Depression is a mood disorder and among the common mental illnesses, affecting hundreds of millions of people worldwide. It can lead to various emotional and physical problems and reduce an individual’s ability to function at work and home. Reference Tang, Huang, Zhou and Ye1 Depression is associated with a wide range of medical conditions, including neurological disorders such as dementia and Parkinson’s disease, stroke and musculoskeletal and cardiovascular diseases, as well as cancer. Reference Starkstein and Robinson2–Reference Pitman, Suleman, Hyde and Hodgkiss4 When co-occurring with other medical conditions, depression can discourage people from seeking treatment, leading to deterioration in health and worsening of depressive symptoms. Reference Pitman, Suleman, Hyde and Hodgkiss4 Furthermore, depression impairs an individual’s ability to maintain relationships with family members, perform well at work and live a normal life. Ultimately, it contributes to a substantial economic and social burden by increasing healthcare costs and reducing life expectancy. Reference Sartorius5 Although psychotherapy and pharmacotherapy are the most common treatment options for depression, the results are not always satisfactory. 6 Intractable depression persists over time and can lead to serious physical and psychological impairment, sometimes resulting in devastating outcomes such as suicide. Reference Tang, Huang, Zhou and Ye1 In addition, emotional barriers to diagnosis, social stigma and the adverse effects associated with medication often cause patients to hesitate in seeking treatment, thereby worsening their condition. Reference Lynch, McDonagh and Hennessy7 Therefore, therapeutic options that are more familiar to, or likely to be tolerated by, the individual are required. In this regard, music can serve as a favourable adjunctive therapeutic option because it can be tailored to patients’ preferences. Music therapy, defined as the professional use of music and its elements as an intervention, has been employed effectively to manage psychological and emotional issues caused by various medical, psychiatric and behavioural disorders. Reference Chiang, Marquardt, Martin, Malyavko and Tabaie8–Reference Aalbers, Fusar-Poli, Freeman, Spreen, Ket and Vink12
The American Music Therapy Association defines music therapy as the clinical and evidence-based use of music to accomplish individualised goals within a therapeutic relationship by a credentialled professional who has completed an approved music therapy programme. Reference Tang, Huang, Zhou and Ye1,Reference Yinger and Gooding13 Music therapy is categorised into active music therapy, receptive music therapy and music medicine. In active music therapy, the subject engages in improvisation, songwriting, playing of musical instruments or singing with therapists or other participants. In receptive music therapy, individuals listen to music rather than creating it; however, this approach emphasises interaction with a therapist using various techniques such as providing music-related imagery, analysing lyrics and recalling feelings, memories or experiences associated with music. In music medicine, patients are simply instructed to listen to music. This approach focuses on the direct effects of music alone, independent of the patient–therapist relationship, which distinguishes it from receptive music therapy. Reference Dhippayom, Saensook, Promkhatja, Teaktong, Chaiyakunapruk and Devine14 All three subscales of music therapy have been found to enhancesubjects’ ability to cope with emotional distress. Reference Jain, Javadekar, Chaudhary and Choudhury15 These effects are believed to be obtained by modulating the neuroendocrine system and activating the limbic system, which is associated with emotional status. Reference Chan, Chan, Mok and Kwan Tse16–Reference Rădulescu, Drăgoi, Trifu and Cristea18
It is both necessary and beneficial to evaluate the efficacy of music therapy and to determine whether its individual subscales, based on different categories and delivery methods, are effective in treating depressive symptoms and related clinical deficits in those with depression and other underlying diseases. This study aimed to evaluate the clinical effectiveness of music therapy and its various subscales in managing those with depressive symptoms (primary outcome) and associated problems (secondary outcome), in comparison with other conventional treatments.
Method
Data source
This systematic review was conducted following the Cochrane Collaboration guidelines for the systematic reviews of interventions. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension statement for reporting systematic reviews of healthcare interventions. The study protocol was registered in PROSPERO in October 2023 (no. CRD42023466833). A comprehensive search of the published literature was conducted in the databases Medline (PubMed), Embase, Cochrane Review, CINAHL, PsyInfo and KMBase for articles published up to 31 August 2023, using the individual search terms listed in the Supplementary material available at https://doi.org/10.1192/bjo.2025.10822.
Study selection
The inclusion criteria included: randomised controlled trials (RCTs) published in either Korean or English; RCTs involving patients of any age with any underlying diseases and who were diagnosed with depression, using either a self-rated depression questionnaire or a validated clinician-rated assessment method; and RCTs evaluating any type of music therapy, including active music therapy, receptive music therapy and music medicine, delivered through either individual- or group-based therapy. Studies that did not clearly indicate depression diagnosed using a validated method at baseline were excluded. Among those studies that met the criteria above, only RCTs that reported clinical outcomes following music therapy in comparison with a control group were finally selected.
Article selection was based initially on title and abstract screening, followed by full-text review. The selection process for both title and abstract screening and full-text review was independently performed by two reviewers (Y.J.L. and J.H.L.), and any discrepancies were resolved by discussion with the entire research group (Y.J.L., S.J.K., J.Y. and J.H.L.).
