databases in July 2013: CENTRAL, Ovid MEDLINE, EMBASE, LILACS, PsycINFO, CINAHL, ERIC, ASSIA, Sociological Abstracts, and Dissertation Abstracts International. We also checked the reference lists of relevant studies and contacted investigators in person.

SELECTION CRITERIA

All randomised controlled trials (RCTs) or controlled clinical trials comparing music therapy or music therapy added to standard care to 'placebo' therapy, no treatment, or standard care for individuals with ASD were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, assessed risk of bias, and extracted data from all included studies. We calculated the pooled standardised mean difference (SMD) and corresponding 95% confidence interval (CI) for continuous outcomes to allow the combination data from different scales and to facilitate the interpretation of effect sizes. Heterogeneity was assessed using the I² statistic. In cases of statistical heterogeneity within outcome subgroups, we examined clients' age, intensity of therapy (number and frequency of therapy sessions), and treatment approach as possible sources of heterogeneity.

MAIN RESULTS

We included 10 studies (165 participants) that examined the short- and medium-term effect of music therapy interventions (one week to seven months) for children with ASD. Music was superior to 'placebo' therapy or standard care with respect to the primary outcomes social interaction within the therapy context (SMD 1.06, 95% CI 0.02 to 2.10, 1 RCT, n = 10); generalised social interaction outside of the therapy context (SMD 0.71, 95% CI 0.18 to 1.25, 3 RCTs, n = 57, moderate quality evidence), non-verbal communicative skills within the therapy context (SMD 0.57, 95% CI 0.29 to 0.85, 3 RCTs, n = 30), verbal communicative skills (SMD 0.33, 95% CI 0.16 to 0.49, 6 RCTs, n = 139), initiating behaviour (SMD 0.73, 95% CI 0.36 to 1.11, 3 RCTs, n = 22, moderate quality evidence), and social-emotional reciprocity (SMD 2.28, 95% CI 0.73 to 3.83, 1 RCT, n = 10, low quality evidence). There was no statistically significant difference in non-verbal communicative skills outside of the therapy context (SMD 0.48, 95% CI -0.02 to 0.98, 3 RCTs, n = 57, low quality evidence). Music therapy was also superior to 'placebo' therapy or standard care in secondary outcome areas, including social adaptation (SMD 0.41, 95% CI 0.21 to 0.60, 4 RCTs, n = 26), joy (SMD 0.96, 95% CI 0.04 to 1.88, 1 RCT, n = 10), and quality of parent-child relationships (SMD 0.82, 95% CI 0.13 to 1.52, 2 RCTs, n = 33, moderate quality evidence). None of the included studies reported any adverse effects. The small sample sizes of the studies limit the methodological strength of these findings.

AUTHORS' CONCLUSIONS

The findings of this updated review provide evidence that music therapy may help children with ASD to improve their skills in primary outcome areas that constitute the core of the condition including social interaction, verbal communication, initiating behaviour, and social-emotional reciprocity. Music therapy may also help to enhance non-verbal communication skills within the therapy context. Furthermore, in secondary outcome areas, music therapy may contribute to increasing social adaptation skills in children with ASD and to promoting the quality of parent-child relationships. In contrast to the studies included in an earlier version of this review published in 2006, the new studies included in this update enhanced the applicability of findings to clinical practice. More research using larger samples and generalised outcome measures is needed to corroborate these findings and to examine whether the effects of music therapy are enduring. When applying the results of this review to practice, it is important to note that the application of music therapy requires specialised academic and clinical training.

Individual music therapy for mental health care clients with low therapy motivation: multicentre randomised controlled trial

BACKGROUND

Music therapy (MT) has been shown to be efficacious for mental health care clients with various disorders such as schizophrenia, depression and substance abuse. Referral to MT in clinical practice is often based on other factors than diagnosis. We aimed to examine the effectiveness of resource-oriented MT for mental health care clients with low motivation for other therapies.

