Issues in Mental Health Nursing

ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: https://www.tandfonline.com/loi/imhn20

The Impact of Combined Music and Tai Chi on

Depressive Symptoms Among Community-
Dwelling Older Persons: A Cluster Randomized
Controlled Trial

S. J. Liao, M. P. Tan, M. C. Chong & Y. P. Chua

To cite this article: S. J. Liao, M. P. Tan, M. C. Chong & Y. P. Chua (2018) The Impact of
Combined Music and Tai Chi on Depressive Symptoms Among Community-Dwelling Older
Persons: A Cluster Randomized Controlled Trial, Issues in Mental Health Nursing, 39:5, 398-402,
DOI: 10.1080/01612840.2017.1417519

To link to this article: https://doi.org/10.1080/01612840.2017.1417519

Published online: 13 Feb 2018.

Submit your article to this journal

Article views: 1071

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=imhn20
ISSUES IN MENTAL HEALTH NURSING
, VOL. , NO. , –
https://doi.org/./..

The Impact of Combined Music and Tai Chi on Depressive Symptoms Among
Community-Dwelling Older Persons: A Cluster Randomized Controlled Trial
S. J. Liao, MN, RNa,b , M. P. Tan, PhD c,d
, M. C. Chong, PhD, RNa , and Y. P. Chua, PhDe
a
University of Malaya, Department of Nursing Science, Faculty of Medicine, Kuala Lumpur, Malaysia; b Department of Nursing Science, Ya’an
Polytechnic College, Ya’an City, Sichuan Province, China; c University of Malaya, Division of Geriatric Medicine, Department of Medicine, Faculty of
Medicine, Kuala Lumpur, Malaysia; d University of Malaya, Ageing and Age-Associated Disorders Research Group, Wellness Research Cluster, Kuala
Lumpur, Malaysia; e Institute of Educational Leadership, University of Malaya, Kuala Lumpur, Malaysia

ABSTRACT
Background: The effectiveness of pharmacological treatment may be limited in older persons. Several stud-
ies using Tai Chi or music therapy separately confirmed positive effects in the reduction of depressive symp-
toms. We conducted a cluster randomized controlled trial to evaluate the possible synergistic effect of com-
bined music and Tai Chi on depressive symptoms. Methods: One hundred and seven older adults with mild
to moderate depressive symptoms were recruited from Ya’an city. Fifty-five participants were cluster ran-
domized to combined music and Tai Chi group for three months, while the other fifty-two individuals were
randomized to the control group that entailed routine health education delivered monthly by community
nurses. The primary outcome of depressive symptoms was measured with the Geriatric Depression Scale
(GDS) at baseline and monthly for three months. Results: At three-month follow-up, a statistically significant
improvement in depressive symptoms was found in the intervention group compared with control group
(F(3,315) = 69.661, P < 0.001). Following adjustments for socio-demographic data, the true effect of interven-
tion on depressive symptoms was significant (F = 41.725, P < 0.01, ηp2 = 0.574). Conclusions: Combined music
and Tai Chi reduced depressive symptoms among community-dwelling older persons. This represents an
economically viable solution to the management of depression in highly populous developing nations.