Data extraction and quality assessment
Data extraction was performed independently by three reviewers (Y.J.L., J.H.L. and J.Y.), and discrepancies were resolved through discussion or consultation with a fourth reviewer (S.J.K.). Data were extracted from the selected studies, including the characteristics of the participants (age, gender and diagnosis); music therapy subscales (music therapy types – active music therapy, receptive music therapy and music medicine); music therapy delivery method (group- or individual-based ); staff profession (certified music therapist or non-music therapist); validated clinical measurement scores of depression; and other associated clinical problems, such as quality of life (QOL), anxiety and sleep quality. These data were considered clinically meaningful and commonly associated with depression, and were sufficiently reported across the selected studies to allow for meta-analysis. Dichotomous variables, such as the number of participants, were extracted to estimate the relative risk ratio. Continuous variables, such as the mean and standard deviation of clinical scores, were extracted to estimate mean differences. If standard deviations were not reported, these were calculated from the confidence interval, mean and number of patients. Data extraction began on 15 October 2023.
Quality assessment of each study and evidence level were conducted using the methodology Grading of Recommendations Assessment, Development and Evaluation (GRADE). Reference Brozek, Akl, Alonso-Coello, Lang, Jaeschke and Williams19–Reference Brozek, Akl, Jaeschke, Lang, Bossuyt and Glasziou21 The bias assessment for each RCT was conducted following the method Risk of Bias (ROB), which consisted of seven domains: random sequence generation, allocation sequence concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting and other biases. Reference Lepage, Conway, Goodson, Wicks, Flight and Devane22 Each of the domains was rated as either ‘low risk’, ‘high risk’ or ‘unclear’. These evaluations were independently performed by two reviewers (Y.J.L. and J.H.L.), and disagreements were resolved through discussion with the entire research group.
Based on a comprehensive evaluation of inconsistency, indirectness, imprecision and publication bias, along with ROB assessment, the evidence level was graded as either high, moderate, low or very low. Furthermore, the recommendation strength was determined as either strong or weak following a comprehensive assessment of not only the evidence level, but also other factors such as benefits and risks, cost-effectiveness and applicability or accessibility. Both evidence level and recommendation strength were determined through discussion with the entire research group.
Data synthesis and analysis
Meta-analysis was conducted using Review Manager software (RevMan version 5.4, The Cochrane Collaboration 2014) to compare clinical outcomes, including depression, QOL, anxiety and sleep quality scores, between the music therapy and control groups within 3 months following treatment. The main comparisons were as follows: (a) music therapy versus control (usual care, such as psychotherapy or pharmacotherapy) for alleviation of depression (1-1) subgroup analysis for active control (such as psychotherapy and pharmacotherapy) and passive control (rest and waiting) (1-2) subgroup analysis, based on whether aetiology or underlying disease was identified; (b) music therapy versus control for improvement of QOL; (c) music therapy versus control for amelioration of anxiety symptoms; and (d) music therapy versus control for improvement of sleep quality. To elucidate the clinical effectiveness of music therapy in subscales, subgroup analysis was conducted according to the following comparisons: (a) active music therapy versus control; (b) receptive music therapy versus control; (c) music medicine versus control; (d) group-based music therapy versus control; (e) individual-based music therapy versus control; (f) music therapist versus control; (g) non-music therapist versus control; and (h) music therapy versus other art therapies such as painting, poetry and creative play. Insufficient parameters, such as pain score, activities of daily living and adverse response scale, were not evaluated in the meta-analysis.
The results are expressed as mean difference and 95% CI for continuous outcome data, or as relative risk ratio and 95% CI for dichotomous outcome data. Pooled effects were estimated using standardised mean difference (SMD) and 95% CI, due to the use of different depression measurement scales across the selected studies. A P-value of <0.05 was considered statistically significant.
A random-effects model was used to estimate effect sizes and their statistical significance, based on the assumption that the participants and methods of the included studies, conducted by independent researchers, were not equivalent and therefore could not share a common effect size. Heterogeneity was assessed using I 2 statistics, with a value of P < 0.05 being considered as indicating a significantly high degree of heterogeneity.
Results
Characteristics of RCTs
Initially, 6714 articles were identified from the database search. Following the removal of 1869 duplicates, 4845 potentially eligible articles remained. Title and abstract screening further led to the exclusion of 4682 articles that did not meet the inclusion criteria. The remaining 163 articles were included in the full-text analysis, of which 137 were subsequently excluded due to irrelevance to the scope of this analysis. Consequently, a total of 26 RCTs were included in this study (Fig. 1 and Tables 1–3). Of these, 25 articles containing continuous data were included in quantitative synthesis (meta-analysis), excluding one article Reference Castillo-Pérez, Gómez-Pérez, Velasco, Pérez-Campos and Mayoral23 that provided only dichotomous data.
Fig. 1 Flow diagram of study selection.
Table 1 Statistics derived from the 26 studies: demograhic data
MT, music therapy group; CG, control group; ICD-10, International Statistical Classification of Diseases and Related Health Problems; GMT, group music therapy; RCS, recreational choir singing; DSM-IV, Diagnostic and Statistical Manual of Mental Disorders-IV; ADHD, attention-deficit hyperactivity disorder.
Table 2 Statistics derived from the 26 studies: treatment methods
MT, music therapy group; CG, control group; GMT, group music therapy; RCS, recreational choir singing.
Table 3 Statistics derived from the 26 studies: evaluation methods and results
MT, music therapy group; GMT, group music therapy; RCS, recreational choir singing; QOL, quality of life.
