music as therapy essay

The Transformative Power of Music in Mental Well-Being

• August 01, 2023
• Healthy living for mental well-being, Patients and Families, Treatment

Music has always held a special place in our lives, forming an integral part of human culture for centuries. Whether we passively listen to our favorite songs or actively engage in music-making by singing or playing instruments, music can have a profound influence on our socio-emotional development and overall well-being.

Recent research suggests that music engagement not only shapes our personal and cultural identities but also plays a role in mood regulation. 1 A 2022 review and meta-analysis of music therapy found an overall beneficial effect on stress-related outcomes. Moreover, music can be used to help in addressing serious mental health and substance use disorders. 2 In addition to its healing potential, music can magnify the message of diversity and inclusion by introducing people to new cultures and amplifying the voice of marginalized communities, thereby enhancing our understanding and appreciation for diverse communities.

Healing Trauma and Building Resilience

Many historically excluded groups, such as racial/ethnic and sexual minorities and people with disabilities, face systemic injustices and traumatic experiences that can deeply impact their mental health. Research supports the idea that discrimination, a type of trauma, increases risk for mental health issues such as anxiety and depression. 3

Music therapy has shown promise in providing a safe and supportive environment for healing trauma and building resilience while decreasing anxiety levels and improving the functioning of depressed individuals. 4 Music therapy is an evidence-based therapeutic intervention using music to accomplish health and education goals, such as improving mental wellness, reducing stress and alleviating pain. Music therapy is offered in settings such as schools and hospitals. 1 Research supports that engaging in music-making activities, such as drumming circles, songwriting, or group singing, can facilitate emotional release, promote self-reflection, and create a sense of community. 5

Empowerment, Advocacy and Social Change

Music has a rich history of being used as a tool for social advocacy and change. Artists from marginalized communities often use music to shed light on social issues (.pdf) , challenge injustices, and inspire collective action. By addressing topics such as racial inequality, gender discrimination, and LGBTQ+ rights, music becomes a powerful medium for advocating for social justice and promoting inclusivity. Through music, individuals can express their unique experiences, struggles, and triumphs, forging connections with others who share similar backgrounds. Research has shown that exposure to diverse musical genres and artists can broaden perspectives, challenge stereotypes, and foster empathy among listeners especially when dancing together. 7

Genres such as hip-hop, reggae, jazz, blues, rhythm & blues and folk have historically served as platforms for marginalized voices, enabling them to reclaim their narratives and challenge societal norms. The impact of socially conscious music has been observed in movements such as civil rights, feminism, and LGBTQ+ rights, where songs have played a pivotal role in mobilizing communities and effecting change. Music artists who engage in activism can reach new supporters and help their fans feel more connected to issues and motivated to participate. 6

Fostering Social Connection and Support

Music can also serve as a catalyst for social connection and support, breaking down barriers and bridging divides. Emerging evidence indicates that music has the potential to enhance prosocial behavior, promote social connectedness, and develop emotional competence. 2 Communities can leverage music’s innate ability to connect people and foster a sense of belonging through music programs, choirs, and music education initiatives. These activities can create inclusive spaces where people from diverse backgrounds can come together, collaborate, and build relationships based on shared musical interests. These experiences promote social cohesion, combat loneliness, and provide a support network that can positively impact overall well-being.

Musicians and Normalizing Mental Health

Considering the healing effects of music, it may seem paradoxical that musicians may be at a higher risk of mental health disorders. 8 A recent survey of 1,500 independent musicians found that 73% have symptoms of mental illness. This could be due in part to the physical and psychological challenges of the profession. Researchers at the Max Planck Institute for Empirical Aesthetics in Germany found that musically active people have, on average, a higher genetic risk for depression and bipolar disorder.

Commendably, many artists such as Adele, Alanis Morrisette, Ariana Grande, Billie Eilish, Kendrick Lamar, Kid Cudi and Demi Lovato have spoken out about their mental health battles, from postpartum depression to suicidal ideation. Having high-profile artists and celebrities share their lived experiences has opened the conversation about the importance of mental wellness. This can help battle the stigma associated with seeking treatment and support.

Dr. Regina James (APA’s Chief of the Division of Diversity and Health Equity and Deputy Medical Director) notes “Share your story…share your song and let's help each other normalize the conversation around mental wellness through the influence of music. My go-to artist for relaxation is jazz saxophonist, “Grover Washington Jr” …what’s yours?” Submit to [email protected] to get featured!

More on Music Therapy

• Music Therapy Fact Sheets from the American Music Therapy Association
• Music Therapy Resources for Parents and Caregivers from Music Therapy Works

By Fátima Reynolds DJ and Music Producer Senior Program Manager, Division of Diversity and Health Equity American Psychiatric Association

• Gustavson, D.E., 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
• Golden, T. L., et al. (2021). The use of music in the treatment and management of serious mental illness: A global scoping review of the literature. Frontiers in Psychology, 12. https://doi.org/10.3389/fpsyg.2021.649840
• Schouler-Ocak, M., et al. (2021). Racism and mental health and the role of Mental Health Professionals. European Psychiatry, 64(1). https://doi.org/10.1192/j.eurpsy.2021.2216
•  Aalbers, S., et al. (2017). Music therapy for Depression. Cochrane Database of Systematic Reviews, 2017(11). https://doi.org/10.1002/14651858.cd004517.pub3
• Dingle, G. A., et al. (2021). How do music activities affect health and well-being? A scoping review of studies examining Psychosocial Mechanisms. Frontiers in Psychology, 12. https://doi.org/10.3389/fpsyg.2021.713818
• Americans for the Arts. (n.d.). A Working Guide to the Landscape of Arts for Change. Animating Democracy. http://animatingdemocracy.org/sites/default/files/Potts%20Trend%20Paper.pdf
• Stupacher, J., Mikkelsen, J., Vuust, P. (2021). Higher empathy is associated with stronger social bonding when moving together with music. Psychology of Music, 50(5), 1511–1526. https://doi.org/10.1177/03057356211050681
• Wesseldijk, L.W., Ullén, F. & Mosing, M.A. The effects of playing music on mental health outcomes. Sci Rep 9, 12606 (2019). https://doi.org/10.1038/s41598-019-49099-9

Medical leadership for mind, brain and body.

Mobile menu.

• Psychiatrists
• Residents & Medical Students
• Patients and Families
• Advocacy & APAPAC
• Diversity & Health Equity
• Research & Registry
• Meetings & Events
• Search Directories & Databases
• International
• Medical Students
• What is Psychiatry?
• Find a Psychiatrist
• Addiction and Substance Use Disorders
• Dementia and Alzheimer's Disease
• Alcohol Use Disorder
• Anxiety Disorders
• Attention-Deficit/Hyperactivity Disorder (ADHD)
• Autism Spectrum Disorder
• Bipolar Disorders
• Climate Change and Mental Health Connections
• Coping After Disaster
• Disruptive, Impulse-Control and Conduct Disorders
• Dissociative Disorders
• Domestic Violence
• Eating Disorders
• E-Cigarettes and Vaping
• Gambling Disorder
• Gender Dysphoria
• Helping a Loved One Cope with Mental Illness
• Hoarding Disorder
• Integrated Behavioral Healthcare
• Intellectual Disability
• Internet Gaming
• Obsessive-Compulsive Disorder
• Opioid Use Disorder
• Perinatal Depression (formerly Postpartum)
• Personality Disorders
• Posttraumatic Stress Disorder (PTSD)
• Prolonged Grief Disorder
• Schizophrenia
• Seasonal Affective Disorder (SAD)
• Sleep Disorders
• Somatic Symptom Disorder
• Specific Learning Disorders
• Stigma, Prejudice and Discrimination Against People with Mental Illness
• Suicide Prevention
• Technology Addictions: Social Media, Online Gaming, and More
• Warning Signs of Mental Illness
• Electroconvulsive Therapy (ECT)
• What is Mental Illness?
• What is Psychotherapy?
• What is Telepsychiatry?
• La Salud Mental
• Childhood Disorders: Medication Guides for Parents
• Lifestyle to Support Mental Health
• Member Benefits
• Honorary Fellowship (FAPA & DFAPA)
• Awards & Leadership Opportunities
• Get Involved
• Directories, Contact Info & FAQs
• District Branches
• APA's Vision, Mission, Values, and Goals
• Meet Our Organization
• Read APA Organization Documents and Policies
• Work At APA
• About APA's Headquarters
• Policy Finder
• News Releases
• Messages from the APA President
• Reporting on Mental Health Conditions
• Goldwater Rule
• Annual Meeting Press Registration + Guidelines
• APA Public Opinion Polls
• Reporter Toolkit: Recommendations on Covering the AAPI Community
• Comunicados de prensa en español
• APA Annual Meeting
• APA Communities
• APA Foundation
• APA JobCentral
• APA Learning Center
• APA Publishing
• Center for Workplace Mental Health
• Melvin Sabshin, M.D. Library & Archives
• Psychiatric News
• Psychiatry Online
• Annual Meeting
• APA On Demand
• At the APA Educational Series
• Books and Journals
• Certification and Licensure
• Diversity and Health Equity Education Resources
• Meeting Submission and Guidelines
• Mental Health Innovation Zone
• The Mental Health Services Conference
• The Virtual Immersive
• Virtual Paid Courses
• Clinical Practice Guidelines
• Covid-19 / Coronavirus
• Digital Mental Health
• Helping Patients Access Care
• Media and Communications
• Mental Health Apps
• Mental Health Parity
• Practice Management
• Professional Interests
• Quality Improvement
• Risk Management
• Social Media
• Sunshine Act
• Telepsychiatry
• The Clozapine Risk Evaluation and Mitigation Strategy (REMS) Program
• Transition to Practice and Early Career Resources
• Well-being and Burnout
• Mental Health and Faith Community Partnership
• Mental Health Equity Looking Beyond Series
• Minority and Underrepresented (M/UR) Caucuses
• Moore Equity in Mental Health Initiative
• News and Updates
• Striving for Excellence Series
• SAMHSA Minority Fellowship Program
• AMNet: Addiction Medicine Practice Based Research Network
• PsychPRO: APA's Mental Health Registry
• Research Colloquium for Junior Psychiatrist Investigators
• Perinatal Mental Health Toolkit
• Psychiatric Bed Crisis Report
• Advocacy Action Center
• Congressional Advocacy Network
• Election Resource Center
• Federal Affairs
• State Affairs
• Implementing 9-8-8
• Advocacy Update Webinars
• 2025 Annual Meeting
• The 2024 Mental Health Services Conference
• Addressing Structural Racism Town Hall Series
• APA Meetings App
• Governance Meetings
• Mental Health Equity Fireside Chat Series
• Moore Equity in Mental Health 5K
• Policy & Practice Insights Series
• September Component Meetings
• Social Determinants of Mental Health Town Hall Series
• Amicus Briefs
• Assembly Directory
• Component Directory
• Conference Publications
• Library and Archive
• Member Directory
• Member Obituaries
• Practice Guidelines
• Resource Documents
• International Trainees
• International Humanitarian Opportunities
• Global Mental Health
• International Medical Graduates Resources
• Residents' Journal
• Featured Publications
• APAF Fellowships
• External Fellowships and Awards
• Helping Residents Cope with a Patient Suicide
• Vacant Resident Positions
• Leadership Positions
• SET for Success
• Apply for Psychiatric Residency
• Choosing a Career in Psychiatry
• Building a Career in Psychiatry
• Medical Student Programs
• Resident-Fellow Census
• Transitioning to Residency During COVID-19
• What Is a Substance Use Disorder?
• Expert Q&A: Addiction and Substance Use Disorders
• What Are Dementia and Alzheimer’s Disease?
• Expert Q&A: Dementia and Alzheimer's Disease
• What are Anxiety Disorders?
• Expert Q&A: Anxiety Disorders
• What is ADHD?
• Expert Q&A: ADHD
• What Is Autism Spectrum Disorder?
• Expert Q&A: Autism Spectrum Disorder
• What Are Bipolar Disorders?
• Expert Q&A: Bipolar Disorder
• How Extreme Weather Events Affect Mental Health
• Who Is Affected by Climate Change?
• What Is Depression?
• Expert Q&A: Depression
• What are Disruptive, Impulse Control and Conduct Disorders?
• Expert Q&A: Disruptive, Impulse Control and Conduct Disorders
• What Are Dissociative Disorders?
• Expert Q&A: Dissociative Disorders
• What are Eating Disorders?
• Expert Q&A: Eating Disorders
• What is Gambling Disorder?
• Expert Q&A: Gambling Disorder
• What is Gender Dysphoria?
• Expert Q&A: Gender Dysphoria
• What is Hoarding Disorder?
• Expert Q&A: Hoarding Disorder
• What is Intellectual Disability?
• Expert Q&A: Intellectual Disability
• What Is Obsessive-Compulsive Disorder?
• Expert Q&A: Obsessive-Compulsive Disorder
• What is Perinatal Depression (formerly Postpartum)?
• Expert Q&A: Perinatal Depression
• What are Personality Disorders?
• Expert Q&A: Personality Disorders
• What is Posttraumatic Stress Disorder (PTSD)?
• Expert Q&A: Posttraumatic Stress Disorder (PTSD)
• What is Schizophrenia?
• Expert Q&A: Schizophrenia
• What are Sleep Disorders?
• Expert Q&A: Sleep Disorders
• What is Somatic Symptom Disorder?
• Expert Q&A: Somatic Symptom Disorder
• What Are Specific Learning Disorders?
• Expert Q&A: Specific Learning Disorders
• What is Technology Addiction?
• Expert Q&A: Technology Addiction
• Cigarrillos electrónicos y vapeo
• Trastorno del espectro autista
• Trastorno por consumo de alcohol
• Trastorno por consumo de opioides
• Trastorno de estrés postraumático (TEPT)
• Adicción a la tecnología: redes sociales, juegos en línea, y más
• ¿Qué es la psiquiatría?
• Conexiones entre el cambio climático y la salud mental
• Más temas de salud mental
• General Members
• Early Career Psychiatrists
• Residents and Fellows
• International Resident-Fellows
• Semi-Retired and Retired
• View Your Profile
• Resident-Fellow Members
• Fellow of the APA
• Distinguished Fellow of the APA
• International Fellow of the APA
• International Distinguished Fellow of the APA
• 2024 Class of Honorary Fellows
• 2025 APA National Elections
• Councils, Committees and Components
• Resident-Fellow Leadership Opportunities
• Volunteer Leadership Opportunities
• Advocacy and APAPAC
• APA/APAF Fellowships
• APA Insider Sessions
• APA Specialty Interest Caucuses, Listservs & Communities
• Leadership, Equity and Diversity Institute
• Mentorship Program for APA/APAF Fellows
• Research Colloquium
• Contact Your Membership Specialist
• Contact Your District Branch
• Membership FAQs
• Semi-Retired and Retired FAQs
• Lump Sum Dues
• 2025 APA Dues Rate Changes FAQs
• District Branch Resources
• District Branch Dues for General Members
• District Branch Dues for Residents and Fellows

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

The PMC website is updating on October 15, 2024. Learn More or Try it out now .

• Advanced Search
• Journal List

Effects of music therapy on depression: A meta-analysis of randomized controlled trials

Qishou tang.

1 Bengbu Medical University, Bengbu, Anhui, China

Zhaohui Huang

2 Anhui Provincial Center for Women and Child Health, Hefei, Anhui, China

3 National Drug Clinical Trial Institution, The First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui, China

Associated Data

All relevant data are within the manuscript and its Supporting Information files.

We aimed to determine and compare the effects of music therapy and music medicine on depression, and explore the potential factors associated with the effect.

PubMed (MEDLINE), Ovid-Embase, the Cochrane Central Register of Controlled Trials, EMBASE, Web of Science, and Clinical Evidence were searched to identify studies evaluating the effectiveness of music-based intervention on depression from inception to May 2020. Standardized mean differences (SMDs) were estimated with random-effect model and fixed-effect model.

A total of 55 RCTs were included in our meta-analysis. Music therapy exhibited a significant reduction in depressive symptom (SMD = −0.66; 95% CI = -0.86 to -0.46; P <0.001) compared with the control group; while, music medicine exhibited a stronger effect in reducing depressive symptom (SMD = −1.33; 95% CI = -1.96 to -0.70; P <0.001). Among the specific music therapy methods, recreative music therapy (SMD = -1.41; 95% CI = -2.63 to -0.20; P <0.001), guided imagery and music (SMD = -1.08; 95% CI = -1.72 to -0.43; P <0.001), music-assisted relaxation (SMD = -0.81; 95% CI = -1.24 to -0.38; P <0.001), music and imagery (SMD = -0.38; 95% CI = -0.81 to 0.06; P = 0.312), improvisational music therapy (SMD = -0.27; 95% CI = -0.49 to -0.05; P = 0.001), music and discuss (SMD = -0.26; 95% CI = -1.12 to 0.60; P = 0.225) exhibited a different effect respectively. Music therapy and music medicine both exhibited a stronger effects of short and medium length compared with long intervention periods.

Conclusions

A different effect of music therapy and music medicine on depression was observed in our present meta-analysis, and the effect might be affected by the therapy process.

Introduction

Depression was reported to be a common mental disorders and affected more than 300 million people worldwide, and long-lasting depression with moderate or severe intensity may result in serious health problems [ 1 ]. Depression has become the leading causes of disability worldwide according to the recent World Health Organization (WHO) report. Even worse, depression was closely associated with suicide and became the second leading cause of death, and nearly 800 000 die of depression every year worldwide [ 1 , 2 ]. Although it is known that treatments for depression, more than 3/4 of people in low and middle-income income countries receive no treatment due to a lack of medical resources and the social stigma of mental disorders [ 3 ]. Considering the continuously increased disease burden of depression, a convenient effective therapeutic measures was needed at community level.

