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Music & Medicine | 2016 | Volume 8 | Issue 1 | Pages 17 – 28 Ahessy | Music Therapy Choir
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Introduction
Singing positively affects a person’s emotion, breath, and
physicality [1] acting in part through cortisol-mediated effects
on the immune system [2,3,4] often after acute exposure as
brief as a single choral rehearsal [5]. There has been increased
community choral support for groups of individuals with
varying health needs, such as acquired brain injuries [‘the
CeleBRation Choir’, New Zealand], Parkinson’s disorder [‘the
Skylarks’, UK], people with dementia and their family
members [‘the Unforgettables’, New York] [6] and people
who have experienced stroke and their carers [‘Singing
Together Measure by Measure,’ New York] [7]. Evidence of a
beneficial effect is largely based on qualitative research,
subjective impressions of participants, articulated usually
through self-administered questionnaires, with means of
verification [5, 8-14]. The positive effects of choral singing on
well-being and mental health are well-illustrated by a study in
which participants with low psychological well-being (WHO-
BREF) reported that singing provided support in coping with
health issues and life difficulties [12,13] and by another in
which singing promoted recovery and maintained wellbeing
in people with enduring mental health challenges [14]. In a
choral study of cancer survivors and their carers, self-reported
improvements included vitality, social functioning, mental
health, and bodily pain with a trend of reduced anxiety and
depression [15]. There were similar considerable well-being
benefits from choral singing for a small sample of homeless
men and also in studies in disadvantaged and privileged
communities [10, 11].
Choral singing may also improve work environment
psychosocial health. For example, it improved well-being and
health, increased workplace involvement and generated a
better work environment among 700 employees in 2
Norwegian hospitals [9]. A longitudinal study on older adults
found that choral singing resulted in improved health and
reduced medication over 1 year. There were also reduced falls,
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PRODUCTION NOTES: Address correspondence to:
B. Ahessy, E-mail: billahessy@gmail.com| COI statement: The
author thanks the Meath Foundation (The Adelaide and Meath
Hospital, Dublin, Incorporating the National Children’s
Hospiaital) for funding this research. The author have no conflict
of interest to declare.
Copyright © 2016 All rights reserved.
International Association for Music & Medicine (IAMM).
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Full-Length Article
The Use of a Music Therapy Choir to Reduce Depression and Improve Quality of Life in Older
Adults – A Randomized Control Trial
Bill Ahessy1
1Health Service Executive, Dublin, Ireland
Abstract
Depression in older adults is prevalent and often undiagnosed and untreated.
This study sought to assess if participation in a music therapy choir intervention could reduce depressive symptoms and improve
quality of life and cognitive functioning in older adults. In this mixed method study, 40 participants were assessed pre- and post-
intervention for depressive symptoms (Cornell Scale), quality of life (Cornell Brown) and cognitive functioning (Mini Mental
State Examination). The treatment group (n=20) actively participated in a music-therapist led choir for 12 weeks, while the
control group (n=20) received standard daily care.
Mean depressive symptoms in the music therapy group were reduced by 54%
(p=0.004), mean quality of life score improved by 57% (p= 0.0004) and there was a statistically significant increase in cognitive
functioning (p= 0.011). Results from self-administered questionnaires highlighted perceived benefits of the intervention. 67%
(n=17) reported improved mood, while 40% reported physical gains. Other themes included increased social interaction and
memory improvement. The results of this controlled study indicate that the intervention significantly reduced depressive
symptoms, improved quality of life and increased cognitive functioning.
Keywords: music therapy, choir, singing, depression, quality of life, older
adults, cognitive function
multilingual abstract
| mmd.iammonline.com
Music & Medicine | 2016 | Volume 8 | Issue 1 | Pages 17 – 28 Ahessy | Music Therapy Choir
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decreased depression, less loneliness and increased morale
[16]. Cohen maintains that such arts-based interventions
foster ‘sustained involvement because of their beauty and
productivity…keeping participants involved…compounding
positive effects’ [16]. Few of these studies conform to the
requirements of a controlled trial, although it must be stated
that was never the intention. A comprehensive review of
singing and well-being [17], concluded that although much of
the research was promising there were many methodological
weaknesses in quantitative studies such as such as ‘lack of
control groups, small sample sizes, and potential selection
bias’ and in qualitative studies such as ‘unclear methods of
recruitment and analysis [17] (p.22). A more rigorous
approach is necessary to test the hypothesis that choral
singing has therapeutic benefits or at least enhances a sense of
well-being.
