Complementary Therapies in Medicine (2013) 21, 682—688

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Effects of group music intervention on

psychiatric symptoms and depression in
patient with schizophrenia
Shiou-Fang Lu a,b, Chi-Hui Kao Lo b, Huei-Chuan Sung b,c,d,
Tsung-Cheng Hsieh b, Shun-Chieh Yu e, Shu-Chuan Chang a,b,f,∗

a
Department of Nursing, Tzu Chi University, Taiwan
b
Institute of Medical Sciences, Tzu Chi University, Taiwan
c
Department of Nursing, Tzu Chi College of Technology, Taiwan
d
Taiwanese Center for Evidence-based Health Care, Taiwan
e
Yu-Li Hospital, Ministry of Health and Welfare, Taiwan
f
Buddhist Tzu Chi General Hospital, Taiwan
Available online 20 September 2013

KEYWORDS Summary
Group music Objectives: To examine the effects of a group music therapy on psychiatric symptoms and
intervention; depression for patient with schizophrenia in a psychiatric nursing home.
Psychiatric Subjects and methods: Eighty patients with schizophrenia were randomly assigned to a music
symptoms; intervention group (MIG) or usual care group (UCG). Both groups received similar medical and
Depression; routine care. The MIG received a 60-min group music therapy twice a week, a total of ten
Schizophrenia sessions. The UAG only received the usual care with no music therapy. Psychiatric symptoms
and depression assessments were conducted using the positive and negative syndrome scale and
the depression scale for schizophrenia at baseline, the posttest, and at a 3-month follow-up.
Results: Thirty-eight patients in the MIG and 42 in the UCG completed the study. After 10 sessions
of group music therapy, the groups showed statistically significant differences in psychiatric
symptoms (p < .05) and depression status (p < .05).
Conclusion: Group music therapy is an economical and easily implemented method of improving
depression and psychiatric symptoms in patients with schizophrenia.
© 2013 Elsevier Ltd. All rights reserved.

Introduction

Schizophrenia is one of the most serious mental disor-

∗ ders, the prevalence rate of which is approximately 1.1%
Corresponding author at: Department of Nursing, Buddhist Tzu
Chi General Hospital, 701, Section 3, Chung Yang Road, Hualien of the population over the age of 18. It is characterized
97004, Taiwan. Tel.: +886 3 8561825x2225; fax: +886 3 8576278. by profound disruptions in thinking, affecting language,
E-mail address: scchang@mail.tcu.edu.tw (S.-C. Chang). perception, and the sense of self.1 It often includes