Music-based interventions is an important nonpharmacological intervention used in the treatment of psychiatric and behavioral disorders, and the obvious curative effect on depression has been observed. Prior meta-analyses have reported an obvious effect of music therapy on improving depression [ 4 , 5 ]. Today, it is widely accepted that the music-based interventions are divided into two major categories, namely music therapy and music medicine. According to the American Music Therapy Association (AMTA), “music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program” [ 6 ]. Therefore, music therapy is an established health profession in which music is used within a therapeutic relationship to address physical, emotional, cognitive, and social needs of individuals, and includes the triad of music, clients and qualified music therapists. While, music medicine is defined as mainly listening to prerecorded music provided by medical personnel or rarely listening to live music. In other words, music medicine aims to use music like medicines. It is often managed by a medical professional other than a music therapist, and it doesn’t need a therapeutic relationship with the patients. Therefore, the essential difference between music therapy and music medicine is about whether a therapeutic relationship is developed between a trained music therapist and the client [ 7 – 9 ]. In the context of the clear distinction between these two major categories, it is clear that to evaluate the effects of music therapy and other music-based intervention studies on depression can be misleading. While, the distinction was not always clear in most of prior papers, and no meta-analysis comparing the effects of music therapy and music medicine was conducted. Just a few studies made a comparison of music-based interventions on psychological outcomes between music therapy and music medicine. We aimed to (1) compare the effect between music therapy and music medicine on depression; (2) compare the effect between different specific methods used in music therapy; (3) compare the effect of music-based interventions on depression among different population [ 7 , 8 ].

Materials and methods

Search strategy and selection criteria.

PubMed (MEDLINE), Ovid-Embase, the Cochrane Central Register of Controlled Trials, EMBASE, Web of Science, and Clinical Evidence were searched to identify studies assessing the effectiveness of music therapy on depression from inception to May 2020. The combination of “depress*” and “music*” was used to search potential papers from these databases. Besides searching for electronic databases, we also searched potential papers from the reference lists of included papers, relevant reviews, and previous meta-analyses. The criteria for selecting the papers were as follows:(1) randomised or quasi-randomised controlled trials; (2) music therapy at a hospital or community, whereas the control group not receiving any type of music therapy; (3) depression rating scale was used. The exclusive criteria were as follows: (1) non-human studies; (2) studies with a very small sample size (n<20); (3) studies not providing usable data (including sample size, mean, standard deviation, etc.); (4) reviews, letters, protocols, etc. Two authors independently (YPJ, HZH) searched and screened the relevant papers. EndNote X7 software was utilized to delete the duplicates. The titles and abstracts of all searched papers were checked for eligibility. The relevant papers were selected, and then the full-text papers were subsequently assessed by the same two authors. In the last, a panel meeting was convened for resolving the disagreements about the inclusion of the papers.

Data extraction

We developed a data abstraction form to extract the useful data: (1) the characteristics of papers (authors, publish year, country); (2) the characteristics of participators (sample size, mean age, sex ratio, pre-treatment diagnosis, study period); (3) study design (random allocation, allocation concealment, masking, selection process of participators, loss to follow-up); (4) music therapy process (music therapy method, music therapy period, music therapy frequency, minutes per session, and the treatment measures in the control group); (5) outcome measures (depression score). Two authors independently (TQS, ZH) abstracted the data, and disagreements were resolved by discussing with the third author (YPJ).

Assessment of risk of bias in included studies

Two authors independently (TQS, ZH) assessed the risk of bias of included studies using Cochrane Collaboration’s risk of bias assessment tool, and disagreements were resolved by discussing with the third author (YPJ) [ 10 ].

Music therapy and music medicine

Music Therapy is defined as the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program. Music medicine is defined as mainly listening to prerecorded music provided by medical personnel or rarely listening to live music. In other words, music medicine aims to use music like medicines.

Music therapy mainly divided into active music therapy and receptive music therapy. Active music therapy, including improvisational, re-creative, and compositional, is defined as playing musical instruments, singing, improvisation, and lyrics of adaptation. Receptive music therapy, including music-assisted relaxation, music and imagery, guided imagery and music, lyrics analysis, and so on, is defined as music listening, lyrics analysis, and drawing with musing. In other words, in active methods participants are making music, and in receptive music therapy participants are receiving music [ 6 , 7 , 9 , 11 – 13 ].

Evaluation of depression

Depression was evaluated by the common psychological scales, including Beck Depression Inventory (BDI), Children’s Depression Inventory (CDI), Center for Epidemiologic Studies Depression (CES-D), Cornell Scale (CS), Depression Mood Self-Report Inventory for Adolescence (DMSRIA), Geriatric Depression Scale-15 (GDS-15); Geriatric Depression Scale-30 (GDS-30), Hospital Anxiety and Depression Scale (HADS), Hamilton Rating Scale for Depression (HRSD/HAMD), Montgomery-sberg Depression Rating Scale (MADRS), Patient Reported Outcomes Measurement Information System (PROMIS), Self-Rating Depression Scale (SDS), Short Version of Profile of Mood States (SV-POMS).

Statistical analysis

The pooled effect were estimated by using the standardized mean differences (SMDs) and its 95% confidence interval (95% CI) due to the different depression rate scales were used in the included papers. Heterogeneity between studies was assessed by I-square ( I 2 ) and Q-statistic (P<0.10), and a high I 2 (>50%) was recognized as heterogeneity and a random-effect model was used [ 14 – 16 ]. We performed subgroup analyses and meta-regression analyses to study the potential heterogeneity between studies. The subgroup variables included music intervention categories (music therapy and music medicine), music therapy methods (active music therapy, receptive music therapy), specific receptive music therapy methods (music-assisted relaxation, music and imagery, and guided imagery and music (Bonny Method), specific active music therapy methods (recreative music therapy and improvisational music therapy), music therapy mode (group therapy, individual therapy), music therapy period (weeks) (2–4, 5–12, ≥13), music therapy frequency (once weekly, twice weekly, ≥3 times weekly), total music therapy sessions (1–4, 5–8, 9–12, 13–16, >16), time per session (minutes) (15–40, 41–60, >60), inpatient settings (secure [locked] unit at a mental health facility versus outpatient settings), sample size (20–50, ≥50 and <100, ≥100), female predominance(>80%) (no, yes), mean age (years) (<50, 50–65, >65), country having music therapy profession (no, yes), pre-treatment diagnosis (mental health, depression, severe mental disease/psychiatric disorder). We also performed sensitivity analyses to test the robustness of the results by re-estimating the pooled effects using fixed effect model, using trim and fill analysis, excluding the paper without information on music therapy, excluding the papers with more high biases, excluding the papers with small sample size (20< n<30), excluding the papers using an infrequently used scale, excluding the studies focused on the people with a severe mental disease. We investigated the publication biases by a funnel plot as well as Egger’s linear regression test [ 17 ]. The analyses were performed using Stata, version 11.0. All P-values were two-sided. A P-value of less than 0.05 was considered to be statistically significant.

Characteristics of the eligible studies

Fig 1 depicts the study profile, and a total of 55 RCTs were included in our meta-analysis [ 18 – 72 ]. Of the 55 studies, 10 studies from America, 22 studies from Europe, 22 studies from Asia, and 1 study from Australia. The mean age of the participators ranged from 12 to 86; the sample size ranged from 20 to 242. A total of 16 different scales were used to evaluate the depression level of the participators. A total of 25 studies were conducted in impatient setting and 28 studies were in outpatients setting; 32 used a certified music therapist, 15 not used a certified music therapist (for example researcher, nurse), and 10 not reported relevent information. A total of 16 different depression rating scales were used in the included studies, and HADS, GDS, and BDI were the most frequently used scales ( Table 1 ).

PRISMA diagram showing the different steps of systematic review, starting from literature search to study selection and exclusion. At each step, the reasons for exclusion are indicated. Doi: 10.1371/journal.pone.0052562.g001.

Note: BDI = Beck Depression Inventory; CDI = Children’s Depression Inventory; CDSS = depression scale for schizophrenia; CES-D = Center for Epidemiologic Studies Depression; CS = Cornell Scale; DMSRIA = Depression Mood Self-Report Inventory for Adolescence; EPDS = Edinburgh Postnatal Depression Scale; GDS-15 = Geriatric Depression Scale-15; GDS-30 = Geriatric Depression Scale-30; HADS = Hospital Anxiety and Depression Scale; HRSD (HAMD) = Hamilton Rating Scale for Depression; MADRS = Montgomery-sberg Depression Rating Scale; PROMIS = Patient Reported Outcomes Measurement Information System; SDS = Self-Rating Depression Scale; State-Trait Depression Questionnaire = ST/DEP; SV-POMS = short version of Profile of Mood States; NA = not available.

Of the 55 studies, only 2 studies had high risks of selection bias, and almost all of the included studies had high risks of performance bias ( Fig 2 ).

The overall effects of music therapy

Of the included 55 studies, 39 studies evaluated the music therapy, 17 evaluated the music medicine. Using a random-effects model, music therapy was associated with a significant reduction in depressive symptoms with a moderate-sized mean effect (SMD = −0.66; 95% CI = -0.86 to -0.46; P <0.001), with a high heterogeneity across studies ( I 2 = 83%, P <0.001); while, music medicine exhibited a stronger effect in reducing depressive symptom (SMD = −1.33; 95% CI = -1.96 to -0.70; P <0.001) ( Fig 3 ).

Twenty studies evaluated the active music therapy using a random-effects model, and a moderate-sized mean effect (SMD = −0.57; 95% CI = -0.90 to -0.25; P <0.001) was observed with a high heterogeneity across studies ( I 2 = 86.3%, P <0.001). Fourteen studies evaluated the receptive music therapy using a random-effects model, and a moderate-sized mean effect (SMD = −0.73; 95% CI = -1.01 to -0.44; P <0.001) was observed with a high heterogeneity across studies ( I 2 = 76.3%, P <0.001). Five studies evaluated the combined effect of active and receptive music therapy using a random-effects model, and a moderate-sized mean effect (SMD = −0.88; 95% CI = -1.32 to -0.44; P <0.001) was observed with a high heterogeneity across studies ( I 2 = 70.5%, P <0.001) ( Fig 4 ).

Among specific music therapy methods, recreative music therapy (SMD = -1.41; 95% CI = -2.63 to -0.20; P <0.001), guided imagery and music (SMD = -1.08; 95% CI = -1.72 to -0.43; P <0.001), music-assisted relaxation (SMD = -0.81; 95% CI = -1.24 to -0.38; P <0.001), music and imagery (SMD = -0.38; 95% CI = -0.81 to 0.06; P = 0.312), improvisational music therapy (SMD = -0.27; 95% CI = -0.49 to -0.05; P = 0.001), and music and discuss (SMD = -0.26; 95% CI = -1.12 to 0.60; P = 0.225) exhibited a different effect respectively ( Fig 5 ).

Sub-group analyses and meta-regression analyses

We performed sub-group analyses and meta-regression analyses to study the homogeneity. We found that music therapy yielded a superior effect on reducing depression in the studies with a small sample size (20–50), with a mean age of 50–65 years old, with medium intervention frequency (<3 times weekly), with more minutes per session (>60 minutes). We also found that music therapy exhibited a superior effect on reducing depression among people with severe mental disease /psychiatric disorder and depression compared with mental health people. While, whether the country have the music therapy profession, whether the study used group therapy or individual therapy, whether the study was in the outpatients setting or the inpatient setting, and whether the study used a certified music therapist all did not exhibit a remarkable different effect ( Table 2 ). Table 2 also presents the subgroup analysis of music medicine on reducing depression.

In the subgroup analysis by total session, music therapy and music medicine both exhibited a stronger effects of short (1–4 sessions) and medium length (5–12 sessions) compared with long intervention periods (>13sessions) ( Fig 6 ). Meta-regression demonstrated that total music intervention session was significantly associated with the homogeneity between studies ( P = 0.004) ( Table 3 ).

A, evaluating the effect of music therapy; B, evaluating the effect of music medicine.

Sensitivity analyses

We performed sensitivity analyses and found that re-estimating the pooled effects using fixed effect model, using trim and fill analysis, excluding the paper without information regarding music therapy, excluding the papers with more high biases, excluding the papers with small sample size (20< n<30), excluding the studies focused on the people with a severe mental disease, and excluding the papers using an infrequently used scale yielded the similar results, which indicated that the primary results was robust ( Table 4 ).

Evaluation of publication bias

We assessed publication bias using Egger’s linear regression test and funnel plot, and the results are presented in Fig 7 . For the main result, the observed asymmetry indicated that either the absence of papers with negative results or publication bias.

A, evaluating the publication bias of music therapy; B, evaluating the publication bias of music medicine; BDI = Beck Depression Inventory; CDI = Children’s Depression Inventory; CDSS = depression scale for schizophrenia; CES-D = Center for Epidemiologic Studies Depression; CS = Cornell Scale; DMSRIA = Depression Mood Self-Report Inventory for Adolescence; EPDS = Edinburgh Postnatal Depression Scale; GDS-15 = Geriatric Depression Scale-15; GDS-30 = Geriatric Depression Scale-30; HADS = Hospital Anxiety and Depression Scale; HRSD (HAMD) = Hamilton Rating Scale for Depression; MADRS = Montgomery-sberg Depression Rating Scale; PROMIS = Patient Reported Outcomes Measurement Information System; SDS = Self-Rating Depression Scale; State-Trait Depression Questionnaire = ST/DEP; SV-POMS = short version of Profile of Mood Stat.

Our present meta-analysis exhibited a different effect of music therapy and music medicine on reducing depression. Different music therapy methods also exhibited a different effect, and the recreative music therapy and guided imagery and music yielded a superior effect on reducing depression compared with other music therapy methods. Furthermore, music therapy and music medicine both exhibited a stronger effects of short and medium length compared with long intervention periods. The strength of this meta-analysis was the stable and high-quality result. Firstly, the sensitivity analyses performed in this meta-analysis yielded similar results, which indicated that the primary results were robust. Secondly, considering the insufficient statistical power of small sample size, we excluded studies with a very small sample size (n<20).

Some prior reviews have evaluated the effects of music therapy for reducing depression. These reviews found a significant effectiveness of music therapy on reducing depression among older adults with depressive symptoms, people with dementia, puerpera, and people with cancers [ 4 , 5 , 73 – 76 ]. However, these reviews did not differentiate music therapy from music medicine. Another paper reviewed the effectiveness of music interventions in treating depression. The authors included 26 studies and found a signifiant reduction in depression in the music intervention group compared with the control group. The authors made a clear distinction on the definition of music therapy and music medicine; however, they did not include all relevant data from the most recent trials and did not conduct a meta-analysis [ 77 ]. A recent meta-analysis compared the effects of music therapy and music medicine for reducing depression in people with cancer with seven RCTs; the authors found a moderately strong, positive impact of music intervention on depression, but found no difference between music therapy and music medicine [ 78 ]. However, our present meta-analysis exhibited a different effect of music therapy and music medicine on reducing depression, and the music medicine yielded a superior effect on reducing depression compared with music therapy. The different effect of music therapy and music medicine might be explained by the different participators, and nine studies used music therapy to reduce the depression among people with severe mental disease /psychiatric disorder, while no study used music medicine. Furthermore, the studies evaluating music therapy used more clinical diagnostic scale for depressive symptoms.

A meta-analysis by Li et al. [ 74 ] suggested that medium-term music therapy (6–12 weeks) was significantly associated with improved depression in people with dementia, but not short-term music therapy (3 or 4 weeks). On the contrary, our present meta-analysis found a stronger effect of short-term (1–4 weeks) and medium-term (5–12 weeks) music therapy on reducing depression compared with long-term (≥13 weeks) music therapy. Consistent with the prior meta-analysis by Li et al., no significant effect on depression was observed for the follow-up of one or three months after music therapy was completed in our present meta-analysis. Only five studies analyzed the therapeutic effect for the follow-up periods after music therapy intervention therapy was completed, and the rather limited sample size may have resulted in this insignificant difference. Therefore, whether the therapeutic effect was maintained in reducing depression when music therapy was discontinued should be explored in further studies. In our present meta-analysis, meta-regression results demonstrated that no variables (including period, frequency, method, populations, and so on) were significantly associated with the effect of music therapy. Because meta-regression does not provide sufficient statistical power to detect small associations, the non-significant results do not completely exclude the potential effects of the analyzed variables. Therefore, meta-regression results should be interpreted with caution.

Our meta-analysis has limitations. First, the included studies rarely used masked methodology due to the nature of music therapy, therefore the performance bias and the detection bias was common in music intervention study. Second, a total of 13 different scales were used to evaluate the depression level of the participators, which may account for the high heterogeneity among the trials. Third, more than half of those included studies had small sample sizes (<50), therefore the result should be explicated with caution.

Our present meta-analysis of 55 RCTs revealed a different effect of music therapy and music medicine, and different music therapy methods also exhibited a different effect. The results of subgroup analyses revealed that the characters of music therapy were associated with the therapeutic effect, for example specific music therapy methods, short and medium-term therapy, and therapy with more time per session may yield stronger therapeutic effect. Therefore, our present meta-analysis could provide suggestion for clinicians and policymakers to design therapeutic schedule of appropriate lengths to reduce depression.

Supporting information

S1 checklist, funding statement.

The Key Project of University Humanities and Social Science Research in Anhui Province (SK2017A0191) was granted by Education Department of Anhui Province; the Research Project of Anhui Province Social Science Innovation Development (2018XF155) was granted by Anhui Provincial Federation of Social Sciences; the Ministry of Education Humanities and Social Sciences Research Youth fund Project (17YJC840033) was granted by Ministry of Education of the People’s Republic of China. These funders had a role in study design, text editing, interpretation of results, decision to publish and preparation of the manuscript.

Data Availability

• PLoS One. 2020; 15(11): e0240862.

