Individual music therapy for depression: randomised controlled trial

Individual music therapy for depression: randomised controlled trial

1. Jaakko Erkkilä, 
2. Marko Punkanen, Lic Phil, 
3. Jörg Fachner, and 
4. Esa Ala-Ruona. 2011
   British Journal of Psychiatry, 199:132-139.

http://bjp.rcpsych.org/content/199/2/132.short

AND

Depression "makes us biologically older"
Michelle Roberts
http://www.bbc.co.uk/news/health-24897247

Summary:
 This study investigates the effect of individual music therapy on working-age (18-50) patients with depression. In particular, this publication set out to describe their methodology with greater clarity in regards to the clinical model, as the authors felt this was often lacking in other publications in this field.

 A few notes of interest from this publication's introduction are that up to 6.5% of the Finnish population suffers from diagnosed depression, and often verbal psychotherapy is insufficient, leading to the authors' investigation of music therapy as an additional treatment strategy. The reason this group investigated improvisational music therapy in particular is because it is considered a non-verbal method of  experiencing emotions and reliving memories.

Here, 79 adults with unipolar depression as a primary diagnosis were investigated. Anxiety was also described due to its high comorbidity with depression. Medication was continued throughout the study. Subjects were not excluded or included based on previous music training; however, repeated suicidal behaviours, acute, severe substance misuse, and psychosis were exclusion factors. The participants were randomized into two groups: standard care, and standard care with music therapy in a 10:7 ratio. Psychiatric evaluation was conducted at baseline, 3 months, and 6 months post treatment. These evaluations were done by a single clinical expert with extensive psychiatric experience, and no knowledge of which patient belonged to which experimental group. The study used the Montgomery-Asberg Depression Rating Scale (MADRS) to quantify primary outcome measures, which was calculated as a 50% or greater decrease in MADRS score. Similarly verified rating scales were used to measure secondary outcomes including anxiety, global functioning, health-related quality of life, and alexithymia (a disorder in which a patient has difficulty identifying and assessing internal emotions). The authors also measured electroencephalographic biomarkers; however, these were reported separately.

 Music therapy was administered in up to 20 bi-weekly sessions, lasting 60 minutes each, and the instruments used included a mallet instrument, a percussion instrument, and an acoustic djembe drum. The theory was that music therapy may be helpful in psychodynamic therapy since they both involve the expression of emotions, metaphor, and association and image.

 Changes in MADRS scores, and  in secondary outcome measures, excluding alexithymia, were significantly greater in the music therapy group, which persisted in the 6-month follow up assessment. Results were not effected by whether or not the patients self-described as musicians or singers, age, or medication. There was no significant difference seen in alexithymia, although there was a greater trend towards improvement with music therapy. This study employed 10 different, equally trained music therapists, and results were consistent among all individuals, which indicates that results were based on music therapy in general, as opposed to a particular therapist.

 In conclusion, this study effectively demonstrates that music therapy, in conjunction with standard treatment, statistically alleviates symptoms of depression, anxiety, and improves general functioning.

 As for the second article by Michelle Roberts, this article from BBC news briefly describes a possible cellular link between more rapid aging and depression, which further validates the medical need for intervention. This cellular link is found in the telomeres, which are chromosomal "caps" protecting the coding DNA from degradation after multiple rounds of replication. In depressed patients, these telomere caps allegedly shorten more rapidly, which increases the rate of genetic DNA degradation or "cell aging". This article was included to complement the above-described study.

Response:

 I was particularly impressed with this publication's outline of their clinical model, and meticulous approach in their experimental design. These qualities are often lacking in music therapy publications, as the authors themselves attest to in the introductory paragraph; however, this publication provides believable, controlled, statistically significant data, and a formidable model for future studies to build upon. This publication was a pleasure to read, and the results were very exciting. The authors reliably find a significant amelioration in depression, and secondary outcomes of patients engaging in music therapy. Also, the authors were able to assess 3 month and 6 month follow up outcomes, and found these improvements were maintained. This data has astounding implications for our current therapy paradigm, and suggests that music therapy should be a standard complement in depression treatment.

 I read Michelle Robert's article first, and it was what inspired me to ask if music can lessen depression. I had gone through several articles before choosing to write about this one. I found my choices were typically either a well-designed protocol outline, or a loosely controlled, poorly described study that directly investigated the effects of music therapy on depression. This article was the first, and most recent, that I could find that did both. I applaud Erkkila and colleagues for this work, and hope that future investigations on music therapy and depression will be forced to meet the same standards set by their precedence.

 As for limitations of this study, the authors themselves address them in the conclusion of the discussion. This study, although impressive with n=79, is still a preliminary trial that did not address every possible variable in music therapy. These variables include musical instrumentation, and frequency and duration of therapy. However, this study was a necessary building block from which more precise investigations can continue.