Music therapy for depression

Sonja Aalbers; Laura Fusar‐Poli; Ruth E Freeman; Marinus Spreen; Johannes CF Ket; Annemiek C Vink; Anna Maratos; Mike Crawford; Xi‐Jing Chen; Christian Gold

doi:10.1002/14651858.CD004517.pub3

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Figure 1

PRISMA flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

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 plus TAU versus TAU alone (primary comparison), Outcome 1 Severity of depression symptoms, clinician‐rated (primary outcome; high=poor).

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Analysis 1.2

Comparison 1 Music therapy plus TAU versus TAU alone (primary comparison), Outcome 2 Severity of depression symptoms, patient‐reported (primary outcome; high=poor).

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Analysis 1.3

Comparison 1 Music therapy plus TAU versus TAU alone (primary comparison), Outcome 3 Any adverse event.

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Analysis 1.4

Comparison 1 Music therapy plus TAU versus TAU alone (primary comparison), Outcome 4 Functioning (high=good).

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Analysis 1.5

Comparison 1 Music therapy plus TAU versus TAU alone (primary comparison), Outcome 5 Quality of life (high=good).

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Analysis 1.6

Comparison 1 Music therapy plus TAU versus TAU alone (primary comparison), Outcome 6 Leaving the study early.

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Analysis 1.7

Comparison 1 Music therapy plus TAU versus TAU alone (primary comparison), Outcome 7 Anxiety (high=poor).

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Analysis 1.8

Comparison 1 Music therapy plus TAU versus TAU alone (primary comparison), Outcome 8 Self‐esteem (high=good).

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Analysis 2.1

Comparison 2 Music therapy versus psychological therapy, Outcome 1 Severity of depressive symptoms, clinician‐rated (primary outcome; high=poor).

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Analysis 2.2

Comparison 2 Music therapy versus psychological therapy, Outcome 2 Severity of depressive symptoms, patient‐reported (primary outcome; high=poor).

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Analysis 2.3

Comparison 2 Music therapy versus psychological therapy, Outcome 3 Quality of life (high=good).

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Analysis 2.4

Comparison 2 Music therapy versus psychological therapy, Outcome 4 Leaving the study early.

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Analysis 3.1

Comparison 3 Active music therapy versus receptive music therapy, Outcome 1 Severity of depressive symptoms, clinician‐reported (primary outcome; high=poor).

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Analysis 3.2

Comparison 3 Active music therapy versus receptive music therapy, Outcome 2 Severity of depressive symptoms, patient‐reported (primary outcome; high=poor).

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Analysis 3.3

Comparison 3 Active music therapy versus receptive music therapy, Outcome 3 Quality of life (high=good).

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Analysis 3.4

Comparison 3 Active music therapy versus receptive music therapy, Outcome 4 Leaving the study early.

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Summary of findings for the main comparison. Music therapy plus treatment as usual (TAU) versus TAU for depression (primary comparison)