Decision Letter 0

PONE-D-20-17706

Effects of music therapy on depression: a meta-analysis of randomized controlled trials

Dear Dr. Ye,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Sep 19 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at gro.solp@enosolp . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see:  http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Sukru Torun

Academic Editor

Additional Editor Comments:

Dear Author,

Thank you for your valuable submission. I think it would be appropriate to emphasize the main problem first. Various musical interventions are used in medical settings to improve the patient's well-being, and of course, there are many publications on this subject. However, it is important to properly differentiate between these interventions for some important reasons I have pointed out below.

The music therapy definition you made, as "Music therapy was defined as music therapy provided by a qualified music teacher, psychological therapist, or nurse" is not universally accepted specific definition for music therapy. Moreover, the specific methods used in receptive music therapy include music-assisted relaxation, music and imagery, and Guided Imagery and Music (Bonny Method). Each of these may have different levels of effects on depression. It is not clear that which receptive music therapy studies in your review have used which of these methods. So, the majority of studies that you accepted as the receptive music therapy seems to be music medicine studies indeed. Similar critiques may also be apply to some of the studies you describe as active music therapy. Today, it is widely accepted that these music-based interventions should be divided into two major categories, namely music therapy (MT) and music medicine (MM). MM mainly based on patients' pre-recorded or rarely listening to live music and the direct effects of the music they listen to. In other words, MM aims to use music like medicines. It often managed by a medical professional other than a music therapist, and not needed a therapeutic relationship with the patients. Conversely, music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed music therapist who has completed an approved music therapy program. So, music therapy is a relational, interaction based form of therapy within a therapeutic relationship between the therapist and the client, and includes the triad of the music, the client and the music therapist. Since music therapy interventions is an evidence-based procedure using special music therapy methods of interventions and a more pragmatic approach than other music-based interventions, their effect levels and results are also different.

In the context of the above mentioned explanations, it is clear that to evaluate the effects of music therapy and other music based intervention studies together on depression can be misleading. The subjects I have mentioned so far have never been addressed in the introduction and discussion sections of your manuscript. I think that will be perceived as a major deficiency at least by the readers who are closer to the subject. In this sense, I think that an attentive revision considering the following views will be valuable and needed:

- The universally accepted definitions of music therapy (including active and receptive music therapy) and music medicine should be taken into account.

- It should be clarified that how many studies in your review did included a certified music therapist.

- Analyses, results and discussion should be submitted to the readers in accordance with all this distinctions and definitions. (The way to this seems to be to compare the effects of music medicine and music therapy on depression in parallel with the possible differences of music interventions used, and to discuss their possible implications on the results.)

- Another important point is that you did not mention nor discuss any of important reviews on same subject (for example please see: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004517.pub3/epdf/full or https://www.frontiersin.org/articles/10.3389/fpsyg.2017.01109/full or https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006911.pub3/full )

I am aware that such a major revision will, in a sense, be a challenging way that may require a new analysis of your data. However, I believe you would appreciate that a study aimed at shedding light on potential music-based interventions in an important public health problem such as depression should not be misleading.

Thank you for your effort in advance.

Besides, according to the statistical reviewer who only reviewed the statistical approach used in this paper, there are two caveats:

1. The authors state that they excluded studies with fewer than 20 participants in one place in the paper (page 4), but fewer than 30 participants in another place in the paper (Table 4). This needs to be corrected for consistency.

2. The authors mention stronger effects of short and medium length vs. long music therapy periods in their results but there is no accompanying figure. I think it would be beneficial to show these findings in a figure (Forest plot).

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files.

3. Thank you for stating the following in the Acknowledgments Section of your manuscript:

"This work was supported by the Key Project of University Humanities and Social Science

Research in Anhui Province (SK2017A0191), Research Project of Anhui Province Social Science

Innovation Development (2018XF155), Ministry of Education Humanities and Social Sciences

Research Youth fund Project (17YJC840033)."

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

"The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

4. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

5. Please amend your list of authors on the manuscript to ensure that each author is linked to an affiliation. Authors’ affiliations should reflect the institution where the work was done (if authors moved subsequently, you can also list the new affiliation stating “current affiliation:….” as necessary).

6. Please ensure that you refer to Figure 5 in your text as, if accepted, production will need this reference to link the reader to the figure.

7. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information .

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: No

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for conducting this research and submitting it for publication consideration.

I recognize that English may not be the primary language of the authors. There are a few instances where the language could be improved, but that is mostly a copy-editing issue. There is also a lot of passive voice in the paper. I recommend making the voice active. This will enhance the readability of the paper.

I have a few comments that I hope will improve the paper.

1. Not all countries have an established music therapy profession. I recognize that this creates challenges for the authors! I'm wondering if the authors might consider including this as a factor in the analysis? For example, if a nurse provides "music therapy" in a country that does not have music therapy as a profession, is the effect equivalent as when a qualified music therapist in a country that has music therapy as a profession provides it? This might provide some incentive for occupational regulation and establishing professional music therapy associations.

2. please fix the "short title" (oxygen)

3. Music therapy with fewer minutes might yield superior effects. This may be misleading. Is there a minimum number of minutes? How many minutes might be optimal for therapeutic outcome? I believe it does make sense that longer sessions may result in less impact - quantity/duration does not always result in enhanced outcome.

4. I believe a stronger case needs to be made for the study. There are existing meta-analyses of MT for depression (Aalbers et al., 2017 Cochrane Review). What makes the current study unique and different? What are the gaps in the literature that warrant this study? Have there been a lot of recent additions to the literature that warrant a new meta-analysis?

5. A stronger discussion of the limitation of this study. Many studies did not evaluate a group with major depression/major depressive disorder (music therapy for chronic pain is important, but the variance of the populations under study does constitute a limitation). So, this study is not exclusive to adults with a major mental health condition. Might effects be different for people who are depressed versus people who are not depressed?

6. Instead of "blinding/blinded" please use "masking/masked."

7. Is there a citation that supports your classification of active versus receptive? (I would think Bruscia would be a good place to start with that...)

8. One item that I am not seeing is group therapy versus individual therapy. Did the authors screen for that? If so, is there an optimal group size? Are effects stronger when in a group format versus an individual format? This would have serious implications for clinical practice.

9. What about inpatient settings (such as a secure [locked] unit at a mental health facility) versus outpatient settings?

10. One item that I believe is missing is the dose. Not necessarily the duration (number of minutes) of each session, but the total number of sessions a participant has received. Gold has done some work in this area. Is there is a certain number of sessions that are needed to reach a therapeutic outcome? The number of sessions/week is good, but the number of total sessions is important.

11. Table 1 has the mean age. I recommend including the SD as well.

Thank you for taking the time to consider these suggestions. While receiving critical feedback can be difficult, please understand that my intentions are to improve the paper and ensure it has maximum impact. This is an important addition to the literature and I am grateful to the authors for their scholarship. I wish you the best!

Reviewer #2: This article addresses an important topic that is of interest to music therapists, psychiatrists and teachers and metal health practitioners. The statistics look promising. However, the major concern is that the definition of music therapy is theoretically and practically incorrect and misleading:

"7 Music therapy was defined as music therapy provided by a qualified music teacher, psychological

8 therapist, or nurse. " The study is missing several research studies that I am aware of and this makes its content suspicious. Also missing is a more depth-ful analysis of what active and passive music therapy is, and if it is indeed performed by those in other professions who have no training in 'musuc therapy;'-than the contents and findings are misleading and irrelevant.

Reviewer #3: I only reviewed the statistical approach used in this paper, which appeared appropriate for the research question under study. There are two caveats:

6. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool,  https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at  gro.solp@serugif . Please note that Supporting Information files do not need this step.

Author response to Decision Letter 0

29 Sep 2020

Response to Reviewers

Dear Editors and Reviewers:

Thank you for your letter and for the reviewers’ comments concerning our manuscript entitled " Effects of music therapy on depression: a meta-analysis of randomized controlled trials (PONE-D-20-17706)".

Those comments are all valuable and very helpful for revising and improving our paper, as well as the important guiding significance to our researches. We have studied comments carefully and have made revision which we hope meet with approval. All the revised portions were marked in red font in the new document. The main corrections in the paper and the responds to the reviewer’s comments are as flowing:

Response：We have studied comments carefully and revised the manuscript extensively according to the reviewer’s comments.

Firstly, We have amended the music therapy definition mainly based on the World Federation of Music Therapy (WFMT) and The American Music Therapy Association (AMTA), WFMT defines music therapy as “the professional use of music and its elements as an intervention inmedical, educational, and everyday environments with individuals, groups, families, or communities who seek to optimize their quality of life and improve their physical, social,communicative, emotional, intellectual, and spiritual health and wellbeing”. AMTA defines music therapy as “Music Therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program”. [American Music Therapy Association (2020). Definition and Quotes about Music Therapy. Available online at: https://www.musictherapy.org/about/quotes/ (Accessed Sep 13, 2020).][van der Steen, J. T., et al. (2017). "Music-based therapeutic interventions for people with dementia." Cochrane Database Syst Rev 5: CD003477.]

Secondly, we have re-studed all included papers carefully and added the specific intervention methods of each paper in table 1 (Table 1. Characteristics of clinical trials included in this meta-analysis). Two main types of music therapy were distinguished in our present study - receptive (or passive) and active music therapy. The specific methods used in receptive music therapy in our included papers including music-assisted relaxation, music and imagery, and guided imagery and music (Bonny Method), while the specific methods used in active music therapy included recreative music therapy, improvisational music therapy, song writing, and so on.

Thirdly, we have added some contents regarding the distinction between music therapy and music medicine in introduction and discussion sections of our manuscript.

The following contents are added in introduction section, “Today, it is widely accepted that the music-based interventions should be divided into two major categories, namely music therapy and music medicine. According to the American Music Therapy Association (AMTA), “music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program”. Therefore, music therapy is an established health profession in which music is used within a therapeutic relationship to address physical, emotional, cognitive, and social needs of individualst, and includes the triad of the music, the client and the qualified music therapist. [American Music Therapy Association (2020). Definition and Quotes about Music Therapy. Available online at: https://www.musictherapy.org/about/quotes/ (Accessed Sep 13, 2020).] While, music medicine is defined as mainly listening to prerecorded music provided by medical personnel or rarely listening to live music. In other words, music medicine aims to use music like medicines. It often managed by a medical professional other than a music therapist, and not needed a therapeutic relationship with the patients. Therefore, the essential difference of music therapy and music medicine is whether a therapeutic relationship is developed between a trained music therapist and the client.

[Bradt, J., et al. (2015). "The impact of music therapy versus music medicine on psychological outcomes and pain in cancer patients: a mixed methods study." Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer 23(5): 1261-1271.

[Yinger, O. S. and L. Gooding (2014). "Music therapy and music medicine for children and adolescents." Child and adolescent psychiatric clinics of North America 23(3): 535-553.]

【Tony Wigram．Inge Nyggard Pedersen＆Lars Ole Bonde，A Compmhensire Guide to Music Therapy．London and Philadelphia：Jessica Kingsley Publishen．2002：143．】

In the context of the clear distinction between these two major cagerories, it is clear that to evaluate the effects of music therapy and other music based intervention studies together on depression can be misleading. While, the distinction was not always clear in most of prior papers, and we found that no meta-analysis comparing the effects of music therapy and music medicine was conducted. Just a few studies made a comparison of music-based interventions on psychological outcomes between music therapy and music medicine. We aimed to (1) compare the effect between music therapy and music medicine on depression; (2) compare the effect between different specific methods used inmusic therapy on depression; (3) compare the effect of music-based interventions on depression among different population.

[Bradt, J., et al. (2015). "The impact of music therapy versus music medicine on psychological outcomes and pain in cancer patients: a mixed methods study." Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer 23(5): 1261-1271.[Yinger, O. S. and L. Gooding (2014). "Music therapy and music medicine for children and adolescents." Child and adolescent psychiatric clinics of North America 23(3): 535-553.]

The last, we have made a new analysis of our data. 1) including three new papers and re-analying of our data, 2) adding the comparison of music therapy and music medicine, 3) adding the comparison of impatient setting and outpatients setting, 4) adding the comparison of depressed people and not depressed people, 5）adding the comparison of countries have having music therapy profession and not, 6) adding the comparison of group therapy and individual therapy, 7) added the comparison of different intervention dose, and so on.

Response: (1)We have amended the of definitions of music therapy. The revised difinitons of music therapy was “Music Therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program”. [American Music Therapy Association (2020). Definition and Quotes about Music Therapy. Available online at: https://www.musictherapy.org/about/quotes/ (Accessed Sep 13, 2020).]

We have added some contents on the distinction between music therapy (MT) and music medicine (MM) in introduction and discussion sections of our manuscript.

We have added the analysis of the comparion of music therapy (MT) and music medicine (MM) in Methord and Results sections

Response: we have re-studed all included papers carefully and added a new varible (Intervenor or therapist) into table 1, and the corresponding description was addded in the results section. Of 55 studies, 32 used a certified music therapist, 15 not used a certified music therapist (for example researcher, nurse), and 10 not reported relevent information.

Response: We have divided music-based interventions into two major categories, namely music therapy and music medicine according to the difinition. With respect to specific methods used in music therapy, we also have divided music therapy into receptive (or passive) and active music therapy. The specific methods used in receptive music therapy in our included papers including music-assisted relaxation, music and imagery, and guided imagery and music (Bonny Method), and the specific methods used in active music therapy included recreative music therapy and improvisational music therapy.

We have added some sub-group analyses by different music intervention categories, different music therapy categories, and specific music therapy methords.

The the above mentioned content have been added to Intruduction Analyses, results and discussion section.

Response: we are very sorry for not mentioning these important reviews. We have studied these reviews carefully and discussed these reviews in Discussion sections.

Some prior reviews have evaluated the effects of music therapy for reducing depression. Aalbers and colleagues included nine studies in their review; they concluded that music therapy provides short-term benefificial effects for people with depression, and suggested that high-quality trials with large sample size were needed. However, this review was limited to studies of individuals with a diagnosis of depression, and did not differentiate music therapy from music medicine. Another paper reviewed the effectiveness of music interventions in treating depression. The authors included 26 studies and found a signifiant reduction in depression in the music intervention group compared with the controp group. The authors made a clear distincition on the definition of music therapy and music medicine; however, they did not include all relevant data from the most recent trials and did not conduct a meta-analysis. A recent meta-analysis compared the effects of music therapy and music medicine for reducing depression in people with cancer with seven RCTs; the authors found a moderately strong, positive impact of music intervention on depression , but found no difference between music therapy and music medicine.

【Aalbers, S., et al. (2017). "Music therapy for depression." Cochrane Database Syst Rev 11: CD004517.】

【Leubner, D. and T. Hinterberger (2017). "Reviewing the Effectiveness of Music Interventions in Treating Depression." Front Psychol 8: 1109.】

【Bradt, J., et al. (2016). "Music interventions for improving psychological and physical outcomes in cancer patients." Cochrane Database Syst Rev(8): CD006911.】

To date, many new trials focued on music therapy and depression in differnt poupulation (such as people with cancer, people with dementia, people with chronic disease, and so on ) have been performed, but they have not yet been systematically reviewed.

Response: Those comments are all valuable and very helpful for revising and improving our paper, as well as the important guiding significance to our researches. We have studied comments carefully and have made revision according to the comments.

Response: We are sorry for making this mistake. In the Methord section, we defined exclusive criteria as studies with a very small sample size (n<20),while in table 4 we performed the sensitivity analyses by excluding the papers with smale sample size ( 20< n<30). We have amended the table 4.

Response: We have added these findings with a forest plot (figure 6) according to the comment.

 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

Response: We have amended our manuscript according to PLOS ONE's style requirements

Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files.

Response: We have adjusted these content according to the comment.

 3. Thank you for stating the following in the Acknowledgments Section of your manuscript:

Response: We would like to update our funding statement as follows: The funders had a role in study design, text editing, interpretation of results, decision to publish and preparation of the manuscript.

4.LOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

Response: We have created a new ORCID iD accordingly to your instructions.

Response: we are sorry for making this mistake, we have amended our list of authors on the manuscript accordingly.

Response: We have checked the refer to Figure 5 and found that the refer to figure 5 was a mistake, and we have amended it.

7. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information:  http://journals.plos.org/plosone/s/supporting-information .

 Response: we only have a Supporting Information files (PRISMA-2009-Checklist), and we have added the captions for this Supporting Information files accordingly. We also have updated in-text citations to match accordingly.

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Response: Thinks very much for your comment.

Response: Thinks very much for your comment. Our manuscript have been edited for proper English language, grammar, punctuation, spelling, and overall style by one qualified native English speaking editors.

Response: This suggestion is valuable and we have tried to judge if the countries in our inluded papers have an established music therapy profession by checking the author's work address, literature review, visiting the important website about music therapy, and consulting to some famous music therapist via emails. The following table showed that four countries may be not have a music therapy profession. We have added the comparison of the country having music therapy profession and not.

https://erikdalton.com/find-a-certified-therapist/

https://www.musictherapy.org/about/listserv/

Table 1. The information on the music therapy profession in the inluded papers

Country Country having music therapy profession

Korea Korean Music Therapy Association

South Korea Korean Music Therapy Association

UK British Association for Music Therapy

Australia Australian Music Therapy Association

Canada Canadian Association of Music Therapists

China Chinese Professional Music Therapist Association

Taiwan China Chinese Professional Music Therapist Association

Denmark Dansk forbund for musikterapie

Finland Finnish Society for Music Therapy

Hong Kong China Hong Kong Music Therapy and Counseling Association

Serbia Music Therapists of Serbia organize workshops

Switzerland Swiss Association of Music Therapy

USA The American Music Therapy Association

Singapore The Association for Music Therapy (Singapore)

Brazil Uniao Braileira Das Associacoes De Musicoterapia

Germany YES

Northern Ireland YES

Spanish YES

Venezuela No

2.please fix the "short title" (oxygen)

Response: We’re sorry for making this mistake, and we have corrected this mistake.