In the meta-analysis, Atiwannapat et al’s study was divided into active and receptive music therapy groups, because it established two music therapy groups and compared these with the control group, respectively. Reference Atiwannapat, Thaipisuttikul, Poopityastaporn and Katekaew24 Baker et al’s study was divided into three music therapy groups, including group music therapy (the GMT group), recreational choir singing (the RCS group) and group music therapy plus recreational choir singing (the GMT + RCS group), because each was compared separately with a control group. Reference Baker, Lee, Sousa, Stretton-Smith, Tamplin and Sveinsdottir25 In addition, in the studies by Fancourt and Perkins, Lin et al, Rezazadeh et al and Arruda et al, two different control groups were used and analysed separately, because these studies included additional control groups such as poetry, creative play control, painting and acupuncture. Reference Fancourt and Perkins26–Reference Arruda, Garcia and Garcia29 Ultimately, 32 comparisons extracted from 25 studies were included in the meta-analysis.
The publication dates of the studies spanned from 2014 to 2023, with their sample sizes ranging from 14 to 318 participants. The studies were conducted across diverse regions, including Asia, Europe, Oceania and Middle and South America. In some Asian studies, traditional music specific to the country was used as a therapeutic method. All included trials evaluated depression using a validated assessment method. Each study compared the clinical effectiveness of music therapy for depression with usual care, pharmacotherapy, psychotherapy, rest or waiting. In addition, some studies examined improvements in other associated conditions such as anxiety, sleep quality, quality of life and self-esteem, alongside depressive symptoms. 6,Reference Atiwannapat, Thaipisuttikul, Poopityastaporn and Katekaew24,Reference Baker, Lee, Sousa, Stretton-Smith, Tamplin and Sveinsdottir25,Reference Rezazadeh, Froutan, Abadi, Mazloum and Moghaddam28,Reference An, Liu, Wang, Wang, Zhang and Zhang30–Reference Deshmukh, Sarvaiya, Seethalakshmi and Nayak35 The characteristics of participants and music therapy, evaluation tools and clinical outcomes are listed in Table 1.
Risk of bias
The ROB of all the selected studies is presented in Fig. 2. Of the 26 RCTs, 14 were assessed as having a high or unclear risk in the random sequence generation because the sequence generation process was not described. 6,Reference Jain, Javadekar, Chaudhary and Choudhury15,Reference Castillo-Pérez, Gómez-Pérez, Velasco, Pérez-Campos and Mayoral23,Reference Fancourt and Perkins26,Reference Rezazadeh, Froutan, Abadi, Mazloum and Moghaddam28,Reference Arruda, Garcia and Garcia29,Reference Daengruan, Chairat, Jenruamjit, Chinwong, Oon-arom and Klaphajone31,32,Reference Deshmukh, Sarvaiya, Seethalakshmi and Nayak35–Reference Zhang, Ding, Zhang, Jiang, Xu and Zhang40 The most frequently biased domain was the blinding of participants and personnel (performance bias), with 25 studies considered high risk because patients or staff were aware of group allocation during treatment sessions, whereas only one study maintained blindness of patients and personnel during data collection and intervention, by providing noise-muffling on headphones rather than music in the control group while maintaining other conditions the same as for the music therapy group. Reference Daengruan, Chairat, Jenruamjit, Chinwong, Oon-arom and Klaphajone31 A total of 20 studies were rated as high or unclear risk in the domain of blinding of outcome assessment (detection bias), due to lack of clarity or absence of assessor blinding. 6,Reference Jain, Javadekar, Chaudhary and Choudhury15,Reference Chan, Chan, Mok and Kwan Tse16,Reference Castillo-Pérez, Gómez-Pérez, Velasco, Pérez-Campos and Mayoral23,Reference Fancourt and Perkins26–Reference An, Liu, Wang, Wang, Zhang and Zhang30,Reference Verrusio, Andreozzi, Marigliano, Renzi, Gianturco and Pecci33,Reference Chan, Chan and Mok34,Reference Oliveira, Gondim, Azevedo, Alves, Asano and Coriolano36–Reference Chen, Sung, Lee and Chang43 Overall, 97 of 182 domains (53.3%) were rated low risk and, therefore, the overall ROB was considered high (Fig. 2). Discrepancies between reviewers were initially observed in 26 of the total 182 domains (14.2%), all of which were resolved through discussion.
Fig. 2 Quality assessment for extracted studies: risk of bias for randomised controlled study. Green, low risk of bias; red, high risk; yellow, unclear risk.
Qualitative analysis
Among the 26 studies included in the final analysis, 21 reported that the music therapy group achieved a significant reduction in depression score compared with the control group, whereas the 5 other studies demonstrated that the music therapy and control groups had a comparable improvement in depression score. 6,Reference Atiwannapat, Thaipisuttikul, Poopityastaporn and Katekaew24,Reference Arruda, Garcia and Garcia29,Reference Daengruan, Chairat, Jenruamjit, Chinwong, Oon-arom and Klaphajone31,Reference Deshmukh, Sarvaiya, Seethalakshmi and Nayak35 Notably, music therapy was superior to other treatments commonly used, including pharmacotherapy and psychotherapy, in managing patients with depression from various aetiologies (Tables 1–3).