Music therapy plus treatment as usual (TAU) versus TAU
Patient or population: individuals with depression Setting: any setting Intervention: music therapy plus treatment as usual Comparison: treatment as usual
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with treatment as usual	Risk with music therapy
Depressive symptoms (clinician‐rated) (various scales) Up to 3 months		Mean clinician‐rated depressive symptoms in the intervention group were SMD 0.98 SD lower (1.69 lower to 0.27 lower).	‐	219 (3 RCTs; 1 CCT)	⊕⊕⊕⊝ MODERATE^a	Lower score equals a better outcome. SMD corresponds to a large effect size.
Depressive symptoms (patient‐reported) (various scales) Up to 3 months		Mean patient‐reported depressive symptoms in the intervention group were SMD 0.85 SD lower (1.37 lower to 0.34 lower).	‐	142 (3 RCTs; 1 CCT)	⊕⊕⊕⊝ MODERATE^a	Lower score equals a better outcome. SMD corresponds to a large effect size.
Any adverse events Up to 3 months	Study population		OR 0.45 (0.02 to 11.46)	79 (1 RCT)	⊕⊕⊝⊝ LOW^b
	22 per 1000	10 per 1000 (0 to 203)
Functioning (GAF) Up to 3 months		Mean functioning in the intervention group was SMD 0.51 SD higher (0.02 higher to 1 higher).	‐	67 (1 RCT)	⊕⊕⊝⊝ LOW^b	Higher score equals a better outcome. SMD corresponds to a moderate effect size.
Quality of life (RAND‐36) Up to 3 months		Mean quality of life in the intervention group was SMD 0.32 SD higher (0.17 lower to 0.80 higher).	‐	67 (1 RCT)	⊕⊕⊝⊝ LOW^b	Higher score equals a better outcome.
Leaving the study early Up to 3 months	Study population		OR 0.49 (0.14 to 1.70)	293 (5 RCTs; 1 CCT)	⊕⊕⊕⊝ MODERATE^a
	65 per 1000	33 per 1000 (10 to 106)
Anxiety (HADS‐A) Up to 3 months		Mean anxiety in the intervention group was SMD 0.74 SD lower (1.40 lower to 0.08 lower).	‐	195 (2 RCTs; 1 CCT)	⊕⊕⊝⊝ LOW^a,c	Lower score equals a better outcome. SMD corresponds to a moderate effect size.
*The risk in the intervention group (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). CCT: controlled clinical trial; CI: confidence interval; GAF: Global Assessment of Functioning scale; HADS‐A: Hospital Anxiety and Depression Scale ‐ Anxiety; OR: odds ratio; RAND‐36: health‐related quality of life survey distributed by RAND; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation; SMD: standardised mean difference.
GRADE Working Group grades of evidence. High quality: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect. Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
^aDowngraded one level for unclear randomisation, allocation concealment, blinding, missing study protocol. ^bDowngraded two levels for wide confidence intervals, although adequately powered, well‐performed trial. ^cDowngraded one level for variation effect sizes, non‐ or small overlap confidence intervals, high heterogeneity.

Summary of findings for the main comparison. Music therapy plus treatment as usual (TAU) versus TAU for depression (primary comparison)

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Summary of findings 2. Music therapy versus psychological treatment for depression

Music therapy versus psychological treatment for depression
Patient or population: adults with depression Setting: any setting Intervention: music therapy Comparison: psychological therapy (counselling, cognitive‐behavioural therapy)
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with psychological treatment	Risk with music therapy	Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
Depressive symptoms (clinician‐rated) (MADRS) Up to 3 months		Mean clinician‐rated depressive symptoms in the intervention group was SMD 0.78 SD lower (2.36 lower to 0.81 higher).	‐	11 (1 RCT)	⊕⊝⊝⊝ VERY LOW^a,b	Lower score equals better outcome. SMD corresponds to a large effect size.
Depressive symptoms (patient‐reported) (various scales) Up to 3 months		Mean patient‐reported depressive symptoms in the intervention group were SMD 1.28 SD lower (3.57 lower to 1.02 higher).	‐	131 (4 RCTs)	⊕⊕⊝⊝ LOW^a,c	Lower score equals better outcome. SMD corresponds to a large effect size.
Any adverse events ‐ not reported	‐	‐	‐	‐	‐
Functioning ‐ not reported	‐	‐	‐	‐	‐
Quality of life (Thai RAND‐36) Up to 3 months		Mean quality of life in the intervention group was SMD 1.31 SD higher (0.36 lower to 2.99 higher).	‐	11 (1 RCT)	⊕⊝⊝⊝ VERY LOW^a,b	Higher score equals better outcome.
Leaving the study early Up to 3 months	Study population		OR 0.17 (0.02 to 1.49)	157 (4 RCTs)	⊕⊕⊕⊝ MODERATE^a
Leaving the study early Up to 3 months	35 per 1000	9 per 1000 (1 to 77)	OR 0.17 (0.02 to 1.49)	157 (4 RCTs)	⊕⊕⊕⊝ MODERATE^a
Anxiety ‐ not reported	‐	‐	‐	‐	‐
*The risk in the intervention group (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; MADRS: Montgomery‐Åsberg Depression Rating Scale; OR: odds ratio; RAND‐36: health‐related quality of life survey distributed by RAND; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation; SMD: standardised mean difference.
GRADE Working Group grades of evidence. High quality: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect. Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
^aDowngraded one level for limitations in design such as unclear allocation concealment, blinding, incomplete outcome data, missing protocol. ^bDowngraded two levels for small sample size. ^cDowngraded one level for non‐overlap of confidence intervals, high heterogeneity (P < 0.00001); I² = 96%.

