# Motivation and emotion/Book/2013/Depression and music

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## Overview

Depression is a chronic disorder that has the potential to affect anyone of any age and can be caused by a number of factors. These factors include Family history of depression, Being Female, Major life stresses, childhood abuse or neglect, chronic Illness, which if appears in childhood or adolescents considerably increases chances of recurrent depressive disorders in adulthood. As the prevalence of depression continues to increase, so does the literature on effective ways in which to treat it. One area of interest that continues to be expanded on is the use of music therapy in the treatment of depression. Not only has music proven to be an effective tool in the treatment of depression, it has also proven to contribute to the development of depression.
This Book chapter aims to tell you how the use of music is an effective tool in the treatment of depression, and also how aspects of music can contribute to the development of depression.

## Background
### Depression

Depression refers to a state of low mood which effects a persons thoughts, feelings and their general well being.

#### Characteristics of Depression

Depression is often characterised by loss of interest in activities that were once enjoyable, loss of appetite or over eating, loss of concentration as well as insomnia or over sleeping. More severe cases of depression may result in attempted suicide.

#### What triggers a depressive episode

There a many possible triggers which can set off a depressive episode. These include separation from a long term romantic relationship, financial struggle, physical illness, problems at home, losing your job, marital problems as well as other negative events involving a person close to you.

### Traditional treatments for depression

There are three main treatments for depression: Psychotherapy, pharmacotherapy and electroconvulsive therapy (Castillo-perex, Gomez-Perez, Velasco, Perez-Campos, & Mayoral, 2010). There a many possible triggers which can set off a depressive episode. These include separation from a long term romantic relationship, financial struggle, physical illness, problems at home, losing your job, marital problems as well as other negative events involving a person close to you (Castillo-perex, Gomez-Perez, Velasco, Perez-Campos, & Mayoral, 2010). Severe depression can often lead to suicide attempts, which is why medical practitioners need to be very careful when it comes to its treatment. Pharmacotherapy, such as the use of tricylic antidepressants or selective serotonin reuptake inhibitors doesn’t seem to make any difference in the amount of suicide attempts amongst people experiencing a major depressive episode (Castillo-perex, Gomez-Perez, Velasco, Perez-Campos, & Mayoral, 2010). However, another form of treatment which is a bit out of the norm seems to be quite effective in the treatment of things like acute pain, cancer pain, labour pain and depression. That treatment is the use of music therapy (Castillo-perex, Gomez-Perez, Velasco, Perez-Campos, & Mayoral, 2010).

## Music therapy

Music therapy refers to the planned use of music in order to achieve a therapeutic outcome. In mental health services, the use of music therapy is a widely offered intervention facilitated through group therapy, as well as individual therapy following a process of referral and assessment. Despite the fact that music therapy seems to be an effective treatment for certain conditions, there has been little research conducted into what potential effects music therapy can have on depression. Music therapy can exhort a positive outcome on mental health; however no adverse effects for music therapy have been reported so far. In a study conducted by Hsu and Lai (2004), music therapy was used over a two week period on patients with major depressive disorder. Their results showed a significant reduction in depression scores for the music-therapy group, as did their sub-scores in comparison to those patients in the control group.

### Perceptions of emotions in music by depressed people

According to recent reviews about music therapy treatment for people with depression, positive mood related effects have been consistently obserserved in conjuction with musical activities (Salimpoor, Benovoy, Longo, Cooperstock, & Zatorre, 2009). Music therapy provides an effective non-intrusive mood induction technique, which has shown to play a central role in the regulation of emotions by depressed people in everyday contexts (Salimpoor, Benovoy, Longo, Cooperstock, & Zatorre, 2009). The underlying mechanisms which cause irregularity in the frontal and pre frontal cortices when processing emotions which have been induced by music therapy, have also been indentified and past studies (Altenmuller, Lim, & Parlitz, 2002). In spite of its beneficial effects and prevalence, these aspects of music have rarely been tested in clinical populations (Altenmuller, Lim, & Parlitz, 2002). On the contrary, two studies in which these underlying mechanisms were explored, depressed patients were shown to make significantly different emotional evaluations of music in comparison to those participants who were healthy (Bodner, et al., 2007). These promising findings prompted further research into the difference in emotional evaluation of music between depressed people and people who are not depressed.
In a study conducted by Punkanen, Erola and Erkkila (2011), seventy nine patients with depression aged between eighteen and fifty years of age were compared to thirty healthy people in terms of their emotional evaluations of music. In this study, participants were played fifteen second excerpts of music, and their emotions were assessed through the use of self-report measures. The researchers hypothesised that the depressed patients would demonstrate a marked negative bias when evaluating the emotional qualities of music and their results showed just that. Depressed patients gave significantly higher ratings of anger than the healthy control group, as well as much higher ratings on scales of sadness. Punkanen, Erola and Erkkila (2011) also hypothesised that for positive emotions such as tenderness and happiness, the depressed people would score much lower than those in the control group. Results showed exactly that, For the positive emotions of tenderness and happiness, the depressed patients scored much lower than those in the control group, however this result failed to reach statistical significance.