Quantitative analysis
Music therapy for depression
For analysis of depression score, 32 comparisons from 25 studies provided continuous data of depression scores for the analysis of effect size using SMD. The overall mean difference was estimated to be –0.97 (95% CI: −1.23 to −0.71), suggesting that music therapy showed greater reduction in depression score with statistical significance (P < 0.01). Almost all included trials, except one, demonstrated favourable outcomes for music therapy in a forest plot. However, individual mean differences varied across studies. For example, Zhang et al reported a mean difference of −2.63 whereas Arruda et al reported a value of 0.07, slightly favouring the control group. Reference Arruda, Garcia and Garcia29,Reference Zhang, Ding, Zhang, Jiang, Xu and Zhang40 A high degree of heterogeneity was observed (I 2 = 85%, P < 0.01) (Fig. 3a).
Fig. 3 Comparison of depression scores: (a) music therapy (MT) versus control, (b) subgroup analysis for active and passive control, (c) subgroup analysis for not identified or identified aetiology or underlying diseases. IV, inverse variance; SMD, standardised mean difference; GMT, group music therapy; RCS, recreational choir singing.
Music therapy demonstrated significantly better effectiveness in controlling depression compared with both active and passive controls, with statistical significance (P < 0.01). The overall mean differences were −0.68 (95% CI: −0.90 to −0.45) and −1.55 (95% CI: −2.12 to −0.98) for active and passive controls, respectively (Fig. 3b). Similarly, the beneficial effect of music therapy remained statistically significant regardless of whether the aetiology or underlying diseases were identified (P < 0.01). The overall mean differences were −0.97 (95% CI: −1.23 to −0.71) in studies with identified underlying conditions and −1.25 (95% CI: −1.75 to −0.75) in those without specified aetiology (Fig. 3c).
Music therapy for depression according to music therapy type (active music therapy, receptive music therapy and music medicine)
The first subgroup analysis was conducted following dividision of the studies into three subgroups based on music therapy type. In the active music therapy subgroup, 13 comparisons from 10 studies were available in the analysis of effect size using the SMD of depression score improvement. 6,Reference Atiwannapat, Thaipisuttikul, Poopityastaporn and Katekaew24–Reference Fancourt and Perkins26,32,Reference Hamid37–Reference Albornoz41 The overall SMD was estimated to be −1.22 (95% CI: −1.65 to −0.79), indicating a statistically significant improvement favouring active music therapy (P < 0.01). In the receptive music therapy subgroup, which included 6 comparisons from 5 studies, Reference Jain, Javadekar, Chaudhary and Choudhury15,Reference Atiwannapat, Thaipisuttikul, Poopityastaporn and Katekaew24,Reference Rezazadeh, Froutan, Abadi, Mazloum and Moghaddam28,Reference Gök Ugur, Yaman Aktaş, Orak, Saglambilen and Aydin Avci44,Reference Yu, Lo, Chen and Lu45 SMD was estimated to be −1.13 (95% CI: −1.79 to −0.46), also suggesting a statistically significant improvement compared with controls (P < 0.01). For music medicine, 13 comparisons from 11 studies provided relevant data, Reference Chan, Chan, Mok and Kwan Tse16,Reference Lin, Gu, Wu, Huang and He27,Reference Arruda, Garcia and Garcia29–Reference Daengruan, Chairat, Jenruamjit, Chinwong, Oon-arom and Klaphajone31,Reference Verrusio, Andreozzi, Marigliano, Renzi, Gianturco and Pecci33–Reference Oliveira, Gondim, Azevedo, Alves, Asano and Coriolano36,42,Reference Chen, Sung, Lee and Chang43 with an overall SMD of −0.97 (95% CI: −1.23 to −0.71), indicating a significant reduction in depression score (P < 0.01). Although all three music therapy types produced statistically significant improvements, active music therapy appeared to have yielded the largest mean difference, followed by receptive music therapy and music medicine, respectively. Notably, within the music medicine subgroup, three studies showed distinctly larger mean differences than the othes. Reference Chan, Chan, Mok and Kwan Tse16,Reference Chan, Chan and Mok34,42 These studies used rest as the control group, whereas other studies usually used active controls such as conventional treatment. A high degree of heterogeneity was observed across all three subgroups (I 2 = 89, 83 and 80%, respectively; P < 0.01) (Fig. 4).
Fig. 4 Comparison of depression scores: active music therapy (MT), receptive MT and music medicine versus control. Active MT, active music therapy; receptive MT, receptive music therapy; IV, inverse variance; GMT, group music therapy; RCS, recreational choir singing; SMD, standardised mean difference.
Music therapy for depression according to music therapy delivery method (group- or individual-based music therapy)
The second subgroup analysis was conducted following dividision of the studies into two subscales based on whether music therapy was conducted by group or individually. In the group-based music therapy subgroup, data were obtained for 12 comparisons from 8 studies. 6,Reference Atiwannapat, Thaipisuttikul, Poopityastaporn and Katekaew24–Reference Fancourt and Perkins26,Reference Perkins, Spiro and Waddell39–Reference Albornoz41,Reference Yu, Lo, Chen and Lu45 The SMD was measured as −1.18 (95% CI: −1.60 to −0.76), suggesting that the music therapy group had a more significant reduction in depression score than the control group (P < 0.01). For individual-based music therapy, 16 comparisons from 14 studies yielded an SMD of −1.0 (95% CI: −1.41 to −0.59), Reference Chan, Chan, Mok and Kwan Tse16,Reference Rezazadeh, Froutan, Abadi, Mazloum and Moghaddam28–Reference Hamid37,42–Reference Gök Ugur, Yaman Aktaş, Orak, Saglambilen and Aydin Avci44 showing a significant reduction in depression score compared with the control group (P < 0.01). Although both groups appear to be effective, the mean difference seemed to be relatively larger in the group-based music therapy subgroup. Notably, studies by Fancourt and Perkins, Yu et al and Zhang et al in the group-based music therapy subgroup reported larger effect sizes than others. Reference Fancourt and Perkins26,Reference Zhang, Ding, Zhang, Jiang, Xu and Zhang40,Reference Yu, Lo, Chen and Lu45 A high degree of heterogeneity was observed in both subgroups (I 2 = 87 and 85%; P < 0.01) (Fig. 5).