0965-2299/$ — see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ctim.2013.09.002
Group music intervention
psychotic experiences, such as hearing voices and delu-
sions. It can impair functioning through the loss of an
acquired capability to earn a living. Serious mental disorders
have considerable individual and societal impact. Antipsy-
chotics are the mainstay of schizophrenia treatment, but
first- and second-generation antipsychotics may cause side
effects.2 In Taiwan, when National Health Insurance began
in 1995, 12,023 schizophrenia patients were registered
with mental and physical disabilities. In 2011, the num-
ber increased to 113,992, which was 9.3 times higher than
that of 15 years earlier.3 Schizophrenia is a crucial chronic
disease which requires long-term rehabilitation. Thus far
several types of social rehabilitation group have been estab-
lished, including social skills training, coping-with-stress
training, occupational therapy, art therapy, music ther-
apy, and entertainment therapy. Of these therapy types,
music therapy has shown significant effects in treating
schizophrenia.4
Music therapy is the controlled use of music on peo-
ple to assist with their physiological, psychological, and
emotional integration during treatment. Active and pas-
sive music therapy can ameliorate psychosis and depression,
including in treatment resistant cases.5 In active music
therapy, the therapist and patient actively create music,
using instruments and their voices. In passive music ther-
apy, the patient rests and the therapist plays music, and
invites the patient to visualize peaceful images to produce
a state of mental rehabilitation. Numerous music therapy
studies have been conducted by different types of med-
ical professional, such as doctors, nurses, psychologists,
and occupational therapists. This shows that music ther-
apy is relevant to numerous disciplines in medicine.6—9
Music therapy is a type of psychotherapy that uses musical
interaction and communication. A study of music ther-
apy for schizophrenia identified four randomized control
trials eligible for meta-analysis.10 This study examined
the effects of music therapy over the short to medium
term (1—3 months), with treatment courses varying from
7 to 78 sessions. Music therapy combined with standard
care is superior to standard care alone. It helps peo-
ple with schizophrenia improve their global state, and
may improve their mental state and functioning if suffi-
cient music therapy sessions are provided. Studies have
concluded that further research should explore the long-
term effects and dose—response relationships of music
therapy.10
Several studies and meta-analyses have reported
that music therapy is an effective intervention for
schizophrenia.5,6,11—16 One study13 used an individual music
intervention treatment, and another 3 used group music
interventions.6,14,16 Patients were hospitalized schizophre-
nia patients. The music interventions, such as listening,
discussing, singing, and instrument playing, continued
for 2—15 weeks. The measurement instruments used in
these studies included the scale for the assessment of
negative symptoms (SANS),14 the positive and negative
syndrome scale (PANSS), and the brief psychiatric rating
scale.13,16 The results showed that music intervention can
significantly improve schizophrenia symptoms,6,13 negative
symptoms,14,16 and quality of life.16 All studies conducted
pretests and posttests.6,13,14 One of the studies also con-
ducted a follow-up test after 4 months.16
683
Taiwan has a shortage of music therapists in medical insti-
tutions; nursing staff are typically responsible for promoting
music therapy activities. Music therapy can enhance the
quality of life for patients with severe and long-term men-
tal illnesses.17 However, no study has explored the effects
of music therapy on schizophrenia patients in a psychi-
atric nursing home setting. This study the effects of group
music intervention on ameliorating psychiatric symptoms
and depression in patients with schizophrenia in nursing
homes.
Materials and methods
Study design
The research design was a randomized controlled trial. Par-
ticipants were randomly assigned to a music intervention
group (MIG) or a usual care group (UCG), using a computer-
generated list of random numbers. Outcomes were assessed
at baseline, the posttest, and a 3-month follow-up. Ran-
domization was conducted by a person independent of
the research, and extensive steps were taken to mask
the research to the participants’ allocation status. Asses-
sors who conducted the PANSS and CDSS assessment for
participants were blinded. Assessors did not know each par-
ticipant’s respective group.
Setting and subjects
The study was conducted in Hualien, a town in Eastern
Taiwan with a population of 350,000. All patients were
recruited from the psychiatric nursing home of a large men-
tal illness hospital in Hualien. The hospital which had 2500
beds includes acute wards, chronic wards, a rehabilitation
home, and a psychiatric nursing home. Most patients were
homeless, unable to live independently, or lacked familial
support. The government social welfare budget covers their
hospital treatment. Of these patients, 95% were diagnosed
with schizophrenia.
The study was conducted in a large nursing home which
had 420 beds. Participants met the following inclusion crite-
ria: an adult diagnosed with schizophrenia by a psychiatrist,
according to the fourth edition of the Diagnosis and Sta-
tistical Manual of Mental Disorders,1 and being able to sit
still for at least 1 h. Patients with hearing deficits and verbal
communication difficulties were excluded.
Intervention
Both the MIG and UCG received their prescribed medica-
tion. Usual care in the nursing home included 24-h care with
activities of daily living, basic nursing care, meal provision,
and social activities (e.g., TV watching, family visiting, and
occasional parties for special events). The patients in the
