Artículo Musicoterapia

Clinical Psychology Review 29 (2009) 193207
Contents lists available at ScienceDirect
Clinical Psychology Review
Doseresponse relationship in music therapy for people with serious mental

disorders: Systematic review and meta-analysis
Christian Gold a,, Hans Petter Solli b,c, Viggo Krger b, Stein Atle Lie a
a
b
c
Unifob Health, Bergen, Norway

University of Bergen, Norway
Lovisenberg Diakonale Hospital, Oslo, Norway
a r t i c l e
i n f o
Article history:
Received 30 June 2008
Received in revised form 6 January 2009
Accepted 12 January 2009
Keywords:
Psychosis
Depression
Psychotherapy
Doseeffect relationship
Mixed-effects meta-analysis
a b s t r a c t
Serious mental disorders have considerable individual and societal impact, and traditional treatments may
show limited effects. Music therapy may be benecial in psychosis and depression, including treatmentresistant cases. The aim of this review was to examine the benets of music therapy for people with serious
mental disorders. All existing prospective studies were combined using mixed-effects meta-analysis models,
allowing to examine the inuence of study design (RCT vs. CCT vs. pre-post study), type of disorder
(psychotic vs. non-psychotic), and number of sessions. Results showed that music therapy, when added to
standard care, has strong and signicant effects on global state, general symptoms, negative symptoms,
depression, anxiety, functioning, and musical engagement. Signicant doseeffect relationships were
identied for general, negative, and depressive symptoms, as well as functioning, with explained variance
ranging from 73% to 78%. Small effect sizes for these outcomes are achieved after 3 to 10, large effects after 16
to 51 sessions. The ndings suggest that music therapy is an effective treatment which helps people with
psychotic and non-psychotic severe mental disorders to improve global state, symptoms, and functioning.
Slight improvements can be seen with a few therapy sessions, but longer courses or more frequent sessions
are needed to achieve more substantial benets.
2009 Elsevier Ltd. All rights reserved.
Contents
1.
2.
3.
Introduction . . . . . . . . . . . . . . . . . . .
1.1.
Music therapy in mental health. . . . . . .
1.2.
Music therapythe evidence to date . . . .
1.3.
Research questions addressed in this review
Method . . . . . . . . . . . . . . . . . . . . .
2.1.
Criteria for selecting studies . . . . . . . .
2.1.1.
Study design . . . . . . . . . . .
2.1.2.
Study quality . . . . . . . . . . .
2.1.3.
Participants . . . . . . . . . . . .
2.1.4.
Interventions . . . . . . . . . . .
2.1.5.
Outcomes. . . . . . . . . . . . .
2.2.
Search strategy . . . . . . . . . . . . . .
2.3.
Selection of studies and data extraction. . .
2.4.
Data analysis . . . . . . . . . . . . . . .
2.4.1.
Individual study results . . . . . .
2.4.2.
Combination of study results . . .
Description of studies . . . . . . . . . . . . . .
3.1.
Selection process . . . . . . . . . . . . .
3.2.
General study characteristics . . . . . . . .
3.3.
Interventions: Music therapy. . . . . . . .
3.4.
Comparison conditions . . . . . . . . . .
3.5.
Data extraction and preprocessing . . . . .
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Corresponding author. Unifob Health, Grieg Academy Music Therapy Research Centre, Lars Hilles gate 3, 5015 Bergen, Norway. Tel.: +47 97501757.
E-mail address: christian.gold@grieg.uib.no (C. Gold).
0272-7358/$ see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2009.01.001
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C. Gold et al. / Clinical Psychology Review 29 (2009) 193207
4.
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.
Comparison of music therapy versus standard care . . . . . .
4.1.1.
General mental state . . . . . . . . . . . . . . . .
4.1.2.
Negative symptoms . . . . . . . . . . . . . . . .
4.1.3.
Depressive symptoms . . . . . . . . . . . . . . .
4.1.4.
Other symptoms: Anxiety and positive symptoms . .
4.1.5.
Functioning . . . . . . . . . . . . . . . . . . . .
4.1.6.
Musical engagement . . . . . . . . . . . . . . . .
4.1.7.
Other outcomes: Global state, leaving the study early,
4.2.
Other outcomes and comparisons. . . . . . . . . . . . . .
5.
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5.1.
Summary of ndings . . . . . . . . . . . . . . . . . . . .
5.2.
The evidence base for music therapy in mental health . . . .
5.3.
The doseresponse relationship in music therapy . . . . . .
5.4.
Limitations . . . . . . . . . . . . . . . . . . . . . . . .
5.5.
Implications for practice . . . . . . . . . . . . . . . . . .
5.6.
Implications for future research. . . . . . . . . . . . . . .
6.
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conict
of interest
. . . . . . . . . . . . . . . . . . . . . . . . . . .
.
Conict
of interest
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. Introduction
Serious mental disorders are common and often long-lasting conditions with considerable impact on society and the individual. Seriousness
may be dened by specic states generally considered as severe, such as
psychosis or suicidal behavior, by low level of functioning or a severe
global impression, or by chronicity and treatment resistance. In a
comprehensive international mental health survey (Demyttenaere et al.,
2004), serious mental disorders were found to be prevalent in between
0.4% in Nigeria and 7.7% in the United States. Seriousness in that study was
dened as severe role impairment, severe overall functional impairment,
substance dependence, or suicidality in conjunction with a mental
disorder, irrespective of the particular diagnosis. Treatment options for
people with serious mental disorders include psychopharmacological and
psychotherapeutic approaches. Both have been shown to be efcacious in
many but not in all patients, and not without limits. Many patients do not
show satisfactory improvement with these traditional approaches and
continue to show substantial symptom levels and impaired functioning.
There is therefore a need for additional, innovative forms of therapy to
help people with serious mental disorders.
1.1. Music therapy in mental health
Music therapy is a special type of psychotherapy where forms of
musical interaction and communication are used alongside verbal
communication. It has been dened as a systematic process of
intervention wherein the therapist helps the client to promote health,
using music experiences and the relationships developing through them
as dynamic forces of change (Bruscia, 1998). The types of music
experiences used in music therapy can include free and structured
improvisation, other types of active music-making by patients, and
listening to music. Improvisation is perhaps the most prominent form of
musical interaction in music therapy. It has been described as central in
many music therapy models. Client(s) and therapist improvise on musical
instruments they have chosen, playing together freely or with a given
structure or a musical or non-musical theme. Music therapists are
specically trained to intervene therapeutically within the medium, for
example to support by providing rhythmical or tonal grounding, to
clarify, to confront or to challenge the client's expression in the music
(Bruscia, 1987; Wigram, 2004). Other modes of music experiences in
music therapy include playing composed music on instruments, singing
and writing or improvising songs (Baker & Wigram, 2005), and listening
to music (Grocke & Wigram, 2006). Songs may be used by clients as a
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quality of life,
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satisfaction, and
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medication level
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safe, structuring and socially acceptable form in which they can express
feelings which otherwise might be too overwhelming to express. Music
listening may be helpful to bring up and make available therapeutically
relevant issues (emotions, associations, memories, identity issues).
All these different modes of music experiences become therapeutic
by being used in the context of a therapeutic relationship. Verbal
discussions, reections, or interpretations connected to the music are
important to help clients explore the potential meaning of an experience,
and to relate a new experience within therapy to situations in the client's
life. The degree to which the music experience itself, versus the verbal
reection connected to it, is seen as the active agent of change may vary
between models of music therapy (Garred, 2004), as well as between
clients. However, treatments that rely solely on the direct effects of music
alone, which do not involve or depend upon a process of intervention and
change within a clienttherapist relationship (auxiliary level, Bruscia,
1998, p. 195), are not music therapy. The term music medicine is
sometimes used to distinguish such treatments from music therapy.
In the context of treatment options for people with serious mental
disorders, music therapy may ll an important gap which traditional
therapies do not ll. Previous clinical reports (Rolvsjord, 2001; Solli, 2008)
as well as research studies (Hannibal, 2005; Hanser & Thompson, 1994;
Meschede, Bender, & Pfeiffer, 1983) have reported that music therapy has
helped some patients who did not benetor not sufcientlyfrom
exclusively verbal psychotherapy. Particularly some of the most severely
disturbed patients may not be able to use verbal language for them to
change. This may obviously concern non-verbal patients, but equally
importantly verbal patients who are, for whatever reasons, unable to
address their problems verbally. Some music therapy models also
speculate that the preverbal qualities of music (in particular of free
improvisation) may help to address early childhood traumas (Wigram,
Nygaard Pedersen, & Bonde, 2002, p. 155). Research on motherinfant
communication supports the notion of music as a medium which is in
some ways similar to language, but less laden with referential semantic
meaning and more rooted in the communication at early developmental
stages (Trevarthen & Malloch, 2000). These qualities may enable its
effective use by patients who are too severely disturbed for purely verbal
psychotherapy.
Likewise, music therapy may be effective in an area of outcome in
which psychopharmacological treatments show limited successnamely
in the area of negative symptoms, including affective attening or
blunting, poor social relationships, and low motivation, among others
(Andreasen, 1982; Buckley & Stahl, 2007; Buchanan et al., 2007). A
previous meta-analysis of RCTs comparing music therapy as an additional
treatment to standard care alone for people with psychotic disorders,