Introduction
Depressive symptoms affect about 35.1% of community-
dwelling older persons (Wang, Song, Chen, Wang, & Ling,
2015), and 65% of institutionalized older persons (Kowalska,
Rymaszewska, & Szczepanska-Gieracha, 2013). In South-West
China, depressive symptoms have been reported in 24.3% of
community-dwelling older persons (Giri, Chen, Yu, & Lü,
2016). Many individuals being treated for depression receive
medication therapy only (Wu et al., 2017). Drug treatment,
however, is often limited by lack of efficacy, side effects and
drug–disease interaction that are particularly problematic
among frail older persons (Konnert, Dobson, & Stelmach,
2009). It is, therefore, important to develop efficient, convenient
and cost-effective solutions of reducing the burden of depressive
symptoms among older persons.
Exercise has been found to be effective in reducing depres-
sive symptoms (Khanzada, Soomro, & Khan, 2015). However,
because older persons often have lower physical-function capac-
ity, not all kinds of exercise is suitable for them (Chan, Wong,
Onishi, & Thayala, 2012). Tai Chi is widely accepted by health
professionals as a moderate intensity aerobic exercise (Chi,
Jordan-Marsh, Guo, Xie, & Bai, 2013), which could improve
the older person’s physical and psychological well-being (Zheng
et al., 2015), and reduce depressive symptoms (Burschka,
Keune, Hofstadt-van Oy, Oschmann, & Kuhn, 2014; Wang
et al., 2014). No adverse effects have been reported in previous
studies (Ahn & Song, 2012). Music therapy and even listening
to music have been found to reduce the symptom burden of
depression (Chan et al., 2012; Chen, Hannibal, & Gold, 2016).
Based on the separate effectiveness of Tai Chi and music
mentioned above, we combined Tai Chi with soft relaxing
Chinese folk music, to determine whether a synergistic effect
would be present in the control of depressive symptoms among
community-dwelling older persons in South-West China.
Methods
Study design
This study was a two-arm cluster randomized controlled trial
determining the effect of a 3-month Tai Chi with Chinese
folk music group therapy on depressive symptoms among
community-dwelling older persons.
Participants
Study participants were 107 older persons with mild to mod-
erate depressive symptoms, who were screened by Geriatricx

CONTACT Chong Mei Chan, PhD, RN mcchong@ummc.edu.my University of Malaya, Department of Nursing Science, Faculty of Medicine,  Kuala Lumpur,
Malaysia.
©  Taylor & Francis Group, LLC