In an emerging area a few recent studies have examined
signing’s effects on lung function and quality of life in patients
with COPD [18-22]. In one study led by a music therapist,
singing interventions were experienced as acceptable,
enjoyable and feasible [21]. There were some respiratory
improvements associated with the interventions [18, 22],
however most improvements were to be found in well-being
and quality of life [23]. The research in this growing area is
promising but further investigation is required [23].
Music Therapy & Depression in Older Adults
Music therapy uses music and its elements as the therapeutic
agent to address clinical goals by adopting a more analytical
approach and there is much evidence supporting music’s
effect on depression. Receptive techniques (music listening)
have been promising in decreasing depressive symptoms,
blood pressure, heart rate and respiratory rate [24] and
individualised music therapy has improved symptoms of
depression and anxiety and general functioning [25]. A
Cochrane review of five studies found that music therapy is
accepted by people with depression and improves mood [26].
Three of the five studies concerned older adults [27-29].
Depression is a major public health burden and the most
frequent mental health problem among older populations [30-
33]. Depression in later life is probably multifactorial and that
no single risk factor is responsible [34,35]. Furthermore,
depressive episodes are almost twice as frequent in nursing
home residents when compared to older adults living at home
(30% as opposed to 10%-15%) [36,37] and depressive
symptomatology can affect up to 50% [38-40] .
In older populations music therapy may be a supportive
treatment for depression and dementia-specific conditions
[41-46]. Depression in later life is associated with disability,
increased mortality; poorer outcomes from physical illness
and can have devastating effects on quality of life [47].
Compared to younger cohorts, older people with depression
typically report less sadness and more physical symptoms
such as appetite loss, weight loss, sleep disturbances, lack of
energy and retardation of movement [48-50]. They are also
more likely to experience anhedonia, cognitive impairment,
memory complaints and psychosis [51,52]. While depressive
symptoms can imply a persisting impairment on psychosocial
functioning and health management in older adults, Clair [53]
emphasizes that an effective way to manage depressive
symptomatology is by involvement in meaningful
interventions such as music therapy.
Music therapy with older adults improves both self-
esteem and feelings of belonging [45] and the behavioral
symptoms of depression [46]. Collaborative approaches
(music therapy and dance movement therapy) result in
improved energy levels, sleep cycles and better appetites as
well as significant decreases in depression [54]. Group music
therapy interventions significantly increase cognitive
functioning, in particular, short-term recall [44].
The general belief that depression is a normal part of
ageing is not only flawed but also unethical according to
Anderson [55] and multiple health problems often account for
any initial association between depression and old age [34,51].
Depression is a major contributor to healthcare expenditure
(up to 50% higher), due to premature immobility and other
associated problems [56-58]. It is often unrecognized and
untreated in older populations due to societal attitudes and
the fact that depression is masked by dementia or comorbid
with other health conditions [59,60]. Therefore medication is
often the first line of treatment, but older adults and
particularly those with dementia are more sensitive to adverse
effects or overtreatment that may cause impaired cognitive
and physical functioning [61,62]. “Music therapy has the
potential to serve as an adjunct to, or facilitator of,
medication, may reduce the amount of medication
administered, or can even serve as a method of choice instead
of medication” [63p.9]. Music therapy’s positive effects on
depression are prompt [43,44,64]. For example, a significant
decrease in depressive symptoms was reported after a five-day
intervention of reminiscence-focused music therapy [64], or
in depression after one music therapy session [44].
Choir Interventions in Music Therapy
Group music therapy involving singing with older adults are
well documented, however the more formalized arrangement
of choir interventions has only recently emerged from the
literature [65-76]. Group singing in music therapy for patients
with neurological conditions is relatively new in the field and
current research has shown high potential for choral singing
on health including socialization, maintaining voice in
Parkinson’s Disease and improved quality of life [70,71].
Music therapists outline ‘Choral Singing Therapy,’ an
accessible model used to address communication
rehabilitation and improve quality of life for people with
neurological conditions [70,71].
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Much research on the effectiveness of group music
therapy on older adults with depressive symptoms involves
group singing or improvisation but rarely with a music
therapist-led choir as the therapeutic method. Music
therapists Zanini and Leao highlighted choral singing as a
positive outlet for self-expression for older adults with
implications for self-esteem, sense of identity and optimism
about the future [65]. Others have drawn attention to the value
of the method for maintaining memory, physical functioning
and socio-emotional health [68,69]. Although there has been a
lack of rigorous studies in the field examining positive effects
of choral singing on older adults, music therapists from both
Australia and Canada have recently contributed valuable
studies to the growing evidence base.
In a pilot study with nursing home residents, Robertson-
Gillam found a choir intervention mitigated symptoms of
depression and was more effective than reminiscence [66].
