Review Article

Psychiatry and music Shamsul Haque Nizamie, Sai Krishna Tikka

Department of Psychiatry, Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India

Abstract

Vocal and/or instrumental sounds combined in such a way as to produce beauty of form, harmony and expression of emotion is music. Brain, mind and music are remarkably related to each other and music has got a strong impact on psychiatry. With the advent of music therapy, as an efficient form of alternative therapy in treating major psychiatric conditions, this impact has been further strengthened. In this review, we deliberate upon the historical aspects of the relationship between psychiatry and music, neural processing underlying music, music’s relation to classical psychology and psychopathology and scientific evidence base for music therapy in major psychiatric disorders. We highlight the role of Indian forms of music and Indian contribution to music therapy. Key words: Major psychiatric disorders, music, music therapy, psychiatry

INTRODUCTION Music is the art of sound in time, expressing ideas and emotions in significant forms through the elements of melody, harmony and color.[1] Tones or sounds occurring either in in a single line (i.e., melody) or in multiple lines (i.e., harmony) and the feeling of movement of sound in time (i.e., rhythm) are the essential elements of music. The Oxford dictionary defines music as vocal and/or instrumental sounds combined in such a way as to produce beauty of form, harmony and expression of emotion. Today, music and its technology is in vogue particularly the use of electronic devices and computer software. From classical Carnatic to Latin folk, from tiny I‑pods to high voltage rock performances, every human being is accompanied by music anytime and anywhere. “Music energizes mood,” “music is a great stress buster,” “music drives away blues,” “music soothes souls” ‑ from a mental health professional point of view, these statements invoke thoughts like “since how long has been this association between music and mind there?” “What aspects of mental health does music impact?” “Can music treat mental illnesses? And if

yes how?” This review makes an attempt to answer such questions. Particularly, we have tried to focus the role of Indian forms of music and Indian contribution to music therapy. HISTORY OF “MUSIC AND MIND” ‑ A FOCUS ON INDIAN CLASSICAL MUSIC Ancient Greek philosopher, Plato (428‑347 BC), quoted “music gives wings to mind”. Plato considered that music played in different modes would arouse different emotions.[2] Much ancient is the association between music and mind. It can be dated back to the vedic age, where attempts were made to relate the “seven” basic notes of music and the “eight” basic moods identified in the Indian drama theory. The seven basic notes are ‑ sadaja, rishaba, gandhara, madhyama, panchama, dhaibata and nishada; whereas, the eight basic emotions are ‑ sringar (love), hasya (laughter), karuna (compassion), vira (heroism), raudra (wrath), bhayanaka (fear), bibhatsa (disgust) and adbhuta (wonder). Love and laughter are associated with madhyama and panchama notes; wrath, wonder and heroism with sadaja Access this article online

Address for correspondence: Dr. Sai Krishna Tikka, Department of Psychiatry, Central Institute of Psychiatry, Kanke, Ranchi ‑ 834 006, Jharkhand, India. E‑mail: [email protected]

How to cite this article: Nizamie SH, Tikka SK. Psychiatry and music. Indian J Psychiatry 2014;56:128-40. 128

Quick Response Code Website: www.indianjpsychiatry.org

DOI: 10.4103/0019-5545.130482

Indian Journal of Psychiatry 56(2), Apr-Jun 2014

Nizamie and Tikka: Psychiatry and music

and rishaba; nishada and gandhara with compassion; and dhaibata with disgust and fear.[3] More intriguing is the relation between “raga” and “rasa.” “raga” is described as “a particular arrangement of sounds in which notes and melodic movements appear like ornaments to enchant mind.”[3] This forms the basic melodic structure of the Indian classical music and is not just the sum of the basic notes but rather forms a “gestalt.” On the other hand, “rasa” is described as “the psychological reaction or the reverberation occurring in persons in response to listening music.” It is assumed to represent both “primary and responding” emotions.[4] Pleasure being the end product of any art form, the “rasa” concept assumed an abstract connotation of “elements” or “essence” in the Upanishads especially in the Bribadranyak Upanishad, whereas in the Taittariya Upanishad “rasa” denotes the “ultimate reality,” which is the basis of “ananda” or highest state of bliss.[5] As raga is analogous to the concept of ‘harmoniai’ of ancient Greece,[6] rasa resembles the ‘ethos’ expressed in the same culture or the similar phenomena in the music of renaissance and baroque periods of the West, particularly to the “Affectnlehre” of the late nineteenth century.[4] MUSIC AND THE BRAIN History of the relation between music and the mind is skewed to the effects of music on one function of the mind ‑ emotion. However studies investigating the neurobiological basis of music have intrinsically linked music to various other brain functions as well. Human nervous system processes music in different ways ‑ perceptual processing, emotional processing, autonomic processing, cognitive processing and behavioral or motor processing. Perceptual processing Although, music stimulates some skin receptors by changes in local pressure, it is primarily made of sound waves that enter the primary acoustic circuit through the outer ear. Human primary acoustic circuit involves auditory nerve, brainstem, medial geniculate body of the thalamus and the auditory cortex. The transduction of music into a neural signal occurs in the cochlea. Music signals are perceived through shearing of hair cells within the cochlea. Cochlea filters these signals and the outputs are ordered tonotopically. The highest frequencies (pitches) are represented near the cochlear base, the lowest near its apex. The basilar membrane is the structure within the cochlea that separates scala media and the scala tympani. For different pitches, different regions on this membrane are activated. For frequencies below 1 kHz or in the range between 1 and 4 kHz or between 4 and 20 kHz there are as many cells on the membrane being sheared. There is a linear Indian Journal of Psychiatry 56(2), Apr-Jun 2014