MIG also received all the same care that the UCG. The MIG
attended 60 min of group music therapy twice a week for 5
weeks. The music therapy comprised of 10 sessions of active
and passive music interventions including music listening,
singing popular Taiwanese songs, playing percussion instru-
ments, watching music videos, and discussions. The music
684
therapy intervention was delivered by a research assistant
trained in music therapy in a group setting.
Data collection
The data were collected by eight blinded assessors with 8 h
of training using the PANSS. The PANSS training was held by a
psychiatrist, who introduced the content and the proposition
of PANSS, and practiced three cases.
Outcome measures
Psychotic symptom measures
The primary outcome measure was the PANSS score.18 The
PANSS contains 30 items, including a positive scale (7 items),
negative scale (7 items), and general psychopathology scale
(16 items). Each symptom is scored between 1 and 7 (1
represents a lack of symptoms and 7 represents extreme
psychopathology). The test is designed as an interview that
allows the interviewer to assess 30 symptoms. Positive items
include delusions, conceptual disorganization, hallucinatory
behavior, excitement, grandiosity, suspiciousness, persecu-
tion, and hostility. Negative items include blunted effect,
emotional withdrawal, poor rapport, passive or apathetic
social withdrawal, difficulty with abstract thinking, lack
of spontaneity and conversational flow, and stereotypical
thinking. The remaining 16 items constitute a general psy-
chopathology scale.
Depression
The secondary outcome measure used was the depression
scale for schizophrenia (CDSS). The CDSS contains 9 items
designed to measure depression in schizophrenia patients in
acute and remission stages.19 The interview contains eight
multiple choice questions and one question that the inter-
viewer answers at the end of the interview. Each item is
scored from 0 to 3 (0 is absent, 1 is mild, 2 is moderate, and
3 is severe). Results have shown that 4—5 points indicate
minor depression and 6—7 points indicate major depres-
sion. This shows that the CDSS is diagnostically similar to
conventional classification manuals (e.g., the DSM-IV).20
Participants
Sample size and ethical approval
The computer program GPOWER was used for a priori cal-
culation of the required sample size.21 The calculation was
based on a two-tailed test. A conventional alpha (0.05), con-
ventional power (0.8), and an effect size of 0.7 required a
sample of 68 patients. Accounting for a normal dropout rate,
the sample size for each group was 40.
Eighty patients were randomly allocated to the MIG
or UCG. Study approval was obtained from the hospital’s
institutional review board. The researchers approached the
patients and explained the study purposes, described data
collection procedures, provided written and verbal informa-
tion on the study, and asked whether they would be willing
to participate in the trial. Before the start of the trial,
all participants were informed that they had the right to
S.-F. Lu et al.
withdraw at any time during the study period. Informed
consent was obtained for each participant.
Data analysis
All data were analyzed using SPSS for Windows (version
17.0). Continuous variables were compared between groups
using, an independent t test and are expressed as the
mean ± standard deviations (SD). Categorical data were
analyzed using Fisher’s exact tests and are reported as per-
centages. The intra-class correlation coefficient (ICC) was
used to compare the interrater reliability of the PANSS
ratings. Two-sample t tests were used to determine the func-
tion of group music therapy. Analysis of covariance (ANCOVA)
was used to compare the PANSS and CDSS results between
the MIG and UCG, controlling for baseline PANSS and CDSS
measurements, and p < .05 was considered statistically sig-
nificant.
Results
Participant flow
Fig. 1 shows the CONSORT diagram for patients. A total of
420 patients were screened during the study. Of these, 266
did not meet the inclusion criteria, and 74 declined to partic-
ipate. The remaining 80 patients were randomly allocated to
treatment groups: 38 were allocated to the MIG, and 42 were
allocated to the UCG. At the 3-month follow-up, 73 patients
(92%) completed the study. A total of 7 patients did not com-
plete the study including 4 patients in the MT group and 3
patients in the UCG group due to relocation to acute wards.
Five of them were lost at the post-test visit, while 2 of them
were lost at the follow-up visit (Fig. 1). The statistical anal-
ysis was conducted based on intention to treat population
including all patients with at least one post-intervention
observation. The measures for 2 patients without follow-up
data were estimated by their post-test observations based
on LVCF (Last-value-carried-forward) method.
The reliability of the eight PANSS raters was evaluated
using the ICC. After training, the ICC was 0.917.
Demographic and clinical characteristics
Table 1 shows the demographic and clinical characteristics
of the patient groups at the baseline assessment. There
were no significant differences between the MIG (n = 38)
and UCG (n = 42) for all demographic characteristics includ-
ing sex, marital status, religion, education level, mean age,
year of diagnosis, length of stay, and medication (p > .05).
In the whole sample, 59 (74%) patients were men, and most
patients (80%) were single. The average age of both groups
was 52 years, with ages ranging from 35 to 65 years. More
than one-third of patients were not religious (38.8%) or were
Buddhist (41.3%). Approximately 65% of the patients had at
least a junior high school level of education. The mean diag-
nosis age for both groups was 25 years. The average length of
stay was 8 years. The average daily doses of chlorpromazine-
equivalent neuroleptics for the MIG and UCG at the
baseline assessment were 548.4 ± 156.5 and 513.8 ± 134.5,
Group music intervention 685