showed large effects on negative symptoms (Gold, Heldal, Dahle, &
Wigram, 2005). This nding is also interesting because it may show some
hints as to what may be regarded as the effective factors of music therapy
(or its mechanisms of change). First, music as a medium for emotional
expression may help patients to improve their expressive range and
diminish affective attening. Second, making music together is always a
social endeavor, inherently connected to forming and building social
relationships, and may therefore help patients to overcome decits in this
area. And third, the possibility to make music in therapy may be a central
motivating factor, especially for patients who otherwise show little or no
motivation (Rolvsjord, 2001; Solli, 2008), which may then generalize to
other situations. These domains, summarized as negative symptoms,
were rst described for schizophrenia but have been shown to be a
transdiagnostic phenomenon which is relevant in non-psychotic mental
disorders as well, particularly major depression (Winograd-Gurvich,
Fitzgerald, Georgiou-Karistianis, Bradshaw, & White, 2006).
Generally, it can be said that music therapy is usually tailored to an
individual patient and his/her specic needs more than to a specic
clinical diagnosis. There is usually no direct link between a patient's
clinical diagnosis and the specic techniques used in therapy,
although the type of disorder will, as part of a larger picture, certainly
play a role in forming the therapist's choices, attitudes and behaviors
during a therapy. (Little research has been conducted to address this
link, but ndings to date are that diagnosis explains only a small
fraction of the variation in techniques, e.g., Drieschner & Pioch, 2002.)
Similarly, indications for music therapy in mental health may be
transdiagnostic, and decisions to offer music therapy to an individual
patient in a given clinical setting may be based on many aspects of
which the primary clinical diagnosis is only one.
Many researchers have argued that dimensional concepts are more
valid to describe psychopathology than categorical systems (Maser &
Akiskal, 2002; Kendell & Jablensky, 2003; Krueger, Watson, & Barlow,
2005). Continuities exist between healthy and disordered states as
well as between different disorders, and notably also between
psychotic and non-psychotic states (Cullberg, 2007; Maser & Akiskal,
2002). The existing evidence for a continuum of mental health
therefore justies the combination of psychotic with non-psychotic
disorders in a meta-analysis (as will be done here). The notion of such
a continuum also ts well with the practice of music therapy being
adapted more to a patient's needs than to his diagnosis.
1.2. Music therapythe evidence to date
Several systematic reviews and meta-analyses have been conducted to examine the effects of music therapy in the eld of mental
health (e.g., Dileo & Bradt, 2005; Gold, Heldal, et al., 2005; Gold,
Voracek, & Wigram, 2004; Gold, Wigram, & Elefant, 2006; Koger,
Chapin, & Brotons, 1999; Maratos, Gold, Wang, & Crawford, 2008;
Pesek, 2007; Silverman, 2003; Vink, Birks, Bruinsma, & Scholten,
2003). Many of these have found promising results; however, the
quality of the included studies varied. Promising results, applying
rigorous study selection criteria, have been found in two recent
Cochrane reviews for psychotic disorders (Gold, Heldal et al., 2005)
and for depression (Maratos et al., 2008). Both reviews suggested that
music therapy has a number of benecial effects for these people
when added to standard care. The review on schizophrenia also
suggested some hints towards a doseeffect relationship: Global
state, general and negative symptoms and functioning improved
signicantly and by large effect sizes in those studies where a
sufciently large number of sessions were offered. However, both
reviews were limited by their very narrow inclusion criteria. The
schizophrenia review meta-analyzed only four studies; the depression
review did not include any meta-analysis and relied solely on a
narrative summary. Therefore an analysis of doseeffect relationship
was well beyond the scope of the previous Cochrane reviews.
195
In psychotherapeutic methods such as music therapy, the term

dose or dosage clearly must be understood metaphorically,
not literally. Howard, Kopta, Krause, & Orlinsky (1986) have argued
that although a therapy model's proposed active ingredients (such as
interpretations, empathic reections, etc.) might be considered
as the most theoretically coherent unit of treatment, these are
not easy to measure. However, the number of therapy sessions a
patient has received is most likely correlated to a patient's exposure
to those ingredients and can therefore be used as a readily available
proxy measure. The number of therapy sessions has been widely
accepted as a measure of dose in psychotherapy since this seminal
paper. The same paper also brought up a discussion on whether the
doseresponse relationship in psychotherapy is linear, or whether
the rst sessions have a greater inuence than subsequent sessions.
This discussion is still ongoing today, and therefore the present
review aims at examining both possibilities for the eld of music
therapy.
The previous Cochrane reviews of the effects of music therapy on
schizophrenia (Gold, Heldal, et al., 2005) and depression (Maratos et
al., 2008) chose very narrow inclusion criteria because they were
aimed at selecting only the most reliable evidence for one particular
mental disorder. This narrow focus, while helping to achieve high
reliability, also necessarily limited the generalizability of its ndings in
several ways:
Focus on only one mental disorder: As described above, music
therapy is not usually targeted at a specic diagnosis, but rather
broad in its goals and methods. This is reected in some studies that
used a mixed patient sample (e.g., de l'Etoile, 2002; Thaut, 1989),
which would consequently have to be excluded in any review
focusing on one selected diagnosis. A transdiagnostic focus also
seems appropriate given the relevance of dimensional concepts in
mental health as summarized above.
Exclusion of non-randomized studies: While ensuring that the most
reliable evidence is used, an exclusive focus on randomized studies
also has its drawbacks. For example, external validitythe extent to
which studies are generalizable to everyday clinical practicemay
be higher in some of the non-randomized studies. RCTs on complex
interventions are difcult to conduct, so that clinically desirable
features may in some cases be given too little attention. This may for
example concern the selection of subjects, the contents of therapy,
and the duration of therapy and follow-up. Excluding nonrandomized studies also implies that there is less evidence to
draw on, which will often make advanced statistical procedures
such as meta-regression impossible to apply.
The present review attempted to overcome these weaknesses by
applying a wider focus, in the hope of enabling broader and clinically
more useful generalizations.
1.3. Research questions addressed in this review
The aim of this review was to examine the effects of music therapy
for people with serious mental disorders, based on all prospective
studies (randomized studies, other controlled studies, uncontrolled
pre-post studies). The main research questions addressed were as
follows:
1. Can the previously hypothesized inuence of the number of
sessions on the effects of music therapy be conrmed and
quantied? What shape does this doseresponse relationship
take in music therapy? Is it possible to predict the number
ofsessions needed for a small, medium, or large effect, respectively?
2. Does the type of mental disorder predict the effect of music
therapy? Does music therapy have a different impact on patients
that are either psychotic or non-psychotic? Where would music
therapy be most indicated?
196
In addition we also aimed to address how the type of study design

may be related to the estimated effect of music therapy. In contrast to
the main research questions above, the inclusion of study design as a
potential predictor was less directly of clinical importance, but was
mainly related to examining the robustness of ndings when
including weaker study designs than RCTs.
(preferably published) rating scale. They had to be assessed either as a

self-report or by an independent (preferably blinded) rater. Ratings done
by therapists were excluded as they were denitely not blinded and at
serious risk of being biased.
2. Method
A comprehensive search strategy was applied to identify all

relevant studies. To avoid the pitfalls of publication bias and English
language publication bias, published as well as unpublished reports in
any language were considered. Highly sensitive search strategies were
employed in previous related reviews on music therapy for psychotic
disorders (Gold, Heldal, et al., 2005), for depression (Maratos, Gold,
Wang, & Crawford, 2008), and for all mental disorders (Heldal & Dahle,
2006), and the results from these searches were used for this review.
Each of those previous searches included searching in relevant
databases as well as hand searching. To identify any later trials, we
used the following search strategies (May 2006):
2.1. Criteria for selecting studies