METHOD

This was a pragmatic parallel trial. In specialised centres in Norway, Austria and Australia, 144 adults with non-organic mental disorders and low therapy motivation were randomised to 3 months of biweekly individual, resource-oriented MT plus treatment as usual (TAU) or TAU alone. TAU was typically intensive (71% were inpatients) and included the best combination of therapies available for each participant, excluding MT. Blinded assessments of the Scale for the Assessment of Negative Symptoms (SANS) and 15 secondary outcomes were collected before randomisation and after 1, 3 and 9 months. Changes were analysed on an intention-to-treat basis using generalised estimating equations in longitudinal linear models, controlling for diagnosis, site and time point.

RESULTS

MT was superior to TAU for total negative symptoms (SANS, d = 0.54, p < 0.001) as well as functioning, clinical global impressions, social avoidance through music, and vitality (all p < 0.01).

CONCLUSION

Individual MT as conducted in routine practice is an effective addition to usual care for mental health care clients with low motivation.

Individual music therapy for agitation in dementia: an exploratory randomized controlled trial

OBJECTIVES

Agitation in nursing home residents with dementia leads to increase in psychotropic medication, decrease in quality of life, and to patient distress and caregiver burden. Music therapy has previously been found effective in treatment of agitation in dementia care but studies have been methodologically insufficient. The aim of this study was to examine the effect of individual music therapy on agitation in persons with moderate/severe dementia living in nursing homes, and to explore its effect on psychotropic medication and quality of life.

METHOD

In a crossover trial, 42 participants with dementia were randomized to a sequence of six weeks of individual music therapy and six weeks of standard care. Outcome measures included agitation, quality of life and medication.

RESULTS

Agitation disruptiveness increased during standard care and decreased during music therapy. The difference at -6.77 (95% CI (confidence interval): -12.71, -0.83) was significant (p = 0.027), with a medium effect size (0.50). The prescription of psychotropic medication increased significantly more often during standard care than during music therapy (p = 0.02).

CONCLUSION

This study shows that six weeks of music therapy reduces agitation disruptiveness and prevents medication increases in people with dementia. The positive trends in relation to agitation frequency and quality of life call for further research with a larger sample.

Shifting effects in randomised controlled trials of complex interventions: a new kind of performance bias?

OBJECTIVE

Randomised controlled trials (RCTs) aim to provide unbiased estimates of treatment effects. However, the process of implementing trial procedures may have an impact on the performance of complex interventions that rely strongly on the intuition and confidence of therapists. We aimed to examine whether shifting effects over the recruitment period can be observed that might indicate such impact.

METHOD

Three RCTs investigating music therapy vs. standard care were included. The intervention was performed by experienced therapists and based on established methods. We examined outcomes of participants graphically, analysed cumulative effects and tested for differences between first vs. later participants. We tested for potential confounding population shifts through multiple regression models.

RESULTS

Cumulative differences suggested trends over the recruitment period. Effect sizes tended to be less favourable among the first participants than later participants. In one study, effects even changed direction. Age, gender and baseline severity did not account for these shifting effects.

CONCLUSION

Some trials of complex interventions have shifting effects over the recruitment period that cannot be explained by therapist experience or shifting demographics. Replication and further research should aim to find out which interventions and trial designs are most vulnerable to this new kind of performance bias.

The Use of Performances in Music Therapy Practice in Australia: A Qualitative Study

The inclusion of performance as a part of the music therapy process is gaining increasing prominence in the literature. Although community music therapy discourse provides a theoretical explanation for the inclusion of performances, better understandings of the practical motivations underlying clinicians' use of performance are needed. Drawing on the responses of 18 Australian music therapists to an emailed questionnaire, this qualitative investigation solicited descriptions of how and why performances were included in their practices and what potential therapeutic outcomes and pitfalls had been experienced. Questionnaire responses were analysed using open coding – an inductive process that facilitates the identification of key ideas from within a data set. Analysis revealed a set of interweaving considerations that led the participating music therapists to use performance, and these were framed into a decision-making tree by the authors. A commitment to the needs of each individual client within performances was identified and this is discussed in light of community music therapy theory. Further investigations of the use of performance in music therapy are needed to better understand the implications of this practice.