Summary of findings 2. Music therapy versus psychological treatment for depression

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Summary of findings 3. Active music therapy versus receptive music therapy for depression

Active music therapy versus receptive music therapy for depression
Patient or population: adults with depression Setting: any setting Intervention: active music therapy Comparison: receptive music therapy
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with receptive music therapy	Risk with active music therapy	Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
Depressive symptoms (clinician‐rated) (MADRS) Up to 3 months		Mean clinician‐rated depressive symptoms in the intervention group were SMD 0.52 SD lower (1.87 lower to 0.83 higher).	‐	9 (1 RCT)	⊕⊝⊝⊝ VERY LOW^a,b	Lower score equals a better outcome.
Depressive symptoms (patient‐reported) (TDI) Up to 3 months		Mean patient‐reported depressive symptoms in the intervention group were SMD 0.01 SD lower (1.33 lower to 1.3 higher).	‐	9 (1 RCT)	⊕⊝⊝⊝ VERY LOW^a,b	Lower score equals a better outcome.
Any adverse events ‐ not reported	‐	‐	‐	‐	‐
Functioning ‐ not reported	‐	‐	‐	‐	‐
Quality of life (SF‐36 Thai) Up to 3 months		Mean quality of life in the intervention group was SMD 0.24 SD lower (1.57 lower to 1.08 higher).	‐	9 (1 RCT)	⊕⊝⊝⊝ VERY LOW^a,b	Higher score equals a better outcome.
Leaving the study early Up to 3 months	Study population		OR 0.27 (0.01 to 8.46)	10 (1 RCT)	⊕⊝⊝⊝ VERY LOW^a,b
Leaving the study early Up to 3 months	200 per 1000	63 per 1000 (2 to 679)	OR 0.27 (0.01 to 8.46)	10 (1 RCT)	⊕⊝⊝⊝ VERY LOW^a,b
Anxiety ‐ not reported	‐	‐	‐	‐	‐
*The risk in the intervention group (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; MADRS: Montgomery‐Åsberg Depression Rating Scale; OR: odds ratio; RCT: randomised controlled trial; RR: risk ratio; SD: standard deviation; SF‐36: Short Form‐36; SMD: standardised mean difference; TDI: Thai Depression Inventory.
GRADE Working Group grades of evidence. High quality: We are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
^aDowngraded one level for limitations in design such as unclear allocation concealment, blinding, missing protocol. ^bDowngraded two levels for small sample size.

Summary of findings 3. Active music therapy versus receptive music therapy for depression

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Comparison 1. Music therapy plus TAU versus TAU alone (primary comparison)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Severity of depression symptoms, clinician‐rated (primary outcome; high=poor) Show forest plot	4		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 short‐term (up to 3 months)	4	219	Std. Mean Difference (IV, Random, 95% CI)	‐0.98 [‐1.69, ‐0.27]
1.2 medium‐term (up to 6 months)	1	64	Std. Mean Difference (IV, Random, 95% CI)	‐0.38 [‐0.87, 0.12]
2 Severity of depression symptoms, patient‐reported (primary outcome; high=poor) Show forest plot	4		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 short‐term (up to 3 months)	4	142	Std. Mean Difference (IV, Random, 95% CI)	‐0.85 [‐1.37, ‐0.34]
3 Any adverse event Show forest plot	1		Odds Ratio (M‐H, Random, 95% CI)	Totals not selected