Qualitative results also revealed increased social interaction
and improved communication, mood, motivation and
attention. In a later study with a nursing home population
with severe dementia, depression was significantly decreased,
as well as significant increases in measures of responsiveness
such as expression of feelings, positive mood changes and
engagement [67]. In a more recent mixed methods,
randomized control trial with middle-aged adults with
depression living in the community, Robertson-Gillam
showed a significant drop in depression and an increase in
wellness [72]. This research was supported by a pilot study
using quantitative electroencephalography (QEEG) with 9
randomly allocated participants from the larger sample [73].
Clements-Cortes most recently conducted a 3-phase
study investigating the benefits of singing for older adults with
mixed cognitive abilities in music therapist led choirs [74-76].
The first pilot study involved participants from a day care
program and assessed the impact of singing on social factors
of health and quality of life [74]. Five themes emerged from
the qualitative data: friendship and companionship,
simplicity, happiness and uplifting and positive feelings,
relaxing and reduced anxiety, and fun. In the second study
with residents in along term care facility, singing in the choir
was found to improve mood, happiness, and energy and
decrease pain and anxiety, with the statistical significance
achieved in the first four indicators [75]. Qualitative results
identified themes including community building, special
moments, a positive climate, the therapeutic value of music,
increased mood energy and alertness [75]. The final study
expanded its range to include residents in a long-term care
facility and their care givers or significant others [76]. Results
indicated statistically significant reductions in pain perception
and increased energy and mood for both groups. Qualitative
themes indicated the intervention encourages maximized
participation, facilitated interaction and bonding, promoted
enjoyment and fun, encouraged improved mood and attitude,
facilitated energy and motivation and promoted stress release
and relaxation [76]. These studies are of particular interest to
practicing music therapists.
Although there is a growing body of research from music
therapy and related disciplines on choral singing and health
[68], there remains a need for further research investigating
the effectiveness of choral interventions with older adults and
in particular with music therapist-led choirs [76,77].
A recent review on the clinical effects of singing on older
adults calls for further research using samples with varying
levels of cognitive impairment as well as studies including
control groups [77]. Furthermore, recommendations in
Cochrane reviews also highlight the need for high quality trials
and more sophisticated research on the effects of music
therapy on depression and older adults [68]. It was timely and
appropriate to conduct a controlled study to investigate
whether active participation in a choral music therapy
intervention would reduce depressive symptoms and increase
quality of life and cognitive functioning in a group of older
adults with mixed cognitive ability in a long-term residential
facility and day-care service.
Methods
Procedure
The study was funded and ethically approved by the Meath
Foundation (Adelaide and Meath Hospital Incorporating the
National Children’s Hospital, Dublin). Clients from the long-
term residential unit and day-care centre in Dublin were
approached and asked if they would like to participate in the
study. Confidentiality and anonymity were ensured and
participants received detailed information sheets and a verbal
explanation about the study. After verbal and written consent
was obtained, participants were randomly assigned to two
groups; a treatment (choir) group (n=20) who would actively
participate in the choir for 12 weeks and a control group
(n=20) who would receive standard nursing care. The control
group were informed that they would receive four choral
sessions once the study had terminated. Equal numbers of
participants from the residential unit and the day care centre
were included in the study. The participants were interviewed
for baseline demographic data; and then all participants were
given a Mini Mental State Examination [MMSE] [79] to assess
cognitive functioning, the Cornell Scale for Depression in
Dementia [CSDD] [80] and the Cornell Brown Scale for
Quality for Life [CBS] [81] before and after the intervention.
The treatment group were also given an optional choir
evaluation questionnaires [CEQ] to complete after the study.
All data received was made only available to the researcher.
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Participant Flow
Attrition in geriatric research can be high due to death, illness
or withdrawal [82]. There was low attrition in this study
considering the frailty of the population and that many of the
sample had chronic health problems. Three participants from
the choir group were excluded due to illness/hospitalization
and death, and in the control group 1 participant was
excluded due to illness. These participants were excluded once
they had missed 5/12 music therapy sessions.
Data Collection
The researcher administered all assessments 1-2 weeks before
the intervention began and then after the intervention
terminated in week 13 and 14. All assessments were carried
out at the same time of day in both the pre and post-tests to
control for circadian effects and improve reliability.
• Mini Mental State Examination (MMSE)
The MMSE [79] is the most commonly used instrument for
screening cognitive function, validated in a numerous
populations. It provides measures of orientation, registration,
short-term memory and language functioning and is brief and
efficient. The MMSE is scored out of 30. Scores of 25 – 30 are
considered normal, 18 – 24 indicate mild to moderate
impairment, and scores of 17 or less indicate severe
impairment.