2.1.1. Study design
Studies with any prospective group design (RCTs, CCTs, and studies
without control groups) were considered relevant. Randomized
controlled trials (RCTs) were dened, according to the strict criteria
of the Cochrane Collaboration (Higgins & Green, 2008), as studies
where participants were allocated to conditions through true
randomization (e.g., using lots, dice, or computer-generated randomization lists), as opposed to quasi-randomization (e.g., using patient
numbers or date of intake). Controlled clinical trials (CCTs) were
dened more loosely as any study using a control group intended to be
equivalent in terms of patient characteristics (including quasirandomization as well as matching techniques). Finally, an uncontrolled study was dened as any other prospective design where all
participants received the same interventions and baseline values were
available so that participants could be used as their own controls (e.g.,
case series, pre-post design).
2.1.2. Study quality
Studies with more than 30% attrition rate were excluded. As other
important study quality characteristics, allocation concealment (in
RCTs) and blindness were assessed and reported. Outcomes were
included if they were either adequately blinded or a self-report. They
were also included if they were possibly blinded but the actual use of
blinding was uncertain. Outcomes that are denitely non-blinded
present a high risk of bias and were excluded. This is in accordance
with the Cochrane Handbook (Higgins & Green, 2008).
2.2. Search strategy
(a) The trial database PsiTri, which contains structured information

on published and unpublished clinical trials in mental health,
based on multiple database searches as well as hand searches
by several Cochrane groups, was searched for entries containing the word music in any eld.
(b) PubMed was searched using its Clinical Queries search
strategy designed to identify scientically strong studies of
therapy outcome, which was expanded with the Medical
Subject Headings (MeSH) term Evaluation Studies, and
crossed with the MeSH terms Music Therapy and Mentally
Ill Persons or Mental Disorders.
2.3. Selection of studies and data extraction
At least two reviewers independently assessed each potentially
relevant study for inclusion and extracted data from the included
studies. Cases of disagreement were resolved by discussion.
2.4. Data analysis
2.1.3. Participants
Study participants eligible for this review were adults with serious
mental disorders diagnosed by an international classication system.
This included psychotic disorders as well as some non-psychotic
disorders such as borderline personality disorder, depression, bipolar
disorder, and suicidality connected to a mental disorder. Serious
mental disorders are characterized by signicant role disability
(Demyttenaere et al., 2004), which could be indicated by low GAF
scores or by admittance to in-patient treatment.
2.1.4. Interventions
Studies were included only if participants were offered music
therapy, according to the denition above. Most importantly, this
excluded interventions of the music medicine type, where music
alone is provided as a treatment, rather than using music as
a medium within a psychotherapeutic process and relationship. Secondly, it had to be possible to disentangle music
therapy from other therapies. Comparison conditions could be no
treatment, standard care, or an active control condition (i.e., a
different therapy, a placebo therapy, or a different type of music
therapy).
2.1.5. Outcomes
All outcomes of clinical relevance were considered, including
measures of general mental state, symptoms, and functioning, but also
outcomes related to music and other patient- or service-relevant
outcomes such as quality of life, medication level, or satisfaction with
care. Continuous outcomes had to be assessed by a standardized
2.4.1. Individual study results

For each study, odds ratios (OR) were calculated for dichotomous
outcomes and standardized mean differences (Hedges' g) for
continuous outcomes. For continuous outcomes we rst checked if
there was evidence for skewness (oor or ceiling effects), which we
then attempted to remove by log-transformation if possible (i.e., if raw
data were available for that study). The effect size index Hedges' g is
similar to Cohen's d (and can be interpreted similarly), but corrects for
small-sample bias and is therefore more conservative in small
samples. For dichotomous outcomes with missing data, we assumed
the negative outcome for the missing cases. Effect estimates were
calculated in such a way that a benecial effect of music therapy is
always represented by a positive effect size (for continuous outcomes)
or by an odds ratio smaller than 1 (for dichotomous outcomes).
The different types of research designs were handled as follows in
the calculation: For RCTs, only post-test means were used, as the
pretest was assumed to be equal in the populations due to the
randomization. For CCTs, we used the post-test mean of the
experimental group, but subtracted the pretest difference between
groups from the post-test mean of the control group in order to adjust
for existing pretest differences. For the studies without separate
control groups, we used the baseline values as control, thereby simply
comparing post-test versus pretest. There is some discussion in the
meta-analytical literature on whether or not the correlation between
pretest and post-test values should be taken into account. However,
such a procedure would give relatively larger weight to the studies
with the weakest designs. We therefore decided not to make use of
these correlations in order not to give undue weight to those studies

(see the related discussion in the appendix of Gold et al., 2004).
2.4.2. Combination of study results
Results for the same type of outcome were combined across
studies in a meta-analysis. Results of different outcomes were not
combined. If the same outcome was measured with different scales in
the same study, both using equally valid methods (in terms of rater
blinding and standardization and validity of instrument), the average
effect size of these measures was used.
For the outcomes where data were available from at least ve
studies, we used mixed-effects meta-analysis, an extension of metaregression, to examine simultaneously the following three predictors:
study design (as a 3-level factor: RCT, CCT, uncontrolled), type of
disorder (as a linear predictor: percentage of participants with
psychotic vs. non-psychotic disorders), and number of sessions
provided (as a linear predictor; alternatively the square root of
sessions if this improved the model t). Model ts using different
combinations of predictors were compared using adjusted R2 (as
recommended by Tabachnick & Fidell, 2001, p. 147), and the model
yielding the best t was selected. This was done in order to t the data
best to the gures and for the prediction of effect sizes.
Mixed-effects models are usually preferred over xed-effects models
in the literature on meta-analysis and meta-regression (Everitt &
Hothorn, 2006; Sutton, Abrams, Jones, Sheldon, & Song, 2000;
Thompson & Higgins, 2002). In contrast to the simpler xed-effects
models, mixed-effects models take into account possible random
variation between the true effects of each study (between-study
heterogeneity not captured by the predictors) and are essentially more
conservative and less prone to bias. The appropriate study weights for
the mixed-effects models were calculated iteratively until they
converged, as recommended and described in Sutton et al. (2000,
p. 98). The open-source statistical software environment R, Version 2.6.1
(R Development Core Team, 2007), was used for the statistical analyses.
For outcomes where data were available from at least two but less
than ve studies, traditional meta-analytic summaries were calculated
(as described in Cooper & Hedges, 1994). Study results were pooled
using a xed effects model. When a substantial amount of statistical
heterogeneity (when I2 N 50%; Higgins & Green, 2008, p. 278) was
found and could not be explained, we subsequently considered a
random effects model. We used R package meta, Version 0.8-2
(Schwarzer, 2007), for these analyses, which replicates the procedures
in the Cochrane Collaboration's meta-analysis software.
197
studies without control groups. Assessor blinding was adequate in six

studies and uncertain in nine studies. Denitely non-blinded
outcomes in one study (Radulovic, 1996) were excluded from the
analysis. Nine countries and three continents are represented in the
included studies, with six studies from Europe (Denmark, Germany,
Italy, Serbia, UK), ve from North and Central America (Mexico, USA),
and four from Asia (China, Japan). Together, the studies enrolled a total
of N = 691 patients. In terms of their primary diagnosis, about two
thirds (n = 456) were diagnosed with a psychotic disorder and the
remaining third (n = 235) with a non-psychotic disorder, most often
depression. There were three studies (de l'Etoile, 2002; Radulovic,
1996; Thaut, 1989) that included both types of disorders; however,
there were several further studies that included the various forms of
overlaps such as schizoaffective or schizotypal disorder. Severity was
indicated in various ways, including psychoticism (11 studies),
institutionalization (10 studies), classication as chronic (6 studies),
lack of response to other therapy (2 studies), and/or suicidality
(1 study; see Table 1).
3.3. Interventions: Music therapy
The various searches yielded initially 166 potentially relevant

studies for any mental disorder (Heldal & Dahle, 2006), 34 for
schizophrenia (Gold, Heldal, et al., 2005), and 16 for depression
(Maratos et al., 2008). The updated database searches did not identify
any newer studies. Studies were excluded if the design, participants,
interventions, or outcomes, as assessed by two reviewers independently, did not meet the inclusion criteria for this review. In addition,
some potentially relevant studies had to be excluded where we were
unable to retrieve the full text of the study report (Castilla-Puentes et
al., 2002), where no usable outcome data were reported and attempts
to retrieve additional data directly from authors failed (Meschede et
al., 1983; Schmuttermayer, 1983), or where the drop-out rate exceeded
30% (Steinberg et al., 1991).
Music therapy was offered between one and six times per week over
a period of one to six months. The maximum number of sessions offered
in each study varied from six to 78 (if not specied directly in a report,
this was calculated by multiplying frequency with durationa potential
overestimate as it does not take into account cancellations and holidays).
Some of the studies (Troice & Sosa, 2003; Hayashi et al., 2002; Talwar
et al., 2006; Zerhusen et al., 1995) also reported how many of this
maximum number actually were received by the patient, ranging from
59% to 90% with a median of 73%. In the further calculations we used
sessions received if reported, and assumed 75% otherwise.
Music therapy was provided in group settings in two thirds of the
studies. Three studies (Hanser & Thompson, 1994; Pavlicevic, 1994;
Talwar et al., 2006) used exclusively individual sessions; two studies
(Thaut, 1989; Yang et al., 1998) combined group and individual sessions.
Most studies used a combination of different working modes, such as
improvisation (described in 8, central in 4 studies), other forms of
playing music on instruments (described in 8, central in 1 study), singing
and/or writing songs (described in 6 studies), listening to music
(described in 10, central in 6 studies), and verbal reection around the
music experiences (described in 11, central in 4 studies; Table 1). In all
studies, music therapy was provided with some degree of processorientation as well as some degree of structure; there seemed to be an
agreement that both elements were necessary in working with this
population. Although there may have been some variation along this
dimension, we did not nd an example that was extreme on either end
of the scale (either extremely open or very rigidly structured). One study
(Ceccato et al., 2006) compared approaches with more versus less
structure.
Information concerning the theoretical background which informed
the approach was sparse. Some studies described a psychodynamic
(Moe et al., 2000; Radulovic, 1996) or cognitive background (Hanser
& Thompson, 1994), but most studies were less explicit in this respect
and appeared to be eclectic in their theoretical orientation. Similarly,
information concerning the qualication level of the music therapist
was infrequent, although this may reect the different state of
development of the profession across countries. Studies from countries
where formalized registration requirements exist reported such board
or state registration (Hanser & Thompson, 1994; Talwar et al., 2006;
Troice & Sosa, 2003); in other studies, therapists were more generally
described as trained, skilled, or experienced.
3.2. General study characteristics
3.4. Comparison conditions
In result, fteen studies were retained and included in the metaanalysis (Table 1). These included eight RCTs, three CCTs, and four
The most basic comparison, where music therapy is added to