3.1 short‐term (up to 3 months)	1		Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
3.2 medium‐term (up to 6 months)	1		Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
4 Functioning (high=good) Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

4.1 short‐term (up to 3 months)	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4.2 medium‐term (up to 6 months)	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
5 Quality of life (high=good) Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

5.1 short‐term (up to 3 months)	1	67	Std. Mean Difference (IV, Random, 95% CI)	0.32 [‐0.17, 0.80]
5.2 medium‐term (up to 6 months)	1	64	Std. Mean Difference (IV, Random, 95% CI)	0.26 [‐0.23, 0.76]
6 Leaving the study early Show forest plot	6		Odds Ratio (M‐H, Random, 95% CI)	Subtotals only

6.1 short‐term (up to 3 months)	6	293	Odds Ratio (M‐H, Random, 95% CI)	0.49 [0.14, 1.70]
6.2 medium‐term (up to 6 months)	1	79	Odds Ratio (M‐H, Random, 95% CI)	0.44 [0.13, 1.53]
7 Anxiety (high=poor) Show forest plot	3		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

7.1 short‐term (up to 3 months)	3	195	Std. Mean Difference (IV, Random, 95% CI)	‐0.74 [‐1.40, ‐0.08]
7.2 medium‐term (up to 6 months)	1	64	Std. Mean Difference (IV, Random, 95% CI)	‐0.40 [‐0.90, 0.10]
8 Self‐esteem (high=good) Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

8.1 short‐term (up to 3 months)	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 1. Music therapy plus TAU versus TAU alone (primary comparison)

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Comparison 2. Music therapy versus psychological therapy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Severity of depressive symptoms, clinician‐rated (primary outcome; high=poor) Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 short‐term (up to 3 months)	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 medium‐term (up to 6 months)	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Severity of depressive symptoms, patient‐reported (primary outcome; high=poor) Show forest plot	4		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 short‐term (up to 3 months)	4	131	Std. Mean Difference (IV, Random, 95% CI)	‐1.28 [‐3.57, 1.02]
2.2 medium‐term (up to 6 months)	1	11	Std. Mean Difference (IV, Random, 95% CI)	‐0.68 [‐2.26, 0.89]
3 Quality of life (high=good) Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

3.1 short‐term (up to 3 months)	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3.2 medium‐term (up to 6 months)	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 Leaving the study early Show forest plot	4		Odds Ratio (M‐H, Random, 95% CI)	Subtotals only

4.1 short‐term (up to 3 months)	4	137	Odds Ratio (M‐H, Random, 95% CI)	0.17 [0.02, 1.49]
4.2 medium‐term (up to 6 months)	1	14	Odds Ratio (M‐H, Random, 95% CI)	0.11 [0.01, 1.92]

Comparison 2. Music therapy versus psychological therapy

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Comparison 3. Active music therapy versus receptive music therapy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Severity of depressive symptoms, clinician‐reported (primary outcome; high=poor) Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

1.1 short‐term (up to 3 months)	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
1.2 medium‐term (up to 6 months)	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2 Severity of depressive symptoms, patient‐reported (primary outcome; high=poor) Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

2.1 short‐term (up to 3 months)	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 medium‐term (up to 6 months)	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3 Quality of life (high=good) Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

3.1 short‐term (up to 3 months)	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3.2 medium‐term (up to 6 months)	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 Leaving the study early Show forest plot	1		Odds Ratio (M‐H, Random, 95% CI)	Totals not selected

4.1 short‐term (up to 3 months)	1		Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
4.2 medium‐term (up to 6 months)	1		Odds Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 3. Active music therapy versus receptive music therapy

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