• Cornell Scale for Depression in Dementia (CSDD)
The CSDD [80] is a 19-item scale that uses information from
interviews with patients and the nursing team to assess
depression in five domains. The CSDD is the only depression-
rating instrument that has been validated with clients with and
without dementia. This was highly relevant for this study, as
both the choir group and the control group contained people
with and without dementia. The score range is from 0 to 38;
with a total score of 8 or more indicating significant
depressive symptoms.
• Cornell Brown Scale for Quality of Life in Dementia (CBS)
The CBS [81] was adapted from the CSDD, but its goal is to
provide a global assessment of quality of life in patients
diagnosed with dementia. The score range is from -38 to +38.
Aggregate negative scores indicate that negative ratings
outweigh positive ratings and are presumed to indicate a
poorer quality of life (and vice versa). Because the CSDD had
already been validated with both groups, the CBS was
considered most appropriate QOL tool for this mixed sample.
• Choir Evaluation Questionnaire (CEQ)
The CEQ, a self-administered questionnaire was designed in
order to elicit data on participant’s feelings and thoughts
regarding the choir intervention, music therapy and
particularly the effect of singing on health. It included a
mixture of closed and open questions.
Intervention
The choir group attended the therapy session weekly on
Friday mornings for approximately 1 hour. The room was
quiet and peaceful and participants sat in a semi-circle around
the piano. The participants were required to attend a
minimum of 8 out of the 12 sessions to be included in the
study. The control group received standard nursing care for
the duration of the study and equal amounts of time was spent
with this group where possible. In considering the duration of
the intervention previous Cochrane reviews on music therapy
and depression and dementia were consulted [78,26]. Studies
included in these reviews specified a minimum of 5 week’s
duration to allow for therapeutic change to occur [78].
Choir Methodology
The principles of adult social learning in which mistakes are
ignored and efforts are noted and encouraged, the ‘no mistake
approach’ [83] were used in the sessions, which were arranged
essentially after Robertson-Gillam [66]. The choir
methodology with approximate durations is explained in
Table 1.
Each choir session was facilitated by a qualified music therapist who led all
the singing and accompanied on a digital piano. There were 5 parts to the
session as follows:
1. Meditation & relaxation Duration – 5 minutes
• The session started with mindful breathing and gentle stretches. Then a
guided meditation was used with visualizations, which incorporates
postural, and breathing exercises.
• The aim was to relax the mind and body and regulate breathing.
• The meditation focused and centered the clients in preparation for
singing and promotes confidence in their voices.
• Exercises that focus specifically on inhalation and exhalation are
beneficial to older adult singers and may increase the vital capacity of
the lungs [84].
2. Vocal improvisation Duration – 5 minutes
• This followed the meditation and involved choir members humming,
singing and toning freely with their eyes closed. The music therapist
often modeled sounds to encourage people and get them started.
• This was often supported with a simple ostinato, chords or a drone on
the piano, played by the therapist to support singers.
• The aim was to encourage clients to explore their voices, expressing
inner feelings while being supported by the group. It also promoted
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trust between group members.
• ‘Vocal improvisation facilitates spontaneous and emotional connection
to self and other’ [1].
3. Singing & articulation exercises Duration – 10 minutes
• A range of exercises were used including oral motor and respiratory
exercises, rhythmic and melodic articulation exercises, scales and
arpeggios.
• Call and response pieces, tongue twisters and rounds/canons were used
to stimulate cognition and improve concentration and attention.
• Participants particular enjoyed exercises that involved humour for
example singing “taut tight tutus” in broken triads or “As one black
bear backed up the back the other black bear backed down” to the
melody of “John Brown’s Body.”
• Singing and articulation exercises are vital to warm up the vocal chords,
improve articulation, pitch, range and projection.
4. Learning & singing repertoire Duration – 35 minutes
• Many genres were included including: popular, jazz, Irish traditional,
gospel, classical and contemporary songs. All songs were accompanied
by the piano.
• Well-known songs were used, but new and unknown songs were taught
to challenge and extend skills. Members of the choir also contributed
songs.
• Songs were sung in unison and in simple two-part harmony.
• Songs were also taught in different languages to provide further
cognitive challenges for example: Italian, Swahili, French and a Maori
dialect.