standard care or minimal therapeutic contact, was available in all
3. Description of studies
3.1. Selection process
198
Table 1
Characteristics of included studies
Study
Design and study quality
Duration
(months)
Participants
Clinical condition and setting
a) Randomized studies
Chen
Design: Parallel
(1992)
Allocation concealment:
Unknown
Blindness: Not reported
Proportion
of psychotic
disorders
Demographicsc
Interventionsa
Typec
No. of sessions
Comparisonb,c
Outcome scalesd
Diagnosis: Depression
Setting: Inpatients
Country: China
0%
N = 68
Age: 60-77 (M = 64)
Sex: 46% male
MT (P, S), 6
sessions pr. wk. of
60 min., plus
antidepressants.
N = 34
Offered: 48
Antidepressants. N = 34
C) HAMD
D) HARS
G) Global state: Overall improvement
Unable to use: Connement in bed
Design: Parallel
Unknown
Diagnosis: Major or minor

depressive disorder
History: 90% were insufciently
improved after previous
psychotherapy
Setting: Outpatients
Country: USA
0%
N = 32
Age: 61-86 (M = 68)
Sex: 23% male
MT (L, V, O), 1
session pr. wk. of
60 min. N = 11
Offered: 8
1.) Minimal
therapeutic contact,
consisting of weekly
phone talks of
20 min. N = 10
2.) No treatment.
N = 11
A) BSI GSI
C) Geriatric Depression Scale, GDS
Not used (secondary measure):
Depressed mood scale on Prole of
Mood States, POMS
Not used (data not reported): BDI
D) Anxiety, Prole of Mood States,
POMS; Hostility, POMS
G) Rosenberg Self-Esteem Scale, RSE
Radulovic
(1996)
Design: Parallel
Unknown
Blindness: Inadequate in
therapist ratings (selfreports usable)
1.5
Diagnosis: Mood disorders,

adjustment disorder,
schizoaffective disorder
Setting: Inpatients
Country: Serbia
2%
N = 60
Age: 21-62
Sex: 33% male
MT (L, V), 2
sessions pr wk. of
20 min., plus
standard care.
N = 30
Offered: 12
Standard care. N = 30
C) BDI
Not used (non-blinded
therapist ratings): HAMD
D) Not used (non-blinded therapist
ratings): HARS
Talwar
et al.
(2006)
Design: Parallel
Adequate
Blindness: Adequate
(assessors blinded)
Diagnosis: Schizophrenia
Setting: Inpatients
Country: UK
100%
N = 81
Age: 18-64 (M = 37)
Sex: 74% male
MT (I, V), 1 session

pr. wk. of 50 min.,
plus standard care.
N = 33
Offered:
12; Attended:
MdN = 8
A) PANSS
B) PANSS
D) Positive symptoms, PANSS
E) GAF
G) Quality of Life, SFQ Satisfaction
with care, CSQ Engagement with
services, HAS Unable to use: EPEX
Tang
et al.
(1994)
Design: Parallel
Unknown
Blindness: Adequate
(assessor blinded)
History: Chronic (residual
subtype)
Setting: Inpatients
Country: China
100%
N = 76
Age: Unknown
Sex: Unknown
MT (L, P, S, V), 5
sessions pr. wk. of
1 hr., plus standard
care. N = 38
Offered: 19
B) SANS
E) Unable to use: Disability, DAS
Ulrich
et al.
(2007)
Design: Parallel
Adequate
Blindness: Adequate
(assessors blinded)
Diagnosis: Schizophrenia,
schizoaffective psychosis,
schizotypal disorder, druginduced psychosis, depression
with psychotic symptoms
Setting: Inpatients
Country: Germany
100%
N = 37
Age: 22-58 (M = 38)
Sex: 54% male
MT (I, P, S, V), 2
sessions pr. wk. of
60-105 min., plus
standard care.
N = 21
Attended: 7.5
B) SANS
E) Social functioning, Giessen Test
(self-report and observer rating)
G) Quality of life, SPG
Satisfaction with care, unpublished
scale
Yang et al.
(1998)
Design: Parallel
Unknown
Blindness: Unknown
History: Chronic (mean duration
of illness 13 yrs.)
Setting: Inpatients
Country: China
100%
N = 72
Age: 21-55
Sex: 59% male
MT (I, P, S, L, V), 6
sessions pr. wk. of 2
hrs., plus standard
care. N = 41
Offered: 78
(6 per week over
3 months)
A) BPRS
B) SANS
E) Social functioning, SDSI
G) Global state: Clinically important
improvement
Zerhusen
et al.
(1995)
Design: Parallel
Unknown
Blindness: Unknown
2.5
Diagnosis: Depression
Setting: Nursing home residents
Country: USA
0%
N = 60
Age: 70-82 (M = 77)
Sex: ca. 25% male
MT (L, P), biweekly

sessions of unknown
length. N = 20
Offered: 20;
Attended: 11.8
(59% of 20)
1.) Cognitive therapy.

N = 20;
2.) Standard care.
N = 20
C) BDI
Hanser &
Thompson
(1994)
b) Other controlled studies

Ceccato
Design: Parallel
et al.
Matching: Age, sex,
(2006)
education, clinical history,
cognitive decits
Blindness: Unknown
Setting: Day patients
Country: Italy
100%
N = 16
Age: M = 34
(SD = 10)
Sex: 81% male
1.) MT (L), 1 session

pr. wk. of 55 min.
N = 8. 2.) MT (I),
1 session pr. wk. of
55 min. N = 8.
Offered: 16
B) (Attention: Paced Auditory Serial

Addition Test, PASAT) (Memory:
Wechsler Memory Scale, WMS)
E) Social functioning: Life
Skills Prole, LSP
Design: Parallel
Matching: Age,
education, marital status,
clinical history, work
status, medication dose
4 (plus
8-month
follow-up in
experimental
group
only)
Diagnosis: Schizophrenia or
schizoaffective psychosis
History: Chronic (ward for
long-stay patients)
Setting: Inpatients
Country: Japan
100%
N = 66
Age: 43-84
Sex: 0% male
MT (P, S, L, V),
1 session pr. wk of
1 hr., plus standard
care. N = 34
Offered: 15;
Attended:
M = 11.8, range
3-15
Standard care.
N = 32
A) PANSS
B) PANSS
E) Unable to use (incompletely
reported): Ward life activity and
adjustment, unpublished scale
F) Musical experiences,
unpublished scale
G) Quality of Life Scale,
QLS; Medication level
Pavlicevic
et al.
(1994)
Design: Parallel
Matching: Age, sex,
social class, clinical history,
severity, musical experience
Blindness: Adequate
(assessor blinded)
2.5
History: Chronic
Country: UK
100%
N = 41
Age: M = 38 (SD = 9)
Sex: 80% male
MT (I), 1 session pr.