Music therapy with fewer minutes might yield superior effects. This may be misleading. Is there a minimum number of minutes? How many minutes might be optimal for therapeutic outcome? I believe it does make sense that longer sessions may result in less impact - quantity/duration does not always result in enhanced outcome.

Response: In 33 included trials, intervention time each session was different, the mimimum time was 15 minutes in only one study (Burrai et al., 2019b), followed by 20 minuters in four studies (Chirico et al., 2020; Guétin et al., 2009; Hanser et al., 1994; Sigurdardóttir et al., 2019). In our subgroup analysis by time per session (minutes), we divided time per session into three groups, namely 15-40, 41-60, >60, and this presentation might be unclear.

In order to respond this comment, we have re-divided the time per session into four groups, namely 15-40, 41-60, 61-120, to explore the optimal minuter per session for therapeutic outcome.

I believe a stronger case needs to be made for the study. There are existing meta-analyses of MT for depression (Aalbers et al., 2017 Cochrane Review). What makes the current study unique and different? What are the gaps in the literature that warrant this study? Have there been a lot of recent additions to the literature that warrant a new meta-analysis?

Response: Some prior reviews have evaluated the effects of music therapy for reducing depression. Aalbers and colleagues (Aalbers et al., 2017）included nine studies in their review; they concluded that music therapy provides short-term benefificial effects for people with depression, and suggested that high-quality trials with large sample size were needed. However, this review was limited to studies of individuals with a diagnosis of depression, and did not differentiate music therapy from music medicine.

Another paper reviewed the effectiveness of music interventions in treating depression. The authors (Leubner D., 2017) included 26 studies and found a signifiant reduction in depression in the music intervention group compared with the controp group. The authors made a clear distincition on the definition of music therapy and music medicine; however, they did not include all relevant data from the most recent trials and did not conduct a meta-analysis. A recent meta-analysis (Bradt et al., 2016) compared the effects of music therapy and music medicine for reducing depression with seven RCTs; the authors found a moderately strong, positive impact of music intervention on depression , but found no difference between music therapy and music medicine. However, this review was limited to studies of individuals with a diagnosis of cancer.

Figure 1 presents the number of published paper ( search from Pubmed) focued on music therapy and depression from 1983 to 2020, the published paper was in the rapidly growing stage during the past five years. While, the above mentioned reviews all included papers published before 2017. To date, many new trials focued on music therapy and depression in differnt poupulation (such as people with cancer, people with dementia, people with chronic disease, and so on ) have been performed, but they have not yet been systematically reviewed.

While, no meta-analysis compared the the difference of music therapy on depression in differnt poupulation (such as people with depression, people with dementia, people with chronic disease, health people, and so on ) have been performed.

Figure 1 The pubished papers from 1983 to 2020 focused on music therapy and depression (searched from Pubmed)

In our persent meta-analysis, we aimed to (1) compare the effect between music therapy and music medicine on depression; (2) compare the effect between different specific methods used inmusic therapy on depression; (3) compare the effect of music-based interventions on depression among different population.

We have added the above content to Intruduction and Dissussion sections.

5.A stronger discussion of the limitation of this study. Many studies did not evaluate a group with major depression/major depressive disorder (music therapy for chronic pain is important, but the variance of the populations under study does constitute a limitation). So, this study is not exclusive to adults with a major mental health condition. Might effects be different for people who are depressed versus people who are not depressed?

Response: This is a very important comment. According to this comment, we have made some revision.

Firstly, we have added a sensitivity analysis by excluding the studes focused on the people with a major mental health condition.

Secondly, we have re-grouped the populations into three groups, namely mental health, severe mental disease /psychiatric disorder, and depression and we have added the subgroup analysis (table 2 in revised manuscript)..

Thirdly, we have added the analysis of the difference between people who are depressed versus people who are not depressed accordingly (table 2 in revised manuscript).

6.Instead of "blinding/blinded" please use "masking/masked."

Response: We have replaced "blinding/blinded" with "masking/masked" according to this comment.

Response: In active methods (improvisational, re-creative, compositional), participants are ‘making music’ , and in receptive music therapy (music-assisted relaxation, music and imagery, guided imagery and music, lyrics analysis ), participants are ‘receiving’ (e.g. listening to) music (Bruscia 2014; Wheeler 2015).

We have amended the difinition and added the citation to the Result section according to this commment.

[Bruscia KE. Defining Music Therapy. 3rd Edition.University Park, Illinois, USA: Barcelona Publishers, 2014.]

[Wheeler BL. Music Therapy Handbook. New York, New York, USA: Guilford Publications, 2015.]

Response: Of the 55 studies, 38 used group therapy, 17 used individual therapy, and 2 not reported. We have added the comparison of group therapy versus individual therapy according to this comment (table 2 in revised manuscript).

Response: Of 55 studies, a total of 25 studies were conducted in impatient setting,28 studies were in outpatients setting setting, and 2 studies not repoted the setting. We have added the subgroup analysis by inpatient settings (secure [locked] unit at a mental health facility versus outpatient settings) according to this comment (table 2 in revised manuscript).

Response: We have added the subgroup analysis by total sessions a participant has received according to this comment.

Response: We have added the SD in table 1

Response: Thanks very much for your important comments, these comments are all valuable and very helpful for revising and improving our paper, as well as the important guiding significance to our researches.

Response: (1) We have amendded the difinition of music therapy. According to the American Music Therapy Association (AMTA), “music therapy is the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program”.. [American Music Therapy Association (2020). Definition and Quotes about Music Therapy. Available online at: https://www.musictherapy.org/about/quotes/ (Accessed Sep 13, 2020).]

(2)We are very sorry for missing several research studies in our present meta-analysis. According to this comment, we have performed more extensive electronic search using the following terms: depression or mood disorders or affective disorders and music. We also performed manual search for the reference of all relevent reviews. In order to ensure the study quality of included papers, we excluded the studies with a very small sample size (n<20), we also excluded the non-english papers due to our language barrier. We included 23 new papers and deleted 1 old paper, in the last a total of 55 paper were included in our present analysis. The following are the new included papers and some excluded papers:

New-included papers

1)Albornoz Y. The effects of group improvisational music therapy on depression in adolescents and adults with substance abuse: a randomised controlled trial. Nordic Journal of Music Therapy 2011;20(3):208–24.

2)Hendricks CB, Robinson B, Bradley B, Davis K. Using music techniques to treat adolescent depression. Journal of Humanistic Counseling, Education and Development 1999; 38:39–46. （unavaliable）

3)Hendricks CB. A study of the use of music therapy techniques in a group for the treatment of adolescent depression. Dissertation Abstracts International 2001;62(2-A):472.

4)Radulovic R. The using of music therapy in treatment of depressive disorders. Summary of Master Thesis. Belgrade: Faculty of Medicine University of Belgrade, 1996.

5)Zerhusen JD, Boyle K, Wilson W. Out of the darkness: group cognitive therapy for depressed elderly. Journal of Military Nursing Research 1995;1:28–32. PUBMED: 1941727]

6)Chen SC, Yeh ML, Chang HJ, Lin MF. Music, heart rate variability, and symptom clusters: a comparative study. Support Care Cancer. 2020;28(1):351-360. doi:10.1007/s00520-019-04817-x

7)Chang, M. Y., Chen, C. H., and Huang, K. F. (2008). Effects of music therapy on psychological health of women during pregnancy. J. Clin. Nurs. 17, 2580–2587. doi: 10.1111/j.1365-2702.2007.02064.x

8)Chen XJ, Hannibal N, Gold C. Randomized Trial of Group Music Therapy With Chinese Prisoners: Impact on Anxiety, Depression, and Self-Esteem. Int J Offender Ther Comp Criminol. 2016;60(9):1064-1081. doi:10.1177/0306624X15572795

9)Esfandiari, N., and Mansouri, S. (2014). The effect of listening to light and heavy music on reducing the symptoms of depression among female students. Arts Psychother. 41, 211–213. doi: 0.1016/j.aip.2014.02.001

10)Fancourt, D., Perkins, R., Ascenso, S., Carvalho, L. A., Steptoe, A., and Williamon, A. (2016). Effects of group drumming interventions on anxiety, depression, social resilience and inflammatory immune response among mental health service users. PLoS ONE 11:e0151136. doi: 10.1371/journal.pone.0151136

11)Giovagnoli AR, Manfredi V, Parente A, Schifano L, Oliveri S, Avanzini G. Cognitive training in Alzheimer's disease: a controlled randomized study. Neurol Sci. 2017;38(8):1485-1493. doi:10.1007/s10072-017-3003-9

12)Harmat, L., Takács, J., and Bodizs, R. (2008). Music improves sleep quality in students. J. Adv. Nurs. 62, 327–335. doi: 10.1111/j.1365-2648.2008.04602.x

13)Liao J, Wu Y, Zhao Y, et al. Progressive Muscle Relaxation Combined with Chinese Medicine Five-Element Music on Depression for Cancer Patients: A Randomized Controlled Trial. Chin J Integr Med. 2018;24(5):343-347. doi:10.1007/s11655-017-2956-0

14)Lu, S. F., Lo, C. H. K., Sung, H. C., Hsieh, T. C., Yu, S. C., and Chang, S. C. (2013). Effects of group music intervention on psychiatric symptoms and depression in patient with schizophrenia. Complement. Ther. Med. 21, 682–688. doi: 10.1016/j.ctim.2013.09.002

15)Mahendran R, Gandhi M, Moorakonda RB, et al. Art therapy is associated with sustained improvement in cognitive function in the elderly with mild neurocognitive disorder: findings from a pilot randomized controlled trial for art therapy and music reminiscence activity versus usual care. Trials. 2018;19(1):615. Published 2018 Nov 9. doi:10.1186/s13063-018-2988-6

16)Nwebube C, Glover V, Stewart L. Prenatal listening to songs composed for pregnancy and symptoms of anxiety and depression: a pilot study. BMC Complement Altern Med. 2017;17(1):256. Published 2017 May 8. doi:10.1186/s12906-017-1759-3

17)Porter S, McConnell T, McLaughlin K, et al. Music therapy for children and adolescents with behavioural and emotional problems: a randomised controlled trial. J Child Psychol Psychiatry. 2017;58(5):586-594. doi:10.1111/jcpp.12656

18)Raglio A, Giovanazzi E, Pain D, et al. Active music therapy approach in amyotrophic lateral sclerosis: a randomized-controlled trial. Int J Rehabil Res. 2016;39(4):365-367. doi:10.1097/MRR.0000000000000187

19)Torres E, Pedersen IN, Pérez-Fernández JI. Randomized Trial of a Group Music and Imagery Method (GrpMI) for Women with Fibromyalgia. J Music Ther. 2018;55(2):186-220. doi:10.1093/jmt/thy005

20)Verrusio, W., Andreozzi, P., Marigliano, B., Renzi, A., Gianturco, V., Pecci, M. T., et al. (2014). Exercise training and music therapy in elderly with depressive syndrome: a pilot study. Complement. Ther. Med. 22, 614–620. doi: 10.1016/j.ctim.2014.05.012

21)Wang, J. , Wang, H. and Zhang, D. (2011) Impact of group music therapy on the depression mood of college students. Health, 3, 151-155

22)Yap AF, Kwan YH, Tan CS, Ibrahim S, Ang SB. Rhythm-centred music making in community living elderly: a randomized pilot study. BMC Complement Altern Med. 2017 Jun 14;17(1):311. doi: 10.1186/s12906-017-1825-x. PMID: 28615007; PMCID: PMC5470187.

23)Koelsch, S., Offermanns, K., and Franzke, P. (2010). Music in the treatment of affective disorders: an exploratory investigation of a new method for music-therapeutic research. Music Percept. Interdisc. J. 27, 307–316. doi: 10.1525/mp.2010.27.4.307

Excluded papers：

24)Bally, K., Campbell, D., Chesnick, K., and Tranmer, J. E. (2003). Effects of patient controlled music therapy during coronary angiography on procedural pain and anxiety distress syndrome. Crit. Care Nurse 23, 50–58. （not provide useable data）

25)Atiwannapat P, Thaipisuttikul P, Poopityastaporn P, Katekaew W. Active versus receptive group music therapy for major depressive disorder - a pilot study. Complementary Therapies in Medicine 2016;26:141–5. (sample size<20)

26)Garrido S, Stevens CJ, Chang E, Dunne L, Perz J. Music and Dementia: Individual Differences in Response to Personalized Playlists. J Alzheimers Dis. 2018;64(3):933-941. doi:10.3233/JAD-180084 （not randomised or quasi-randomised controlled trials）

27)Sánchez A, Maseda A, Marante-Moar MP, de Labra C, Lorenzo-López L, Millán-Calenti JC. Comparing the Effects of Multisensory Stimulation and Individualized Music Sessions on Elderly People with Severe Dementia: A Randomized Controlled Trial. J Alzheimers Dis. 2016;52(1):303-315. doi:10.3233/JAD-151150 （the control group also received music intervention）

28)Mondanaro JF, Homel P, Lonner B, Shepp J, Lichtensztein M, Loewy JV. Music Therapy Increases Comfort and Reduces Pain in Patients Recovering From Spine Surgery. Am J Orthop (Belle Mead NJ). 2017;46(1):E13-E22. (No full text available)

29)Castillo-Pérez, S., Gómez-Pérez, V., Velasco, M. C., Pérez-Campos, E., and Mayoral, M. A. (2010). Effects of music therapy on depression compared with psychotherapy. Arts Psychother. 37, 387–390. doi: 0.1016/j.aip.2010.07.001 （not provide useable data)

30)Alcântara-Silva TR, de Freitas-Junior R, Freitas NMA, et al. Music Therapy Reduces Radiotherapy-Induced Fatigue in Patients With Breast or Gynecological Cancer: A Randomized Trial. Integr Cancer Ther. 2018;17(3):628-635. doi:10.1177/1534735418757349（not provide useable data)

31)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. Reprod Biomed Online. 2018;37(2):145-152. doi:10.1016/j.rbmo.2018.04.049（not provide useable data)

32)Pezzin LE, Larson ER, Lorber W, McGinley EL, Dillingham TR. Music-instruction intervention for treatment of post-traumatic stress disorder: a randomized pilot study. BMC Psychol. 2018;6(1):60. Published 2018 Dec 19. doi:10.1186/s40359-018-0274-8 (the control group also received music intervention)

33)Silverman, M. J. (2011). Effects of music therapy on change and depression on clients in detoxification. J. Addict. Nurs. 22, 185–192. doi: 10.3109/10884602.2011.616606 （the control group also received music intervention）

34)Särkämö T, Laitinen S, Numminen A, Kurki M, Johnson JK, Rantanen P. Clinical and Demographic Factors Associated with the Cognitive and Emotional Efficacy of Regular Musical Activities in Dementia. J Alzheimers Dis. 2016;49(3):767-81. doi: 10.3233/JAD-150453. PMID: 26519435.

35)Tuinmann G, Preissler P, Böhmer H, Suling A, Bokemeyer C. The effects of music therapy in patients with high-dose chemotherapy and stem cell support: a randomized pilot study. Psychooncology. 2017 Mar;26(3):377-384. doi: 10.1002/pon.4142. Epub 2016 May 5. PMID: 27146798.（not provide useable data)

36)Hsu, W. C., and Lai, H. L. (2004). Effects of music on major depression in psychiatric inpatients. Arch. Psychiat. Nurs. 18, 193–199. doi: 10.1016/j.apnu.2004.07.007（not provide useable data)

（3）We have added some new analyses of our data. 1) including three new papers and re-analying of our data, 2) adding the comparison of music therapy and music medicine (figure 3 in revised manuscript) , 3) adding some subgroup analyses by country having music therapy profession, intervention settings, therapy mode, specific music therapy methord, intervenor /therapist, and total intervention session (table 2 in revised manuscript) .

Response: We are sorry for making this mistake. In the Methord section, we defined exclusive criteria as studies with a very small sample size (n<20),while in table4 we performed the sensitivity analyses by excluding the papers with smale sample size ( 20< n<30). We have amended the table 4.

Response: We have added these findings with a forest plot (figure 6 in revised manuscript) according to the comment.

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Submitted filename: Response to Reviewers.docx

Decision Letter 1

PONE-D-20-17706R1

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/ , click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at gro.solp@gnillibrohtua .

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact gro.solp@sserpeno .

Additional Editor Comments (optional):

Thank you for your satisfactory effort to correct the many important issues highlighted in my and our reviewers' comments, and to make necessary adjustments that meet our recommendations to improve the quality of your article.

Acceptance letter

30 Oct 2020

Dear Dr. Ye:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact gro.solp@sserpeno .

If we can help with anything else, please email us at gro.solp@enosolp .

Thank you for submitting your work to PLOS ONE and supporting open access.

PLOS ONE Editorial Office Staff

on behalf of

Prof. Dr. Sukru Torun

Our systems are now restored following recent technical disruption, and we’re working hard to catch up on publishing. We apologise for the inconvenience caused. Find out more: https://www.cambridge.org/universitypress/about-us/news-and-blogs/cambridge-university-press-publishing-update-following-technical-disruption

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings .

Login Alert

• > Journals
• > The British Journal of Psychiatry
• > Volume 199 Issue 2
• > Music therapy for depression: it seems to work, but...

Article contents

Meaningfulness and pleasure, physicality, music - therapy, music therapy for depression: it seems to work, but how.

Published online by Cambridge University Press:  02 January 2018

Evidence is beginning to emerge that music therapy can improve the mental health of people with depression. We examine possible mechanisms of action of this complex intervention and suggest that music therapy partly is effective because active music-making within the therapeutic frame offers the patient opportunities for new aesthetic, physical and relational experiences.