• Songs were selected from lists complied from books from a previous
music therapy choir the researcher and been involved with. Participants
were asked to select preferred songs. Then the researcher added some
canons/rounds and new songs. Some songs included: ‘Somewhere Over
the Rainbow (1939), Amazing Grace (1779), ‘What a Wonderful
World’ (1967), ‘Alexander’s Ragtime Band’ (1938), ‘Danny Boy’
(1915),’Santa Lucia’ (1835), ‘Catch a Falling Star’ (1957), ‘You’ll Never
Walk Alone’ (1945), ‘Tulips from Amsterdam’ (1958), ‘Po Atarau’
(1915), ‘Lean on Me’ (1972) and ‘Dublin Saunter’ (unknown).
• All songs were accompanied by the music therapist on a keyboard.
Sometimes handheld instruments such as drums, tambourines, shakers
and kazoos were included to stimulate, rhythmic awareness, physical
activity and coordination.
• Singing the repertoire provided further opportunities to address
‘breathing, pitch accuracy, vocal range, rhythmic accuracy, dynamics
and projection in the context of meaningful music’ [71].
5. Concluding song Duration – 5 minutes
• The choir session finished with a final song to bid farewell and close the
session. Sometimes that was a song with a slow tempo, such as “Now is
the Hour” (1927) providing opportunity to reflect. On other occasions
it was a more rousing song with a goodbye theme such as “Goodnight
Sweetheart,” (1953) “Show Me the Way to Go Home,” (1925) or “We’ll
Meet Again.” (1939). These songs were accompanied by the piano.
Table 1. Choir methodology
The experimental design of the study is summarised in Table
2.
Group
Pre-test
Intervention
Post-test
Choir
Group
(n=20)
Cornell Scale
Depression
Cornell Brown
Scale Quality of
Life
MMSE
Cognitive
Functioning
12 x 1 hour
weekly choir
sessions led by a
music therapist
Cornell Scale
Depression
Cornell Brown
Scale
Quality of Life
MMSE
Cognitive
Functioning
Choir Evaluation
Surveys
Control
Group
(n=20)
Cornell Scale
Depression
Cornell Brown
Scale Quality of
Life
MMSE
Cognitive
Functioning
Standard Daily
Care
No Music
Therapy for 12
weeks
Cornell Scale
Depression
Cornell Brown
Scale
Quality of Life
MMSE
Cognitive
Functioning
Table 2. Experimental design of the study
Data Analysis
Before and after scores for the CSDD, CBS and MMSE were
tested with a paired t-test. Inter-group comparisons were
tested with an unpaired t-test. Differences occurring with the
probability less than 0.05 were considered significant. The
data from the questionnaires were summarized and expressed
as proportions of respondents. Participant’s responses to open
ended questions were presented under the theme heading of
the question. An independent statistician analyzed all data.
Results
Participants
The demographic data from the participants is presented in
Table 3. All participants were Caucasian and of Irish decent.
There was a male to female ratio of 5:31. The age range was
from 72 to 99 years old with similar age range and mean age in
both groups. Just under half of both groups had some previous
musical experience or exposure to music in school. Only 3/36
participants were familiar with music therapy, but had never
engaged in a session.
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Choir Group n=17
Control Group n=19
Gender
Male
Female
Age
Age Range
Mean age
Marital status
Married
Divorced
Widowed
Single
Education
Primary/Nationa
l
Secondary
3rd Level
Religion
Catholic
(Religious)
(Not religious)
Protestant
(Religious)
Musical
Experience
Music Therapy
2
15
72 – 94
83
1
0
11
5
17
4
1
16
18
1
1
1
8
2
3
16
72 – 99
84
2
1
13
3
19
2
0
19
16
3
0
0
9
1
Table 3. Demographic profile of participants
Demographic characteristics for the choir group and the
control group were well matched and the difference between
the pre-treatment tests scores for the two groups for their
depressive symptoms, quality of life or cognitive functioning
were not significant, See table 4.
Pre-treatment
Choir
Control
Depressive Symptoms
Quality of Life Score
Cognitive Functioning
6.88
11.47
25.4
5.37
10.68
23.52
P = 0.88, ns
P = 0.25, ns
P = 0.28, ns
Table 4. Participant’s pre-treatment scores (ns=not significant)
Depressive symptoms
The intervention significantly improved scores on CSDD. The
choir’s mean depressive symptoms score decreased by almost
54% from 6.88 at the start of the study to 3.17 at the end. The
control group showed no such improvement but rather had a
slight non-significant increase in depressive symptoms with
the mean score moving from 5.37 to 6.53, a 21.6% increase.
From the statistical analysis we can see that there was
significant difference between the pre-treatment and post-
treatment and the post-treatment and post-control (Figure 1.)