relation between position of cells on the membrane being activated and frequency, up to 500 Hz. And between 500 and 8000 Hz, for distances on the membrane there is a doubling in frequency.[7] The auditory brainstem processes the neural signals from cochlea and sends them to the thalamus, which projects them into the auditory cortex.[8] The primary auditory cortex is located on the transverse gyri of Heschl in the lateral fissure, with a small part of it extending into the lateral surface of the temporal lobe. Organization of the primary auditory cortex is such that different parts of this area can be activated by music of different pitches. The secondary auditory cortex, the posterior and the anterior auditory fields are also involved in processing of music.[9] All these areas carry out perceptual analysis in terms of pitch (generally tones are physically referred to as frequencies, but in respect to music they are referred as pitches), timbre (the quality of a musical sound that distinguishes different types of sound production), rhythm (the organizational pattern of sound in time or the timing of musical sound), intensity and roughness. Functional auditory projections are also found between medial geniculate body, amygdala, cingulate gyrus and medial orbitofrontal cortex.[9,10] Different brain regions are assumed to perform a specific function in the processing of music: Musical aptitude (primary auditory cortex and heschl’s gyrus); musical syntax (frontal operculum); musical semantic (superior temporal sulcus); and language of music (perisylvian cortical language areas).[11] Table 1 shows involvement of various brain regions in different aspects of processing of music. Emotional processing Now, amygdala, cingulate gyrus and medial orbitofrontal cortex are involved in processing of emotional behaviors. Hence, as these structures are found to have auditory projections, these are proposed to be involved in emotional processing of music. There is evidence also to suggest that music activates these regions.[9,11] Table 2 shows the relation between various structural parameters of the music and different emotions. There is no specificity in the association of a particular parameter with one particular emotion, i.e., same emotions can be perceived by different musical parameters. Research on different neuronal responses to pleasant and unpleasant music has found that: 1. Brain activity is present predominantly in the frontal lobes for pleasant music and in the temporal lobes for unpleasant music.[12] 2. Pleasant music activates the inferior frontal gyrus, inferior brodmann’s area of the neocortex, anterior superior insula, ventral striatum, heschl’s gyrus, as well as the rolandic operculum and unpleasant music activates the amygdala, hippocampus, parahippocampal gyrus and temporal lobes.[13] 129

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Table 1: Brain regions involved in music processing (adapted from Lin et al., 2011[10]) Pitch Timbre Rhythm Melody Heschl’s gyrus Planum temporale Anterior superior‑ temporal gyrus Middle/inferior temporal gyri Temporal pole Parietal lobe (wholly) Frontal lobe (wholly) Premotor cortex Supplemental motor area Left dorsolateral cortex Right inferior frontal cortex Orbitofrontal cortex Limbic circuit Insula Nucleus accumbens Basal ganglia Ventral tegmental area Cerebellum

Table 2: Structural parameters of the music and emotions (adapted from Gabrielsson and Lindström, 2001)

Music Music recognition emotion

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3. There exists a complex relationship between the intrinsic happy‑sad character of music and the subjective perception, i.e., sadness can sometimes be a source of pleasure in music, whereas in most other forms of creative art it is negatively perceived.[14] 4. Left frontal asymmetry, associated with positive affect or decreased negative affect in response to musical stimuli and right frontal asymmetry associated with negative affect or decreased positive affect is found on electroencephalography (EEG).[15] 5. EEG findings also suggest that in men, pleasant emotions are processed in the left hemisphere and unpleasant emotions in the right hemisphere, whereas in women, pleasant emotions are processed in the left hemisphere and unpleasant emotions bilaterally.[16] Autonomic processing Music has been found to induce relaxation and to alter pain perception, blood pressure and respiratory and heart rates.[17,18] Soft, slow, non‑lyrical music significantly decreased systolic blood pressure, heart rate, respiratory rate and oxygen saturation.[18] Music with a faster tempo significantly increased heart rate, minute ventilation, blood pressure and sympathetic nervous activity and that music with complex rhythms increased, though insignificantly, the same parameters.[19] 130

Parameters emotions Amplitude Round Sharp Articulation Staccato Legato Harmony Simple/consonant Complex/dissonant Loudness Loud Soft Variation in loudness Large Small Rapid change Melodic range Wide Narrow Mode Major Minor Pitch level High Low Tempo Fast Slow Timbre Few harmonics Many harmonics Soft Sharp

Disgust, sadness, fear, boredom, potency, tenderness Pleasantness, happiness, surprise, activity, anger Fear, anger Tenderness, sadness Relaxation, tenderness Anger, tension, fear Anger Fear, tenderness, sadness Fear Happiness, pleasantness, activity Fear Fear Sadness Happiness Sadness, disgust, anger Surprise, potency, anger, fear, activity Boredom, pleasantness, sadness Activity, surprise, happiness, pleasantness, potency, fear, anger Sadness, boredom, disgust, tenderness Pleasantness, boredom, happiness, sadness Potency, anger, disgust, fear, activity, surprise Tenderness, sadness Anger

Cognitive processing Cognitive processing of music is hypothesized under two mechanisms: Affective or indirect mediation and non‑affective or direct mediation. Affective mediation basically refers to activation of certain cognitive networks by means of activation of emotional music processing networks.[20] Direct or the non‑affective processing of music basically means activation of regions involved in a particular cognitive function by music. It can further be explained based on two mechanisms. Firstly, “neuronal network priming,” according to which exposure to one type of material improves learning or identification of another related type of material, i.e., prior exposure to complex music “primes” the neuronal networks that would also be recruited to perform specific cognitive tasks.[20] In other words, musical activity strengthens inherent neural firing patterns that are also utilized by cognitive tasks. Specific cognitive functions that are found to be processed via music are spatial‑temporal performance including abstraction[21,22] and verbal learning.[23,24] Studies have also found that musically enhanced spatial‑temporal performance correlated significantly with increases in Indian Journal of Psychiatry 56(2), Apr-Jun 2014