According to a national poll of listeners to a popular BBC music station in 2004, the best way to ameliorate one's depressive symptoms musically is to listen to ‘I Know It's Over’ by The Smiths. 1 Alas, the widespread availability of down-hearted rock does not appear to have diminished the prevalence of depression. And although listening alone to music that is personally meaningful is what many people imagine music therapy to be, the reality as practised in the UK and in many other parts of Europe is quite different.

It is therefore gratifying to read the article by Erkkilä et al Reference Erkkilä, Punkanen, Fachner, Ala-Ruona, Pöntiö and Tervaniemi 2 in this issue of the Journal that reports the results of a randomised controlled trial of interactive one-to-one music therapy for adults of working age with depression. In this study, conducted in Finland, trained music therapists engaged participants in up to 20 sessions of co-improvisational active music-making as the basis of a therapeutic relationship. This is a high-quality randomised trial of music therapy specifically for depression and the results suggest that it can improve the mood and global functioning of people with this disorder.

Among the challenges involved in evaluating complex interventions such as music therapy are those associated with treatment fidelity. Erkkilä et al have addressed this issue by ensuring that the music therapists who delivered treatment all completed an extensive induction focused on ensuring fidelity, and videotaped their sessions with participants to monitor adherence. The attention to fidelity is borne out in results that do not vary between therapists. This suggests that the agent of change is not likely to be the personality of the therapist or the nature of the particular therapist-patient alliance (as highlighted by the common factors approach, for example Messer & Wampold Reference Messer and Wampold 3 ) but rather may be attributable to the music or the therapy (if they are indeed distinguishable).

So why might this be so? Aside from any explanations derived from non-musical aspects of the therapy, the authors report that ‘active doing’ (i.e. the playing of musical instruments with the music therapists) was important to many participants in the active arm of the trial. They suggest that this is an important characteristic of music therapy and a meaningful way of dealing with issues associated with depression. We would like to suggest that this ‘active doing’ within music therapy has at least three interlinked dimensions: aesthetic, physical and relational.

First, the relationship between a diagnosis of depression and an experienced lack of pleasure and meaningfulness in life is well established. Perhaps in response to this, there is also a well-established recognition of the value of meaning-making via aesthetic experience within psychotherapy (e.g. Zukowski, Reference Zukowski 4 Hagman & Press Reference Hagman and Press 5 ). Here the conception is of the whole (verbal) therapeutic process as essentially aesthetic: how much more of an immediate aesthetic experience is on offer where the therapeutic interaction is musical? In music therapy, the therapist brings their musicianship to the musical encounter by listening acutely and attuning to the musical components implied in the patient's improvised sounds. For example, the therapist might draw out a shaky pulse or reinforce an implied tonal centre. Or they might create suspense or an implied direction (using a bass line or a harmonic progression underpinning an individual's melodic fragment) to entice a withdrawn person to engage in the relationship. There are often moments in music therapy when there is a ‘buzz’ between the two players, for example when they spontaneously come together at a cadence point or somehow know when to end or where to go next.

When a satisfying aesthetic is achieved within a co-improvised musical relationship there is potential not just for some kind of catharsis but for development, even if the music is not used as a springboard to discussion and insight: the aesthetic draws in the players to take the risk of doing things differently with others - to behave differently towards each other and to experience themselves differently. Reference Ansdell 6

Second, and rather obviously, the act of playing musical instruments requires purposeful physical movement. The role of physical activity in averting depression and alleviating its effects is well recognised. This is not simply a matter of getting people moving, but also of enabling people to experience themselves as physical beings. Music has its own internal sense of meaning founded on structure and cultural norms: this engages us and draws us into it whether or not we are aware of it on a technical level. Hence we find ourselves tapping our foot along to a song on the radio or being dissatisfied by a piece that does not finish as we expect. We are therefore entrained into musical participation: music itself offers us ways in - even in circumstances where we may feel distinctly unmotivated. Where we find ourselves musically entrained into physical participation with others we can have a physical experience of ourselves with others. This mirrors the experiences of musicians when playing in groups as can be seen in the coordinated movements of the players in a string quartet. Reference Davidson and Good 7 Our participation in turn enables us to hear (and feel) ourselves in the context of the aesthetic experiences outlined earlier, and this lends a potent sense of being part of something meaningful in the here-and-now:

… music heard so deeply That it is not heard at all, but you are the music While the music lasts. (T. S. Eliot: p. 48) Reference Eliot and De Masirevich 8

This leads to a third category of ‘active doing’: the relational. Our first experiences of relating (with our primary caregiver) are fundamentally musical. Developmental psychologists use musical vocabulary to describe the finely attuned interplay of gesture and sound between parent and newborn baby (e.g. Hobson Reference Hobson 9 ): it is in this pre-verbal interaction that we first learn who we are, how to think and to take pleasure in the possibilities that the world around us has to offer. Where mothers of infants are depressed, the musicality of infant-directed speech and conversational engagement is demonstrably affected with significant developmental implications for the child. Reference Marwick, Murray, Malloch and Trevarthen 10 These early experiences of musicality are frequently offered as a rationale for music therapy as a whole (e.g. Trevarthen & Malloch Reference Trevarthen and Malloch 11 ) and from this perspective the role of the therapist can be seen as neo-parental: musically nurturing the patient in order to facilitate a similar process of discovery of self and self in relation to others, including the capacity for experiencing meaning and pleasure. Once again, it is music itself that facilitates this: a melodic riff, a harmonic progression, a rhythmic catch - these all naturally engage people in active participation (and hence meaning-making) in ways that words may simply not be able to. It has been argued that music therapy builds on people's capacity for communicative musicality, that we are hard-wired for this kind of engagement and interaction, and that through music-making we experience a kind of relating that is very different from that which talking has to offer. Reference Ansdell, Pavlicevic, Miell, MacDonald and Hargreaves 12

In these respects, then, music cannot be treated simply as a stimulus intended to provoke a predetermined behavioural response. Rather, music-making offers what DeNora Reference DeNora 13 terms affordances - physical, relational and aesthetic. Above all, music-making is social (and hence interpersonal), pleasurable and meaningful: this may also be why randomised trials of music therapy have shown high levels of engagement with patient groups who are traditionally difficult to engage (e.g. Talwar et al Reference Talwar, Crawford, Maratos, Nur, McDermott and Procter 14 ).

Clinical trials inevitably focus on the outcomes of interventions rather than the process through which these outcomes may be achieved. Further research using mixed methods is needed if a better understanding of the active ingredients of music therapy that enhance patient outcomes is to be reached.

Nevertheless, Erkkilä et al Reference Erkkilä, Punkanen, Fachner, Ala-Ruona, Pöntiö and Tervaniemi 2 lay down a clear marker for the value of music therapy as part of the range of interventions available for the treatment of people with depression.

See pp. 132–139, this issue.

Declaration of interest

A.M. and M.J.C. are members of the International Centre for Research in Arts Therapies (ICRA), a non-profit group that aims to promote research in the arts therapies.

This article has been cited by the following publications. This list is generated based on data provided by Crossref .

• Google Scholar

View all Google Scholar citations for this article.

Save article to Kindle

To save this article to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle .

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

• Volume 199, Issue 2
• Anna Maratos (a1) , Mike J. Crawford (a2) and Simon Procter (a3)
• DOI: https://doi.org/10.1192/bjp.bp.110.087494

Save article to Dropbox

To save this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about saving content to Dropbox .

Save article to Google Drive

To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about saving content to Google Drive .

Reply to: Submit a response

- No HTML tags allowed - Web page URLs will display as text only - Lines and paragraphs break automatically - Attachments, images or tables are not permitted

Your details

Your email address will be used in order to notify you when your comment has been reviewed by the moderator and in case the author(s) of the article or the moderator need to contact you directly.

You have entered the maximum number of contributors

Conflicting interests.

Please list any fees and grants from, employment by, consultancy for, shared ownership in or any close relationship with, at any time over the preceding 36 months, any organisation whose interests may be affected by the publication of the response. Please also list any non-financial associations or interests (personal, professional, political, institutional, religious or other) that a reasonable reader would want to know about in relation to the submitted work. This pertains to all the authors of the piece, their spouses or partners.

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• Review Article
• Open access
• 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

45k Accesses

34 Citations

80 Altmetric

Metrics details

• 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.

Similar content being viewed by others

Biological principles for music and mental health

A comprehensive investigation into the genetic relationship between music engagement and mental health

The effects of music listening on somatic symptoms and stress markers in the everyday life of women with somatic complaints and depression

Introduction.

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 ].

Experimental studies

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

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 ].

Interim summary

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

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.

Neuroimaging

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.

Concluding remarks

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.

Mankel K, Bidelman GM. Inherent auditory skills rather than formal music training shape the neural encoding of speech. Proc Natl Acad Sci. 2018;115:13129–34.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Swaminathan S, Schellenberg EG. Musical competence is predicted by music training, cognitive abilities, and personality. Sci Rep. 2018;8:9223.

Article   PubMed   PubMed Central   CAS   Google Scholar  

Mosing MA, Pedersen NL, Madison G, Ullen F. Genetic pleiotropy explains associations between musical auditory discrimination and intelligence. PLos One. 2014;9:e113874.

Weinberg MK, Joseph D. If you’re happy and you know it: Music engagement and subjective wellbeing. Psychol Music. 2017;45:257–67.

Article   Google Scholar  

Theorell TP, Lennartsson AK, Mosing MA, Ullen F. Musical activity and emotional competence - a twin study. Front Psychol. 2014;5:774.

Article   PubMed   PubMed Central   Google Scholar  

Cirelli LK, Trehub SE, Trainor LJ. Rhythm and melody as social signals for infants. Ann N Y Acad Sci. 2018;1423:66–72.

Zentner M, Eerola T. Rhythmic engagement with music in infancy. Proc Natl Acad Sci. 2010;107:5768–73.

Lense MD, Beck S, Liu C, Pfeiffer R, Diaz N, Lynch M, et al. Parents, peers, and musical play: Integrated parent-child music class program supports community participation and well-being for families of children with and without Autism Spectrum Disorder. Front Psychol. 2020;11:11.

Honing H. On the biological basis of musicality. Ann N Y Acad Sci. 2018;1423:51–6.

Maratos AS, Gold C, Wang X, Crawford MJ. Music therapy for depression. Cochrane Database Syst Rev. 2008;1:CD004517.

Ansdell G, Meehan J. “Some Light at the End of the Tunnel”: exploring Users’ evidence for the effectiveness of music therapy in adult mental health settings. Music Med. 2010;2:29–40.

Khalfa S, Bella SD, Roy M, Peretz I, Lupien SJ. Effects of relaxing music on salivary cortisol level after psychological stress. Ann N Y Acad Sci. 2003;999:374–6.

Article   PubMed   Google Scholar  

McKinney CH, Antoni MH, Kumar M, Tims FC, McCabe PM. Effects of guided imagery and music (GIM) therapy on mood and cortisol in healthy adults. Health Psychol. 1997;16:390–400.

Article   CAS   PubMed   Google Scholar  

Chanda ML, Levitin DJ. The neurochemistry of music. Trends Cogn Sci. 2013;17:179–93.

Olff M, Koch SB, Nawijn L, Frijling JL, Van Zuiden M, Veltman DJ. Social support, oxytocin, and PTSD. Eur J Psychotraumatol. 2014;5:26513.

Ferreri L, Mas-Herrero E, Zatorre RJ, Ripollés P, Gomez-Andres A, Alicart H, et al. Dopamine modulates the reward experiences elicited by music. Proc Natl Acad Sci. 2019;116:3793–8.

Evers S, Suhr B. Changes of the neurotransmitter serotonin but not of hormones during short time music perception. Eur Arch Psychiatry Clin Neurosci. 2000;250:144–7.

Blum K, Simpatico T, Febo M, Rodriquez C, Dushaj K, Li M, et al. Hypothesizing music intervention enhances brain functional connectivity involving dopaminergic recruitment: Common neuro-correlates to abusable drugs. Mol Neurobiol. 2017;54:3753–58.

Kotov R, et al. The hierarchical Taxonomy of psychopathology (HiTOP): a dimensional alternative to traditional nosologies. J Abnorm Psychol. 2017. https://doi.org/10.1037/abn0000258 .

Caspi A, Houts RM, Belsky DW, Goldman-Mellor SJ, Harrington H, Israel S, et al. The p factor: one general psychopathology factor in the structure of psychiatric disorders? Clin Psychological Sci. 2014;2:119–37.

Whiteside SP, Lynam DR. Understanding the role of impulsivity and externalizing psychopathology in alcohol abuse: Application of the UPPS impulsive behavior scale. Exp Clin Psychopharmacol. 2003;11:210–7.

Tackett JL, Lahey BB, van Hulle C, Waldman I, Krueger RF, Rathouz PJ. Common genetic influences on negative emotionality and a general psychopathology factor in childhood and adolescence. J Abnorm Psychol. 2013;122:1142–53.

Young SE, Friedman NP, Miyake A, Willcutt EG, Corley RP, Haberstick BC, et al. Behavioral disinhibition: liability for externalizing spectrum disorders and its genetic and environmental relation to response inhibition across adolescence. J Abnorm Psychol. 2009;118:117–30.

Gustavson DE, Franz CE, Panizzon MS, Lyons MJ, Kremen WS. Internalizing and externalizing psychopathology in middle age: Genetic and environmental architecture and stability of symptoms over 15 to 20 years. Psychological Med. 2019;50:1–9.

Google Scholar  

Martin J, Taylor MJ, Lichtenstein P. Assessing the evidence for shared genetic risks across psychiatric disorders and traits. Psychological Med. 2018;48:1759–74.

Panteleeva Y, Ceschi G, Glowinski D, Courvoisier DS, Grandjean D. Music for anxiety? Meta-analysis of anxiety reduction in non-clinical samples. Psychol Music. 2017;46:473–87.

Leubner D, Hinterberger T. Reviewing the effectiveness of music interventions in treating depression. Front Psychol. 2017;8:1109.

Perkins R, Mason-Bertrand A, Fancourt D, Baxter L, Williamon A. How participatory music engagement supports mental well-being: a meta-ethnography. Qualitative Health Res. 2020. https://doi.org/10.1177/1049732320944142 .

Lilienfeld SO. Comorbidity between and within childhood externalizing and internalizing disorders: reflections and directions. J. Abnorm Child Psychol. 2003;31:285–91.

Kendler KS, Myers J. The boundaries of the internalizing and externalizing genetic spectra in men and women. Psychological Med. 2014;44:647–55.

Article   CAS   Google Scholar  

Robb SL, Burns DS, Carpenter JS. Reporting guidelines for music-based interventions. J Health Psychol. 2011;16:342–52.

Robb SL, Hanson-Abromeit D, May L, Hernandez-Ruiz E, Allison M, Beloat A, et al. Reporting quality of music intervention research in healthcare: a systematic review. Complement Ther Med. 2018;38:24–41.

Carr C, Odell-Miller H, Priebe S. A systematic review of music therapy practice and outcomes with acute adult psychiatric in-patients. PLos One. 2013;8:e70252.

Miranda D, Blais-Rochette C. Neuroticism and emotion regulation through music listening: a meta-analysis. Musica Sci. 2018. https://doi.org/10.1177/1029864918806341 .

Miranda D. The emotional bond between neuroticism and music. Psychomusicology: Music, Mind, Brain. 2019. https://doi.org/10.1037/pmu0000250 .

Landis-Shack N, Heinz AJ, Bonn-Miller MO. Music therapy for posttraumatic stress in adults: a theoretical review. Psychomusicology. 2017;27:334–342.

Schäfer K, Saarikallio S, Eerola T. Music may reduce loneliness and act as social surrogate for a friend: evidence from an experimental listening study. Music Sci. 2020;3. https://doi.org/10.1177/2059204320935709 .

Braun Janzen T, Al Shirawi MI, Rotzinger S, Kennedy SH, Bartel L. A pilot study investigating the effect of music-based intervention on depression and anhedonia. Front Psychol. 2019;10:1038.

Biasutti M, Mangiacotti A. Music training improves depressed mood symptoms in elderly people: a randomized controlled trial. Int J Aging Hum Dev. 2019. https://doi.org/10.1177/0091415019893988 .

Castillo-Pérez S, Gómez-Pérez V, Velasco MC, Pérez-Campos E, Mayoral M-A. Effects of music therapy on depression compared with psychotherapy. Arts Psychother. 2010;37:387–390.

Hendricks CB, Robinson B, Bradley LJ, Davis K. Using music techniques to treat adolescent depression. J Humanist Counseling. 1999;38:39–46.

Chwalek CM, McKinney CH. The use of dialectical behavior therapy (DBT) in music therapy: a sequential explanatory study. J. Music Ther. 2015;52:282–318.

Tang YY, Yang L, Leve LD, Harold GT. Improving executive function and its neurobiological mechanisms through a mindfulness-based intervention: advances within the field of developmental neuroscience. Child Dev. Perspect. 2012;6:361–66.

PubMed   PubMed Central   Google Scholar  

Didonna F. Mindfulness-based interventions in an inpatient setting. In: Clinical handbook of mindfulness. Springer, New York, NY; 2009. p. 447–62.

Chin T, Rickard NS. Beyond positive and negative trait affect: flourishing through music engagement. Psychol Well-Being. 2014;4:25.

Miranda D, Claes M. Personality traits, music preferences and depression in adolescence. Int J Adolescence Youth. 2008;14:277–98.

Fancourt D, Garnett C, Spiro N, West R, Mullensiefen D. How do artistic creative activities regulate our emotions? Validation of the Emotion Regulation Strategies for Artistic Creative Activities Scale (ERS-ACA). PLos One. 2019;14:e0211362.

Saarikallio S. Development and validation of the brief music in mood regulation scale (B-MMR). Music Percept. 2012;30:97–105.

Saarikallio S, Gold C, McFerran K. Development and validation of the healthy-unhealthy music scale. Child Adolesc Ment Health. 2015;20:210–17.