Figure 1. Mean pre and post-test depression scores in both groups (ns=not
significant)
There was much variability in the individual depression
scores. In the choir group 8/17 (47%) displayed depressive
symptoms at the beginning of the study with a score of 8 or
more on the scale. After the intervention no choir member
displayed depressive symptoms of more than 8. In the control
group 7/19 (36.8%) participants displayed depressive
symptoms to begin and by the end of the study that had
increased to 10/19 or 52.6% (an increase of 16% in the
number showing significant depressive symptoms). In total
74% (n=14) of the control group participant’s depressive
symptoms stayed the same or increased over the twelve weeks.
Quality of life (QOL)
Quality of life scores increased significantly after the
intervention. The mean QOL scores in the choir group
increased by 57% from 11.47 to 18, and 76% of the group had
some increase in QOL score. By contrast, the control group
did not show this improvement. In fact their score decreased
non-significantly from 10.68 to 8.95 (a decrease of 16%).
From the statistical analysis in Figure 2. we can see that there
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was significant difference between the pre-treatment and post-
treatment and the post- treatment and post-control.
Figure 2. Mean pre and post-test quality of life scores in both groups (ns=not
significant)
Again there was much variability in the choir group's
individual scores and 13/17 (76.4%) participant’s quality of
life scores improved over the intervention. There was also
much variability in the control group where 13/19 (68.4%)
quality of life scores dis-improved over the course of the
study.
Cognitive functioning
While MMSE scores ranged from 8 to 30, the mean pre-scores
in both groups were not different. There was a significant
increase in cognitive functioning in the choir group from 25.4
to 26.27 (p = 0.011: Figure 3), while the control group’s score
did not change (23.53 at the start of the study and 23.47 at the
end). There was no difference between the post-treatment and
post-control.
Figure 3. Mean pre and post-test cognitive functioning scores in both groups
(ns=not significant)
Results from the CEQs
Fifty-five percent of the choir group rated their health as fair
or poor. Over 23.5% (n=4) stated they suffered from
depression and loneliness. Almost 40% (n=7) reported
physical problems (including speech problems and breath
control) and 17% (n=3) reported isolation and stress. Figure 4.
reveals the perceived benefits participants experienced from
the choir. The most common response was learning new
songs (n=16). Over two-thirds (n=12) reported social
interaction as a benefit and almost 40% (n=7) reporting
physical benefits including improved speech and breath
control. Over one-fifth reported enhanced mood, improved
memory and confidence. Only two members rated improving
their voice as a gain.
Figure 4. Perceived benefits from participating in the choir study
All participants (n=17) reported they thought that singing was
good for them and over three-quarters (n=14) of felt that
singing affected their health in some capacity. One member
with Parkinson’s disease said “With my health condition it
really helps me with my breathing and my voice.” Participant’s
perceived effects of singing on their health are presented in
Figure 5.
Figure 5. Perceived Effects of Singing on Participant’s Health
When asked about how the choir members felt after music
therapy sessions there were many responses. The theme of
community and interaction was very prominent, improved or
positive mood was also obvious. A selection of the responses is
presented in Table 5.
How the Participants Feel After a Choral Therapy Session
'I feel happy, I feel part of the community'
'In a nutshell, happy, the songs brighten me up.'
'I feel good; I really like the feeling of having achieved something.'
'I feel very refreshed, I feel good after the company.'
'I feel like singing the whole way home.'
'It's a great hour; I forget all my worries and troubles.'
‘I feel great! I’m getting so much out of it, especially meeting new friends.’
I feel relaxed, I feel very happy. I get so much pleasure from it, and I always
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come out in good humor.
It lifts your spirits for the whole day.’
Table 5. Participants describe how they feel after a music therapy session
All participants attributed these positive feelings to the choir.
Furthermore, exactly half (n=9) of the participants reported
that the positive feelings lasted the whole day. Over one-
quarter (n=5) said a few days and 17% (n=3) stated the
feelings lasted a week or more. The participants were asked to
state in their own words what the choir means to them. Many
said how they found the choir to be an enjoyable experience
and how it made them feel part of the community. Other’s
commented on improved mood and feeling valued. A
selection of these answers is presented in Table 6.
What the Choir Means to the Participants
'I've been here for 7 years and the choir really gives me a lift. Everyone looks
forward to it.'
'It means an awful lot to me. I enjoy mixing with different people from the
community.'
'I always enjoy the choir. It is something I would never have done in my life.’
‘It makes me look forward to every Friday.'
'The community element is the best. Singing music that I like really makes
me feel joy.'
'It's a kind of musical family. The people are very important., I would miss
the choir if it wasn’t on.'
'I really enjoy it. If you sing more often you don't feel depressed. It makes
you forget.'