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frontal and temporal EEG power and coherence.[25,26] The second mechanism that explains direct processing is “synaptic plasticity.” It has been established that the brain can be permanently modified by music training, i.e., cortical areas associated with finger control and size of the corpus callosum are found to be larger in musicians.[20] Many skills associated with music training can be explained on the basis of synaptic plasticity; these include fine tuning of sensorimotor coordination, extensive memorization and sustained attention, spatial‑temporal visualization[27] and reading performance.[28]

effects such as vasodilatation, local warming of the skin and a reduction in blood pressure as a response to listening music respectively are described.[9] A study[36] has found that listening to techno‑music is accompanied by a significant increase in plasma norepinephrine, β‑endorphin, adrenocorticotropic hormone, cortisol and growth hormone. However, while listening to classical music, no significant changes were detected in hormonal concentrations.[36]

Behavioral or motor processing Behavioral response to music is most evident in the form of dancing. Functional brain imaging has shown that music activates the cerebellum, basal ganglia and motor area. These areas are reported to coordinate motor movement in response to music.[29,30] Activation of the mirror neurons, the precuneus region of the parietal lobe, pre‑supplementary motor area, the supplemental motor area, the dorsal premotor cortex, the dorsolateral prefrontal cortex, the inferior parietal lobule and lobule VI of the cerebellum is seen during dancing or tapping to musical beats.[31] Medial geniculate nucleus processes complementary movements that occur while listening to music, such as a body sway, foot tap, or simple head nod.[31]

Apart from a dominant biological perspective, music can also be considered from a psychological view point. Music expresses the forms of feelings which the individual is not able to express otherwise, which are basically non lingual and non‑discursive including experiences anchored in the early childhood of the individual as well as the unconscious traumatic experiences.[37] Here, the listeners who associate those experiences are able to do so without pain and anxiety;[38] music helps to bring those memories spontaneously. Psychoanalysis has a distinct contribution in describing the relationship of the human psyche with that of music listening. Most psychoanalytic theorists (including those of ego psychologists) subscribe to the view that there are three possible functions of music ‑ “emotional catharsis for repressed wishes (Id), mastering the threats of trauma (ego) and enjoyable submission to rules (super‑ego).”[1,3] Conceptually, psychoanalytic theory of music depends on upon the libido as an energetic source; the transformation of unconscious content in analogy with dreams, imagination and humor; the dominance of the sublimitive mechanism and; the relative flexibility of the repressive mechanism.[39] Apart from such mature defenses, primary process mechanisms like displacement, condensation and inversion are also suggested to operate in a music intervention.[1]

Hemispheric heterogeneity Although the music is traditionally thought to be mainly processed (i.e., perceptually) in the right hemisphere, according to modular theory of music perception different aspects of music are processed in distinct, although partly overlapping, neuronal networks in both cerebral hemispheres with considerable subjective variability.[32] Goodman[1] stated that music might prove to be a means of transfer between the right and left hemispheres. Melody processing is proposed to be a specialization of the right hemisphere, whereas left hemisphere is postulated to be specialized in rhythm processing.[11] Emotional processing of music however, is noted to primarily involve the right hemisphere, with some contribution from the left frontal lobe.[9,14] Further, this hemispheric variability has been found to be gender specific (as described earlier).[16] Affective prosody, the term referred to the poetic rhythm and emotional tone of language is a function of the right hemisphere.[33] It has been observed that patients with right hemisphere brain lesions lacked prosody, while having intact other major language skills.[34] Neurochemistry Dopamine is postulated to be involved in the enjoyment of music.[9] It is demonstrated to be released from the ventral striatum and in the ventral tegmental area in subjects listening to pleasant music.[35] In addition, role of endorphins/endocannabinoids and nitrous oxide in emotional perception of music and in producing physical Indian Journal of Psychiatry 56(2), Apr-Jun 2014

PSYCHOANALYSIS AND MUSIC

Winnicott[40] suggested that sounds initiated by a child before falling asleep, which soothes him at the time of anxiety (loss) is extended to his later cultural life in the form of music. It has also been suggested that all music (1) reaches down into the preverbal realm of the listener, composer and performer (2) engages his/her emotive life in some way and to some degree and (3) appeals to his/her sense of form as that sense has come to be inextricably bound up with affective and perceptual tendencies.[41] In other words, music is a language that represents emotional life and is suggested to be more easily liable to evade the defenses and to reach the unconscious.[42] Further, music has the capacity to attain all the Maslow’s hierarchy of human needs ‑ physiological, safety, belonging, esteem and self‑actualization; and Jung’s four functions of the psyche ‑ thinking, feeling, sensation and intuition are integral components of the musical experience.[1] 131

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Apart from implying communication, these psychic mechanisms associated with listening music signify a couple more related mental activities. The first is the individualistic responses to a tune, which is claimed to be derived from the projection of his/her, own emotions rather than being solely a direct consequence of music.[43] From this perspective, a musical tune acts rather in the same way a projective test of personality does, (like Rorschach Ink Blot Test), where a “subject is induced to ascribe his own thoughts and attitudes to someone or something outside himself.”[3] And the second is that in spite of the fact that some music may evoke negative feelings, individuals do not get very much disturbed and even sometimes benefited by that. This second theme refers to the age old practice of catharsis.[3] DEVELOPMENTAL PSYCHOLOGY AND MUSIC Tones or sounds occurring either in in a single line (i.e., melody) or in multiple lines (i.e., harmony) and the feeling of movement of sound in time (i.e., rhythm) are the essential elements of music. These are linked to human early development. As a primitive response, melody appears first when an infant’s voice assumes differentiated crying and then babbling. Attending to mother’s voice during infancy is the first melodic affective experience. Rhythm on the other hand has its origin in utero itself, i.e., prenatally. It starts with production of heart beat and chest and limb movements rhythmically. Experience of rhythm occurs when these movements are responded by the fetus through sounds transmitted by vibrations.[1] Rhythm is dynamically invested in various stages of early post natal development like, various cries that change in rhythm at different periods, rhythms of neonatal sucking and mouthing, neonatal movement patterns, etc., Rhythm has a special significance as it is suggested to be the driving factor for music as the pattern or manner in which it is expressed determines the amount of energy invested in responding to music.[1] If we consider Piagetian framework, development of music evolves in the same stages of development proposed by Piaget. Infant emits sound and reacts to changes in sound (sensorimotor stage), sounds begin to acquire commonly shared meaning (symbolic stage), child is able to voice a set of organized sounds to one another (concrete operational stage) and the child is able to analyze a music composition and is able to invent certain patterns of music (formal operational stage).[1] PSYCHOPATHOLOGY AND MUSIC Musical hallucinations Musical hallucinations as a particular type of auditory hallucinations are a disorder of complex sound processing in which the perception is formed by instrumental music, sounds, or songs.[44] Perception can be unilateral or 132