Fig. 5 Comparison of depression scores: group music therapy (MT) and individual MT versus control. Group MT, group-based music therapy; individual MT, individual-based music therapy; IV, inverse variance; GMT, group music therapy; RCS, recreational choir singing; SMD, standardised mean difference.
Music therapy for depression according to staff profession (certified music therapist or non-music therapist)
The third subgroup analysis was conducted following division of the studies into two subgroups depending on whether music therapy was guided by a certified music therapist or a non-music therapist. In the music therapist subgroup, 13 comparisons from 9 studies were available for the analysis of effect size using the SMD of depression score improvement. 6,Reference Atiwannapat, Thaipisuttikul, Poopityastaporn and Katekaew24,Reference Baker, Lee, Sousa, Stretton-Smith, Tamplin and Sveinsdottir25,Reference Rezazadeh, Froutan, Abadi, Mazloum and Moghaddam28,32,Reference Park, Lee, Lee, Kwon, Choo and Nam38–Reference Zhang, Ding, Zhang, Jiang, Xu and Zhang40,Reference Gök Ugur, Yaman Aktaş, Orak, Saglambilen and Aydin Avci44 Three comparisons from Baker’s study showed a smaller mean difference favouring music therapy over other comparisons. In the non-music therapist subgroup, 19 comparisons from 16 studies provided data for the analysis. Reference Jain, Javadekar, Chaudhary and Choudhury15,Reference Chan, Chan, Mok and Kwan Tse16,Reference Fancourt and Perkins26,Reference Lin, Gu, Wu, Huang and He27,Reference Arruda, Garcia and Garcia29–Reference Daengruan, Chairat, Jenruamjit, Chinwong, Oon-arom and Klaphajone31,Reference Verrusio, Andreozzi, Marigliano, Renzi, Gianturco and Pecci33–Reference Hamid37,Reference Albornoz41–Reference Chen, Sung, Lee and Chang43,Reference Yu, Lo, Chen and Lu45 Both groups showed statistically significant reductions in depression scores compared with control, with SMDs of −0.97 (95% CI: −1.30 to −0.64; P < 0.01) and −0.99 (95% CI: −1.39 to −0.60; P < 0.01), respectively. The degree of heterogeneity for the groups was 81 and 85%, respectively (P < 0.01) (Fig. 6).
Fig. 6 Comparison of depression scores: music therapist and non-music therapist versus control. MT, music therapy; IV, inverse variance; GMT, group music therapy; RCS, recreational choir singing; SMD, standardised mean difference.
Music therapy versus art therapies for depression
Music therapy was compared with other art therapies, including painting, poetry and creative play, among controls to investigate whether music therapy has a greater effectiveness in improving depression scores than other art therapy types. This analysis, made by 6 comparisons from 4 studies, revealed a SMD of −0.56, favouring music therapy with statistical significance (95% CI: −0.82 to −0.31; P < 0.01). Reference Baker, Lee, Sousa, Stretton-Smith, Tamplin and Sveinsdottir25,Reference Fancourt and Perkins26,Reference Rezazadeh, Froutan, Abadi, Mazloum and Moghaddam28,Reference Arruda, Garcia and Garcia29
Fancourt and Perkins’ study, involving women with postnatal depression, demonstrated that the music therapy group showed significant improvement in depressive symptoms, whereas neither the control nor the creative play group exhibited such improvement. Reference Fancourt and Perkins26 Rezazadeh et al’s study of children aged 6–12 years with burn injuries found that the music therapy group achieved significantly greater improvement in depression than the painting group. Reference Rezazadeh, Froutan, Abadi, Mazloum and Moghaddam28 Arruda et al reported that the music therapy and poetry groups produced significant improvement in depressive symptoms, with no significant difference in adult patients with cancer pain. Reference Rezazadeh, Froutan, Abadi, Mazloum and Moghaddam28 In Baker’s study of patients with dementia, the choir singing group showed significantly better results than the control group (which included activities such as group games, entertainment, art classes and gardening), while the music therapy group did not yield better results. Reference Baker, Lee, Sousa, Stretton-Smith, Tamplin and Sveinsdottir25 The level of heterogeneity was measured as high (I 2 = 57%, P = 0.04) (Fig. 7).
Fig. 7 Comparison of depression scores: music therapy (MT) versus other art therapies. GMT, group music therapy; IV, inverse variance; RCS, recreational choir singing; SMD, standardised mean difference.