Groarke JM, Hogan MJ. Development and psychometric evaluation of the adaptive functions of music listening scale. Front Psychol. 2018;9:516.

Thomson CJ, Reece JE, Di Benedetto M. The relationship between music-related mood regulation and psychopathology in young people. Musica Sci. 2014;18:150–65.

Shifriss R, Bodner E, Palgi Y. When you’re down and troubled: views on the regulatory power of music. Psychol Music. 2014;43:793–807.

Garrido S, Schubert E. Moody melodies: do they cheer us up? A study of the effect of sad music on mood. Psychol Music. 2013;43:244–261.

Wesseldijk LW, Ullen F, Mosing MA. The effects of playing music on mental health outcomes. Sci Rep. 2019;9:12606.

Niarchou M, Lin G, Lense MD, Gordon RL, Davis LK. The medical signature of musicians: a phenome-wide association study using an electronic health record database. medRxiv. 2020;10:51. https://doi.org/10.1101/2020.08.14.20175109 .

Vaag J, Sund ER, Bjerkeset O. Five-factor personality profiles among Norwegian musicians compared to the general workforce. Musica Sci. 2017;22:434–445.

Fancourt D, Garnett C, Müllensiefen D. The relationship between demographics, behavioral and experiential engagement factors, and the use of artistic creative activities to regulate emotions. Psychol Aesthet Creat Arts. 2020.(advance online publication)

Mak HW, Fancourt D. Longitudinal associations between ability in arts activities, behavioural difficulties and self-esteem: Analyses from the 1970 British Cohort Study. Sci Rep. 2019;9:14236.

West SG, Taylor AB, Wu W. Model fit and model selection in structural equation modeling. In: Hoyle RH, editor. Handbook of structural equation modeling. New York, NY: The Guilford Press; 2012. p. 209–31.

Weiss B, Susser K, Catron T. Common and specific features of childhood psychopathology. J Abnorm Psychol. 1998;107:118–27.

Krueger RF, McGue M, Iacono WG. The higher-order structure of common DSM mental disorders: Internalization, externalization, and their connections to personality. Personal Individ Differences. 2001;30:1245–159.

Morse S, et al. Audio therapy significantly attenuates aberrant mood in residential patient addiction treatment: putative activation of dopaminergic pathways in the meso-limbic reward circuitry of humans. J Addict Res Ther. 2011;3:2.

Baker FA, Gleadhill LM, Dingle GA. Music therapy and emotional exploration: exposing substance abuse clients to the experiences of non-drug-induced emotions. Arts Psychother. 2007;34:321–330.

Dingle GA, Gleadhill L, Baker FA. Can music therapy engage patients in group cognitive behaviour therapy for substance abuse treatment? Drug Alcohol Rev. 2008;27:190–6.

Hohmann L, Bradt J, Stegemann T, Koelsch S. Effects of music therapy and music-based interventions in the treatment of substance use disorders: A systematic review. PLos One. 2017;12:e0187363.

Swope PM. Effects of learning the drums on inattention, vigilance, and sustained attention in adolescents with ADHD. Spalding University; 2018.

Zimmermann MB, Diers K, Strunz L, Scherbaum N, Mette C. Listening to Mozart improves current mood in adult ADHD: a randomized controlled pilot study. Front Psychol. 2019;10:1104.

Madjar N, Gazoli R, Manor I, Shoval G. Contrasting effects of music on reading comprehension in preadolescents with and without ADHD. Psychiatry Res. 2020;291:113207.

Pelham WE, Waschbusch DA, Hoza B, Gnagy EM, Greiner AR, Sams SE, et al. Music and video as distractors for boys with ADHD in the classroom: comparison with controls, individual differences, and medication effects. J Abnorm Child Psychol. 2011;39:1085–98.

Porter S, McConnell T, McLaughlin K, Lynn F, Cardwell C, Braiden HJ, et al. Music therapy for children and adolescents with behavioural and emotional problems: a randomised controlled trial. J Child Psychol Psychiatry. 2017;58:586–94.

Chong HJ, Kim SJ. Education-oriented music therapy as an after-school program for students with emotional and behavioral problems. Arts Psychother. 2010;37:190–96.

Rickson DJ, Watkins WG. Music therapy to promote prosocial behaviors in aggressive adolescent boys—a pilot study. J. Music Ther. 2003;40:283–301.

Montello L, Coons EE. Effects of active versus passive group music therapy on preadolescents with emotional, learning, and behavioral disorders. J Music Ther. 1999;35:49–67.

Mulder J, Ter Bogt TF, Raaijmakers QA, Gabhainn SN, Monshouwer K, Vollebergh WA. The soundtrack of substance use: Music preference and adolescent smoking and drinking. Subst Use Misuse. 2009;44:514–31.

Mulder J, Ter Bogt TF, Raaijmakers QA, Nic Gabhainn S, Monshouwer K, Vollebergh WA. Is it the music? Peer substance use as a mediator of the link between music preferences and adolescent substance use. J Adolescence. 2010;33:387–94.

Chen MJ, Miller BA, Grube JW, Waiters ED. Music, substance use, and aggression. J Stud Alcohol. 2006;67:373–81.

ter Bogt TF, Gabhainn SN, Simons-Morton BG, Ferreira M, Hublet A, Godeau E, et al. Dance is the new metal: adolescent music preferences and substance use across Europe. Subst Use Misuse. 2012;47:130–42.

Slater JL, Tate MC. Timing deficits in ADHD: insights from the neuroscience of musical rhythm. Front Comput Neurosci. 2018;12:51.

Carrer LR. Music and sound in time processing of children with ADHD. Front Psychiatry. 2015;6:127.

Miksza P. Relationships among impulsivity, achievement goal motivation, and the music practice of high school wind players. Bull Council Res Music Educ. 2009;180:9–27.

Miksza P. Relationships among achievement goal motivation, impulsivity, and the music practice of collegiate brass and woodwind players. Psychol Music. 2010;39:50–67.

Geretsegger M, Mössler KA, Bieleninik Ł, Chen XJ, Heldal TO, Gold C. Music therapy for people with schizophrenia and schizophrenia-like disorders. Cochrane Database Syst Rev. 2017;5:CD004025.

PubMed   Google Scholar  

Volpe U, Gianoglio C, Autiero L, Marino ML, Facchini D, Mucci A, et al. Acute effects of music therapy in subjects with psychosis during inpatient treatment. Psychiatry. 2018;81:218–27.

Pavlov A, Kameg K, Cline TW, Chiapetta L, Stark S, Mitchell AM. Music therapy as a nonpharmacological intervention for anxiety in patients with a thought disorder. Issues Ment Health Nurs. 2017;38:285–8.

Haugwitz, B. (2021). Music therapy in the early detection and indicated prevention in persons at risk of bipolar disorders: state of knowledge and potential. Br J Music Ther. 2021. https://doi.org/10.1177/1359457521997386 .

Power RA, Steinberg S, Bjornsdottir G, Rietveld CA, Abdellaoui A, Nivard MM, et al. Polygenic risk scores for schizophrenia and bipolar disorder predict creativity. Nat Neurosci. 2015;18:953–5.

Fancourt D, Ockelford A, Belai A. The psychoneuroimmunological effects of music: a systematic review and a new model. Brain Behav. Immun. 2014;36:15–26.

Baker FA, Metcalf O, Varker T, O’Donnell M. A systematic review of the efficacy of creative arts therapies in the treatment of adults with PTSD. Psychol Trauma. 2018;10:643–51.

Lense MD, Camarata S. PRESS-Play: musical engagement as a motivating platform for social interaction and social play in young children with ASD. Music Sci. 2020. https://doi.org/10.1177/2059204320933080 .

Walker EF, Diforio D. Schizophrenia: a neural diathesis-stress model. Psychological Rev. 1997;104:667–85.

Zuckerman M, Riskind JH. Vulnerability to psychopathology: a biosocial model. J Cogn Psychother. 2000;14:407–8.

Trucco EM, Madan B, Villar M. The impact of genes on adolescent substance use: a developmental perspective. Curr Addict Rep. 2019;6:522–531.

Butkovic A, Ullen F, Mosing MA. Personality related traits as predictors of music practice: underlying environmental and genetic influences. Personal Individ Differences. 2015;74:133–8.

Coon H, Carey G. Genetic and environmental determinants of musical ability in twins. Behav Genet. 1989;19:183–93.

Ullén F, Mosing MA, Holm L, Eriksson H, Madison G. Psychometric properties and heritability of a new online test for musicality, the Swedish Musical Discrimination Test. Personal Individ Differences. 2014;63:87–93.

Hambrick DZ, Tucker-Drob EM. The genetics of music accomplishment: evidence for gene-environment correlation and interaction. Psychonomic Bull Rev. 2015;22:112–20.

Wesseldijk LW, Mosing MA, Ullen F. Gene-environment interaction in expertise: the importance of childhood environment for musical achievement. Dev Psychol. 2019;55:1473–9.

Ullen F, Mosing MA, Madison G. Associations between motor timing, music practice, and intelligence studied in a large sample of twins. Ann N Y Acad Sci. 2015;1337:125–9.

Botvin GJ. Substance abuse prevention: theory, practice, and effectiveness. Crime Justice. 1990;13:461–519.

Fredricks JA, Simpkins S, Eccles JS. Family socialization, gender, and participation in sports and instrumental music. In: Developmental pathways through middle childhood. Mahwah, NJ: Psychology Press; 2006. p. 53–74.

Maes HH, Neale MC, Kirkpatrick RM, Kendler KS. Using multimodal inference/model averaging to model causes of covariation between variables in twins. Behav Genet. 2020. https://doi.org/10.1007/s10519-020-10026-8 .

Sala G, Gobet F. When the music’s over. Does music skill transfer to children’s and young ado escents’ cognitive and academic skills? A meta-analysis. Educ Res Rev. 2017;20:55–67.

Salimpoor VN, Zald DH, Zatorre RJ, Dagher A, McIntosh AR. Predictions and the brain: how musical sounds become rewarding. Trends Cogn Sci. 2015;19:86–91.

Loui P, Patterson S, Sachs ME, Leung Y, Zeng T, Przysinda E. White matter correlates of musical anhedonia: Implications for evolution of music. Front Psychol. 2017;8:1664.

Salimpoor VN, van den Bosch I, Kovacevic N, McIntosh AR, Dagher A, Zatorre RJ. Interactions between the nucleus accumbens and auditory cortices predict music reward value. Science. 2013;340:216–9.

Zatorre RJ, Salimpoor VN. From perception to pleasure: music and its neural substrates. Proc Natl Acad Sci. 2013;110:10430–7. Suppl 2

Alluri V, Brattico E, Toiviainen P, Burunat I, Bogert B, Numminen J, et al. Musical expertise modulates functional connectivity of limbic regions during continuous music listening. Psychomusicology. 2015;25:443–54.

Vanyukov MM, Tarter RE, Kirisci L, Kirillova GP, Maher BS, Clark DB. Liability to substance use disorders: 1. Common mechanisms and manifestations. Neurosci Biobehav Rev. 2003;27:507–515.

Volkow ND, Morales M. The brain on drugs: from reward to addiction. Cell. 2015;162:712–25.

Wise RA. Dopamine and reward: the anhedonia hypothesis 30 years on. Neurotox Res. 2008;14:169–83.

Koob GF, Volkow ND. Neurocircuitry of addiction. Neuropsychopharmacology. 2010;35:217–38.

Mukherjee S, Coque L, Cao JL, Kumar J, Chakravarty S, Asaithamby A, et al. Knockdown of Clock in the ventral tegmental area through RNA interference results in a mixed state of mania and depression-like behavior. Biol Psychiatry. 2010;68:503–11.

Kaufling J. Alterations and adaptation of ventral tegmental area dopaminergic neurons in animal models of depression. Cell Tissue Res. 2019;377:59–71.

Small KM, Nunes E, Hughley S, Addy NA. Ventral tegmental area muscarinic receptors modulate depression and anxiety-related behaviors in rats. Neurosci Lett. 2016;616:80–5.

Kokal I, Engel A, Kirschner S, Keysers C. Synchronized drumming enhances activity in the caudate and facilitates prosocial commitment-if the rhythm comes easily. PLos One. 2011;6:e27272.

Goldstein A. Thrills in response to music and other stimuli. Physiological Psychol. 1980;8:126–9.

Moore E, Schaefer RS, Bastin ME, Roberts N, Overy K. Can musical training influence brain connectivity? Evidence from diffusion tensor MRI. Brain Sci. 2014;4:405–27.

Imfeld A, Oechslin MS, Meyer M, Loenneker T, Jancke L. White matter plasticity in the corticospinal tract of musicians: a diffusion tensor imaging study. Neuroimage. 2009;46:600–7.

Han Y, Yang H, Lv YT, Zhu CZ, He Y, Tang HH, et al. Gray matter density and white matter integrity in pianists’ brain: a combined structural and diffusion tensor MRI study. Neurosci Lett. 2009;459:3–6.

Schmithorst VJ, Wilke M. Differences in white matter architecture between musicians and non-musicians: a diffusion tensor imaging study. Neurosci Lett. 2002;321:57–60.

Hudziak JJ, Albaugh MD, Ducharme S, Karama S, Spottswood M, Crehan E, et al. Cortical thickness maturation and duration of music training: Health-promoting activities shape brain development. J Am Acad Child Adolesc Psychiatry. 2014;53:1153–61.

Gingras B, Honing H, Peretz I, Trainor LJ, Fisher SE. Defining the biological bases of individual differences in musicality. Philos Trans R Soc B. 2015;370:20140092.

Heath AC, Kessler RC, Neale MC, Hewitt JK, Eaves LJ, Kendler KS. Testing hypotheses about direction of causation using cross-sectional family data. Behav Genet. 1993;23:29–50.

Coleman JRI, Peyrot WJ, Purves KL, Davis KAS, Rayner C, Choi SW, et al. Genome-wide gene-environment analyses of major depressive disorder and reported lifetime traumatic experiences in UK Biobank. Mol Psychiatry. 2020;25:247353–1446.

Domingue BW, Liu HX, Okbay A, Belsky DW. Genetic heterogeneity in depressive symptoms following the death of a spouse: polygenic score analysis of the US Health and Retirement Study. Am J Psychiatry. 2017;174:963–970.

Barcellos SH, Carvalho LS, Turley P. Education can reduce health differences related to genetic risk of obesity. Proc Natl Acad Sci USA. 2018;115:E9765–E9772.

Howard DM, Adams MJ, Shirali M, Clarke TK, Marioni RE, Davies G, et al. Genome-wide association study of depression phenotypes in UK Biobank identifies variants in excitatory synaptic pathways. Nat Commun. 2018;9:1470.

Okbay A, Baselmans BM, De Neve JE, Turley P, Nivard MG, Fontana MA, et al. Genetic variants associated with subjective well-being, depressive symptoms, and neuroticism identified through genome-wide analyses. Nat Genet. 2016;48:624–33.

Walters RK, Polimanti R, Johnson EC, McClintick JN, Adams MJ, Adkins AE, et al. Transancestral GWAS of alcohol dependence reveals common genetic underpinnings with psychiatric disorders. Nat Neurosci. 2018;21:1656–69.

Niarchou M, et al. Unraveling the genetic architecture of music rhythm. https://www.biorxiv.org/content/10.1101/836197v1 . 2019 ; 29:S62.

Purcell S. Variance components models for gene-environment interaction in twin analysis. Twin Res. 2002;5:554–71.

Barch DM, Albaugh MD, Avenevoli S, Chang L, Clark DB, Glantz MD, et al. Demographic, physical and mental health assessments in the adolescent brain and cognitive development study: rationale and description. Dev Cogn Neurosci. 2018;32:55–66.

Uban KA, Horton MK, Jacobus J, Heyser C, Thompson WK, Tapert SF, et al. Biospecimens and the ABCD study: rationale, methods of collection, measurement and early data. Dev Cogn Neurosci. 2018;32:97–106.

Mullensiefen D, Gingras B, Musil J, Stewart L. The musicality of non-musicians: an index for assessing musical sophistication in the general population. PLos One. 2014;9:e89642.

Blood AJ, Zatorre RJ. Intensely pleasurable responses to music correlate with activity in brain regions implicated in reward and emotion. Proc Natl Acad Sci. 2001;98:11818–23.

Jenkins LM, Skerrett KA, DelDonno SR, Patrón VG, Meyers KK, Peltier S, et al. Individuals with more severe depression fail to sustain nucleus accumbens activity to preferred music over time. Psychiatry Res Neuroimaging. 2018;275:21–7.

Belfi AM, Loui P. Musical anhedonia and rewards of music listening: current advances and a proposed model. Ann N Y Acad Sci. 2020;1464:99–114.

Insel T, et al. Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. Am Psychiatric Assoc. 2010;167:748–51.

Loo SK, McGough JJ, McCracken JT, Smalley SL. Parsing heterogeneity in attention-deficit hyperactivity disorder using EEG-based subgroups. J Child Psychol Psychiatry. 2018;59:223–31.

Zotev V, Mayeli A, Misaki M, Bodurka J. Emotion self-regulation training in major depressive disorder using simultaneous real-time fMRI and EEG neurofeedback. Neuroimage Clin. 2020;27:102331.

Yang AC, Jann K, Michel CM, Wang DJJ. Editorial: advances in multi-scale analysis of brain complexity. Front Neurosci. 2020;14:337.

Lin C, Lee SH, Huang CM, Chen GY, Ho PS, Liu HL, et al. Increased brain entropy of resting-state fMRI mediates the relationship between depression severity and mental health-related quality of life in late-life depressed elderly. J Affect Disord. 2019;250:270–7.

Bhattacharya J, Lee EJ. Modulation of EEG theta band signal complexity by music therapy. Int J Bifurc Chaos. 2016;26:1650001.