Figure . Subjects progress through the trail.
Depression Scale (GDS). Participants were recruited from eight
communities in Ya’an city, Sichuan Province, China. Each of the
eight communities involved in the study was cluster random-
ized using computer generated random number sequences. The
progress of subjects in this study was displayed in Figure 1.
Inclusion criteria
Participants recruited into the study needed to fulfill the follow-
ing criteria:
(i) Aged 60 years or above, (ii) residing in the targeted com-
munities for at least one year, (iii) mentally adequately alert
to complete the intervention as judged by trained researchers,
(iv) with a GDS score of 11–25 (inclusive of 11 and 25), and
(v) agreeable to take part in entire intervention process.
Exclusion criteria
Participants with the following characteristics were excluded:
(i) Individuals who were bedridden, or with severe hearing
or visual impairment leading to difficulty completing the inter-
vention, (ii) those with a stroke or cardiovascular event within
the past 6 months and the presence of other conditions which
require medical assessments prior to physical exercise, (iii) indi-
viduals with a GDS score of 26 or greater (severely depressed),
ISSUES IN MENTAL HEALTH NURSING 399
(iv) those who were receiving medical treatment for depression,
(v) those who exercised more than three times per week.
Intervention
Individuals randomized to the intervention group received
combined music and Tai Chi delivered within their cluster as
group therapy. This therapy involved 24 movements in the style
of Yang’s Tai Chi, accompanied by soft and relaxing Chinese
folk music. Each intervention session took up a total of 50 min:
5-min warm up, 40-min Tai Chi exercises and 5-min cool down.
The length and intensity of the exercises were decided upon
based of the World Health Organization’s recommendation of
at least 150 min of moderate-intensity aerobic physical activ-
ity each week or 75 min of vigorous-intensity aerobic physical
activity each week, or an equivalent combination of the above
(Behrman & Ebmeier, 2014). Individuals in intervention group
were asked to participate in three sessions per week for three
consecutive months. Individuals assigned to the control group
received routine health education monthly delivered by a com-
munity nurse.
Measurement instruments
The Chinese version of the GDS was used to assess the depres-
sive symptoms. The GDS is a self-rated scale consisting of 30
400 S. J. LIAO ET AL.
items with responses of “yes” or “no” to measure a person’s emo-
tional state in the past week. The entire score of GDS ranges from
0 to 30, with a total score 0–10 indicating no depression, 11–20
suggesting mild depression, 21–25 indicating moderate depres-
sion and 26–30 indicating of severe depression. Good reliability
and validity has been demonstrated in the Chinese population
with a Cronbach’s-α coefficient of 0.94 (Chiu et al., 1994).
Data collection
Data were collected during May–July 2016. Written informed
consent was obtained from all participants prior to recruitment.
All participants completed the form independently, among
those with low-levels of literacy, the researchers read out the
items verbatim and recorded answers on their behalf accord-
ingly. Socio-demographic data was collected at the beginning
of the study. The GDS was administrated on four occasions
throughout the duration of the 3-month study: baseline and
at the end of the first, second month and third month after
recruitment.
Blinding
This study was a single-blinded trial. It was not possible to blind
participants to the intervention. Therefore, only assessors were
blinded to treatment allocation while collecting data, to reduce
subjective bias.
Data analysis
Data were analyzed using the SPSS software, version 22.0. All
statistical tests used were two-sided, and a P-value of less than
0.05 was considered statistically significant. Descriptive statis-
tics such as mean and standard deviation (SD), and proportion
with percentages in parentheses, were used to summarize the
socio-demographic data and GDS scores. Chi-square and inde-
pendent t-test were used to conduct baseline comparison. Split-