wk. of 30 min., plus
standard care.
N = 21
Offered: 10
Minimal
therapeutic
contact (2
sessions) plus
standard
care. N = 20
A) BPRS
B) SANS
C) HAMD
F) Music Interaction Rating for
Schizophrenia, MIR(S)
1.5
bipolar disorder
History: All had previous
therapy, 63% (5/8) had a clinical
history of 10-20 years
Country: USA
88%
N=8
Age: 30-45
Sex: 75% male
MT (I, P, S, L, V, O),
weekly sessions of
60 min. N = 8
Offered: 6
Baseline
A) SCL-90R GSI
C) Depression subscale of SCL-90R
D) Obsessive-compulsive, Hostility,
Paranoid deation, all SCL-90R
subscales
G) Not used: Attitude to seeking
help (4 factors), Fisher & Turner
Attitude Scale
Not used: Helpfulness of
therapeutic factors
(10 factors), unpublished scale
Diagnosis: Schizotypal disorder,

schizophrenia, schizoaffective
disorder
Setting: 89% (8/9)
inpatients/day patients
Country: Denmark
100%
N=9
Age: 23-40
(M = 29)
Sex: 78% male
MT (L, V), 1
session pr. wk. of
90 min. N = 9
Attended:
Range 23-32
Baseline
E) GAF
G) Unable to use: Qualitative
rating of therapy contents
c) Studies without control groups

de l'Etoile
Design: Pre-post
(2002)
Moe et al.
(2000)
Design: Pre-post
Thaut
(1989)
3
Design: Pre-post
Blindness: Not applicable
(self-reported outcomes only)
bipolar disorder, depression,
adjustment disorder,
suicidal tendencies
Setting: Forensic patients
Country: USA
70%
N = 50
Age: 18-45
Sex: 100% male
MT (I, P, L, V, O),
3 weekly sessions
of 60-90 min. N = 50
Offered: 39
(3 per week
over 13 weeks)
Baseline
C) (Mood, 1-item rating)

G) Relaxation, 1-item rating;
Positive thoughts, 1-item rating
Troice & Sosa

(2003)
Design: Pre-post
History: Chronic
(mean duration of illness 8 yrs.)
Setting: Outpatients
Country: Mexico
100%
N = 15
Age: M = 32
(SD = 8)
Sex: 67% male
MT (I, V),
biweekly sessions
of 1 hour. N = 15
Offered: 40;
mean 35.8
Baseline
A) PANSS
B) PANSS
F) Unable to use (incompletely reported):
Experiences with music
G) Unable to use (incompletely
reported): Subjective well-being
199
a
Including all music therapy interventions. MT music therapy; working modes in MT: I improvisation, P playing music on instruments (excl. improvisation), S singing songs, L music listening, V verbal reection, O other. Central
working modes are marked with .
b
Including all non-music therapy interventions.
c
N = participants included in the study (including any who may have dropped out after inclusion).
d
Outcomes were categorized as follows: A) General mental state; B) Negative symptoms; C) Depressive symptoms; D) Other symptoms; E) Functioning and related; F) Music-related; G) Other. Outcomes partly related to a category are listed
in brackets. Abbreviations of common outcome measures are explained in the text.
Hayashi
et al.
(2002)
200
studies (Table 1). Standard care, in whatever specic way this was
dened by the authors, included any form of treatment as usual which
was provided to all participants (i.e. both experimental and control
group). Only two studies included other comparisons: One study
compared to cognitive behavior therapy (Zerhusen et al., 1995), one
study compared two types of music therapy approaches (Ceccato et al.,
2006). Meta-analyses were therefore only calculated for the comparison between music therapy and standard care.
When various types of music therapy were provided simultaneously
(Thaut, 1989), so that this prevented separation of the effects of each of
these types, the study was included as an uncontrolled (pre-post) study,
although it may have originally been described as a CCT. When a CCT
comparing different types of music therapy also allowed for a pre-post
comparison, but not a controlled comparison, of music therapy versus
standard care (Ceccato et al., 2006), it was included as a CCT but treated
as an uncontrolled study for the respective comparison.
3.5. Data extraction and preprocessing
Data were reported in varying ways in the studies. When
necessary, study authors were contacted to retrieve additional data.
For some studies, we received from the study authors either individual
patient data (Ceccato et al., 2006; Talwar et al., 2006; Ulrich et al.,
2007) or unpublished summary data (Radulovic, 1996) which we were
able to use. Log-transformation to remove skewness, based on
individual patient data, was performed in one instance (negative
symptoms in Ulrich et al., 2007). In two instances (negative symptoms
in Ceccato et al., 2006, functioning in Ulrich et al., 2007), we calculated
and used the average effect size of two equally valid measures for the
same outcome category. In one instance (global state in Yang et al.,
1998) we encountered missing values in a dichotomous outcome and
inserted the negative event.
4. Results
4.1. Comparison of music therapy versus standard care
For the comparison of music therapy versus standard care, there
were four outcomes where we were able to estimate a doseresponse
relationship. In addition, there was a range of other outcomes where
simple meta-analysis was performed.
4.1.1. General mental state
Seven studies (Table 1), including 315 participants, measured
general mental state on a continuous scale, using one of the
following standardized measures: The Symptom Checklist SCL-90R
General Severity Index (SCL-90R GSI), the Brief Symptom Inventory
General Severity Index (BSI GSI), the Brief Psychiatric Rating Scale
(BPRS), or the Positive and Negative Syndrome Scale (PANSS). The
model selection process for this outcome is shown in Table 2. It
can be seen that the number of sessions alone explained 78%
of the variance in this outcome (p b .01). Design and disorder alone
were not useful predictors. We also examined a full model adjusting
for all predictors simultaneously, which yielded no additional

information (data not presented). Therefore, the number of sessions
was selected as the only predictor for this outcome. The dose
response relationship is illustrated graphically in Fig. 1. An increasing
trend can be seen in the symbols for the individual studies, as well as
in the regression line from the mixed-effects model. From the
regression model, it can be predicted how many sessions will be
needed on average to achieve a certain effect. Table 3 shows that a
small effect on general symptoms will be expected after ten sessions, a
large effect after 39 sessions.
4.1.2. Negative symptoms
Eight studies, with a total of 404 participants, measured negative
symptoms on a continuous scale, typically using either the Scale for
the Assessment of Negative Symptoms (SANS) or the negative
symptoms subscale of the PANSS. One study (Ceccato et al., 2006)
measured sub-domains of negative symptoms (attention and memory) using other scales (Table 1). Again, Table 2 shows the model
selection process. As all studies involved exclusively participants with
psychotic disorders, only design and dosage could be examined as
potential predictors. As in the previous outcome, design was not a
useful predictor, whereas dosage was highly signicant and explained
a large proportion of the variance. In this outcome, the square root of
sessions turned out to be a better predictor than the untransformed
number of sessions, and was therefore selected as the only predictor in
the model. Fig. 2 illustrates the doseresponse relationship for
negative symptoms. Here, the regression line is curvilinear, showing
a steep increase of effect for the rst sessions and a moderate but
continuing increase for later sessions. This is also reected in Table 3,
which shows that a small effect on negative symptoms can be
expected already after as little as three sessions, whereas it takes 42
sessions to produce a large effect.
4.1.3. Depressive symptoms
Data for depressive symptoms, measured on a continuous scale,
were available from seven studies (319 participants). Measures used
included the Hamilton Rating Scale for Depression (HAMD), the Beck
Depression Inventory (BDI), and other related measures (Table 1). As
for the previous outcomes, design and disorder showed no relation to
the effect size, but dosage was a highly signicant predictor, with the
number of sessions explaining 73% of the variance in effects (Table 2).
The steep linear relationship is shown in Fig. 3. Although there is one
positive outlier (from an RCTHanser & Thompson, 1994), most
studies fall into the condence range of the prediction line, which
appears to be equally valid for psychotic (white boxes) and nonpsychotic disorders (black boxes). Table 3 reects the steep regression
line, showing that small effects on depressive symptoms are expected
after four sessions, and even large effects may occur after relatively
few (16) sessions.
4.1.4. Other symptoms: Anxiety and positive symptoms
Simple meta-analyses were applied for other symptom domains
which were measured on continuous scales in less than ve studies.
Table 2
The model selection processexplained variance (adjusted R2) for all possible mixed-effect models
Variance explained by each model (Adjusted R2)
Outcome
N of
studies
N of
participants
Design
Disorder
Sessions
Square root of sessions
General symptoms
Negative symptoms
Depressive symptoms
Level of functioning
7
8
7
5
315
404
319
215
.23
.03
.00
.00
.00
NAa
.16
NAa
.78
.69
.73
.66
.70
.77
.66
.74
Note. The table shows explained variance (adjusted R2) and signicance levels (p b .05, p b .01, p b .001) for each model. Negative values of adjusted R2 were set to zero. Full
models including all predictors simultaneously were also examined but not presented as they did not improve the prediction for any of the outcomes. The selected models (i.e. the
ones with the highest explained variance, if signicant) are highlighted in bold font.
a
Not available (the predictor was constant for this outcome).
201
Fig. 1. Doseeffect relationship of music therapy for general symptoms. Note. Each individual study is plotted at the position indicated by the number of sessions provided and the
effect size found in that study. The box symbol for each study is lled white if the majority of participants had a psychotic disorder, and black otherwise. The size of the box represents
each study's weight in the analysis. The vertical line added to each individual study indicates the 95% condence interval (CI) of the observed effect; the line type (solid, dashed, or
dotted) indicates the strength of the study's design. Finally, the dashed regression line shows the result of a mixed-effects meta-regression analysis, indicating the relationship
between the number of sessions provided and the predicted effect size. The 95% CI of the regression is shown by the dotted lines around the regression line.
Anxiety was measured in three studies (108 participants) with the