bilateral.[45] Although well‑known they are rare phenomenon in neurological and psychiatric patients. Its prevalence ranges from 0.16%[46] to 2.5%.[47] Prevalence is usually higher in elder population and specifically highest among patients with obsessive compulsive disorder (OCD).[48] Moderate or severe acquired loss of hearing ability or deafness is broadly the main etiological factor.[45] Perceptual release theory best explains this psychopathology.[49] The phenomenon of musical hallucinations is heterogeneous in terms of clinical characteristics and etiology. They are found in many psychiatric disorders such as schizophrenia, major depression, bipolar disorder, anxiety disorders etc.,[48] focal brain lesions, general brain atrophy and epilepsy[45] and intoxication with various substances ‑ opioids,[50] baclofen, ketamine,[51] tricyclic anti‑depressants.[52,53] Content of these hallucinations can either be familiar or unfamiliar, popular radio songs or unpopular, childhood and religious songs and classical or folk.[45] Many heterogeneous mechanisms have been proposed to explain the pathophysiology of musical hallucinations. De‑afferentiation phenomenon ‑ hallucination become prominent when the surrounding noise is low, inner ear disease pathology, dysfunction of the left temporal cortex, ‘parasitic memory’ ‑ musical perception in most cases is never unlearned and represents a so‑called autonomic, that is unchangeable, memory feature which is then experienced by chance or by external stimuli etc.,[45] are some of the proposed theories. Musical obsessions Prevalence of musical halluciantions was specifically found to be highest among patients with OCD.[48] The questionnaire used in the study has been reported not to have differentiated hallucinations from obsessive imagery of music.[54] When compared to musical hallucinations, musical obsessions are more common and represent a mild symptom of obsession.[55] Musical obsession was first described by Kraepelin as a mild form of OCD and subsequently there have been occasional case reports in which musical obsessions were documented.[55] OCD patients with musical obsessions usually explain that the symptoms are irrational music or nonsense musical tunes (e.g. a commercial jingle) recurrently and persistently sounding in their mind and they often attempt to suppress the obsessions by substituting other thoughts without any covert or mental compulsion.[56] The pathophysiology of musical obsessions is understood on the basis of abnormalities in the fronto‑cortico‑basal‑subcortical circuits.[55] MUSIC THERAPY Definition and classification It is defined as “a systematic process of intervention wherein the therapist helps the client to promote health, using music experiences and the relationships developing through them Indian Journal of Psychiatry 56(2), Apr-Jun 2014

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as dynamic forces of change.”[57] Music experiences here mean musical interaction, which can be either free or improvised. It includes either active music playing by patients or active listening to music or both. Other modes include playing composed music on instruments, singing and writing songs. Discussing, reflecting or interpreting themes related to music help clients to understand the potential meaning of the experience. Therapist helps these clients to relate this meaning to situations in the client’s life.[58] According to the World Federation of Music Therapy and the American Music Therapy Association, music therapy is defined as the clinical and evidence based use of music and/or its elements (sound, rhythm, melody, harmony, dynamic and tempo) by a qualified music therapist to accomplish individualized goals within a therapeutic relationship with one client or a group.[59] Use of the term “a qualified music therapist” in this definition helps us to distinguish music therapy from the concept of ‘music medicine,” in which music is employed as a supplementary therapy by those who are not necessarily specialized music therapy. Another term with which it distinguishes from is “music training.” Here, along with the element that sessions are delivered by a musician untrained in music therapy, the delivery of the intervention is in a non‑trial situation.[60]

healing. Magical healing phase is the one where the primitive man believed that certain sounds in the nature were the media with which man can communicate with the invisible, supernatural spirit. The next phase ‑ the religious healing phase is the one where man believed that music and musical instruments are gifts from god and he used them in ritual purification treatments. The scientific phase started with Greek philosophers like Socrates, Aristotle and Plato. Although Aristotle was the first to recognize the cathartic power of music, Plato identified specific harmonic rhythms and modes for different emotions. Further the emergence of renaissance gave a new lease to music therapy in terms of psychology and physiology.

Different schools of psychology ‑ behavioral, psychoanalytic, educational, humanistic, contribute to the various approaches in music therapy. Broadly two basic types of music therapy are described ‑ active and receptive. In the active form, the client makes music either alone or with a therapist or within a group, whereas in the receptive form the client is made to listen to music, exclusively. Receptive or combined approaches are most commonly used in the US, whereas in Europe, active approaches are the most prevalent.[61] Receptive forms are influenced by cognitive‑behavioral or humanistic schools and involve the use of adjunctive techniques such as relaxation, meditation, reminiscing etc., Music experiences and music interaction is the main focus of the active form and this from is psychoanalytically oriented.[61]

Music therapy in India Traditional systems of healing in India such as Ayurveda and Yoga systems include various musical treatment approaches.[62] Indian system of music treatment is defined as an “individualistic, subjective and spiritual art, aiming at personal harmony with one’s own being and not at symphonic elaborations.”[63] Indian music therapy in contrast to the Western form, which has its theoretical background predominantly based on psychotherapy, involves expression of devotional feelings as a key factor.[64] Most common approach used in the Indian form of music therapy is the “raga‑based approach.” It basically involves the application of musical pieces focusing on the swara patterns. This approach is found to be stimulating, anxiolytic and sedative. It has been found that it also