Plot ANOVA was used to compare the difference within groups.
Ethical consideration
This study had been registered on 30 November 2014 (clini-
cal trial registration number: ChiCTR-IPR-15006300). Written
informed consent was obtained from all participants prior to
recruitment. Participation in the study was entirely voluntary,
and participants were informed of their rights to withdraw at
any point without any adverse influence in their care. Rewards
were provided in terms of blood pressure and blood sugar tests
at no fee and supermarket vouchers totaling 50 Yuan to each par-
ticipant who had completed the whole study.
Results
Socio-demographic data
One hundred and forty-two older individuals from eight com-
munities were screened for eligibility. One hundred and four-
teen fulfilled the study criteria and all individuals agreed to
take part. Following cluster randomization, 58 participants in
Huaxinjie, Tuqiao, Qiangjiang and Shangba were allocated to the
intervention group, while 56 participants in Hanbei, Yaoqiao,
Yucai and Weijiagang were allocated to control group. Seven
participants were eventually lost to follow up, three from the
intervention group, four from the control group. One hundred
and seven, fifty-five and fifty-two in the intervention and control
group, respectively, were included in the final analysis (Figure 1).
The participants’ age ranged from 60 to 93 years old, 66 were
women (61.7%). The basic characteristics of both groups were
summarized in Table 1.
Changes in depressive symptoms
Split-Plot ANOVA was adopted to identify the changes in
depressive symptoms between the two groups based on repeated
measures, which indicated that combined music and Tai Chi
group therapy had effectively reduced the severity of depres-
sive symptoms (F(3,315) = 69.661, P < 0.001) (Table 2). After
analysis with socio-demographic data as control variables, the
true effect of combined music and Tai Chi in relieving depres-
sive symptoms among community-dwelling older persons was
assured (F = 41.725, P < 0.01; ηp 2 = 0.574), with the large effect
size of 0.574 (Cohen, 1988). (Table 3).
Discussion
The findings of this study contribute to existing knowledge on
non-pharmacological management of depressive symptoms by
supporting the effectiveness of combined music and Tai Chi
for depressive symptoms among community-dwelling older per-
sons in South-West China.
Tai Chi is a traditional Chinese martial art, and is com-
monly believed to increase physical activity and lower depres-
sion among older persons(Sherman, 2012) by combining mind
management with body movement, as well as increasing social
participation (Chi et al., 2013). The movements and cadence
emphasize the philosophy of “letting go” of interpersonal con-
flicts and stress, and maintaining peace of mind and a sense
of harmony, which are congruent with the aspiration of life
fulfillment (Wang et al., 2010). Biological pathways activated
by exercise like Tai Chi include increases in central nore-
pinephrine transmission, serotonin synthesis, beta-endorphins
and metabolism, and increased neurogenesis and synaptic plas-
ticity in key brain regions that are involved in mood control
(Rosenberg & Lenze, 2013).
Although many previous studies have demonstrated the
effectiveness of Tai Chi in reducing depression (Burschka et al.,
2014; Chi et al., 2013), yet the benefit of Tai Chi remains contro-
versial (Yin & Dishman, 2014). The difference in effect may be
attributable to differences in population characteristics or length
of intervention. Our findings have also demonstrated a dose-
dependent response with increasing benefit observed over the
time-period individuals received intervention.
The effect of music as a single intervention on depressive
symptoms has been evaluated by several studies. A random-
ized controlled trial conducted in Singapore found that listening
to music helped reduce depressive symptoms in older persons
(Chan et al., 2012). A recent quasi-experimental study has also
shown that music therapy had a valuable effect on depression
among older persons in nursing homes (Gopi & Preetha, 2016).
It was reported that the limbic system could be influenced by
 ISSUES IN MENTAL HEALTH NURSING 401