Hamilton Anxiety Rating Scale (HARS) or other related scales
(Table 1). An initial meta-analysis of the three studies suggested a
large and signicant effect size, but also a high amount of statistical
heterogeneity (Table 4). Visual inspection of the results revealed that
the study with the weakest design (de l'Etoile, 2002, an uncontrolled
study) was responsible for the heterogeneity. Therefore, the analysis
was repeated with this study excluded. Meta-analysis of the two
remaining, methodologically strong studies (Chen, 1992; Hanser &
Thompson, 1994, both RCTs) yielded a large and signicant effect
(g = 1.31, p b .001) and no statistical heterogeneity (I2 = 0%). It should be
noted that both studies included in this meta-analysis concerned
people with depression.
Positive symptoms were measured in four studies (170 participants), using the respective subscale of the PANSS or a related scale
(Table 1). A meta-analysis of these studies did not reveal a signicant
effect; however, the condence interval was wide enough to include
potential effects of clinically meaningful size (Table 3).
4.1.5. Functioning
Five studies (215 participants) had usable data on the effects of music
therapy on functioning, using the Global Assessment of Functioning
(GAF) or related scales (Table 1). The mixed-effects meta-analytic
models shown in Table 2 suggested that design was not related to the
effect. Type of disorder could not be examined as a predictor because all
studies concerned people with psychotic disorders only. As for the
previous outcomes, therapy dosage was the only strong and signicant
predictor of the effect of music therapy compared to standard care. The
square-root model explained 74% of the variance (p b .05) and was
selected as the best model. Fig. 4 shows that effects increase with the
number of therapy sessions provided, most steeply during the rst
sessions. Table 3 shows the estimated number of sessions necessary for
each effect size.
4.1.6. Musical engagement
Two studies (107 participants) had usable data on music-related
outcomes, measured on continuous scales (Table 1). These form a
Table 3
Model formulae and prediction of numbers of sessions needed to achieve relevant effects
Outcome
General symptoms
Negative symptoms
Depressive symptoms
Functioning
Regression model
.02 sessions
.12 (sessions)
.05 sessions
.11 (sessions)
Number of sessions needed

Small effect
Medium effect
Large effect
10
3
4
3
24
16
10
20
39
42
16
51
Note. This table shows the regression parameters of the previously described mixed-effects meta-regression models and predicted values based on these parameters. Small, medium,
and large effects are dened according to Cohen's (1988) guidelines for the interpretation of the effect size index Cohen's d. The effect size index Hedges' g which was used in the
calculation is comparable but corrected for small-sample bias (i.e., it is more conservative when studies are small, but asymptotically identical to Cohen's d).
202
Fig. 2. Doseeffect relationship of music therapy for negative symptoms. Note. Explanations see under Fig. 1.
relatively heterogeneous category which might be summarized as

musical engagement. One study (Pavlicevic, 1994) assessed musical
interaction in a music therapy assessment session, the other study
(Hayashi et al., 2002) assessed musical experiences in daily life. Metaanalysis of these studies (Table 4) showed a medium-sized effect
(g = 0.49, p b .05) with no heterogeneity (I2 = 0%), suggesting that music
Fig. 3. Doseeffect relationship of music therapy for depressive symptoms. Note. Explanations see under Fig. 1.
203
Table 4
Meta-analyses for outcomes measured in less than ve studies
Outcome
N of studies
N of participants
Effect sizea
Heterogeneityb
a) Dichotomous outcomes
Global state
2 (Chen 1992; Yang et al., 1998)
140
Odds ratio (95% CI)

0.03 (0.01 to 0.09)
NNT = 1.59
I2
0%
4 (Hanser & Thompson, 1994; Pavlicevic et al., 1994;

Talwar et al. 2006; Yang et al., 1998)
226
1.11 (.42 to 2.92)
0%
3 (Chen 1992, de l'Etoile 2002, Hanser & Thompson, 1994)
108
Hedges' g (95% CI)

1.05 (0.63 to 1.48)
I2
73.8%
Anxiety (excluding
weak design)
2 (Chen 1992; Hanser & Thompson, 1994)
100
1.31 (0.85 to 1.78)
0%
Positive symptoms
4 (de l'Etoile 2002; Hayashi et al., 2002; Talwar et al. 2006; Troice & Sosa, 2003)
170
0.18 (0.12 to 0.48)
0%
Musical engagement
2 (Hayashi et al., 2002, Pavlicevic 1994)
107
0.49 (0.09 to 0.88)
0%
Quality of life
2 (Hayashi et al., 2002; Ulrich et al., 2007)
103
0.16 (0.24 to 0.56)
0%
Satisfaction
2 (Talwar et al. 2006; Ulrich et al., 2007)
118
Fixed: 0.13 (0.28 to 0.53)

Random: 0.06 (0.57 to 0.68)
52%
Medication level
2 (Hayashi et al., 2002; Tang, 1994)
142
0.25 ( 0.58 to 0.08)
41%
Leaving the study earlyc
b) Continuous outcomes
Anxiety (initial analysis)
Effect sizes are shown for the xed-effects models where no unexplained heterogeneity was found, and for both xed and random-effects models where unexplained
heterogeneity was found. For dichotomous outcomes where a signicant effect was found, the number-needed-to-treat statistic (NNT) is also shown. All effect sizes were coded such
that OR b 1 and g N 0 represent a positive effect.
b 2
I describes the percentage of variability in effect estimates that is due to heterogeneity, rather than sampling error (Higgins & Green, 2008). Signicance of heterogeneity is
shown for the Q test.
c
Only calculated for controlled studies (RCTs and CCTs) with at least one drop-out in any group.
therapy improved the musical engagement of those receiving music

therapy, compared to standard care. Rather than as a clinical endpoint in
itself, the outcome might best be understood as an indicator of
mechanisms of change in music therapy.
4.1.7. Other outcomes: Global state, leaving the study early, quality of life,
satisfaction, and medication level
Five further outcomes, two dichotomous and three continuous
ones, were available from at least two but less than ve studies. Metaanalyses for each of these outcomes are shown in Table 4.
Global state (2 studies, 140 participants) was rated as a dichotomous outcome (no overall improvement as rated by a psychiatrist).
The results were clearly in favor of music therapy, with a very low and
signicant odds ratio (OR = 0.03, p b .001) and no statistical heterogeneity (I2 = 0%). To improve interpretability, the result was also
translated into the number needed to treat (NNT), which indicated
that less than two patients need to be referred to music therapy so that
one will benet. It should be noted that this result was based on RCTs,
that it concerned psychotic as well as depressed patients, and that
(although doseresponse relationship was not addressed for this
outcome) both included studies provided a large number of sessions.
The odds of leaving the study early (as a proxy measure of
tolerability) were calculated from four controlled studies. The metaanalysis suggested no difference, indicating good tolerability of music
therapy as well as of standard care. Quality of life, satisfaction with care,
and medication level were each available from two studies. No
signicant effects were found for these outcomes.
4.2. Other outcomes and comparisons
All outcomes with usable data from at least two studies were
included in the analyses presented above, but we chose not to metaanalyze non-replicated outcomes with usable data from only one
study. For the comparison of music therapy versus standard care,
these included hostility, self-esteem (Hanser & Thompson, 1994), and
engagement with services (Talwar et al., 2006). Non-replicated results
concerning other comparisons included structured versus improvisa-
tional music therapy (Ceccato et al., 2006) and music therapy versus
cognitive behavior therapy (Zerhusen et al., 1995). Later follow-ups
(some months after termination of therapy) or intermediate assessments (during therapy) were included in some studies (Hanser &
Thompson, 1994, Hayashi et al., 2002), but not frequently and
consistently enough across studies to be included in a meta-analysis.
5. Discussion
5.1. Summary of ndings
This study is the most comprehensive systematic review and metaanalysis of the effects of music therapy in adult mental health to date.
It showed that music therapy, when added to standard care, has strong
and signicant effects on global state, level of general symptoms,
negative symptoms, depression, anxiety, functioning, and musical
engagement. It showed further that the effects do not depend on
diagnosis, which conrms music therapy's broad applicability. Neither
did the results depend on study design, conrming the robustness of
our ndings. In contrast, effects do depend strongly on the number of
sessions provided.
For all outcomes where data were available from sufciently
many studies (i.e., for general symptoms, negative symptoms,
depressive symptoms, and functioning), the results of the review
suggest that the dosage of music therapy was the best predictor of
its effects, explaining more than 70% of the variance. This indicates
clearly that the effects of music therapy are related to the number of
sessions provided. For two of the outcomes, the square root of the
number of sessions seemed to be a better predictor than the
untransformed number of sessions, indicating that the dose
response relationship may be non-linear (increasing more steeply
with the rst few sessions) for negative symptoms and functioning.
However, a linear doseresponse relationship also tted the data
relatively well for all of these outcomes. From the ndings it was
estimated that between 16 sessions (for depressive symptoms) and
51 sessions (for functioning) will be needed until large effects are
seen.
204
Fig. 4. Doseeffect relationship of music therapy for functioning. Note. Explanations see under Fig. 1.
5.2. The evidence base for music therapy in mental health