Carpentier SM, McCulloch AR, Brown TM, Faber S, Ritter P, Wang Z, et al. Complexity matching: brain signals mirror environment information patterns during music listening and reward. J Cogn Neurosci. 2020;32:734–45.

Etkin A. A reckoning and research agenda for neuroimaging in psychiatry. Am J Psychiatry. 2019;176:507–11.

Rissling AJ, Makeig S, Braff DL, Light GA. Neurophysiologic markers of abnormal brain activity in schizophrenia. Curr Psychiatry Rep. 2010;12:572–8.

Loo SK, Makeig S. Clinical utility of EEG in attention-deficit/hyperactivity disorder: a research update. Neurotherapeutics. 2012;9:569–87.

Boyle EA, Li YI, Pritchard JK. An expanded view of complex traits: from polygenic to omnigenic. Cell. 2017;169:1177–86.

Sivagnanam S, Yoshimoto K, Carnevale T, Nadeau D, Kandes M, Petersen T, et al. Neuroscience Gateway enabling large scale modeling and data processing in neuroscience research. In: Practice and Experience in Advanced Research Computing. Association for Computing Machinery, Portland, OR, USA ; 2020. p.510–513.

Download references

Acknowledgements

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.

Author information

Authors and affiliations.

Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA

• 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

The Curb Center, Vanderbilt University, Nashville, TN, USA

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Daniel E. Gustavson .

Ethics declarations

Competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Cite this article.

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

Download citation

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

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

This article is cited by

Evaluating music education interventions for mental health in chinese university student: a dual fuzzy analytic method.

• Sri Azra Attan

Scientific Reports (2024)

• Laura W. Wesseldijk
• Miriam A. Mosing

Translational Psychiatry (2023)

Effects of music-based interventions on cancer-related pain, fatigue, and distress: an overview of systematic reviews

• Ana Trigueros-Murillo
• Javier Martinez-Calderon
• Alberto Marcos Heredia-Rizo

Supportive Care in Cancer (2023)

A Systematic Review of Music-Based Interventions to Improve Treatment Engagement and Mental Health Outcomes for Adolescents and Young Adults

• Aaron H. Rodwin
• Rei Shimizu
• Michelle R. Munson

Child and Adolescent Social Work Journal (2023)

Heritability of Childhood Music Engagement and Associations with Language and Executive Function: Insights from the Adolescent Brain Cognitive Development (ABCD) Study

• Srishti Nayak

Behavior Genetics (2023)

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

• Bipolar Disorder
• Therapy Center
• When To See a Therapist
• Types of Therapy
• Best Online Therapy
• Best Couples Therapy
• Managing Stress
• Sleep and Dreaming
• Understanding Emotions
• Self-Improvement
• Healthy Relationships
• Student Resources
• Personality Types
• Sweepstakes
• Guided Meditations
• Verywell Mind Insights
• 2024 Verywell Mind 25
• Mental Health in the Classroom
• Editorial Process
• Meet Our Review Board
• Crisis Support

What to Know About Music Therapy

Music can help improve your mood and overall mental health.

Verywell / Lara Antal

Effectiveness

Things to consider, how to get started.

Music therapy is a therapeutic approach that uses the naturally mood-lifting properties of music to help people improve their mental health and overall well-being.  It’s a goal-oriented intervention that may involve:

• Making music
• Writing songs
• Listening to music
• Discussing music  

This form of treatment may be helpful for people with depression and anxiety, and it may help improve the quality of life for people with physical health problems. Anyone can engage in music therapy; you don’t need a background in music to experience its beneficial effects.

Types of Music Therapy

Music therapy can be an active process, where clients play a role in creating music, or a passive one that involves listening or responding to music. Some therapists may use a combined approach that involves both active and passive interactions with music.

There are a variety of approaches established in music therapy, including:

• Analytical music therapy : Analytical music therapy encourages you to use an improvised, musical "dialogue" through singing or playing an instrument to express your unconscious thoughts, which you can reflect on and discuss with your therapist afterward.
• Benenzon music therapy : This format combines some concepts of psychoanalysis with the process of making music. Benenzon music therapy includes the search for your "musical sound identity," which describes the external sounds that most closely match your internal psychological state.
• Cognitive behavioral music therapy (CBMT) : This approach combines cognitive behavioral therapy (CBT) with music. In CBMT, music is used to reinforce some behaviors and modify others. This approach is structured, not improvisational, and may include listening to music, dancing, singing, or playing an instrument.
• Community music therapy : This format is focused on using music as a way to facilitate change on the community level. It’s done in a group setting and requires a high level of engagement from each member.
• Nordoff-Robbins music therapy : Also called creative music therapy, this method involves playing an instrument (often a cymbal or drum) while the therapist accompanies using another instrument. The improvisational process uses music as a way to help enable self-expression.
• The Bonny method of guided imagery and music (GIM) : This form of therapy uses classical music as a way to stimulate the imagination. In this method, you explain the feelings, sensations, memories, and imagery you experience while listening to the music.
• Vocal psychotherapy : In this format, you use various vocal exercises, natural sounds, and breathing techniques to connect with your emotions and impulses. This practice is meant to create a deeper sense of connection with yourself.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

Music Therapy vs. Sound Therapy

Music therapy and sound therapy (or sound healing ) are distinctive, and each approach has its own goals, protocols, tools, and settings: 

• Music therapy is a relatively new discipline, while sound therapy is based on ancient Tibetan cultural practices .
• Sound therapy uses tools to achieve specific sound frequencies, while music therapy focuses on addressing symptoms like stress and pain.  
• The training and certifications that exist for sound therapy are not as standardized as those for music therapists.
• Music therapists often work in hospitals, substance abuse treatment centers, or private practices, while sound therapists may offer their service as a component of complementary or alternative medicine.

When you begin working with a music therapist, you will start by identifying your goals. For example, if you’re experiencing depression, you may hope to use music to naturally improve your mood and increase your happiness . You may also want to try applying music therapy to other symptoms of depression like anxiety, insomnia, or trouble focusing.

During a music therapy session, you may listen to different genres of music , play a musical instrument, or even compose your own songs. You may be asked to sing or dance. Your therapist may encourage you to improvise, or they may have a set structure for you to follow.

You may be asked to tune in to your emotions as you perform these tasks or to allow your feelings to direct your actions. For example, if you are angry, you might play or sing loud, fast, and dissonant chords.

You may also use music to explore ways to change how you feel. If you express anger or stress, your music therapist might respond by having you listen to or create music with slow, soft, soothing tones.

Music therapy is often one-on-one, but you may also choose to participate in group sessions if they are available. Sessions with a music therapist take place wherever they practice, which might be a:

• Community health center
• Correctional facility
• Private office
• Physical therapy practice
• Rehabilitation facility

Wherever it happens to be, the room you work in together will be a calm environment with no outside distractions.

What Music Therapy Can Help With

Music therapy may be helpful for people experiencing:

• Alzheimer’s disease
• Anxiety or stress
• Cardiac conditions
• Chronic pain
• Difficulties with verbal and nonverbal communication
• Emotional dysregulation
• Feelings of low self-esteem
• Impulsivity
• Negative mood
• Post-traumatic stress disorder (PTSD)
• Problems related to childbirth
• Rehabilitation after an injury or medical procedure
• Respiration problems
• Substance use disorders
• Surgery-related issues
• Traumatic brain injury (TBI)
• Trouble with movement or coordination

Research also suggests that it can be helpful for people with:

• Obsessive-compulsive disorder (OCD)
• Schizophrenia
• Stroke and neurological disorders

Music therapy is also often used to help children and adolescents:

• Develop their identities
• Improve their communication skills
• Learn to regulate their emotions
• Recover from trauma
• Self-reflect

Benefits of Using Music as Therapy

Music therapy can be highly personalized, making it suitable for people of any age—even very young children can benefit. It’s also versatile and offers benefits for people with a variety of musical experience levels and with different mental or physical health challenges.

Engaging with music can:

• Activate regions of the brain that influence things like memory, emotions, movement, sensory relay, some involuntary functions, decision-making, and reward
• Fulfill social needs for older adults in group settings
• Lower heart rate and blood pressure
• Relax muscle tension
• Release endorphins
• Relieve stress and encourage feelings of calm
• Strengthen motor skills and improve communication for children and young adults who have developmental and/or learning disabilities

Research has also shown that music can have a powerful effect on people with dementia and other memory-related disorders.

Overall, music therapy can increase positive feelings, like:

• Confidence and empowerment
• Emotional intimacy

The uses and benefits of music therapy have been researched for decades. Key findings from clinical studies have shown that music therapy may be helpful for people with depression and anxiety, sleep disorders, and even cancer.

Depression 

Studies have shown that music therapy can be an effective component of depression treatment. According to the research cited, the use of music therapy was most beneficial to people with depression when it was combined with the usual treatments (such as antidepressants and psychotherapy). 

When used in combination with other forms of treatment, music therapy may also help reduce obsessive thoughts , depression, and anxiety in people with OCD.

In 2016, researchers conducted a feasibility study that explored how music therapy could be combined with CBT to treat depression . While additional research is needed, the initial results were promising.

Many people find that music, or even white noise, helps them fall asleep. Research has shown that music therapy may be helpful for people with sleep disorders or insomnia as a symptom of depression.

Compared to pharmaceuticals and other commonly prescribed treatments for sleep disorders, music is less invasive, more affordable, and something a person can do on their own to self-manage their condition.

Pain Management

Music has been explored as a potential strategy for acute and chronic pain management in all age groups. Research has shown that listening to music when healing from surgery or an injury, for example, may help both kids and adults cope with physical pain.

Music therapy may help reduce pain associated with:

• Chronic conditions : Music therapy can be part of a long-term plan for managing chronic pain, and it may help people recapture and focus on positive memories from a time before they had distressing long-term pain symptoms. 
• Labor and childbirth : Music therapy-assisted childbirth appears to be a positive, accessible, non-pharmacological option for pain management and anxiety reduction for laboring people.
• Surgery : When paired with standard post-operative hospital care, music therapy is an effective way to lower pain levels, anxiety, heart rate, and blood pressure in people recovering from surgery.

Coping with a cancer diagnosis and going through cancer treatment is as much an emotional experience as a physical one. People with cancer often need different sources of support to take care of their emotional and spiritual well-being.

Music therapy has been shown to help reduce anxiety in people with cancer who are starting radiation treatments. It may also help them cope with the side effects of chemotherapy, such as nausea.

Music therapy may also offer emotional benefits for people experiencing depression after receiving their cancer diagnosis, while they’re undergoing treatment, or even after remission.

On its own, music therapy may not constitute adequate treatment for medical conditions, including mental health disorders . However, when combined with medication, psychotherapy , and other interventions, it can be a valuable component of a treatment plan.

If you have difficulty hearing, wear a hearing aid, or have a hearing implant, you should talk with your audiologist before undergoing music therapy to ensure that it’s safe for you.

Similarly, music therapy that incorporates movement or dancing may not be a good fit if you’re experiencing pain, illness, injury, or a physical condition that makes it difficult to exercise.  

You'll also want to check your health insurance benefits prior to starting music therapy. Your sessions may be covered or reimbursable under your plan, but you may need a referral from your doctor.

If you’d like to explore music therapy, talk to your doctor or therapist. They can connect you with practitioners in your community. The American Music Therapy Association (AMTA) also maintains a database of board-certified, credentialed professionals that you can use to find a practicing music therapist in your area.

Depending on your goals, a typical music therapy session lasts between 30 and 50 minutes. Much like you would plan sessions with a psychotherapist, you may choose to have a set schedule for music therapy—say, once a week—or you may choose to work with a music therapist on a more casual "as-needed" basis.  

Before your first session, you may want to talk things over with your music therapist so you know what to expect and can check in with your primary care physician if needed.

Aigen KS. The Study of Music Therapy: Current Issues and Concepts . Routledge & CRC Press. New York; 2013. doi:10.4324/9781315882703

Jasemi M, Aazami S, Zabihi RE. The effects of music therapy on anxiety and depression of cancer patients . Indian J Palliat Care . 2016;22(4):455-458. doi:10.4103/0973-1075.191823

Chung J, Woods-Giscombe C. Influence of dosage and type of music therapy in symptom management and rehabilitation for individuals with schizophrenia . Issues Ment Health Nurs . 2016;37(9):631-641. doi:10.1080/01612840.2016.1181125

MacDonald R, Kreutz G, Mitchell L. Music, Health, and Wellbeing . Oxford; 2012. doi:10.1093/acprof:oso/9780199586974.001.0001

Monti E, Austin D. The dialogical self in vocal psychotherapy . Nord J Music Ther . 2018;27(2):158-169. doi:10.1080/08098131.2017.1329227

American Music Therapy Association (AMTA). Music therapy with specific populations: Fact sheets, resources & bibliographies .

Wang CF, Sun YL, Zang HX. Music therapy improves sleep quality in acute and chronic sleep disorders: A meta-analysis of 10 randomized studies . Int J Nurs Stud . 2014;51(1):51-62. doi:10.1016/j.ijnurstu.2013.03.008

Bidabadi SS, Mehryar A. Music therapy as an adjunct to standard treatment for obsessive compulsive disorder and co-morbid anxiety and depression: A randomized clinical trial . J Affect Disord . 2015;184:13-7. doi:10.1016/j.jad.2015.04.011

Kamioka H, Tsutani K, Yamada M, et al. Effectiveness of music therapy: A summary of systematic reviews based on randomized controlled trials of music interventions . Patient Prefer Adherence . 2014;8:727-754. doi:10.2147/PPA.S61340

Raglio A, Attardo L, Gontero G, Rollino S, Groppo E, Granieri E. Effects of music and music therapy on mood in neurological patients . World J Psychiatry . 2015;5(1):68-78. doi:10.5498/wjp.v5.i1.68

Altenmüller E, Schlaug G. Apollo’s gift: New aspects of neurologic music therapy . Prog Brain Res . 2015;217:237-252. doi:10.1016/bs.pbr.2014.11.029

Werner J, Wosch T, Gold C. Effectiveness of group music therapy versus recreational group singing for depressive symptoms of elderly nursing home residents: Pragmatic trial . Aging Ment Health . 2017;21(2):147-155. doi:10.1080/13607863.2015.1093599

Dunbar RIM, Kaskatis K, MacDonald I, Barra V. Performance of music elevates pain threshold and positive affect: Implications for the evolutionary function of music . Evol Psychol . 2012;10(4):147470491201000420. doi:10.1177/147470491201000403

Pavlicevic M, O'neil N, Powell H, Jones O, Sampathianaki E. Making music, making friends: Long-term music therapy with young adults with severe learning disabilities . J Intellect Disabil . 2014;18(1):5-19. doi:10.1177/1744629513511354

Chang YS, Chu H, Yang CY, et al. The efficacy of music therapy for people with dementia: A meta-analysis of randomised controlled trials . J Clin Nurs . 2015;24(23-24):3425-40. doi:10.1111/jocn.12976

Aalbers S, Fusar-Poli L, Freeman RE, et al. Music therapy for depression . Cochrane Database Syst Rev . 2017;11:CD004517. doi:10.1002/14651858.CD004517.pub3

Trimmer C, Tyo R, Naeem F. Cognitive behavioural therapy-based music (CBT-music) group for symptoms of anxiety and depression . Can J Commun Ment Health . 2016;35(2):83-87. doi:10.7870/cjcmh-2016-029

Jespersen KV, Koenig J, Jennum P, Vuust P. Music for insomnia in adults . Cochrane Database Syst Rev . 2015;(8):CD010459. doi:10.1002/14651858.CD010459.pub2

Redding J, Plaugher S, Cole J, et al. "Where's the Music?" Using music therapy for pain management . Fed Pract . 2016;33(12):46-49.

Novotney A. Music as medicine . Monitor on Psychology . 2013;44(10):46.

McCaffrey T, Cheung PS, Barry M, Punch P, Dore L. The role and outcomes of music listening for women in childbirth: An integrative review . Midwifery . 2020;83:102627. doi:10.1016/j.midw.2020.102627

Liu Y, Petrini MA. Effects of music therapy on pain, anxiety, and vital signs in patients after thoracic surgery . Complement Ther Med . 2015;23(5):714-8.doi:10.1016/j.ctim.2015.08.002

Rossetti A, Chadha M, Torres BN, et al. The impact of music therapy on anxiety in cancer patients undergoing simulation for radiation therapy . Int J Radiat Oncol Biol Phys . 2017;99(1):103-110. doi:10.1016/j.ijrobp.2017.05.003

American Music Therapy Association (AMTA). Guidance for music listening programs .

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Music as therapy

Affiliation.

• 1 Department of Pediatrics, Section of Hematology and Oncology, Wake Forest University School of Medicine, Medical Center Blvd., WinstonSalem, NC 27157, USA. [email protected]
• PMID: 15813154
• DOI: 10.1097/01.SMJ.0000154773.11986.39

Music is widely used to enhance well-being, reduce stress, and distract patients from unpleasant symptoms. Although there are wide variations in individual preferences, music appears to exert direct physiologic effects through the autonomic nervous system. It also has indirect effects by modifying caregiver behavior. Music effectively reduces anxiety and improves mood for medical and surgical patients, for patients in intensive care units and patients undergoing procedures, and for children as well as adults. Music is a low-cost intervention that often reduces surgical, procedural, acute, and chronic pain. Music also improves the quality of life for patients receiving palliative care, enhancing a sense of comfort and relaxation. Providing music to caregivers may be a cost-effective and enjoyable strategy to improve empathy, compassion, and relationship-centered care while not increasing errors or interfering with technical aspects of care.