Music therapies can also be classified based on the level of structuring as structured and flexible. Structured music therapy is where more structured forms of music‑making are used and activities are selected before the sessions. On the other hand, flexible form refers to therapy where structure of music‑making and selection of activities is done during dialogue with the client. Most of the studies use some structure as well as some flexibility and extreme forms are rarely observed.[58] Another method of classifying music therapies is based on the focus of attention. Focus of attention may either be on the processes taking place within the music itself or on the verbal reflection of the client’s issues triggered by these musical processes.[58] History of music therapy Goodman[1] has identified three phases that describe the healing ability of music ‑ magical, religious and scientific Indian Journal of Psychiatry 56(2), Apr-Jun 2014

The origin of modern music therapy dates back to post‑world war II period, where several musicians visited various hospitals around United states of America to play music for people suffering from post‑war physical and emotional traumas.[59] Here, clinicians started hiring musicians at their clinics as they observed significant benefits of music on health of post‑war sufferers. Since then there have been many significant milestones in the field of music therapy across the globe [Table 3].

Table 3: Significant milestones in the field of music therapy (adapted from Rose and Bartsch, 2009[59]) Events 1944 1950 1958 1973 1976 1985 1990 1998 2008

First music therapy program at Michigan State University First professional association for music therapists-NAMT First European association, the BSMT First world congress for music therapy took place in Vitoria, Spain Ground for a global association of music therapists was prepared at World Congress in Buenos Aires, Argentina WFMT found at World Congress in Genoa, Italy EMTC was formed Formation of a major professional organization-AMTA Formation of the German music therapy society; legal recognition of practice of music therapy as a profession in Austria

NAMT – National association for music therapy; BSMT – British society for music therapy; WFMT – World federation of music therapy; EMTC – European music therapy confederation; AMTA – American music therapy association

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increases attention and additionally the approach is able to target musical preference and listening pattern.[62] Despite its strong connections to tradition, music therapy currently is in its nascent stage of development. A reason which can be clearly understood is lack of scientific evidence. First conference of Indian music therapy was organized and held at the Nada Center for Music Therapy, Chennai in 2006.[65] Delivering comprehensive training in music therapy, alleviating daily stress in otherwise healthy people, targeting specific populations such as pregnant women to achieve therapeutic effects with music are some of its objectives.[66] It aims at achieving international standards while honoring the distinctiveness of the Indian music.[67] Music within a psychiatric setting Music has numerous applications within a psychiatric setting. It can be in the form of background music, group singing sessions and music to accompany dance apart from music therapy per se. There are numerous benefits of the application of music in a therapeutic environment such as making positive alteration in mood and emotional states, improving concentration and attention span, developing coping and relaxation skills, exploring self‑esteem and personal insight, enhancing awareness of the self and the environment and improving social interactions.[68] Such benefits were acknowledged decades ago at the Central Institute of Psychiatry, Ranchi, which held weekly dance and music “socials” since its establishment in 1918. Since early 1920s, the hospital had a music band too of its own.[69] Currently, each of the 14 inpatient wards have a music stereo facility with which patients listen to classical as well as modern music. Specifically such facility makes the ward environment socially more interactive. This mode of delivering can be broadly conceptualized under music medicine (describe earlier). We believe that every psychiatric in‑patient facility should have such a commodity. Music as therapy in psychiatry ‑ emphasis on efficacy Various psychiatric conditions are treated with either psychopharmacological or psychotherapeutic approaches or a combination of both. Specific to the approach chosen or to that particular disorder, these treatment approaches have been shown to be efficacious in many but not in all patients and not without limits. For example in depression, only small differences have been found between anti‑depressants and active placebos.[70] This implied the need for additional, innovative forms of therapy for treating psychiatric conditions. Music therapy is one such innovative form of therapy. The first formal report on music therapy was published in as early as 1964.[71] However, until the early 1990s, majority of publications were case studies and implication of music therapy in terms of scientific evidence for meager.[59] Last 15‑20 years has seen a significant upshift in the number 134

of clinical studies and reviews in music therapy, especially those on psychiatric disorders. Although the type of disorder influences the therapist’s choices, attitudes and behaviors during music therapy, it is usually designed for an individual patient and his/her specific symptoms or needs rather than for a specific psychiatric diagnosis. Or putting in other words, indications for music therapy in psychiatry or in mental health at large may be based on various aspects, one of which is the primary clinical diagnosis.[58] Clinical studies and reviews on music therapy in psychiatry, however, are based on the primary clinical diagnosis. Psychiatric disorders that have been studied to investigate the effect of music therapy can be broadly classified into ‑ adult and pediatric categories. Among the adult psychiatric disorders are depression, schizophrenia and other psychoses, substance use disorders and dementia, whereas pediatric or child and adolescent psychiatric disorders are autism, attention deficit hyperactivity disorder, learning disorder and mental retardation. Depression and music therapy Maratos et  al.,[61] a Cochrane review identified 16 studies, of which they included five studies in their review. Four studies were randomized trials, one was controlled trial; three studies compared music therapy plus standard care to standard care alone, one study compared music therapy plus standard care with cognitive behavioral therapy (CBT) plus standard care and another compared music therapy plus standard care, CBT plus standard care and standard care alone. The duration of treatment varied between 6 weeks and 10 weeks. Three studies focused on older adults aged between 60/70 and 77/85 years; one on adults aged between 21 and 62 years; and another on adolescents aged 14‑15 years. Sample sizes ranged between 19 and 68 participants. One study used the active form (individual therapy) and the rest used the receptive technique (three group and one individual therapy). Sessions lasted from 60 to 90 min, 1 to 6 times a week. Drop‑out rates in all five studies were very low, with two studies reporting no drop‑outs. Marked variations in the type of interventions used and in the populations studied quantitative data analysis was not applicable. However, four studies reported greater reductions in symptoms of depression among those randomized to music therapy and one study reported no change. None of the studies reviewed compared any two forms of music therapy. Studies included in the review compared music therapy with either standard care or with CBT or a combination of both. Hsu and Lai,[72] not included in the review, assessed the effectiveness of soft music versus simple bed rest for treatment of major depressive disorder. They found significantly lesser depressive scores in the music group. Another study, Jones and Field[73] assessed the Indian Journal of Psychiatry 56(2), Apr-Jun 2014

