Music therapy for people with schizophrenia and schizophrenia‐like disorders

Karin Mössler; XiJing Chen; Tor Olav Heldal; Christian Gold

doi:10.1002/14651858.CD004025.pub3

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Figure 1

Study flow diagram (all searches)

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Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 1 Global state: No clinically important overall improvement (as rated by trialists).

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Analysis 1.2

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 2 Mental state: General ‐ 1a. Average endpoint score (PANSS, high score = poor).

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Analysis 1.3

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 3 Mental state: General ‐ 1b. Average endpoint score (BPRS, high score = poor).

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Analysis 1.4

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 4 Mental state: Specific ‐ 2. Negative symptoms ‐ average endpoint score (SANS, high score = poor).

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Analysis 1.5

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 5 Mental state: Specific ‐ 3a. Depression ‐ average endpoint score (SDS, high score = poor).

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Analysis 1.6

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 6 Mental state: Specific ‐ 3b. Depression ‐ average endpoint score (Ham‐D, high score = poor).

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Analysis 1.7

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 7 Mental state: Specific ‐ 4. Anxiety ‐ average endpoint score (SAS, high score = poor).

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Analysis 1.8

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 8 Leaving the study early.

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Analysis 1.9

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 9 General functioning: Average endpoint score (GAF, high score = good).

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Analysis 1.10

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 10 Social functioning: Average endpoint score (SDSI, high score = poor).

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Analysis 1.11

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 11 Behaviour: 1. Positive behaviour ‐ average endpoint score (NOSIE, high score = poor).

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Analysis 1.12

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 12 Behaviour: 2. Negative behaviour ‐ average endpoint score (NOSIE, high score = poor).

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Analysis 1.13

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 13 Cognitive functioning: 1. Attention ‐ average endpoint score (PASAT, high score = good).

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Analysis 1.14

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 14 Cognitive functioning: 2. Vigilance and attention ‐ average endpoint score (CCPT, high score = good).

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Analysis 1.15

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 15 Cognitive functioning: 3. Memory ‐ average endpoint score (WMS, high score = good).

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Analysis 1.16

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 16 Cognitive functioning: 4. Abstract thinking ‐ average endpoint score (BCST, high score = good) ).

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Analysis 1.17

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 17 Patient satisfaction: Average endpoint score (CSQ, high score = good).

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Analysis 1.18

Comparison 1 Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months), Outcome 18 Quality of life: Average endpoint score (SPG, high score = good).

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Summary of findings for the main comparison. MUSIC THERAPY versus STANDARD CARE for people with schizophrenia and schizophrenia‐like disorders

MUSIC THERAPY versus STANDARD CARE for people with schizophrenia and schizophrenia‐like disorders
Patient or population: people with schizophrenia and schizophrenia‐like disorders Settings: Intervention: MUSIC THERAPY versus STANDARD CARE
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Control	MUSIC THERAPY versus STANDARD CARE
Mental state: Negative symptoms SANS Follow‐up: 1‐3 months		The mean Mental state: Negative symptoms in the intervention groups was 0.74 standard deviations lower (1 to 0.47 lower)		240 (4 studies)	⊕⊕⊕⊕ high^1,2	SMD ‐0.74 (‐1 to ‐0.47)
Social functioning SDSI Follow‐up: 3 months		The mean Social functioning in the intervention groups was 0.78 standard deviations lower (1.27 to 0.28 lower)		70 (1 study)	⊕⊕⊕⊕ high^2,3	SMD ‐0.78 (‐1.27 to ‐0.28)
Global state: No clinically important overall improvement as rated by trialists Follow‐up: 3 months	Study population		RR 0.1 (0.03 to 0.31)	72 (1 study)	⊕⊕⊕⊕ high^3,4
	710 per 1000	71 per 1000 (21 to 220)
	Medium risk population
	710 per 1000	71 per 1000 (21 to 220)
General mental state PANSS Follow‐up: 3 months		The mean General mental state in the intervention groups was 0.36 standard deviations lower (0.84 lower to 0.12 higher)		69 (1 study)	⊕⊕⊕⊕ high	SMD ‐0.36 (‐0.84 to 0.12)
General mental state BPRS Follow‐up: 1.5‐3 months		The mean General mental state in the intervention groups was 0.73 standard deviations lower (1.16 to 0.31 lower)		100 (2 studies)	⊕⊕⊕⊝ moderate^1,2,5	SMD ‐0.73 (‐1.16 to ‐0.31)
General functioning GAF Follow‐up: 3 months		The mean General functioning in the intervention groups was 0.05 standard deviations lower (0.53 lower to 0.43 higher)		69 (1 study)	⊕⊕⊕⊝ moderate³	SMD ‐0.05 (‐0.53 to 0.43)
Quality of life SPG Follow‐up: 1 months		The mean Quality of life in the intervention groups was 0.05 standard deviations higher (0.66 lower to 0.75 higher)		31 (1 study)	⊕⊕⊕⊝ moderate³	SMD 0.05 (‐0.66 to 0.75)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Limitations in the designs such as poorly reported randomisation and blinding, as well as less‐well defined music therapy. ² The effect was in the large range according to Cohen 1988. ³ Imprecision ‐ only one study reported results on this outcome. ⁴ Very large effect based on direct evidence with no major threats to validity. ⁵ Inconsistency ‐ Heterogeneity between studies was high and significant.