### Music therapy compared to psychotherapy

A study was conducted by Castillo-Perez et al (2010) which compared the effectiveness of psychotherapy and music therapy on the treatment of depression. They based this study on the hypothesis that music can stimulate and activate signal pathways which can then modulate chemical mediators, which in turn leads to facilitation of recovery or the diminishment of depressive symptoms. The results of their study showed a statistically significant effect for music, revealing a better improvement in symptoms in the music therapy group than in the psychotherapy group. What was also interesting about these results was at the beginning of the study, many of the chosen participants did not seem to have any interest in listening to music, but after participating, not only were they interested, but they also asked the researchers for more of the type of music that they used in the experiment.

### Music, Mood and Movement theory

One theory that attempts to explain how music therapy affects human psychological response is the theory of Music, Mood and Movement (MMM). This theory proposes that music produces a psychological response altering mood which therefore leads to improved health outcomes (reference). Aspects of music such as its melody, its pitch and its harmony have shown to elicit a wide range of emotional reactions within the listener (Murrock & Higgins, 2009). As these elements of music start to pass through the auditory cortex of the brain, the processing of the music occurs within the limbic system of the brain to bring forth emotions (Tramo, 2001). Jourdain (1997) claims that music calls upon past memories and experiences that has some sort of emotion attached to them which in turn changes the emotional state of the listener. What this indicates is that if the right type of music is played, it has the potential to alter the listener’s emotional state, which can then lead to achieving some sort of therapeutic outcome such as a reduction in symptoms of depression (Guzzetta, 1991).

### Entrainment of body rhythms

Hass, Distendeld, & Axen (1986) and Watkins (1997) indicated that music exerts its effects through the entrainment of body rhythms. Entrainment is the tendency for two oscillating bodies to lock into phase and thus vibrate in synchronization (Chlan, 1998). When a person is feeling stressed, uncomfortable, angry, or depressed then their body rhythms such a heartbeat, blood flow and breathing will change. People who are feeling depressed, angry or stressed will also have adrenaline released from their adrenal medulla which can then effect their breathing and heart rate, as well as lead to changes in blood pressure, respiratory rate and oxygen saturation (Chlan, 1998). In a study Hass, Distendeld, & Axen (1986), a close relationship was found between musical rhythm and a person’s breath or respiratory patterns.

### Recreational music making

One aspect of music therapy in the treatment of depression which has been under researched is the use of improvisational music therapy. Improvisational music therapy is defined as a method that ultilises improvising as a primary therapeutic experiences (Bruscia, 1987). Improvising is the extemporaneous process of inventing music while singing or playing, using whatever sound sources you are able to get your hands on within a theraputic setting (Bruscia, 1987).
Recent studies looking at improvisation music therapy have concluded that improvisation music therapy activities such as drumming, moving to music and music games is an effective way in reducing depressive symptoms as it induces comfort and relaxation as well as promotes positive physiological changes (Mishne, 2001). Albornoz (2011) conducted a study which test the efficacy of improvisational music therapy in reducing depressive symptoms. Twenty four participants completed the Beck Depression Inventory (BDI) and the Hamilton Rating scale for Depression (HRSD) before randomly being assigned to either the control group or the experimental group. The experimental group received a mixture between improvisation music therapy and regular therapeutic interventions where as the control group only received the regular therapeutic interventions. Pre test scores on both the Beck Depression Inventory and the Hamilton Rating Scale for Depression equally matched between both the control and the experimental group. Post test results were statistically significant, showing that the experimental group was significantly less depressed after treatment than the control group. Quantification of research in the area of improvisational music therapy is still very limited, however further research into this area would be worthwhile as improvisational music therapy has so far been found useful in reducing depressive symptoms.