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effects of massage therapy and music therapy on frontal EEG asymmetry in depressed adolescents and reported significantly attenuated frontal EEG asymmetry during and after the massage and music sessions. No report of significant difference between the groups is on depression reported. Most of the studies in the literature have focused on either adolescents or older adults. Argstätter et al., (2009)[74] in their review of 10 meta‑analyses and four reviews found that music therapy was particularly effective when applied to child and adolescent populations. This proposition may have been influenced by the bias in the number of studies. Gold et  al.[58] studying the dose‑response relationship in music therapy have shown that dosage was a highly significant predictor, with the number of sessions explaining 73% of the variance in effects on depressive symptoms; whereas design and disorder showed no relation to the effect size. This finding implies that more number of sessions of music therapy is required to treat depressive symptoms irrespective of the underlying disorder. Literature search was conducted to find studies conducted after the Cochrane review. Erkkilä et  al.[75] published the study protocol, according to which they were to examine the efficacy of active music therapy in an individual setting on 85 (largest sample size of all studies) adults aged between 18 and 50 years with depression. As proposed, Erkkilä et al.[76] compared active music therapy with standard care in biweekly sessions that went on for 3 months. However, they could only include 79 (still the largest sample size) participants out of 91 participants initially assessed. Patients receiving music therapy showed greater improvement than those receiving standard care alone in depression symptoms. Similarly, Choi et al.[77] found that fifteen sessions of music intervention significantly improved depression compared with a control group. Indian studies Among these, two studies were conducted in India with Indian classical music. Deshmukh et  al.[78] studied 50 individuals diagnosed with major depressive disorder. Participants in the music group were made to listen to music with selected ragas while the control group received treatment with psychotropics. Depression scores improved with the music group comparable to the control group and these effects persisted beyond the treatment period. Four out of the 18 participants, included in the other Indian study by Rumball,[79] were diagnosed of depression and all four of them scored significantly lesser depression scores on the self‑rated questionnaire both during and after the sessions. Major limitations of this study were lack of randomization and extremely small sample size. The sessions included a short quiet prayer (5‑10 songs) for 1 h with discussion Indian Journal of Psychiatry 56(2), Apr-Jun 2014

of the “feeling” of the song; this pattern lacked a proper standardization. Among other Indian studies, Singh and Khess[80] (unpublished dissertation) assessed the efficacy of music therapy as an adjuvant treatment for patients with major depressive disorder. Participants in the music group were compared with a control group that received treatment with psychotropics. Results showed that both the experimental and control groups improved significantly over a period of 4 weeks and there was significantly greater improvement in the music group than the group receiving only psychotropic medications. Another study, Gupta and Gupta,[81] which lacks a clinical setting and randomization, has used Indian music, i.e., listening to one raga, played on the flute (without lyrics) for 30 min a day for 20 days and has found a significant decrease in the scores on depression, state and trait anxiety in study participants compared with the pre‑test measurements. Overall, studies on depression and music therapy suggest that music therapy has significant efficacy on depression. Further, it can be recommended for treating depression that is associated with other psychiatric disorders. Schizophrenia and music therapy Apart from case studies, one of the earliest studies reported on the effect of “music” in schizophrenia patients is Margo et al.[82] They investigated the effect of variations of auditory output (according to the amount of structure present and its attention commanding properties) on duration, loudness and clarity of hallucinations. They concluded that both stimulation per se and the amount of structure determine hallucinatory experiences. However Pfeiffer et al.[83] was the first to study the effect of “music therapy” in patients of schizophrenia. Literature search revealed that since 1987, more than 25 studies on music therapy in schizophrenia patients have been published in MedLine/PubMed indexed journals. Of which, eight are randomized control trials, five are review cum meta‑analysis and the rest non‑controlled or partially controlled studies. Summary of the non‑ or partially controlled studies Most studies compared music therapy plus standard care with standard care alone, others were pre‑post designs. Gold et al.[84] compared music plus standard care, standard care alone and no treatment groups, while one study, i.e., Leung et al.[85] studied the comparative efficacy of karaoke singing and simple singing. Sample size ranged from 8[86] to 81.[87] Schizophrenia population included had both acute[60,88] and chronic patients. Both, group and individual, active and receptive forms were studied. Frequency of sessions varied from 1/week[83,88‑91] to 5/week.[60] Duration of therapy lasted from 2 weeks[60] to 6 months.[83] Most of the studies found positive results except Pfeiffer et al.[83] which found no improvements in psychopathology 135

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as well as recreational and social behaviors. Outcome measures in these positive results were clinical symptoms ‑ auditory hallucinations,[92] positive and negative symptoms,[60,87,93] specifically negative symptoms[84,88,94,95] and general clinical status;[89,96] and social symptoms ‑ contact making and emotional expression,[96] social interaction and relations,[85,90,91,94] quality of life and intimate non‑verbal communication,[89] social disability,[95] attitude toward help seeking,[86] psychosocial orientation[88] and overall social functioning.[84] In addition, Jin[93] found that and the mean dosage of medication required in the experimental group was significantly less than in the control group. Randomized control trials Recently, a Cochrane review, Mössler et al.[97] reviewed the eight randomized controlled trials (RCTs) done in music therapy on schizophrenia. The duration of studies ranged from 1 to 4 months. Short‑term effects were investigated in five studies and three studies reported medium‑term effects. Three studies restricted their inclusion to only schizophrenia, one each to chronic and type II subtypes of schizophrenia. Most of the studies were conducted on in‑patients, whereas one study included both in‑ and out‑patients. Sample size ranged from 30 to 81. All studies compared music therapy plus standard care with standard care alone. The setting varied from individual therapy (in one study) to group therapy (in six studies). One other study used a combination of the group and individual music therapy. Four studies included exclusive receptive modality, two trials included exclusively active mode and two used both active and receptive forms. More structured form of therapy was used in six studies (one study ‑ exclusively fixed), whereas in the remaining two it was more flexible and process oriented. The frequency of sessions varied greatly from 1 to 6/week. Total number of sessions varied from 7.5 to 78. The results showed a significant effect of music therapy on global state. Music therapy showed moderate to large effects on general mental state, negative symptoms, depression and anxiety. There were the difference between individual studies and they were explained based on the number of sessions (music therapy providing more than 20 sessions showed significant effects on most mental state scores) and quality of music therapy applied. Significant effect on social functioning has been found for “high‑dose” music therapy whereas no significant effects were found on cognitive functions for “low‑dose” music therapy (note: Studies examining cognitive tasks delivered less number of sessions). Quality‑of‑life showed no significant effect and was addressed only in one “low‑dose” study. Other review cum meta‑analyses Apart from the Cochrane review, we found four other review‑cum meta‑analyses on music therapy and schizophrenia. Yi et al.[98] reviewed 11 articles, synthesized six 136