Table . Baseline characteristics of participants.

Characteristics Overall N =  Intervention n =  Control n =  P-value

Age, Mean ± SD . ± . . ± . . ± . .

Gender, n (%) .
Male  (.%)  (.%)  (.%)
Female  (.%)  (.%)  (.%)
Monthly income(RMB), Mean ± SD . ± . . ± . . ± . .
Marital status, n (%) .
Married  (.%)  (.%)  (.%)
Single, widow and devoiced  (.%)  (.%)  (.%)
Living arrangements, n (%) .
Living with family  (.%)  (.%)  (.%)
Living alone  (.%)  (.%)  (.%)
Negative life events (past three years), n (%) .
Yes  (.%)  (.%)  (.%)
No  (.%)  (.%)  (.%)
Educational background, n (%) .
Secondary and below  (.%)  (.%)  (.%)
College and above  (.%)  (.%)  (.%)
Exercise habit, n (%) .
Once a week or less  (.%)  (.%)  (.%)
More than twice a week  (.%)  (.%)  (.%)
Score of GDS, Mean ± SD . ± . . ± . . ± . .

SD = Standard deviation; GDS = Geriatric Depression Scale.

Table . Geriatric depression scale scores for intervention and control participants. was chosen. This could have created bias in sample selection. It
Intervention Control was not possible to blind participants to the intervention, so only
n =  N =  F-statistic assessors were blinded to treatment allocation. In addition, we
Time point Mean ± SD Mean ± SD (df = ,) P-value only compared Tai Chi and music in combination with a con-
Baseline . ± . . ± . . <. trol group. In order to demonstrate a true synergic effect, we
-month . ± . . ± . would have had to include Tai Chi and music as single inter-
-month . ± . . ± . ventions as two additional intervention groups. Therefore, the
-month . ± . . ± .
findings of our study should go toward informing the power cal-
SD = Standard deviation. culations for a future larger intervention study to evaluate the
mechanisms of action as well as to confirm synergism between
musical pitch and rhythm if engaged in processing music stim- Tai Chi and music. Interventions were provided for 3 months, in
uli (Guetin et al., 2009). Based on these positive findings, it is this study, which is of similar length to other studies involving
possible that music evokes a psychological response by altering exercise interventions, however, the long-term effect of exercise
mood (Murrock & Higgins, 2009). interventions is not demonstrated in this study. In addition, it is
This study suggests that combining the slow-meditative also unclear whether exercises were continued by individuals on
movements of Tai Chi with soft Chinese folk music may lead to their own at the end of the intervention.
a synergistic effect. The intervention in our study was delivered
by Tai Chi instructors rather than psychologists. As developing
countries rarely have enough trained clinical psychologists, such Conclusion
an intervention may well prove to be an economically viable Combined music and Tai Chi reduced depressive symptoms
solution to reducing the burden of depressive symptoms in an among community-dwelling older person. This may represent
older population. an economically viable solution to management of depression
It was not possible to randomize individuals to intervention in highly populous developing nations. The potential synergis-
and control arms, which was why a cluster randomized approach tic effect of exercise and music as well as the long-term effects of
the intervention will need to be explored in future studies.
Table . True effect of combined music and Tai Chi on depressive symptoms after
controlling socio-demographic variables.