## Music therapy for depression in the elderly

A recent survey in Singapore on the prevalence of depression in the elderly revealed that approximately 4.1 percent of senior citizens suffer from the condition (Ministry of Community Development, 2010). Pharmacotherapy is the most common treatment for depression in the elderly, however, because of age related physiological changes, pharmacotherpy is often associated with adverse reactions (Spina & M.G, 2002). Their have been studies conducted on the effects of music therapy on depression in the elderly and has shown some positive results. In a study conducted by Chan et al. (2011), 52 participants were placed into either the music group or the non music group. Those participants in the music group were treated with music therapy once a week over a period of eight weeks. Their results showed a significant decrease in depression scores from the music group in comparison to the non music group and the periods of week 4. Week 6, and weeks 8. The depression scores within the music group consistently reduced over the 8 week period, where as the depression scores from those who were not in the music group did not.
Several empirical studies have provided support for the use of the theory of Music, Mood and Movement (MMM) and its effects on depression levels amongst the elderly. However, there have also been conflicting findings across individual studies. For example, there were two particular studies that showed no significant effect of music therapy on reducing depressive symptoms (reference). Elliot (1994) suggested that there may be not enough time or enough interventions for there to be increasing effects.
Chan, Chan, Mok, and Tse (2009) conducted a study which aimed to explore the effects of music on levels of depression and physiological parameters in elderly people. Results showed a statistically significant reduction in depressive symptoms and so the researchers concluded that listening to music can be an effective intervention for depression in elderly people if they are willing to accept it. Results of this study encourages patients to suggest listening to music to elderly patients as an alternative self help skill. This can also enable them to release their negative feelings and develop a cheap, effective healing processing in their daily lives.

## Music Therapy for depression children from divorced families

One major contributing factor to childhood depression is divorce (Lugaila, 1998). Kurdek and Berg (1987) said that children with superior cognitive ability who make “personal sense” of their parents divorce assess their own role in the divorce and as result, are able to take control over their behaviour and suffer less consequences. Other researchers have suggested that children tend to whole irrational beliefs about their parents divorce such as “Its my fault” and “They will get back together” (Kurdek & Berg, 1987). Stark, Brookman and Frazier (1990) came to the conclusion that irrational thoughts such are mediating factors in the treatment of depression and their for must be dealt with. Recent literature is mixed about the impact of musical interventions on group process, however prior to a study by DeLucia-Waack & Gellman (2007), little to know research had been conducted into the effectiveness of musical intervention in the group process for children of divorced families. They examined the efficacy of a children of divorce group using musical intervention in comparison to a children of divorce group using traditional psycho educational methods. They hypothesised that children of divorce groups using musical intervention would have a significantly greater impact on the children's level of anxiety, depression and irrational beliefs about their parents divorce. Results showed that there was no significant difference in depression, anxiety and irrational belief levels between the children of divorce group using musical intervention and the children of divorce group using traditional psycho educational methods. In fact, all participants in the study experienced a significant decrease in anxiety and depression levels not as a result of introduced music, but as a result of simply participating in a group session. Although this study was one of the first to look at the effects of music intervention in children from divorced families, these results were puzzling to the researchers because of the effective nature of music intervention in other types of patients. These results could have come about from improper use of the intervention outside of the group, or because the group leaders in the no music group compensated in some way because they knew that the other group was receiving music intervention. These results could have also come about due to the studies reliance on self report measures, in which case the children could have answered the questions on the self report measure in a socially desirable manner.