RCTs and concluded that short‑term effect of music therapy is positive for patients with chronic schizophrenia. They too concluded that short‑term effect of music therapy (especially on negative symptoms and general psychopathology) is positive for patients with chronic schizophrenia. Silverman[99] conducted meta‑analysis on 19 studies and indicated that music therapy has proven efficacy on psychosis. In addition, they commented that no differing effects of live versus recording, active versus receptive and classical versus non‑classical forms were noted. Gold et  al.[58] combined all existing prospective studies and examined the influence of study design, disorder type and number of sessions. They found that in schizophrenia patients, music therapy when added to standard care has significant effects on negative symptoms, depression, anxiety and global functioning. Indian studies Among the two published studies is Rumball,[79] which studied nine schizophrenia patients and found that in all the nine patients “energy” (sluggishness) improved and this was implicated as improvement in negative symptoms. Study by De souse and De souse[100] is the largest randomized control trial in terms of sample size (272 chronic schizophrenia patients). Music therapy given as an adjunct to medications found that scores on positive and negative syndrome scales and on the anergia, activation and depression subscales of the positive and negative syndrome scale (PANSS) improved significantly and also were significantly better than in the control group. Three studies were conducted at the Central Institute of Psychiatry, Ranchi on music therapy examining various outcome factors in schizophrenia patients. Chakrabarty et  al.[3] (unpublished dissertation) divided 60 patients into two groups (experimental‑receiving music therapy, i.e., 15 alternate day sessions lasting 45 min each plus standard care and control group‑receiving standard care alone) by random sampling and found that experimental group had significantly lower scores on thought disturbance, depression and percentage of disability than the control group. Other two studies examined the effect of music therapy on cognitive functions. Banerjee et  al.[101] (unpublished dissertation) studied 32 patients and found significantly better performance on reading time in Part W and Part C of the stroop test in schizophrenia patients receiving music therapy. Recently, Sitaram et  al.[102] (unpublished dissertation) that studied 40 patients with schizophrenia and found that the experimental group that received music therapy (3/week for 6 weeks) showed significantly higher improvement in positive symptoms, negative symptoms, general psychopathology scores, quality‑of‑life as well as performance on the trail making (A and B) test and auditory and visual working memory. Indian Journal of Psychiatry 56(2), Apr-Jun 2014

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Dementia and music therapy Promising pharmacological interventions are available for the treatment of dementias, but have a restricted ability to treat many of its features. Non‑pharmacological treatments and research into this dimension is relatively ignored. Common approach in dementia treatment is to limit the extent and rate of progression of the pathological processes and slow down the cognitive decline. Music therapy is one of the novel approaches proposed for achieving such targets. Greatest advantage of music therapy is that it creates an alternate mode of communication to patients who have limited ability to speak and understand language. Vink et al.,[103] a Cochrane review, analyzed 10 randomized control trials. Seven of them were parallel and three were crossover designs. Three were receptive and individual, whereas seven were active and group music therapy interventions. Out of the three crossover design studies, two received receptive forms (one of them studied preferred vs. classical music) and one received active form of music therapy. Sample size ranged from 18 to 60 (in two studies) participants. Duration of each treatment session was 30 min in all studies except one. Frequency of sessions varied from 1/day to 2/week. Duration of total therapy ranged from 15 days to 6 months. Outcome measures were very heterogeneous. Discrete measures rather than a comprehensive set of outcomes were studied in most papers. They were aggression, agitation (in two studies), wandering behaviors or behavioral problems in general (in three studies); language functioning; and anxiety and depression. Only one study investigated social, cognitive and emotional functioning together. Both individual receptive and active group music therapy were more effective than control or no intervention on behavioral problems; have doubtful effect on cognitive skills; and are effective on social and emotional functioning including depression and anxiety. What type of dementia responds well to such forms of therapy? What is the predictive ability of age of onset of dementia in the effect of music therapy? Such queries are still unanswered. Indian studies No study conducted in India has investigated the role of music therapy on dementia. Substance use disorders and music therapy Alcohol portrayals in music videos and listening to music and songs that refers to substance use in one way or the other effect the substance use or seeking behavior in patients with substance use disorders. When society mourns for rock stars, who die from overdoses; then people especially at risk like adolescents believe all role models use drugs and its okay to use drugs. Moreover recently, Kornreich Indian Journal of Psychiatry 56(2), Apr-Jun 2014