Effect F df P ηp  Declaration of interest

Treatment × age . , . . No potential conflicts of interest were disclosed.
Treatment × gender . , . .
Treatment × marital status . , . .
Treatment × living situation . , . . Funding
Treatment × monthly income . , . .
Treatment × negative life events . , . . This work is supported under Grand challenge PISA [GC002C-14HTM].
Treatment × exercise habit . , . .
Treatment × educational background . , . .
Treatment × group . , <. .
ORCID
Effect size based on Partial Eta Squared ηp : Small = .; Moderate = .;
Large = .. M. P. Tan http://orcid.org/0000-0002-3400-8540
402 S. J. LIAO ET AL.
References
Ahn, S., & Song, R. (2012). Effects of Tai Chi Exercise on glucose control,
neuropathy scores, balance, and quality of life in patients with type 2
diabetes and neuropathy. The Journal of Alternative and Complemen-
tary Medicine, 18(12), 1172–1178. doi:10.1089/acm.2011.0690
Behrman, S., & Ebmeier, K. (2014). Can exercise prevent cognitive decline?
The Practitioner, 258(1767), 17–21, 2–3.
Burschka, J. M., Keune, P. M., Hofstadt-van, Oy, U., Oschmann, P., &
Kuhn, P. (2014). Mindfulness-based interventions in multiple scle-
rosis: Beneficial effects of Tai Chi on balance, coordination, fatigue
and depression. BMC Neurology, 14(1), 165. doi:10.1186/s12883-014-
0165-4.
Chan, M. F., Wong, Z. Y., Onishi, H., & Thayala, N. V. (2012).
Effects of music on depression in older people: A randomised
controlled trial. Journal of Clinical Nursing, 21(5–6), 776–783.
doi:10.1111/j.1365-2702.2011.03954.x.
Chen, X.-J., Hannibal, N., & Gold, C. (2016). Randomized trial of group
music therapy with Chinese prisoners: Impact on anxiety, depression,
and self-esteem. International Journal of Offender Therapy and Com-
parative Criminology, 60(9), 1064–1081. doi:10.1177/0306624X155
72795.
Chi, I., Jordan-Marsh, M., Guo, M., Xie, B., & Bai, Z. (2013). Tai chi and
reduction of depressive symptoms for older adults: A meta-analysis of
randomized trials. Geriatrics & Gerontology International, 13(1), 3–12.
doi:10.1111/j.1447-0594.2012.00882.x.
Chiu, H., Lee, H., Wing, Y., Kwong, P., Leung, C., & Chung, D. (1994). Reli-
ability, validity, and structure of the Chinese Geriatric Depression Scale
in a Hong Kong context: A preliminary report. Singapore Medical Jour-
nal, 35, 477–480.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences. Hils-
dale, NJ: Lawrence Earlbaum Associates, 2.
Giri, M., Chen, T., Yu, W., & Lü, Y. (2016). Prevalence and correlates of cog-
nitive impairment and depression among elderly people in the world’s
fastest growing city, Chongqing, People’s republic of China. Clinical
Interventions in Aging, 11, 1091. doi:10.2147/CIA.S113668.
Gopi, D., & Preetha, A. (2016). Effectiveness of music therapy on depres-
sive symptoms among elderly in selected geriatric homes. Interna-
tional Journal of Nursing Education, 8(3), 163–166. doi:10.5958/0974-
9357.2016.00110.0.
Guetin, S., Portet, F., Picot, M., Pommié, C., Messaoudi, M., Djabelkir, L.,
… Touchon, J. (2009). Effect of music therapy on anxiety and depres-
sion in patients with Alzheimer’s type dementia: Randomised, con-
trolled study. Dementia and Geriatric Cognitive Disorders, 28(1), 36–46.
doi:10.1159/000229024.
Khanzada, F. J., Soomro, N., & Khan, S. Z. (2015). Association of physical
exercise on anxiety and depression amongst adults. Journal of the Col-
lege of Physicians and Surgeons Pakistan, 25(7), 546–548.
Konnert, C., Dobson, K., & Stelmach, L. (2009). The prevention of
depression in nursing home residents: A randomized clinical trial
of cognitive–behavioral therapy. Aging and Mental Health, 13(2),
288–299. doi:10.1080/13607860802380672.
Kowalska, J., Rymaszewska, J., & Szczepanska-Gieracha, J. (2013). Occur-
rence of cognitive impairment and depressive symptoms among the
elderly in a nursing home facility. Advances in Clinical and Experimen-
tal Medicine, 22(1), 111–117.
Murrock, C. J., & Higgins, P. A. (2009). The theory of music, mood and
movement to improve health outcomes. Journal of Advanced Nursing,
65(10), 2249–2257. doi:10.1111/j.1365-2648.2009.05108.x.
Rosenberg, A., & Lenze, E. (2013). More than just a pill. How to include
psychosocial approaches sin the treatment of anxiety & depressive dis-
orders. Missouri Medicine, 110(6), 517–523.
Sherman, L. (2012). Tai chi helps seniors with depression. The Journal of
Chinese Medicine, 100(86), p. 18.
Wang, C., Bannuru, R., Ramel, J., Kupelnick, B., Scott, T., & Schmid, C.
H. (2010). Tai Chi on psychological well-being: Systematic review and
meta-analysis. BMC Complementary and Alternative Medicine, 10(1),
23. doi:10.1186/1472-6882-10-23.
Wang, F., Lee, E.-K. O., Wu, T., Benson, H., Fricchione, G., Wang, W.,
& Yeung, A. S. (2014). The effects of tai chi on depression, anx-
iety, and psychological well-being: A systematic review and meta-
analysis. International Journal of Behavioral Medicine, 21(4), 605–617.
doi:10.1007/s12529-013-9351-9.
Wang, L., Song, R., Chen, Z., Wang, J., & Ling, F. (2015). Prevalence of
depressive symptoms and factors associated with it in type 2 diabetic
patients: A cross-sectional study in China. BMC Public Health, 15(1),
188. doi:10.1186/s12889-015-1567-y.
Wu, C.-S., Yu, S.-H., Lee, C.-Y., Tseng, H.-Y., Chiu, Y.-F., & Hsiung, C. A.
(2017). Prevalence of and risk factors for minor and major depression
among community-dwelling older adults in Taiwan. International Psy-
chogeriatrics, 29(7), 1113–1121. doi:10.1017/S1041610217000199.
Yin, J., & Dishman, R. K. (2014). The effect of Tai Chi and Qigong
practice on depression and anxiety symptoms: A system-
atic review and meta-regression analysis of randomized con-
trolled trials. Mental Health and Physical Activity, 7(3), 135–146.
doi:10.1016/j.mhpa.2014.08.001.
Zheng, G., Lan, X., Li, M., Ling, K., Lin, H., Chen, L., … Chen, B. (2015).
Effectiveness of tai chi on physical and psychological health of college
students: Results of a randomized controlled trial. PLoS One, 10(7),
e0132605. doi:10.1371/journal.pone.0132605.