## How music can effect depression?
### Different genres

Research has shown that the type of music a person listens to can have an effect on depression levels. For example, Shafron and Karno (2013) conducted a study comparing levels of depression between people who listen to heavy metal music to those who do not listen to heavy metal music. The researchers hypothesised that those who listened to heavy metal music would score higher on scales of depression, anxiety and trait anger in comparison to those who do not listen to heavy metal music. As predicted, their results showed a significant difference in depression and anxiety scores between those who listened to heavy metal music, and those who do not listen to heavy metal music. These difference in scores between heavy metal listeners and non heavy metal listeners could have something to do with the content of the songs. All Media Guide (2011) describes the lyrical content of much of heavy metal music as violent and depicting imagery that is bloody. Furthermore lyrical content of much modern rock music also has a tendency to make reference to subject matter such as fear of being alone, insecurity over being abandoned, anxiety over infidelity as well as rage over parental abandonment. With this lyrical content in mind, it is possible that those participants who listen to heavy metal music score higher on depression and anxiety scales in comparison to those who do not listen to heavy metal music simply due to the messages conveyed through their lyrics.
Despite these statistically significant findings saying that listeners of heavy metal music tends to score higher on depression scales than those who do not listen to heavy metal music, the litrature still displays mixed results (Ekinci, Topcuoglu, Topcuoglu, Sabuncuoglu, & Berkem, 2012). For example, Lacourse et al. found no relationship between preference in heavy metal music and suicidal ideation. Ballard & Coates (1995) also reported so significant relationship between heavy metal preference and suicidal ideation. Furthermore, Becknell et al (2008) recently indicated that young people with a preference in heavy metal music do not become depressed as a result of listening to it, but actually get some sort of theraputic relief from their depressive symptoms. It has been shown that in adolescents, independent of the music type, listening to music had a positive effect on mood (Scheel & Westefeld, 1999). Characteristics of depression can include suicidal ideation's and self harm, and their have been studies conducted into the relationship between music preference and these characteristics of depression. A Canadian study correlated the music preferences of 14-18 year old with the several depression scales. These included the parental bonding instrument, self perception of alienation and attempted suicide/serious suicide ideation. Results showed that a preference for heavy metal music did not correlate with suicide risk but was actually associated with a positive change in affect (Stack, Gundlack, & Reeves, 1994). An Australian study investigated the music preferences of year ten students and its connection to suicide vulnerability. Significant associations were found between rock and metal music and suicidal thoughts, acts of deliberate harm and depression, with a higher association being found for females (Martin, Clarke, & Pearce, 1993). Furthermore , a US study involving university students found that those with a preference for rock music and watched rock music videos with suicidal themes wrote more suicide related scenarios than those who did not preference rock music (Rustad, Small, Jobes, Safer, & Peterson, 2003).
Another interesting find was that non-violent rap songs elicited higher depression scores than violent rap songs (Ballard & Coates, 1995). Another us study of young adults (mean age of 24) correlated preference of music with depression, suicidal preoccupation and personality using the Becks depression inventory (BDI) (Laster & Whipple, 1998). Results showed that suicide ideation was associated with a preference for heavy metal music.

### Music Videos

Research into the relationship between music and mental health issues (such as depression) has identified another dimension of current popular music, the music videos. A recent study revealed that children and adolescents between the ages of twelve and fifteen years watch some sort of music video approximately 4.3 days per week (Council on Communications and Media from the American Academy of Paediatrics, 2009). Music videos can be classified into two categories: Performance videos and concept videos (Ekinci, Topcuoglu, Topcuoglu, Sabuncuoglu, & Berkem, 2012). Performance videos consists of the artist or group being filmed during a live performance of a song, where as concept videos show the viewer a theme and a story which is usually closely related the lyrical content of the song (Ekinci, Topcuoglu, Topcuoglu, Sabuncuoglu, & Berkem, 2012). This may result result in the addition of content to the lyrics which provides a particular interpretation which is then enforced every time the viewer hears that song outside of the music video. In saying this, viewing the music video of a song which has a depressing theme to it (death, break up etc) has the potential to intensify the depressing feelings the viewer is feeling (Ekinci, Topcuoglu, Topcuoglu, Sabuncuoglu, & Berkem, 2012).

## Summary

Music therapy has proven to be a very effective method when treating depression. It has shown to be effective in people of all ages and has even shown to be more effective then traditional therapeutic techniques such as psychotherapy. However, aspects of music such as music genre and music videos have shown to have negative effects on people such as intensifying depressive symptoms. Research and clinical trials supports the use of music therapy in the treatment of depression as it is an cost effective and simple method that can be practised at home