et  al.[104] has shown that alcohol dependent patients who are completing detoxification have impaired capacity to recognize emotions in music. Here, music rather than being a help to persons with psychiatric disorders is being seen as a taboo. However, all is not worse for music with respect to substance use disorders. Koordeman et al.[105] has recently concluded that on‑screen alcohol exposure does not affect everyone and not all media alcohol portrayal provokes substance use. In addition, music therapy has been shown to be able to engage patients with substance use disorders into other usual therapies used in these disorders.[106] Indian studies No study is published until date from India with respect to substance use and music. Ongoing dissertation Choudhary et  al.,[107] at the Central Institute of Psychiatry, Ranchi is investigating the effect of music therapy in patients with alcohol dependence syndrome. Pediatric psychiatric disorders and music therapy As discussed earlier, there has been a lot of work on adolescent depression. The other major disorder in the child and adolescent age group is autism and autism spectrum disorders. Four systematic reviews are available in the literature on the effect of music therapy on autism. Whipple[108] concluded that music therapy is effective for people with autistic spectrum disorders and Ball[109] concluded that effects of music therapy on autism are unknown. A more comprehensive systematic Cochrane review, Gold et al.,[110] included three controlled studies (two crossover‑ and 1 parallel design). Most of the participants included in the studies were boys and were in the age group of 2‑9 years. The duration of therapy ranged between 1 and 4 weeks. Mental retardation was mild to severe and autism was mild to moderate in the patients. All three studies included individual daily sessions. Two used receptive form whereas one delivered active music therapy. All studies compared music therapy to “placebo” activity, which matched the music therapy condition, but there was no music used. Outcome measures were communication skills and behavioral problems. The results showed a significant effect of music therapy on communication skills and only marginal effect on behavioral problems. Recently, in another review, Simpson and Keen[111] identified 20 experimental studies. Interestingly in contrast to Gold et al.,[110] they found that most studies used active or improvisational music therapy technique. Outcome measures in the identified studies included socialization in addition to communication and behavior. Overall, the conclusion was that the evidence to generalize the finding that music therapy is effective is limited. A proposed randomized controlled trial of improvisational music therapy in 235 children with autism spectrum disorder, Geretsegger et  al.[112] has taken up this issue of generalizability. In addition, Lanovaz and Sladeczek[113] studied the effects of music intensity manipulation on vocal stereotypies in children with autism 137

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and found that although, non‑contingent access to music reduced immediate vocal stereotypies, it had only slight effects on subsequent engagement. Among other pervasive developmental disorders, children with Rett syndrome have been shown to benefit from music therapy in terms of indulgence in music, minute motion, language, personal relation and sociality.[114] Other psychiatric disorders where music therapy has been studied are attentional deficit hyperactivity disorder, learning disorder and epilepsy. Contrasting findings are reported in patients with attention deficit hyperactivity disorder (ADHD). Rickson[115] found that music therapy contributes to reduction in a range of ADHD symptoms in the classroom setting, Pelham et  al.[116] has shown no additional effects of music on the classroom behavior and performance. In determining the efficacy of using music as a remedial strategy to enhance the reading skills, Register et  al. (2007)[117] found that students a specific reading disability receiving music therapy improved significantly on word decoding, word knowledge, reading comprehension and the test total. Lin et  al.[118] found that epileptiform discharges in 18 children with epilepsy with well‑controlled seizures decreased significantly after listening to Mozart music for 8 min once a day before bedtime for 6 months. Indian studies Sairam[119] has designed three methods of music training for children with special needs. Music with rapid fire orchestral rhythms has to increase the participation and alertness and manage anger; and music without rhythms to induce relaxation; and repeated rhythms to regulate the emotions. WHEN TO USE WHAT? So far we have discussed the effect of music therapy on various psychiatric disorders. Coming to the question of what type of music therapy to be used in a particular disorder, we see that it is the active/improvisational form of music therapy that is predominantly used. Gold et al.[58] has suggested that active music therapy techniques can be more useful in severely disturbed patients and that more receptive approaches can be of better efficacy in milder conditions. Apart from this there are no other guidelines, which suggest the indication of other types, i.e., group versus individual etc., indication of duration and frequency of each session and others. HOW DOES IT WORK? Next question is how does music therapy work? Practice of music therapy in the modern day is mostly based on the scientific evidences. This section would deal with the scientific evidences that explain how music therapy works. Apart from the neuroscience explanation (discussed earlier), there are other answers to it too. 138

1. The phenomenon that is able to generate tension can also assist in reducing it.[59] 2. An underlying assumption is that everyone is endowed with a basic musicality.[120] 3. Music as a medium for emotional expression may help patients to improve their expressive range and diminish affective flattening. Music may be used as a safe and socially acceptable form in which they can express feelings with ease.[97] 4. Making music together is always a social endeavor, inherently connected to forming and building social relationships and may therefore help patients to overcome social deficits ease.[97] 5. Making music is in itself motivating, hence work well in those who otherwise have little or no motivation.[121] 6. Lack of pleasure and meaningfulness in life associated with psychiatric disorders are made to overcome through esthetic experience inherent to music therapy.[122] 7. Rather obvious, the act of playing musical instruments requires purposeful physical movement and hence it improves “psychomotor” activity. Playing instruments may improve gross and fine motor coordination in dementia patients with motor impairments.[103] 8. Relational dimension in the pre‑verbal interaction stage of parent‑baby relation, we first learn how to take pleasure in the possibilities that the world around us has to offer‑“experiences of musicality.” From this perspective, the role of the therapist can be seen as neo‑parental, i.e., musically nurturing the patient in order to facilitate a similar process of discovery of self and self in relation to others.[122] This is the rationale for using music therapy for individuals with communication disorders, i.e., autism.[110] 9. Singing critically depends upon right‑hemispheric structures; hence it can be exploited to facilitate speech reconstruction in patients suffering from dementias, with predominantly left‑hemisphere lesions.[117] 10. In patients with dementia, singing can further help the development of articulation, rhythm and breathe control. Musical rhythm may help them to organize time and space.[103] Although, music therapy based on scientific evidences is being practiced predominantly, even today practice of music as religious healing is apparent. Indian music healing methods especially are more based on religious healing and a perfect blend of religious and scientific methods might create wonders for Indian form of music therapy. REFERENCES 1. 2. 3.

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Source of Support: Nil, Conflict of Interest: None declared

Indian Journal of Psychiatry 56(2), Apr-Jun 2014

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