Music therapy for QOL
Nine comparisons from six studies provided continuous data regarding increased QOL scores for the analysis of effect size, using SMD. 6,Reference Atiwannapat, Thaipisuttikul, Poopityastaporn and Katekaew24,Reference Baker, Lee, Sousa, Stretton-Smith, Tamplin and Sveinsdottir25,Reference An, Liu, Wang, Wang, Zhang and Zhang30–32 Overall SMD was estimated to be 0.51 (95% CI: 0.19 to 0.83), suggesting that QOL improvement was significantly better in the music therapy group than in the control group (P < 0.01). A high degree of heterogeneity was observed (I 2 = 71%, P < 0.01) (Fig. 8a).
Fig. 8 Comparison of (a) quality of life scores, (b) anxiety scores and (c) sleep quality scores: music therapy (MT) versus control. IV, inverse variance; GMT, group music therapy; RCS, recreational choir singing; SMD, standardised mean difference.
Music therapy for anxiety
Four comparisons from three studies provided continuous data for the measurement of effect size on anxiety score reduction, using SMD. Reference Rezazadeh, Froutan, Abadi, Mazloum and Moghaddam28,32,Reference Verrusio, Andreozzi, Marigliano, Renzi, Gianturco and Pecci33 This suggested that music therapy exhibited greater reduction in anxiety score than the control group, with an effect size of −0.98 (95% CI: −2.01 to 0.06) but without statistical significance (P = 0.06). A significantly high level of heterogeneity was observed (I 2 = 89%, P < 0.01) (Fig. 8b).
Music therapy for sleep quality
Two studies were included in the analysis of effect size for sleep score improvement, using SMD. Reference Chan, Chan and Mok34,Reference Deshmukh, Sarvaiya, Seethalakshmi and Nayak35 The overall SMD was estimated to be −0.61 (95% CI: −1.03 to −0.19), which favoured music therapy with statistical significance (P < 0.01). The level of heterogeneity was low (I 2 = 0%, P = 0.88) (Fig. 8c).
Level of evidence
The ROB was considered high (problematic or serious), as previously mentioned. Directness was not considered problematic because all the included studies directly compared music therapy with other controls. Funnel plot analyses were conducted in the category of music therapy for depression, and in the subgroup analysis of group-based music therapy, individual-based music therapy, active music therapy, music medicine and music therapist and non-music therapist for depression, because more than ten studies were included for each category. Although all funnel plots demonstrated asymmetry, this could not be completely attributed to publication bias due to the high level of heterogeneity across the selected studies. Consistency was considered problematic owing to clinical heterogeneity across the selected studies and statistical heterogeneity, as demonstrated by I 2 values, in all the meta-analysis categories. In addition, the degree of precision was regarded as problematic due to the small number of patients in the selected studies. Consequently, the evidence level as determined using the GRADE system was evaluated as being very low (Table 4).
Table 4 The Grading of Recommendations Assessment, Development and Evaluation system
SMD, standardised mean difference.
a Overall, 97 (53.3%) of 182 domains were rated as low risk.
b Clinical and statistical heterogeneity.
c All the included studies directly compared music therapy with other controls.
d Small number of patients in the selected studies.
Discussion
Depression is associated with significant structural alterations and functional disruptions in the cortical and limbic circuits that regulate mood and emotion. Elevated plasma cortisol levels are relevant to the suppression of neural plasticity, causing the enhancement of negative coping mechanisms for emotional problems. Furthermore, deficiency of neurotransmitters such as serotonin, and abnormal functioning of their receptors, are implicated in the pathophysiology of depression. Reference Rădulescu, Drăgoi, Trifu and Cristea18 A study investigating the effectiveness of music therapy in controlling depression in children with attention-deficit hyperactivity disorder observed improvement in the depression scale, as well as serotonin activation and cortisol reduction, in the music therapy group. Reference Park, Lee, Lee, Kwon, Choo and Nam38
Auditory stimulation by music pitch and tones can modulate emotional disturbances by influencing the limbic system, which plays a key role in memory, learning, motivation and emotional states. Reference Chan, Chan, Mok and Kwan Tse16,Reference Hanser and Thompson17 Aside from the limbic system, music enhances connectivity between the auditory cortex and other areas related to emotional control. In addition, it facilitates motor coordination, cognitive functions such as memory, attention span and behavioural augmentation, which contribute to improved emotional and neurological status. Reference Toader, Tataru, Florian, Covache-Busuioc, Bratu and Glavan46 Music possesses an inherent ability to alleviate depression and other emotional distress, irrespective of underlying disease conditions, by modulating neurotransmitters or the interconnection between various brain regions. Reference Särkämö47 Our findings also support the effectiveness of music therapy, regardless of delivery method or associated disease entities. In addition, the therapeutic benefit of music therapy was not observed in comparison with only passive controls, such as just waiting or rest, but also in comparison with active controls, including psychotherapy and pharmacology. However, many of the included studies established diverse controls and their combinational use – for example, pharmacotherapy and psychotherapy, which made it difficult to ensure that music therapy was superior to all types of control treatments. Meta-analyses demonstrated that music therapy showed statistically significant improvement in depression compared with various controls that were not subdivided, Reference Tang, Huang, Zhou and Ye1,Reference Wang, Wu and Yan48 while another analysis was undecided as to whether music therapy outperformed psychological therapies in controlling depression. Reference Aalbers, Fusar-Poli, Freeman, Spreen, Ket and Vink12
Active music therapy, involving direct and active participation in producing and playing music, helped to establish interpersonal links between patients and therapists or other patient groups. In addition, active music therapy supports the development of problem-solving skills and enhances a feeling of self-worth or achievement. Reference Zhang, Ding, Zhang, Jiang, Xu and Zhang40 The creation and expression of musical sounds by patients helped to alleviate emotional problems, and to improve immunity, physical performance and QOL. Reference Kreutz, Bongard, Rohrmann, Hodapp and Grebe49–Reference Seinfeld, Figueroa, Ortiz-Gil and Sanchez-Vives52 These properties of active music therapy are presumed to underlie its effectiveness in alleviating depression compared with receptive music therapy or music medicine. Active music therapy was reported to be more efficient than music listening for children with autistic spectrum disorders. Reference Rabeyron, Robledo Del Canto, Carasco, Bisson, Bodeau and Vrait53 Contrarily, a meta-analysis indicated that receptive music therapy was better than active music therapy in controlling depression. This finding was attributed to the tendency of individuals with depression to adopt a passive attitude and exhibit reduced motivation for active engagement. Reference Wang, Wu and Yan48 Therefore, the choice between active and passive music therapy may depend on an individual’s characteristics, including the severity and nature of their depressive symptoms.