'It brightens up your day. You forget all your worries when you're singing.'
'It's good to be able to be active, I am happy to be able to take part.'
'I didn't think I'd enjoy it, but then I loved it. The music helps people to gel
together.'
‘It’s good for your health. It gives you a different outlook.’
‘It’s great that we are such a happy group. Social well-being and interactive
benefits.’
'It's the best thing that has happened to us. It makes us feel important.'
Table 6. Participant’s describe what the choir means to them
All the participants (n=17) affirmed that ‘singing is good for
you.’ One participant referred to it as “a tonic.” When asked if
they would like to continue with the music therapy choir after
experiencing it for 12 weeks 94% (n=16) said yes.
Discussion
The present study was a controlled experiment and from the
results it is clear that the choir intervention reduced
depressive symptoms and improved quality of life and had a
secondary outcome of increased cognitive functioning. Both
treatment and control groups were selected at random and
from the outset were not different from one another (as
presented in their pre-treatment scores). Twelve weeks after
the intervention however, they differed significantly. Thus
robust conclusions may be drawn. In the CSDD pre-tests 47%
(n=8) of the choir group displayed depressive symptoms,
however in the CEQs only 22% of the participants rated
themselves as having depression. This however may be due to
the broad range of depressive symptoms, which are often
unacknowledged or reported in older adults [85]. There was
an association between lower quality of life score of those
living in residential care in both groups. The depression scores
and the fact that the depressive symptoms actually became
worse in the control group over the 12 weeks supported this.
The fact that the participants chose ‘learning new songs’
as the main benefit of the choir demonstrates that older adults
are still eager to learn new skills and supports the theory that
human beings are always looking for novelty in order to keep
their lives purposeful and meaningful until death [86]. In fact,
as participant’s confidence grew they requested songs and in
the questionnaire when asked for suggestions two comments
included: “We could all improve our voices“ and learn more
songs in different languages.” Social interaction has been
identified as a recurring theme in many recent studies on
singing and health [76] and in this instance was the second
most perceived benefit. This is important because many of the
group, whom almost 90% of were female, reported loneliness
and isolation as issues affecting their health. A high level of
loneliness has been noted to be a relevant risk factor for
mental ill health and has more frequently been found among
older women than older men [88]. Physical benefits (breath
control) were as a prime benefit from participation in the
choir. This was mirrored in a study with seniors in the United
Kingdom where improved breathing was reported as the most
common physical benefit [87]. Breathing exercises have also
been linked to improved respiratory well-being by
participants in another [74].
When reporting on singing’s effect on health participants
stated that singing had the greatest effect on their mood, and
this was also reflected in their own comments in Figure 6. This
supports the quantitative results that show that the
intervention had a significant effect on mood in the choir
group. The choir participants also reported positive feelings
felt after sessions lasting from one day to a full week.
When asked what the choir meant to the participants,
taking part and achieving was seen as very important but the
most prominent theme was that of community. The choir
provided a creative vehicle for integration, where cognitive
deficits or physical disabilities became invisible and clients
from both (residential and day-care) communities interacted
creatively with each other. The clients from the day care
centre strengthened and energised the group stimulating,
supporting and encouraging those less able to engage
productively. Indeed it could be said both groups enjoyed a
sense of purpose and agency. Working therapeutically with a
group of people with varying health conditions from different
care regimes can be challenging. Fogg & Talmage highlight
these challenges in meeting the needs of a mixed group, but
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also the opportunities to focus on strengths and group support
[6].
Having a music therapist lead the choir intervention had
many benefits in supporting people at different cognitive
levels, creating a therapeutic environment and checking in on
people who may have had emotional responses to certain
songs. The positive impact of the music therapist in
facilitating choirs has been highlighted in the literature for
facilitating reminiscence, discussion and fostering social
interaction through a positive and engaging environment
[76,77].
The choir was a positive experience for the participants
who all acknowledged that singing is good for them and all
except one wished to continue attending the choir after the
study finished. The desire to continue with this form of
therapy and improve one’s quality of life has also been echoed
in other studies [74]. The choir provided a social community
based on creativity, respect and trust. The importance of social
interaction and community is very important and a significant
mental health-promoting factor among older adults is social
capital, which encompasses social networks, social support,
reciprocity and trust [89]. In contemporary society, the
original geographical communities that existed, especially in
the inner cities are often fragmented. The concept of
‘belonging’ has been identified as being important in
contemporary communities and that these communities must
be ‘performed’ [90]. The music therapy choir provided a
therapeutic platform where participants were responsible for,
creating and ‘performing’ their community. Group-based
music therapy in aged care settings provides valuable ‘social
and psychological stimulus.’ The ‘presence of others can
reassure us, spur us on to greater efforts and provide support
and comfort’ [91]. The choir have become a cohesive group
with a sense of purpose, as they contribute to the on-going life
within the unit and the community. We are hardwired for
creativity no matter what age we are. ‘When we sing together,
we affirm and celebrate each other’s existence and that is a
most worthy song’ [92].