The ndings of this review demonstrate that music therapy is an
effective treatment for serious mental disorders with a clear dose
effect relationship. This extends the more basic knowledge from
previous related reviews demonstrating music therapy's effectiveness
for schizophrenia (Gold, Heldal, et al., 2005) and depression (Maratos
et al., 2008). The fact that the size of music therapy's effect was not
signicantly related to the type of diagnosis for any of the outcomes
examined makes most sense in the context of a dimensional model of
mental health, which emphasizes the commonalities of the different
mental disorders rather than conceptualizing them as distinct entities.
This does not imply that no differences existbut differences may be
more likely to show on other than diagnoses-related dimensions. This
will be discussed further under implications for practice. The same
nding lends support to a contextual model of therapy which focuses
on encounter, relationship, and therapeutic process, as opposed to a
medical model where specic techniques are applied to treat specic
diseases or symptoms (Wampold, 2001). Music therapy appears to be
indicated for a broad range of serious mental disorders.
The fact that the effect sizes found in this review were also not
related to the type of study design justies and underlines the
appropriateness of the range of study designs included. Although nonrandomized study designs may bear a greater risk of bias and caution
is warranted, such caution was applied in the analysis and no
indication of bias was found. Overall, the fact that all study designs
and all types of serious mental disorder included showed the same
results strengthens the condence with which conclusions can be
drawn from this review.
5.3. The doseresponse relationship in music therapy
The one predictor that was signicant consistently across all
outcomes was the dosage of music therapy. In line with previous
ndings from research in verbal psychotherapy (Howard et al., 1986),

our ndings indicate that the effects of music therapy increase with
the number of sessions provided. The number of sessions explained
high proportions of the variance in effects (between 73% and 78%),
indicating a clear and strong relationship. With the ndings from this
review, it is now possible to predict the expected effect size from the
number of sessions, or to predict the number of sessions needed to
achieve a given effect size. The results indicate that small effects are
seen after 3 to 10 sessions; medium effects are achieved after 10 to 24
sessions and large effects after 16 to 51 sessions. This facilitates the
planning of future research in the eld and may also have direct
implications for practice and policy. As others have noted, the
presence of a doseresponse gradient may also increase our
condence in the ndings of observational studies and thereby
enhance the assigned quality of evidence (Higgins & Green, 2008,
p. 367). The ndings of this review therefore conrm the effectiveness
of music therapy and underline the strength of causal inference from
the existing evidence.
5.4. Limitations
The results of a meta-analysis depend rstly on the results of the
individual studies included. Therefore, their limitations should be
mentioned here rst. We excluded studies with very high risk of bias
(e.g. with very high drop-out rates) from the review. However, we did
include studies with weaker designs than the strongest ones that
exist. This was done to enhance external validity, and the choice was
accompanied by a clear strategy to statistically identify the impact of a
potential bias. The results showed no impact of study design,
indicating that their inclusion was justied in this sample of studies.
However, other limitations of the primary studies' quality, as well as
the quality of their reporting, should also be mentioned. In more than
half of the studies it was uncertain whether or not outcome
assessment was adequately blinded. Similarly, concealment of
allocation (relevant in RCTs) was only rarely reported and often

uncertain. It was not possible to assess the impact of methodological
quality in greater detail in this meta-analysis, both due to the lack of
methodological transparency and due to the need for parsimony in
selecting predictor variables in meta-regression models. For example,
it would have been desirable to assess the impact of adequate blinding
as a further methodological predictor in addition to study design.
Likewise, greater transparency had also been desirable for many
clinical aspects, particularly for the kind of music therapy that was
applied in the studies. While some aspects, such as duration, setting, and
general working modalities were fairly clear from the study reports, it
sometimes proved difcult to identify clearly the theoretical orientation
and the formal qualication level of the music therapist(s) who applied
the therapy. This may in part be related to the stage of development of
music therapy as an academic discipline and as a regulated profession,
both of which vary across countries. The implication of this limitation for
the present review is that conclusions can only be about music therapy
in general (within the denition provided in the beginning of this
article), rather than about more specic theoretical or methodological
approaches within music therapy. Relatedly, as the vast majority of
studies compared music therapy to standard care and did not include an
active control intervention, it is not possible at this stage to make any
statements about the specicity of music therapy's effects. The current
evidence suggests that music therapy has an effect. Based on that, a
logical and useful next step in this eld of research would be to examine
to what extent this effect is due to its specic ingredientsthe use of
musicor due to other, more general factors.
The potential impact of researcher allegiance has been much debated
in psychotherapy research (e.g., Luborsky et al., 1999). Although it was
not the focus of this review, it should be mentioned here as a potential
limitation. It is plausible to assume that most studies in this review were
carried out by researchers who have a somewhat positive allegiance
towards music therapy. One notable exception is the Zerhusen et al.
(1995) study, where music therapy was used as a comparison condition
only, which might indicate neutral or negative allegiance towards music
therapy. However, the high consistency of the doseresponse relationship identied in this review makes bias from researcher allegiance
seem unlikely here. Researcher allegiance is presumably independent of
the number of sessions in a study; we can see no plausible reason why
the impact of researcher allegiance should be greater in studies where
many sessions were provided. Therefore, researcher allegiance can be
ruled out as a potential threat to the validity of our ndings. To
summarize, the existence of a clear doseresponse relationship
strengthens the conclusion that the results reect the true effects of
therapy rather than methodological artifacts.
Finally, the small number of studies deserve mentioning as a
limitation. Specically, one might ask how conclusive the results
concerning the doseeffect relationship are, given that they are based
on only 15 studies. Concerning this possible criticism, it is rst important
to note that these 15 studies reect information from almost 700
patients, who were offered a widely ranging number of music therapy
sessions. Secondly, one should recall the unusually high proportion of
explained variance that was found in this meta-analysis. According to
Cohen's (1988, pp. 413414) guidelines for interpretation of effects in the
behavioral sciences, an effect expressed as explained variance is large
when R-squared is .26. The doseeffect relationship we discovered, with
an R-squared of around .75 for all outcomes examined, by far exceeds the
conventions of a large effect. This lends credibility to its interpretation as
a true doseeffect relationship and makes alternative explanations
unlikely (Higgins & Green, 2008). Nevertheless, there is a need for further
studies, as is discussed further below.
5.5. Implications for practice
The ndings of this review have several implications for practice.
First, they underline the value of music therapy as an effective
205
treatment in mental health care. Music therapy helps patients with