The relative advantage of group- or individual-based therapy remains a subject of debate. One study showing results contrary to our findings stressed the advantage of an individual-based approach, arguing that it allows for more tailored interventions that address specific subject needs. That study highlighted that group-based therapy, which centres on human interactions, may not effectively meet the needs of those with depression who have a tendency for weak social interactions and increased social avoidance. Reference Wang, Wu and Yan48 However, social avoidance or insufficiency was also one of the key factors in managing depressive symptoms. In this context, group-based therapy could be more clinically beneficial or effective than individual-based therapy. Many articles have stated that group-based therapy promotes social bonding by improving interpersonal relationships, placing the individual in contact with their musical and psychological resources and allowing acceptance of others in socialised activities, which, in turn, provides opportunities to build inner resources of coping, resilience and hope. 6,Reference Zhang, Ding, Zhang, Jiang, Xu and Zhang40,Reference Solli, Rolvsjord and Borg54,Reference Porter, McConnell, McLaughlin, Lynn, Cardwell and Braiden55
Contrary to expectation, music therapy guided by certified professional therapists failed to show significant benefits compared with that guided by non-professional staff. However, despite this finding, given that group-based or active music therapy, which is more dependent on specialised therapists, appeared to be better than individual-based or receptive music therapy, respectively, there was a probability that a professional music therapist might be more advantageous in regard to more effective music therapy. The lack of statistical significance regarding the professional background of the intervention provider in this review can be attributed to the characteristics of the study population. Four comparisons from two studies performed by a music therapist showed a smaller mean difference favouring music therapy, which might have contributed to statistical insignificance. Reference Baker, Lee, Sousa, Stretton-Smith, Tamplin and Sveinsdottir25,Reference Gök Ugur, Yaman Aktaş, Orak, Saglambilen and Aydin Avci44 In both studies, the participants were elderly patients with dementia or in a nursing home. It is plausible that advanced age and cognitive dysfunction had a more pronounced influence on the outcome than the professional qualifications of the staff.
Music therapy exhibited greater clinical effectiveness in reducing depressive symptoms than other active art therapies. However, inconsistent results were observed across the included studies, possibly because the art therapies used as control and the characteristics of participants in the selected studies were highly variable. To the best of our knowledge, no study has clearly defined whether music therapy is better than other art therapies, or provided strong, supportive evidence for such a claim. Although it is being cautious to assert that music therapy was better than other art therapies for depression based solely on the current study, music might be considered a better option than other arts in managing emotional problems. This is supported by the evidence that auditory stimuli from musical sound activate the limbic system, which is closely related to emotional control, thus helping to relieve psychological stress and depression. Reference de Witte, Spruit, van Hooren, Moonen and Stams56
Four studies included in this analysis showed a trend in which the superiority of music therapy over other art therapies was more prominent in young patients and children, but diminished in patients of older age or in those with more serious medical problems, such as cancer and dementia. Based on this tendency, music therapy may be more effective in younger patients with less severe disease and intact cognitive function, who are able to accept and understand music more efficiently and communicate with both peers and therapists.
Music therapy promoted interpersonal communication and created a harmonious environment, which may contribute to the amelioration of anxiety symptoms. Furthermore, music therapy encouraged patients to concentrate on the rhythm of the music, thereby distracting them from their underlying disease and its associated problems, including the emotional distress experienced during treatment. Music also played a role in both relaxing tightened muscles and hyperarousal status, which induced a positive change in the subject’s mental state and improved sleep condition. Reference Tang, Chen, Wang, Zhang, Yang and Yang57,Reference Harmat, Takács and Bódizs58 Ultimately, music therapy resulted in the improvement of QOL by reducing emotional problems, enhancing sleep quality and providing distraction from underlying disease and associated problems. Reference Nguyen, Hoang, Bui, Chan, Choi and Chan59
This study has several limitations. First, the quality of some included studies is a concern, mainly because of the unclear allocation sequence concealment, lack of blinding of participants and personnel and lack of blinding of outcome assessment. Second, the degree of statistical and clinical heterogeneity was high in almost all analyses, which reduced the statistical power of the meta-analysis. Third, the number of participants was small in a considerable number of studies, affecting the confidence intervals of some categories and therefore limiting the precision and accuracy of the results. These limitations ultimately lowered the evidence level and strength of recommendation.