Assessed for eligibility (N=420)

Excluded (n=340)
Not meeting inclusion criteria (n=266)
Declined to participate (n=74)

Randomized(N=80)

Allocated to MIG (n=38) Allocated to UCG (n=42)

Lost to post-test Lost to post-test

(transfer to acute ward)(n=3) (transfer to acute ward)(n=2)

Lost to follow-up Lost to follow-up

(transfer to acute ward)(n=1) (transfer to acute ward)(n=1)

Analyzed(n=35) Analyzed(n=40)

Figure 1 Flow-chart following participants through the randomized controlled trial.

Table 1 Demographic characteristics of the participants.

Characteristic Total (n = 80) MIG (n = 38) UCG (n = 42) p value

Gender (%) 0.60

Male 59 (73.8%) 27 (71.1%) 32 (76.2%)
Female 21 (26.3%) 11 (28.9%) 10 (23.8%)
Marital status (%) 0.89
Married 14 (17.5%) 6 (15.8%) 8 (19.0%)
Single 64 (80.0%) 31 (81.6%) 33 (78.6%)
Other 2 (2.5%) 1 (2.6%) 1 (2.4%)
Religion (%) 0.49
No 31 (38.8%) 11 (28.9%) 20 (47.6%)
Taoism 6 (7.5%) 2 (5.3%) 4 (9.5%)
Buddhism 33 (41.3%) 19 (50.0%) 14 (33.3%)
Christian 4 (5.0%) 2 (5.3%) 2 (4.8%)
Catholic 3 (3.8%) 2 (5.3%) 1 (2.4%)
Other 2 (2.5%) 1 (2.6%) 1 (2.4%)
Education (%) 0.42
Illiterate 1 (1.3%) 0 (0.0%) 1 (2.4%)
Primary 27 (33.8%) 16 (42.1%) 11 (26.2%)
Junior 22 (27.5%) 10 (26.3%) 12 (28.6%)
High school 21 (26.3%) 7 (18.4%) 14 (33.3%)
College 9 (11.3%) 5 (13.2%) 4 (9.5%)
Mean age (SD) 52.02 (7.64) 51.66 (7.46) 52.35 (7.87) 0.69
Mean diagnosis years (SD) 24.96 (9.82) 25.57 (8.98) 24.41 (10.61) 0.61
Mean length of stay years (SD) 8.01 (7.52) 9.32 (7.24) 6.83 (7.66) 0.14
Medication: CPZ equivalent (SD) 531.1 (145.5) 548.4 (156.5) 513.8 (134.5) 0.29
686 S.-F. Lu et al.

Table 2 Change in outcomes between groups at baseline and post-test (n = 75).

Variable Mean (SD) Absolute difference, p value Effect size,

mean (95% CI) Cohen d
MIG (n = 35) UCG (n = 40)