Limitations & Future Research
Due to funding restrictions it was not possible to offer the
control group on going music therapy after the study. Control
group participants may have felt disappointed not being
chosen for the singing group and this could result in negative
outcomes. 77 Taking this into consideration the control group
were informed that they would receive four choral sessions
with the music therapist once the study terminated. An
obvious limitation in this study was the dual role of the author
as the principal researcher and clinician. If replicating the
study it would be desirable to have a larger research team
where these roles are separate, ensuring the post-test
evaluations were blind. In further research, it would be
important to examine in detail and identify what were the
variables associated with the responses of the individuals in
the study. It is crucial to understand why and how the
treatment worked and that involves a more in-depth analysis
of the post-test results. Furthermore, it would be desirable to
replicate the music therapy study with a new treatment and
control group. This would strengthen the reliability and verify
that the results are consistent. Considering the ‘inherent social
nature of choral singing’ [93], it would also be of interest to
compare the music therapy group with a social group with no
music to examine the mechanisms of change beyond a social
event to look forward to. The lack of controlled trials
exploring the health benefits of choral singing on older adults
has been highlighted and further studies would greatly
contribute to the growing evidence base. It would also be of
useful to compare the differences between a music therapist-
led choir and a non-music therapist led choir with this
population.
Conclusion
The results of this study indicate that the use of a music
therapist led choir is an effective psychosocial intervention for
reducing depression and improving quality of life in older
adults. It may have a secondary outcome of increased
cognitive functioning. The choir’s mean depressive symptoms
were reduced by 54% and where 8/17 displayed significant
depressive symptoms at the beginning of the study (scoring 8
or more on the CSDD), none of participant scored with
significant depressive symptoms after 12 weeks. The mean
QOL scores in the choir group increased by 57% and 76.4% of
participants experienced an overall improvement in QOL.
There was also a statistically significant increase in cognitive
functioning as measure by the MMSE.
Participants identified learning new songs (89%),
socialization (67%) and physical benefits (39%) as the main
benefits of singing in the music therapy choir, where when
considering the benefits of singing for health in general they
identified enhanced mood and feel good factor (61%),
physical gains (39%) and relaxation (22%). Comments made
by participants demonstrate how choral singing had a positive
impact on their physical health and mood. They emphasized
the importance of the social benefits and the sense of
community as well as feeling valued. The need for more
rigorous research on the effectiveness of choral singing and
more specifically the use of a music therapist-led choir as a
psychosocial intervention for older adults has been
highlighted. Thus, this study is timely, relevant and delivered
within an experimentally controlled paradigm. The music
therapy choir is an efficient and cost-effective treatment
option to support older adults with depressive symptoms in
residential and community settings, which may be a more
desirable alternative to pharmacological interventions.
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Acknowledgements
Many thanks to Netta O Doherty (Director of Nursing) and
the staff and clients at the Meath Community Unit, Dublin. I
would like to especially acknowledge Prof Tom Hayden for his
assistance with the statistical analysis and editing and Prof
Jane Edwards and Dr. Kristin Robertson-Gilliam for their
input and support.
Note
A preliminary presentation of the results appears in Ahessy, B.
Creating community through song: a music therapy choir for
older adults. In Brooke S. L, Myres, C E, eds. The Use of
Creative Therapies in Treating Depression. Springfield,
Illinois: Charles C Thomas Publisher; 2015: 141-163.
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older adults. In Brooke S. L, Myres, C E, eds. The Use of Creative
Therapies in Treating Depression. Springfield, Illinois: Charles C
Thomas Publisher; 2015: 141-163.
93. Busch Sl, Gick ML. A quantitative study of choral singing and
psychological well-being. Canadian Journal of Music Therapy. 2012;
18(1): 45-61.
Biographical Statements
Bill Ahessy NMT, MMT, PGD MT, BMus is a senior music
therapist working in Dublin for the Health Service Executive
with older adults and the City of Dublin Educational Training
Board with children who have visual impairment and multiple
disabilities. He is a guest lecturer at Trinity College Dublin
and the University of Limerick and past council member of
the Irish Association of Creative Arts Therapists.
Music & Medicine | 2016 | Volume 8 | Issue 1 | Pages 17 – 28 Ahessy | Music Therapy
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