Fourth, subgroup analysis according to music therapy intensity, considered an important point of music therapy, was not performed. One previous meta-analysis conducted subgroup analysis according to high- and low-intensity groups (60 min/week or less versus >60 min/week). Reference Dhippayom, Saensook, Promkhatja, Teaktong, Chaiyakunapruk and Devine14 However, that study also did not account for the number of sessions per week or the total number of sessions, which are important factors in determining treatment intensity. In our review, we were unable to obtain sufficient data regarding music therapy protocols across the selected studies.
Fifth, the included studies involved various underlying aetiologies, which could have introduced bias when concluding the effect of music therapy on depression. We conducted subgroup analysis only, by dividing the studies into those with identified or unidentified aetiologies. This study primarily focused on the therapeutic effects of music therapy based on various methodological subcategories, including subtype, delivery methods and professionality, in relation to reducing depression-related clinical symptoms. Music therapy was not considered a treatment for underlying diseases, but rather a method to manage emotional symptoms. Reference Tang, Huang, Zhou and Ye1,Reference Toader, Tataru, Florian, Covache-Busuioc, Bratu and Glavan46,Reference Särkämö47 In this context, we did not choose a specific diagnosis or aetiology. Furthermore, many articles included in this study did not limit participants by a specific diagnosis. Instead, they applied broad eligibility criteria, such as those diagnosed with depression based on a self-rated questionnaire or a clinician-rated assessment method, regardless of the underlying morbidity. 6,Reference Jain, Javadekar, Chaudhary and Choudhury15,Reference Chan, Chan, Mok and Kwan Tse16,Reference Castillo-Pérez, Gómez-Pérez, Velasco, Pérez-Campos and Mayoral23,Reference Atiwannapat, Thaipisuttikul, Poopityastaporn and Katekaew24,Reference Daengruan, Chairat, Jenruamjit, Chinwong, Oon-arom and Klaphajone31–Reference Deshmukh, Sarvaiya, Seethalakshmi and Nayak35,Reference Hamid37,Reference Zhang, Ding, Zhang, Jiang, Xu and Zhang40,42–Reference Yu, Lo, Chen and Lu45 As a result, sufficient data for subgroup analysis by aetiology or underlying disease were not available. Similarly, previous systematic reviews with meta-analyses published up to that point in time, including the Cochrane review, also focused on depression itself, irrespective of aetiology. Reference Pérez-Eizaguirre and Vergara-Moragues10,Reference Aalbers, Fusar-Poli, Freeman, Spreen, Ket and Vink12,Reference Wang, Wu and Yan48,Reference Solli, Rolvsjord and Borg54 A Cochrane review stated that they included participants with comorbidities such as anxiety disorder, alcohol abuse, personality disorder, dementia, autism, schizophrenia, psychosis and somatoform disorder, recognising that depression often co-occurs with other diagnoses. Reference Aalbers, Fusar-Poli, Freeman, Spreen, Ket and Vink12 However, when sufficient data become available, conducting a meta-analysis based on different underlying diseases would provide valuable insights.
Overall, the synthesised results of the selected studies and meta-analysis indicate that music therapy might be superior, or at least not inferior to, various controls, including pharmacotherapy, psychotherapy and even other art therapies, in the treatment of depression and related clinical aspects such as QOL, anxiety and sleep conditions. This advantage of music therapy could be achieved regardless of whether it is employed as active music therapy, receptive music therapy or music medicine; whether a professional therapist guided it; and whether it was performed in a group or individually. Music therapy can be applied to individuals without requiring high-cost, trained staff members or skillful techniques. Most people widely enjoy music, and it can therefore be used in those with depression without hesitation. In addition, music is not associated with serious adverse effects, offering reassurance to people who may be anxious about the potential side effects of pharmacotherapy.
In conclusion, considering that the meta-analysis of relevant studies demonstrated statistically significant superiority of music therapy over controls, along with the inherent characteristics of music – being popularly enjoyable, easily accessible, low in cost and free of serious side effects – music therapy could be recommended with weak strength for individuals with depression to control depressive symptoms and anxiety, and to improve QOL and sleep quality, despite the low level of evidence. Future studies analysing the effects of music therapy according to more specific underlying aetiologies or disease entities, once further RCTs have been accumulated, would provide more meaningful clinical implications.
Supplementary material
The supplementary material is available online at https://doi.org/10.1192/bjo.2025.10822
Data availability
Extracted data are available on request from the corresponding author.
Acknowledgements
We thank Editage (www.editage.co.kr) for English language editing.
Author contributions
Y.J.L. and J.H.L. designed the study and established the search terms, supervised by S.J.K. J.Y., Y.J.L. and J.H.L. undertook the data search and study selection. All authors took part in the review process, selected studies comprehensively and decided the risk of bias, evidence level and recommendation level. Y.J.L. and J.H.L. drafted the tables and conducted meta-analysis following data selection. Y.J.L. and J.H.L. drafted the article initially. All authors critically revised the manuscript and approved the final version. All authors had full access to all data in the study and had final responsibility for the decision to submit for publication.
Funding
This research received no specific grant from any funding agency, or commercial or not-for-profit sectors.
Declaration of interest
None.
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