Summary of findings for the main comparison. MUSIC THERAPY versus STANDARD CARE for people with schizophrenia and schizophrenia‐like disorders

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Table 1. Music therapeutic approach: Further characteristics of included studies

	No. of sessions (offered/ received)	Adequate method	Adequate training	Modality (active/ receptive/ both)	Form of therapy						Therapy process (fixed structure/ process‐ oriented)
	No. of sessions (offered/ received)	Adequate method	Adequate training	Modality (active/ receptive/ both)	Improvisation	Playing and/or singing pre‐ composed music	Songwriting	Listening to music	Verbal discussion/reflection of therapy process	Others	Therapy process (fixed structure/ process‐ oriented)
Ceccato 2009	Max. 16 (1/week over 4 months)	Yes	Yes	Receptive	No	No	No	Central	No	No	Fixed structure
He 2005	Max. 30 (5/week over 6 weeks)	Yes	Unclear	Receptive	No	No	No	Central	Yes	Dancing, reading poems with music background	Unclear
Li 2007	Max. 30 (5/week over 6 weeks)	Yes	Unclear	Receptive	No	No	No	Central	Yes	No	Unclear
Talwar 2006	Max. 12 sessions (1/week over 3 months)	Yes	Yes	Active	Central	Yes	No	No	Central	No	Process‐ oriented
Tang 1994	19 sessions received	Yes	Unclear	Both	Yes	Yes	No	Central	Yes	No	Fixed structure
Ulrich 2007	7.5 sessions received	Yes	Yes	Active	Yes	Yes	No	No	Yes	No	Process‐ oriented
Wen 2005	Max. 30 (5/week over 6 weeks)	Yes	Unclear	Receptive	No	No	No	Central	Yes	Dancing	Unclear
Yang 1998	Max. 78 (6/week over 3 months)	Yes	Yes	Both	Yes	Yes	No	Yes	Yes	Learning musicology	Unclear
Adequate music therapeutic method: A "yes" indicates that the method applied considered both musical experiences and relational aspects as dynamic forces of change in music therapy. A "no" indicates that relational aspects are missing. Adequate music therapy training: A "yes" indicates that the persons conducting the music therapy have attended an appropriate music therapy training. A "no" indicates that the person conducting the music therapy had limited or even no music therapy training.

Table 1. Music therapeutic approach: Further characteristics of included studies

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Comparison 1. Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Global state: No clinically important overall improvement (as rated by trialists) Show forest plot	1	72	Risk Ratio (M‐H, Fixed, 95% CI)	0.10 [0.03, 0.31]

1.1 20 or more sessions	1	72	Risk Ratio (M‐H, Fixed, 95% CI)	0.10 [0.03, 0.31]
2 Mental state: General ‐ 1a. Average endpoint score (PANSS, high score = poor) Show forest plot	1	69	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.36 [‐0.84, 0.12]

2.1 less than 20 sessions	1	69	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.36 [‐0.84, 0.12]
3 Mental state: General ‐ 1b. Average endpoint score (BPRS, high score = poor) Show forest plot	2		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only

3.1 20 or more sessions	2	100	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.73 [‐1.16, ‐0.31]
4 Mental state: Specific ‐ 2. Negative symptoms ‐ average endpoint score (SANS, high score = poor) Show forest plot	4	240	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.74 [‐1.00, ‐0.47]

4.1 less than 20 sessions	2	110	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.79 [‐1.19, ‐0.40]
4.2 20 or more sessions	2	130	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.69 [‐1.05, ‐0.33]
5 Mental state: Specific ‐ 3a. Depression ‐ average endpoint score (SDS, high score = poor) Show forest plot	2	90	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.63 [‐1.06, ‐0.21]