PubMed Disclaimer

Similar articles

• Music therapy in pediatric palliative care: family-centered care to enhance quality of life. Lindenfelser KJ, Hense C, McFerran K. Lindenfelser KJ, et al. Am J Hosp Palliat Care. 2012 May;29(3):219-26. doi: 10.1177/1049909111429327. Epub 2011 Dec 4. Am J Hosp Palliat Care. 2012. PMID: 22144660
• Can live music therapy reduce distress and pain in children with burns after wound care procedures? A randomized controlled trial. van der Heijden MJE, Jeekel J, Rode H, Cox S, van Rosmalen J, Hunink MGM, van Dijk M. van der Heijden MJE, et al. Burns. 2018 Jun;44(4):823-833. doi: 10.1016/j.burns.2017.12.013. Epub 2018 Feb 1. Burns. 2018. PMID: 29395407 Clinical Trial.
• Music's use for anesthesia and analgesia. Matsota P, Christodoulopoulou T, Smyrnioti ME, Pandazi A, Kanellopoulos I, Koursoumi E, Karamanis P, Kostopanagiotou G. Matsota P, et al. J Altern Complement Med. 2013 Apr;19(4):298-307. doi: 10.1089/acm.2010.0235. Epub 2012 Sep 18. J Altern Complement Med. 2013. PMID: 22989077 Review.
• [Use of music in palliative care]. Skrbina D, Simunović D, Santek V, Njegovan-Zvonarević T. Skrbina D, et al. Acta Med Croatica. 2011 Dec;65(5):415-23. Acta Med Croatica. 2011. PMID: 22994012 Croatian.
• [Music therapy as a part of complex healing]. Sliwka A, Jarosz A, Nowobilski R. Sliwka A, et al. Pol Merkur Lekarski. 2006 Oct;21(124):401-5. Pol Merkur Lekarski. 2006. PMID: 17205788 Review. Polish.
• Therapeutic use of music in neurological disorders: A concise narrative review. Ramaswamy M, Philip JL, Priya V, Priyadarshini S, Ramasamy M, Jeevitha GC, Mathkor DM, Haque S, Dabaghzadeh F, Bhattacharya P, Ahmad F. Ramaswamy M, et al. Heliyon. 2024 Aug 8;10(16):e35564. doi: 10.1016/j.heliyon.2024.e35564. eCollection 2024 Aug 30. Heliyon. 2024. PMID: 39220936 Free PMC article. Review.
• A randomized controlled trial of acupuncture and receptive music therapy for sleep disorders in the elderly-ELAMUS: study protocol. Klocke C, Rhein K, Cramer H, Kröger B, Wetzel AJ, Vagedes J, Mauch H, Beißner F, Joos S, Valentini J. Klocke C, et al. BMC Complement Med Ther. 2024 Aug 2;24(1):295. doi: 10.1186/s12906-024-04581-4. BMC Complement Med Ther. 2024. PMID: 39095748 Free PMC article. Clinical Trial.
• Accelerated construction of stress relief music datasets using CNN and the Mel-scaled spectrogram. Choi S, Park JI, Hong CH, Park SG, Park SC. Choi S, et al. PLoS One. 2024 May 24;19(5):e0300607. doi: 10.1371/journal.pone.0300607. eCollection 2024. PLoS One. 2024. PMID: 38787824 Free PMC article.
• The effect of music therapy on language communication and social skills in children with autism spectrum disorder: a systematic review and meta-analysis. Shi Z, Wang S, Chen M, Hu A, Long Q, Lee Y. Shi Z, et al. Front Psychol. 2024 May 7;15:1336421. doi: 10.3389/fpsyg.2024.1336421. eCollection 2024. Front Psychol. 2024. PMID: 38774719 Free PMC article.
• Effectiveness of Music on Perinatal Anxiety Among Pregnant Women and Newborn Behaviors: A Systematic Review and Narrative Synthesis. Konsam M, D'Souza SRB, Praharaj SK, Nayak BS, Shetty J, Bhat S, Noronha JA, Panda S. Konsam M, et al. Indian J Psychol Med. 2023 Nov;45(6):565-572. doi: 10.1177/02537176231167077. Epub 2023 May 6. Indian J Psychol Med. 2023. PMID: 38545536 Free PMC article. Review.

Publication types

• Search in MeSH

Grants and funding

• R25 AT00538/AT/NCCIH NIH HHS/United States

LinkOut - more resources

Full text sources.

• Ovid Technologies, Inc.
• Southern Medical Association
• MedlinePlus Health Information

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

Science Watch

Music as medicine

Researchers are exploring how music therapy can improve health outcomes among a variety of patient populations, including premature infants and people with depression and Parkinson’s disease.

By Amy Novotney

November 2013, Vol 44, No. 10

Print version: page 46

• Psychotherapy

The beep of ventilators and infusion pumps, the hiss of oxygen, the whir of carts and the murmur of voices as physicians and nurses make rounds — these are the typical noises a premature infant hears spending the first days of life in the neonatal intensive care unit (NICU). While the sounds of such life-saving equipment are tough to mute, a new study suggests that some sounds, such as lullabies, may soothe pre-term babies and their parents, and even improve the infants' sleeping and eating patterns, while decreasing parents' stress ( Pediatrics , 2013).

Researchers at Beth Israel Medical Center's Louis Armstrong Center for Music and Medicine conducted the study, which included 272 premature babies 32 weeks gestation or older in 11 mid-Atlantic NICUs. They examined the effects of three types of music: a lullaby selected and sung by the baby's parents; an "ocean disc," a round instrument, invented by the Remo drum company, that mimics the sounds of the womb; and a gato box, a drum-like instrument used to simulate two-tone heartbeat rhythms. The two instruments were played live by certified music therapists, who matched their music to the babies' breathing and heart rhythms.

The researchers found that the gato box, the Remo ocean disc and singing all slowed a baby's heart rate, although singing was the most effective. Singing also increased the amount of time babies stayed quietly alert, and sucking behavior improved most with the gato box, while the ocean disc enhanced sleep. The music therapy also lowered the parents' stress, says Joanne Loewy, the study's lead author, director of the Armstrong center and co-editor of the journal Music and Medicine .

"There's just something about music — particularly live music — that excites and activates the body," says Loewy, whose work is part of a growing movement of music therapists and psychologists who are investigating the use of music in medicine to help patients dealing with pain, depression and possibly even Alzheimer's disease. "Music very much has a way of enhancing quality of life and can, in addition, promote recovery."

Music to treat pain and reduce stress

While music has long been recognized as an effective form of therapy to provide an outlet for emotions, the notion of using song, sound frequencies and rhythm to treat physical ailments is a relatively new domain, says psychologist Daniel J. Levitin, PhD, who studies the neuroscience of music at McGill University in Montreal. A wealth of new studies is touting the benefits of music on mental and physical health. For example, in a meta-analysis of 400 studies, Levitin and his postgraduate research fellow, Mona Lisa Chanda, PhD, found that music improves the body's immune system function and reduces stress. Listening to music was also found to be more effective than prescription drugs in reducing anxiety before surgery ( Trends in Cognitive Sciences , April, 2013).

"We've found compelling evidence that musical interventions can play a health-care role in settings ranging from operating rooms to family clinics," says Levitin, author of the book "This is Your Brain on Music" (Plume/Penguin, 2007). The analysis also points to just how music influences health. The researchers found that listening to and playing music increase the body's production of the antibody immunoglobulin A and natural killer cells — the cells that attack invading viruses and boost the immune system's effectiveness. Music also reduces levels of the stress hormone cortisol.

"This is one reason why music is associated with relaxation," Levitin says.

One recent study on the link between music and stress found that music can help soothe pediatric emergency room patients ( JAMA Pediatrics , July, 2013). In the trial with 42 children ages 3 to 11, University of Alberta researchers found that patients who listened to relaxing music while getting an IV inserted reported significantly less pain, and some demonstrated significantly less distress, compared with patients who did not listen to music. In addition, in the music-listening group, more than two-thirds of the health-care providers reported that the IVs were very easy to administer — compared with 38 percent of providers treating the group that did not listen to music.

"There is growing scientific evidence showing that the brain responds to music in very specific ways," says Lisa Hartling, PhD, professor of pediatrics at the University of Alberta and lead author of the study. "Playing music for kids during painful medical procedures is a simple intervention that can make a big difference."

Music can help adult patients, too. Researchers at Khoo Teck Puat Hospital in Singapore found that patients in palliative care who took part in live music therapy sessions reported relief from persistent pain ( Progress in Palliative Care , July, 2013). Music therapists worked closely with the patients to individually tailor the intervention, and patients took part in singing, instrument playing, lyric discussion and even song writing as they worked toward accepting an illness or weighed end-of-life issues. 

"Active music engagement allowed the patients to reconnect with the healthy parts of themselves, even in the face of a debilitating condition or disease-related suffering," says music therapist Melanie Kwan, co-author of the study and president of the Association for Music Therapy, Singapore. "When their acute pain symptoms were relieved, patients were finally able to rest."

The healing power of vibration

At its core, music is sound, and sound is rooted in vibration. Led by Lee Bartel, PhD, a music professor at the University of Toronto, several researchers are exploring whether sound vibrations absorbed through the body can help ease the symptoms of Parkinson's disease, fibromyalgia and depression. Known as vibroacoustic therapy, the intervention involves using low frequency sound — similar to a low rumble — to produce vibrations that are applied directly to the body. During vibroacoustic therapy, the patient lies on a mat or bed or sits in a chair embedded with speakers that transmit vibrations at specific computer-generated frequencies that can be heard and felt, says Bartel. He likens the process to sitting on a subwoofer.

In 2009, researchers led by Lauren K. King of the Sun Life Financial Movement Disorders Research and Rehabilitation Centre at Wilfrid Laurier University, in Waterloo, Ontario, found that short-term use of vibroacoustic therapy with Parkinson's disease patients led to improvements in symptoms, including less rigidity and better walking speed with bigger steps and reduced tremors ( NeuroRehabilitation , December, 2009). In that study, the scientists exposed 40 Parkinson's disease patients to low-frequency 30-hertz vibration for one minute, followed by a one-minute break. They then alternated the two for a total of 10 minutes. The researchers are now planning a long-term study of the use of vibroacoustic therapy with Parkinson's patients, as part of a new partnership with the University of Toronto's Music and Health Research Collaboratory, which brings together scientists from around the world who are studying music's effect on health.

The group is also examining something called thalmocortical dysrhythmia — a disorientation of rhythmic brain activity involving the thalamus and the outer cortex that appears to play a role in several medical conditions including Parkinson's, fibromyalgia and possibly even Alzheimer's disease, says Bartel, who directs the collaboratory.

"Since the rhythmic pulses of music can drive and stabilize this disorientation, we believe that low-frequency sound might help with these conditions," Bartel says. He is leading a study using vibroacoustic therapy with patients with mild Alzheimer's disease. The hope is that using the therapy to restore normal communication among brain regions may allow for greater memory retrieval, he says.

"We've already seen glimmers of hope in a case study with a patient who had just been diagnosed with the disorder," Bartel says. "After stimulating her with 40-hertz sound for 30 minutes three times a week for four weeks, she could recall the names of her grandchildren more easily, and her husband reported good improvement in her condition."

The goal of all of this work is to develop "dosable" and "prescribable" music therapy and music as medicine protocols that serve specific neurologic functions and attend to deficits that may result from many of these neurologically based conditions. Rather than viewing music only as a cultural phenomenon, Bartel says, the art should be seen as a vibratory stimulus that has cognitive and memory dimensions.

"Only when we look at it in this way do we start to see the interface to how the brain and body work together."

Amy Novotney is a writer in Chicago.

Letters to the editor.

• Send us a letter

Home — Essay Samples — Nursing & Health — Music Therapy — How Music Affects Mental Health

How Music Affects Mental Health

• Categories: Mental Health Music Therapy

About this sample

Words: 704 |

Published: Jun 13, 2024

Words: 704 | Pages: 2 | 4 min read

Table of contents

Introduction, music as a therapeutic tool, music as an emotional outlet, music and social connectivity.

Cite this Essay

To export a reference to this article please select a referencing style below:

Let us write you an essay from scratch

• 450+ experts on 30 subjects ready to help
• Custom essay delivered in as few as 3 hours

Get high-quality help

Verified writer

• Expert in: Nursing & Health

+ 120 experts online

By clicking “Check Writers’ Offers”, you agree to our terms of service and privacy policy . We’ll occasionally send you promo and account related email

No need to pay just yet!

Related Essays

1 pages / 675 words

3 pages / 1532 words

5 pages / 2723 words

2 pages / 968 words

Remember! This is just a sample.

You can get your custom paper by one of our expert writers.

121 writers online

Still can’t find what you need?

Browse our vast selection of original essay samples, each expertly formatted and styled

Related Essays on Music Therapy

The relationship between music and mental health is a topic of growing interest and research. This essay delves into the intricate connection between music and mental well-being, examining the ways in which music can influence [...]

Music has long been recognized as a universal language that transcends boundaries and connects people across cultures. Beyond its entertainment value, music holds the remarkable ability to influence our emotions and well-being. [...]

Music therapy is a powerful and effective form of treatment that harnesses the healing power of music. It has a rich history, with roots in ancient civilizations, and has evolved into a recognized profession in the 20th century. [...]

Music is an integral part of human life. It has the power to evoke emotions, bring people together, and provide a sense of identity and belonging. From ancient civilizations to modern societies, music has played a significant [...]

Have you ever spent three hours studying but still can’t remember anything? You panic because tomorrow is the day of your examination. Have you ever stared at your clock at 3 a.m. but still can’t fall asleep? Your eyes look like [...]

The healing influence of music was talked about and proved from long ago. Nowadays, the research done in the field of music therapy show the benefits obtained with the help of the new measuring instruments or new discoveries in [...]

Related Topics

By clicking “Send”, you agree to our Terms of service and Privacy statement . We will occasionally send you account related emails.

Where do you want us to send this sample?

By clicking “Continue”, you agree to our terms of service and privacy policy.

Be careful. This essay is not unique

This essay was donated by a student and is likely to have been used and submitted before

Download this Sample

Free samples may contain mistakes and not unique parts

Sorry, we could not paraphrase this essay. Our professional writers can rewrite it and get you a unique paper.

Please check your inbox.

We can write you a custom essay that will follow your exact instructions and meet the deadlines. Let's fix your grades together!

Get Your Personalized Essay in 3 Hours or Less!

We use cookies to personalyze your web-site experience. By continuing we’ll assume you board with our cookie policy .

• Instructions Followed To The Letter
• Deadlines Met At Every Stage
• Unique And Plagiarism Free

Advertisement

Supported by

Sean Combs Is Denied Bail on Sex Trafficking and Racketeering Charges

A day after his arrest, the music mogul known as Diddy was accused of running a “criminal enterprise” that threatened and abused women. He pleaded not guilty.

• Share full article

Prosecutors Accuse Sean Combs of Running a ‘Criminal Enterprise’

Sean combs, also known as diddy, was indicted on tuesday on three counts of sex trafficking, racketeering and transportation to engage in prostitution..

As alleged in the indictment, to carry out this conduct Sean Combs led and participated in a racketeering conspiracy that used the business empire he controlled to carry out criminal activity, including sex trafficking, forced labor, kidnapping, arson, bribery and the obstruction of justice. As alleged, Combs used force, threats of force and coercion to cause victims to engage in extended sexual performances with male commercial sex workers, some of whom he transported or caused to be transported over state lines. Combs allegedly planned and controlled the sex performances, which he called freak offs, and he often electronically recorded them. The freak off sometimes lasted days at a time, involved multiple commercial sex workers and often involved a variety of narcotics such as ketamine, ecstasy and GHB, which Combs distributed to the victims to keep them obedient and compliant. As alleged, when Combs didn’t get his way, he was violent and he subjected victims to physical, emotional and verbal abuse so that they would participate in the freak offs. In addition to the violence, the indictment alleges that Combs threatened and coerced victims to get them to participate in the freak offs. He used the embarrassing and sensitive recordings he made of the freak offs as collateral against the victims Because of all of this, the indictment alleges that the victims did not believe they could refuse combs without risking their security or facing more abuse.

By Ben Sisario and Julia Jacobs

Sean Combs, the embattled music mogul, was denied bail on Tuesday after pleading not guilty to charges of sex trafficking, racketeering conspiracy and transportation to engage in prostitution.

In a federal indictment unsealed on Tuesday , Mr. Combs, 54, was described as the boss of a yearslong criminal enterprise that threatened and abused women, coercing them to participate against their will in drug-fueled orgies with male prostitutes and threatening them with violence or the loss of financial support if they refused.

The 14-page indictment against Mr. Combs, a producer, record executive and performer who is also known as Diddy and Puff Daddy, came a day after he was arrested in a Manhattan hotel room , following an investigation that has been active since at least early this year. Prosecutors said Mr. Combs and his employees engaged in kidnapping, forced labor, arson and bribery, and kept firearms at the ready.

In asking a magistrate to deny Mr. Combs’s request to be released on bail, prosecutors argued that he was a threat to the community. One of the prosecutors, Emily A. Johnson, called him a “serial abuser and a serial obstructer,” and said his wealth would make it easy for him to escape undetected. She noted that after Mr. Combs was arrested, law enforcement found what they suspected to be narcotics in his hotel room, in the form of pink powder.

Mr. Combs’s lawyers suggested a $50 million bond. But Judge Robyn F. Tarnofsky denied their request, citing Mr. Combs’s anger issues and history of substance abuse, and ordered Mr. Combs detained while he awaits trial.

“My concern,” the judge said, “is that this is a crime that happens behind closed doors.”

As Mr. Combs walked out of the courtroom, he looked toward his supporters in the room, including his three adult sons, and put his hand on his heart.

We are having trouble retrieving the article content.

Please enable JavaScript in your browser settings.

Thank you for your patience while we verify access. If you are in Reader mode please exit and  log into  your Times account, or  subscribe  for all of The Times.

Thank you for your patience while we verify access.

Already a subscriber?  Log in .

Want all of The Times?  Subscribe .