Randomised controlled trial of improvisational music therapy's effectiveness for children with autism spectrum disorders (TIME-A): study protocol

Background

Previous research has suggested that music therapy may facilitate skills in areas typically affected by autism spectrum disorders such as social interaction and communication. However, generalisability of previous findings has been restricted, as studies were limited in either methodological accuracy or the clinical relevance of their approach. The aim of this study is to determine effects of improvisational music therapy on social communication skills of children with autism spectrum disorders. An additional aim of the study is to examine if variation in dose of treatment (i.e., number of music therapy sessions per week) affects outcome of therapy, and to determine cost-effectiveness.

Methods/Design

Children aged between 4;0 and 6;11 years who are diagnosed with autism spectrum disorder will be randomly assigned to one of three conditions. Parents of all participants will receive three sessions of parent counselling (at 0, 2, and 5 months). In addition, children randomised to the two intervention groups will be offered individual, improvisational music therapy over a period of five months, either one session (low-intensity) or three sessions (high-intensity) per week. Generalised effects of music therapy will be measured using standardised scales completed by blinded assessors (Autism Diagnostic Observation Schedule, ADOS) and parents (Social Responsiveness Scale, SRS) before and 2, 5, and 12 months after randomisation. Cost effectiveness will be calculated as man years. A group sequential design with first interim look at N = 235 will ensure both power and efficiency.

Discussion

Responding to the need for more rigorously designed trials examining the effectiveness of music therapy in autism spectrum disorders, this pragmatic trial sets out to generate findings that will be well generalisable to clinical practice. Addressing the issue of dose variation, this study's results will also provide information on the relevance of session frequency for therapy outcome.

Trial Registration

Current Controlled Trials ISRCTN78923965.

Individual music therapy for depression: randomised controlled trial

BACKGROUND

Music therapy has previously been found to be effective in the treatment of depression but the studies have been methodologically insufficient and lacking in clarity about the clinical model employed. Aims To determine the efficacy of music therapy added to standard care compared with standard care only in the treatment of depression among working-age people.

METHOD

Participants (n = 79) with an ICD-10 diagnosis of depression were randomised to receive individual music therapy plus standard care (20 bi-weekly sessions) or standard care only, and followed up at baseline, at 3 months (after intervention) and at 6 months. Clinical measures included depression, anxiety, general functioning, quality of life and alexithymia.

TRIAL REGISTRATION

ISRCTN84185937.

RESULTS

Participants receiving music therapy plus standard care showed greater improvement than those receiving standard care only in depression symptoms (mean difference 4.65, 95% CI 0.59 to 8.70), anxiety symptoms (1.82, 95% CI 0.09 to 3.55) and general functioning (-4.58, 95% CI -8.93 to -0.24) at 3-month follow-up. The response rate was significantly higher for the music therapy plus standard care group than for the standard care only group (odds ratio 2.96, 95% CI 1.01 to 9.02).

CONCLUSIONS

Individual music therapy combined with standard care is effective for depression among working-age people with depression. The results of this study along with the previous research indicate that music therapy with its specific qualities is a valuable enhancement to established treatment practices.

The Clinical Application and Relevance of Resource-Oriented Principles in Music Therapy within an International Multicentre Study in Psychiatry

This article is based on an international randomised controlled trial (RCT) in psychiatry investigating the effects of music therapy on difficult to treat psychiatric clients who show a lack of motivation to attend therapy. Previous research has shown that music therapy can be an alternative therapeutic treatment for this client group and this RCT aimed to address this observation.

The RCT was a collaboration between music therapists from different therapeutic cultures - Norway, Austria and Australia. Consequently, the music therapy provided was influenced by different training backgrounds. To provide a common methodological basis the therapists also focused on resource-oriented principles. These were especially developed for the study to ensure treatment fidelity, yet first of all have an important impact on the practical work.

Five case vignettes depict how different therapists made use of these principles and in which ways these affected the therapeutic process. It will be shown how these principles serve as a methodological tool for reflecting the therapist's attitude towards the client.

The relevance of the principles in terms of the establishment of a therapeutic relationship as well as the importance of a resource-oriented focus both in long-term and short-term therapeutic settings is highlighted. Finally, it can be assumed that resource-oriented principles exist at least implicitly throughout music therapeutic cultures and that these emphasise the relationship between therapist and client.