5.1 20 or more sessions	2	90	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.63 [‐1.06, ‐0.21]
6 Mental state: Specific ‐ 3b. Depression ‐ average endpoint score (Ham‐D, high score = poor) Show forest plot	1	30	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.52 [‐1.25, 0.21]

6.1 20 or more sessions	1	30	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.52 [‐1.25, 0.21]
7 Mental state: Specific ‐ 4. Anxiety ‐ average endpoint score (SAS, high score = poor) Show forest plot	1	60	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.61 [‐1.13, ‐0.09]

7.1 20 or more sessions	1	60	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.61 [‐1.13, ‐0.09]
8 Leaving the study early Show forest plot	8	493	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.38, 2.78]

8.1 less than 20 sessions	4	261	Risk Ratio (M‐H, Fixed, 95% CI)	1.04 [0.36, 2.99]
8.2 20 or more sessions	4	232	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.06, 15.45]
9 General functioning: Average endpoint score (GAF, high score = good) Show forest plot	1	69	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.05 [‐0.53, 0.43]

9.1 less than 20 sessions	1	69	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.05 [‐0.53, 0.43]
10 Social functioning: Average endpoint score (SDSI, high score = poor) Show forest plot	1	70	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.78 [‐1.27, ‐0.28]

10.1 20 or more sessions	1	70	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.78 [‐1.27, ‐0.28]
11 Behaviour: 1. Positive behaviour ‐ average endpoint score (NOSIE, high score = poor) Show forest plot	1	60	Std. Mean Difference (IV, Fixed, 95% CI)	‐1.24 [‐1.79, ‐0.68]

11.1 20 or more sessions	1	60	Std. Mean Difference (IV, Fixed, 95% CI)	‐1.24 [‐1.79, ‐0.68]
12 Behaviour: 2. Negative behaviour ‐ average endpoint score (NOSIE, high score = poor) Show forest plot	1	60	Std. Mean Difference (IV, Fixed, 95% CI)	‐2.22 [‐2.87, ‐1.57]

12.1 20 or more sessions	1	60	Std. Mean Difference (IV, Fixed, 95% CI)	‐2.22 [‐2.87, ‐1.57]
13 Cognitive functioning: 1. Attention ‐ average endpoint score (PASAT, high score = good) Show forest plot	1	67	Std. Mean Difference (IV, Fixed, 95% CI)	0.72 [0.22, 1.21]

13.1 less than 20 sessions	1	67	Std. Mean Difference (IV, Fixed, 95% CI)	0.72 [0.22, 1.21]
14 Cognitive functioning: 2. Vigilance and attention ‐ average endpoint score (CCPT, high score = good) Show forest plot	1	67	Std. Mean Difference (IV, Fixed, 95% CI)	0.25 [‐0.23, 0.74]

14.1 less than 20 sessions	1	67	Std. Mean Difference (IV, Fixed, 95% CI)	0.25 [‐0.23, 0.74]
15 Cognitive functioning: 3. Memory ‐ average endpoint score (WMS, high score = good) Show forest plot	1	67	Std. Mean Difference (IV, Fixed, 95% CI)	0.43 [‐0.06, 0.92]

15.1 less than 20 sessions	1	67	Std. Mean Difference (IV, Fixed, 95% CI)	0.43 [‐0.06, 0.92]
16 Cognitive functioning: 4. Abstract thinking ‐ average endpoint score (BCST, high score = good) ) Show forest plot	1	67	Std. Mean Difference (IV, Fixed, 95% CI)	0.09 [‐0.39, 0.58]

16.1 less than 20 sessions	1	67	Std. Mean Difference (IV, Fixed, 95% CI)	0.09 [‐0.39, 0.58]
17 Patient satisfaction: Average endpoint score (CSQ, high score = good) Show forest plot	1	69	Std. Mean Difference (IV, Fixed, 95% CI)	0.32 [‐0.16, 0.80]

17.1 less than 20 sessions	1	69	Std. Mean Difference (IV, Fixed, 95% CI)	0.32 [‐0.16, 0.80]
18 Quality of life: Average endpoint score (SPG, high score = good) Show forest plot	1	31	Std. Mean Difference (IV, Fixed, 95% CI)	0.05 [‐0.66, 0.75]

18.1 less than 20 sessions	1	31	Std. Mean Difference (IV, Fixed, 95% CI)	0.05 [‐0.66, 0.75]

Comparison 1. Music therapy versus standard care (all outcomes short‐term ‐ 1 to 3 months)

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