serious mental disorders to improve their general mental state,
symptom levels, and level of functioning. This has been known before
for patients with schizophrenia (Gold, Heldal, et al., 2005); the current
review both conrms and extends the ndings from that previous
review. The current review extended from the previous meta-analysis
by including not only schizophrenic, but also non-psychotic serious
mental disorders. Compared to the previous review, the current
review was also based on a broader selection of studies, including
practice-based studies, which likely improved the generalizability and
clinical applicability of the ndings. Particular mention should be
made of the important group of patients with depression where no
meta-analysis existed previously (only a narrative review of depression studies was provided by Maratos et al., 2008). This broad range of
patients will benet if music therapy is added to their usual care.
Second, the ndings imply that the number of sessions is an
important factor for music therapy to be benecial. Small benets of
music therapy can be seen already after a few sessions, as may be most
typical on an acute inpatient ward. However, for stronger, clinically
more meaningfuland potentially more lastingeffects, a considerable number of sessions will be required. The ndings therefore also
underline the value of either intensive or long-term engagement of
patients in music therapy, the latter of which may be most typical in
outpatient settings or in private practice. Mood changes seem to occur
more quickly than improvements in general symptom levels. It has to
be noted, however, that the extent of individual benet from music
therapy will necessarily vary from patient to patient. Some may
respond rapidly after few sessions, whereas others may need more
time than expected and predicted by the model. Further, the results of
this review do not tell us if, the total number of sessions being equal, a
higher frequency of sessions over a shorter time or a lower frequency
over a longer time will be more benecial. This may also vary across
client groups.
As a third implication for practice, the lack of difference of effect
between psychotic and non-psychotic disorders raises the question of
differential indication for music therapy. If diagnosis is not the main
determinant of music therapy's effect, then what other criteria might
be more fruitful in determining who should receive music therapy?
Psychotherapy researchers have argued that factors such as the match
between therapist and client and the client's motivation for a specic
type of therapy should be recognized more (Wampold, 2001). That the
use of such soft indications can often be more fruitful than an
uncritical prescription based on diagnosis alone, is very much in
accordance with our clinical experience as music therapists. For
example, clients are often referred to music therapy because they are
deemed unsuitable or unmotivated for verbal psychotherapy (Hannibal, 2005; Hanser & Thompson, 1994; Meschede et al., 1983; Rolvsjord,
2001; Solli, 2008). An international multicenter RCT is currently
investigating the effects of music therapy for this specic population
(Gold, Rolvsjord, et al., 2005). It is important to be aware that referral
based on such types of indications requires referrers to think more
carefully about the individual patient and necessitates more and
better communication between referrers and therapists than referral
based on diagnosis.
For policy makers, it will be important to know how easily music
therapy can be implemented into the care of seriously mentally
disordered patients. In many countries, qualied music therapists with
an appropriate level of training are available; in other countries, there
may be an insufcient level of training, an insufcient number
of qualied music therapists, or an insufcient focus of the music
therapy training on mental health care. The ndings of this review
suggest that music therapists in this eld need to be clinically skilled to
enable a range of music experiences, as well as a fruitful reection of
these experiences, in a framework that offers both sufcient structure
and openness towards the patient's individual therapeutic process.
This requires extensive and adequate clinical training.
206
5.6. Implications for future research
6. Conclusion
This review has established the efcacy and doseresponse

relationship of music therapy for people with serious mental
disorders. This is an important, but still fairly general nding.
Studies will be needed to ll gaps in client populations and to
extend our knowledge on the effects of therapy variables other
than dosage. Concerning client populations, the ndings of this
review indicate that not all mental disorders have been covered
equally well. Most of the studies identied focused on either
psychotic disorders or on depression. Some important disorders
where music therapy is applied, including for example borderline
personality disorder and eating disorders, have not received specic
attention in music therapy outcome research to date. Furthermore, as
noted in the previous section, there seem to be specic subgroups
across diagnoses that warrant closer investigation, such as patients
with low therapy motivation. Future research should attempt to close
these gaps.
Concerning the further specication of the treatment, effects of
music therapy approaches may vary not only by the treatment dose
(number of sessions), but also according to theoretical background,
qualication of the therapist, therapeutic setting, and working
modalities within therapy. Another wide area for more specic future
studies on differences in types of music therapy will be related to
individual therapist variables, which may be at least as important as
the more formal characteristics of therapy (Wampold, 2001). As a
related but different issue, it would also be useful to compare music
therapy to active control conditions in order to establish to what
extent the effect of music therapy is due to using music in therapy or
due to other factors.
To improve the methodological quality of future outcome research
in the eld, researchers should adhere to guidelines such as the
CONSORT statement for RCTs (Moher, Schulz, & Altman, 2001) and
related statements for other study designs (as listed on www.consortstatement.org). Many of the methodological weaknesses identied in
the available research to datefrom design aspects such as allocation
concealment and blinding through to the adequate reporting of
statisticsare related to transparency of reporting, which can easily be
improved by using those guidelines.
Specically and concretely, the numeric results of the metaregression models can be used directly in the planning of future
research. Power calculation, an issue which was long ignorednot
onlyin music therapy research (Gold, 2004), is now increasingly
being used by music therapy researchers to identify the required
sample size for their study hypotheses. One central assumption
in power calculation is the expected effect size. The results of this
review are a strong reminder that this effect size again depends
to the number of sessions. Researchers planning an outcome
study in the eld should make use of this knowledge. One can use
the model formulae and predicted values (Table 3) to make an
informed decision on the expected effect size, based on the
number of music therapy sessions to be provided. For example,
in a study with general symptoms as the primary outcome, one
can see from the table that a medium effect size is expected
after 24 sessions, and a large effect size after 39 sessions. Power
calculation then shows that the required sample size will decrease
considerably (from 64 to 26 participants per group) if the higher
number of sessions is chosen.1 Our ndings therefore enable
researchers to make more informed decisions in planning research
by using the number of therapy sessions as a parameter in power
calculation.
This review has shown that music therapy is an effective therapy

for serious mental disorders, which helps patients to improve global
state, symptoms, and functioning. This adds to the knowledge on
effective therapy for a population which often does not respond easily
to traditional approaches. Music therapy appears to contribute
something unique to this eld, with music helping in at least three
different waysas a motivating factor, as a medium for emotional
expression, and as a social endeavor. At the same time, this research is
rooted in the wider eld of psychotherapy research, and its ndings
contribute to research on contextual models in psychotherapy
(Wampold, 2001) as well as to research on doseresponse relationship
in psychotherapy (Howard et al., 1986). It is hoped that the ndings of
the present review will also be fruitful for those related elds, as well
as furthering the knowledge and application of music therapy as a
treatment that is rooted in good clinical practice, guided by adequate
theory and supported by reliable evidence.
1
Calculated for an independent samples t-test comparing two groups of equal size,
with signicance level = .05 and test power 1 = .80, using the function power.t.test
in R. The same results can be found in the sample size tables in Cohen (1988).
Conict of interest
Christian Gold, Hans Petter Solli, and Viggo Kruger are clinically
trained music therapists.
Acknowledgements
The authors would like to thank Zulian Liu and Huo LiHua for help
with the translation and Tor Olav Heldal and Trond Dahle for help with
the data extraction. Johan Cullberg provided valuable comments on an
earlier version of this article. This review was enabled by intramural
support by Sogn og Fjorde University College, Sandane, Norway, and
external funding from the Research Council of Norway. Parts of this
article were written at Caf Museum, Vienna, Austria.
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Clinical Psychology Review 29 (2009) 193207

Contents lists available at ScienceDirect

Clinical Psychology Review

Doseresponse relationship in music therapy for people with serious mental

Unifob Health, Bergen, Norway

C. Gold et al. / Clinical Psychology Review 29 (2009) 193207

C. Gold et al. / Clinical Psychology Review 29 (2009) 193207

treatment to standard care alone for people with psychotic disorders,

In psychotherapeutic methods such as music therapy, the term

C. Gold et al. / Clinical Psychology Review 29 (2009) 193207

In addition we also aimed to address how the type of study design

(preferably published) rating scale. They had to be assessed either as a

A comprehensive search strategy was applied to identify all

2.1. Criteria for selecting studies

2.2. Search strategy

(a) The trial database PsiTri, which contains structured information

2.4.1. Individual study results

C. Gold et al. / Clinical Psychology Review 29 (2009) 193207

these correlations in order not to give undue weight to those studies

studies without control groups. Assessor blinding was adequate in six

The various searches yielded initially 166 potentially relevant

3.2. General study characteristics

3.4. Comparison conditions

The most basic comparison, where music therapy is added to

Design and study quality

Diagnosis: Major or minor

Diagnosis: Mood disorders,

MT (I, V), 1 session

MT (L, P), biweekly

1.) Cognitive therapy.

C. Gold et al. / Clinical Psychology Review 29 (2009) 193207

b) Other controlled studies

1.) MT (L), 1 session

B) (Attention: Paced Auditory Serial

MT (I), 1 session pr.

Diagnosis: Schizotypal disorder,

c) Studies without control groups

C) (Mood, 1-item rating)

Troice & Sosa

C. Gold et al. / Clinical Psychology Review 29 (2009) 193207

C. Gold et al. / Clinical Psychology Review 29 (2009) 193207

for all predictors simultaneously, which yielded no additional

Square root of sessions

C. Gold et al. / Clinical Psychology Review 29 (2009) 193207

Anxiety was measured in three studies (108 participants) with the

Number of sessions needed

C. Gold et al. / Clinical Psychology Review 29 (2009) 193207

relatively heterogeneous category which might be summarized as

C. Gold et al. / Clinical Psychology Review 29 (2009) 193207

2 (Chen 1992; Yang et al., 1998)

Odds ratio (95% CI)

4 (Hanser & Thompson, 1994; Pavlicevic et al., 1994;

1.11 (.42 to 2.92)

3 (Chen 1992, de l'Etoile 2002, Hanser & Thompson, 1994)

Hedges' g (95% CI)

2 (Chen 1992; Hanser & Thompson, 1994)

1.31 (0.85 to 1.78)

0.18 (0.12 to 0.48)

2 (Hayashi et al., 2002, Pavlicevic 1994)

0.49 (0.09 to 0.88)

2 (Hayashi et al., 2002; Ulrich et al., 2007)

0.16 (0.24 to 0.56)

2 (Talwar et al. 2006; Ulrich et al., 2007)