PANSS-total
Baseline 73.89 (19.14) 71.30 (22.56)
Post-test 65.77 (18.19) 80.80 (22.73)
Difference 8.11 (18.49) −9.50 (17.90) 17.61 (−25.99, −9.23) <0.001 0.96
Effect size, Cohen d 0.43
PANSS-positive
Baseline 15.14 (5.45) 14.90 (6.02)
Post-test 13.57 (4.42) 17.50 (5.11)
Difference 1.57 (4.79) −2.60 (6.01) 4.17 (−6.70, −1.65) 0.002 0.76
Effect size, Cohen d 0.31
PANSS-negative
Baseline 19.60 (6.44) 19.38 (8.10)
Post-test 17.69 (6.60) 21.28 (7.36)
Difference 1.91 (6.39) −1.90 (3.86) 3.81 (−6.21, −1.42) 0.002 0.72
Effect size, Cohen d 0.29
PANSS-general
Baseline 39.14 (9.73) 37.03 (11.79)
Post-test 34.51 (8.88) 42.03 (12.08)
Difference 4.63 (10.33) −5.00 (10.94) 9.63 (−14.55, −4.71) <0.001 0.90
Effect size, Cohen d 0.49
CDSS
Baseline 4.23 (4.78) 3.38 (4.65)
Post-test 0.89 (1.62) 3.33 (4.25)
Difference 3.34 (3.88) 0.05 (5.52) 3.29 (−5.52, −1.07) 0.004 0.68
Effect size, Cohen d 0.93

respectively. No significant difference in average dose
existed between the groups at baseline. The average num-
ber of group therapy sessions patients had experienced was
8.4. No significant differences in PANSS and CDSS scores
existed at the baseline assessment (Table 2). The MIG and
UCG had baseline average PANSS scores of 74.74 ± 18.61 and
68.74 ± 21.26, respectively. This shows that the patients in
both groups exhibited certain psychiatric symptoms. The
mean CDSS scores were 4.03 ± 4.66 and 2.95 ± 4.18 for the
MIG and UCG, respectively. CDSS scores were below 7 points,
indicating less than mild depression levels.
Psychotic symptom measures
For the posttest, the MIG and UCG PANSS scores were
65.77 ± 19.18 and 80.80 ± 22.73, respectively, and CDSS
scores were 0.89 ± 1.62 and 3.33 ± 4.25, respectively
(Table 2).
After 5 weeks of intervention, the changes in primary
outcomes from the baseline to the posttest measurements
between the groups were all significant. The mean PANSS
score difference between groups was 17.61 (p < .001, ES
0.96). For positive items, this was 4.17 (p < .05, ES 0.76),
3.81 for negative items (p < .05, ES 0.72), and 9.63 for gen-
eral items (p < .001, ES 0.9). The mean difference between
group CDSS scores was 3.29 (p < .05, ES 0.68).
At the 3-month follow-up, the change in primary out-
comes between groups showed no significant differences
between the baseline and follow-up (Table 3). The mean
difference between group PANSS scores was 10.09 (p > .05,
ES 0.37). For positive items, this was 1.54 (p > .05, ES 0.21),
1.33 for negative items (p > .05, ES 0.21), and −6.68 for gen-
eral items (p = .05, ES 0.41). The mean difference between
group CDSS scores was −0.68 (p > .05, ES 0.12). This indi-
cates that the effect of music therapy was not maintained
for 3 months for total PANSS, positive PANSS, negative PANSS,
general PANSS, and CDSS scores. However, the change in
total PANSS scores for the MIG was significant (t = 2.142,
p < .05), and the change in general PANSS scores was signifi-
cant (t = 2.572, p < .05). The results show that the MIG PANSS,
positive PANSS, and general PANSS significantly improved
from baseline to the follow-up assessments.
For ANCOVA results (controlling for baseline PANSS and
CDSS measurements), the time x group interaction exhib-
ited significant differences for the positive PANSS (F = 10.09,
p = .002), negative PANSS (F = 8.111, p = .006), general PANSS
(F = 11.513, p = .001), total PANSS (F = 18.896, p < .001), and
Group music intervention 687

Table 3 Change in outcomes between groups at baseline and follow up (n = 75).

Variable Mean (SD) Absolute difference, p value Effect size,

mean (95% CI) Cohen d
MIG (n = 35) UCG (n = 40)

PANSS-total
Baseline 73.89 (19.14) 71.30 (22.56)
Follow-up 64.34 (21.57) 71.85 (27.25)
Difference 9.54 (26.36) −0.55 (27.75) 10.09 (−22.60, 2.41) 0.111 0.37
Effect size, Cohen d 0.46
PANSS-positive
Baseline 15.14 (5.45) 14.90 (6.02)
Follow-up 13.00 (5.65) 14.30 (6.37)
Difference 2.14 (7.00) 0.60 (7.71) 1.54 (−4.93, 1.87) 0.367 0.21
Effect size, Cohen d 0.38
PANSS-negative
Baseline 19.60 (6.44) 19.38 (8.10)
Follow-up 18.94 (6.40) 20.05 (8.74)
Difference 0.66 (6.73) −0.67 (5.65) 1.33 (−4.18, 1.52) 0.361 0.21
Effect size, Cohen d 0.10
PANSS-general
Baseline 39.14 (9.73) 37.03 (11.79)
Follow-up 32.69 (11.37) 37.25 (14.65)
Difference 6.45 (18.53) −0.22 (13.97) 6.68 (−13.32, −0.05) 0.050 0.41
Effect size, Cohen d 0.60
CDSS
Baseline 4.23 (4.78) 3.38 (4.65)
Follow-up 3.37 (4.65) 3.20 (4.74)
Difference 0.86 (6.61) 0.18 (4.11) 0.68 (−3.18, 1.82) 0.589 0.12
Effect size, Cohen d 0.18

CDSS (F = 10.15, p = .002) scores. Therefore, the main effects
on the total PANSS, PANSS subscale, and CDSS scores indicate
a significant group effect over time.
Discussion
Main findings
We examined the effectiveness of group music therapy on
ameliorating psychiatric symptoms and depression in nurs-
ing home patients with schizophrenia. The study shows
that group music therapy may effectively reduce PANSS and
CDSS scores in nursing home patients with schizophrenia.
The results show that PANSS and CDSS scores significantly
improved from baseline to posttest assessments between
the two groups. However, this improvement was not main-
tained over 3 months in the intervention group. This may
be because the music therapy intervention did not continue
during this 3-month period, which also indicates that the
effect of music therapy may only last for 1 month.
This is the first RCT music therapy study in which nursing
homes in a mental illness hospital in Taiwan are examined.
The dropout rate of the study (8%) is lower than that of
other studies.13,14 To avoid interference with rehabilitation
courses for schizophrenia patients in the nursing home, the
group music therapy was conducted twice a week for 5
weeks. Therefore, 10 group music therapy sessions were
conducted with an average attendance of 8.2 sessions. This
is higher than that in other research.15 Therefore, patients
attended more sessions, and fewer patients left this study
than in other studies. The choice of music was based on a
schizophrenia patient preference survey conducted before
the intervention because research suggested that patient
backgrounds and interests should be considered when choos-
ing therapy music.20 Patients preferred popular music, which
they typically listened to every day. The majority of the par-
ticipants’ preferred Taiwanese and Chinese songs from the
1950s to 1970s with pleasant moderate rhythm and tempo.
The percussion instruments used in the study included hand
bell, snare drum, castanet, tambourine, claves, triangle
and wood block. The study included pretest, posttest, and
follow-up measurements because a previous study showed
that follow-up measurements reflect the length of music
therapy effectiveness.3
This study has two limitations: no double-blind design
meant that patients were aware of the group assignment,
and limited time and funding meant that follow-up data
were not collected after 6 and 12 months. The research
results confirmed the effects of group music therapy on
688
ameliorating psychiatric symptoms and depression in nurs-
ing home residents. This suggests that group music therapy
should be used as routine care in nursing homes. Future stud-
ies could include long-term observation of changes in quality
of life, psychiatric symptoms, and depression.
Implication
Nurses interact closely with nursing home residents. There-
fore, nurses should be educated in group music therapy.
Familiarity with musical activity techniques for conducting
group music therapy sessions provides mentally ill patients
with broader, more humane psychiatric rehabilitative care.
Group music therapy is an economical and easily adminis-
tered method for ameliorating depression and psychiatric
symptoms, and improving quality of life for schizophrenic
patients.
Conflict of interest statement
The authors declare that they have no competing financial
interests.
Acknowledgments
We thank the trial patients and Yuli Hospital for providing
research space and funding.
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