Music Therapy as Group Singing improves Geriatric Depression Scale Score and Loneliness in Institutionalized Geriatric Adults with Mild Depression: A Randomized Controlled Study

Abstract

Aims: This study was conducted with an aim to evaluate the effect of group music therapy in the form of group singing, led by a music therapist, on depressive symptoms and loneliness in institutionalized geriatric individuals having mild depression. Settings and Design: The study was conducted as a randomized control trial at St. Mary′s Home for the aged, Cuddalore, Tamil Nadu. The study was conducted as a randomized control trial. Subjects and Methods: The experiment group (n = 40) received daily music therapy in the form of group singing lead by a music therapist for 3 weeks. The control group (n = 40) did not receive any specific intervention. Baseline and weekly Geriatric Depression Scale-Short Form (GDS-SF) and UCLA Loneliness Scale scores were recorded in both groups. Statistical Analysis Used : Measures of Central Tendency, Mann-Whitney U-test, and Wilcoxon W value. Results: Statistically significant improvement (P < 0.05) was seen in both the scores at the end of 3 weeks in the experiment group as compared to the control group. On intragroup comparison, both scores showed statistically significant improvement (P < 0.001) in the experiment group at the end of 3 weeks as compared to baseline but not in the control group. No adverse event was reported. Conclusions: Group singing significantly improves GDS-SF scores and loneliness in institutionalized geriatric adults having mild depression at the end of 3 weeks. Further research in this area is desirable which could contribute to the well-being of the aged population.

Full text

International
Journal of
Educational &
Psychological Researches
Official Publication of
Islamic Azad University Isfahan(Khorasgan) Branch
VOL. 3 | Issue 1 | January-March 2017
ISSN 0000-0000
VOL. 1 | Issue 2 | April-June 2015

© 2017 International Journal of Educational and Psychological Researches | Published by Wolters Kluwer - Medknow
6
Music therapy as group singing improves
Geriatric Depression Scale score and loneliness
in institutionalized geriatric adults with mild
depression: A randomized controlled study
Divya Mathew, Sumathy Sundar1, Easwaran Subramaniam2, Parin N. Parmar1
Chennai School of Music Therapy, Chennai, Tamil Nadu, 1Center for Music Therapy Education and Research, Mahatma Gandhi Medical College
and Research Institute, 2Department of Psychiatry, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
Introducon
Depression is a common geriatric problem. The prevalence
of depression in the elderly population is estimated to be
as high as 20% by some researchers.[1]
Clinical spectrum of geriatric depression is broad as it
includes many subtypes of depression.[2] Characteristic
symptoms of depression include feelings of worthlessness
or guilt, changes in sleep (insomnia or hypersomnolence),
changes in appetite (anorexia or hyperphagia),
psychomotor retardation or irritability, low self‑esteem,
and suicidal thoughts. In addition to symptoms of
depression, comorbidities such as heart diseases,
diabetes mellitus, stroke, Alzheimer’s dementia, cancer,
Parkinsonism, and bone fractures are also common in
geriatric depression.[2,3] The severity of depression can
vary from mild to severe.
ABSTRACT
Aims: This study was conducted with an aim to evaluate the effect of group music therapy in
the form of group singing, led by a music therapist, on depressive symptoms and loneliness in
institutionalized geriatric individuals having mild depression. Settings and Design: The study was
conducted as a randomized control trial at St. Mary’s Home for the aged, Cuddalore, Tamil Nadu.
The study was conducted as a randomized control trial. Subjects and Methods: The experiment
group (n = 40) received daily music therapy in the form of group singing lead by a music therapist for
3 weeks. The control group (n=40)didnotreceiveanyspecicintervention.Baselineandweekly
Geriatric Depression Scale‑Short Form (GDS‑SF) and UCLA Loneliness Scale scores were recorded
in both groups. Statistical Analysis Used: Measures of Central Tendency, Mann–Whitney U‑test,
and Wilcoxon W value. Results: Statisticallysignicant improvement(P < 0.05) was seen in both
the scores at the end of 3 weeks in the experiment group as compared to the control group. On
intragroupcomparison,bothscoresshowedstatisticallysignicantimprovement(P < 0.001) in the
experiment group at the end of 3 weeks as compared to baseline but not in the control group. No
adverse event was reported. Conclusions: GroupsingingsignicantlyimprovesGDS‑SFscoresand
loneliness in institutionalized geriatric adults having mild depression at the end of 3 weeks. Further
research in this area is desirable which could contribute to the well‑being of the aged population.
Key words: Complementary therapies, depression, depressive disorder, geriatric psychiatry,
music therapy
Address for Correspondence:
Dr. Sumathy Sundar,
Center for Music Therapy Education
and Research, Mahatma Gandhi
Medical College and Research
Institute, Pondy‑Cuddalore Road,
Pillaiyarkuppam,
Puducherry ‑ 607 402, India.
E‑mail: sumusundhar@yahoo.com
Original Article
How to cite this article: Mathew D, Sundar S, Subramaniam E, Parmar
PN. Music therapy as group singing improves Geriatric Depression
Scale score and loneliness in institutionalized geriatric adults with mild
depression: A randomized controlled study. Int J Educ Psychol Res
2017;3:6-10.
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DOI:
10.4103/2395-2296.198415

Mathew, et al.: Effect of music therapy as group singing on geriatric adults with mild depression
International Journal of Educational and Psychological Researches / Vol 3 / Issue 1 / January-March 2017 7
Music therapy has wide applications in geriatrics
including but not limited to depression, dementia,
Parkinsonism, etc.[4‑6] Conventional management of
geriatric depression consists of antidepressant drugs,
psychotherapy, or combination of both. However, the
side effects of antidepressant medications, multiple
drug interactions (which are more common in elderly
population), and economic burden are important concerns
with conventional management. Various techniques of
music therapy such as receptive music therapy, singing,
instrument playing, songwriting, and group music therapy
have been explored for elderly persons with depression.
However, there are only a few studies evaluating the
effect of group music therapy in institutionalized geriatric
patients.
Loneliness is significantly related to geriatric depression;
lonelier elderly have been reported to score higher on
Geriatric Depression Scale‑Short Form (GDS‑SF).[7] A lower
level of perceived emotional togetherness in a common
feature in both loneliness and depression.[8] Group singing
is a music therapy technique that improves social and
emotional bonding among individuals. In a study, group
singing has been shown to promote a faster bonding
among a group of unrelated individuals due to “ice‑breaker
effect.”[9] Considering the potential relationship between
institutionalized elderly persons, geriatric depression, and
loneliness, we conducted this study to evaluate the effect of
group music therapy in the form of group singing, led by
a music therapist, in institutional elderly persons having
mild depression.
Subjects and Methods
The study was conducted from June 10, 2015, to August
31, 2015, at St. Mary’s Home for the aged, Cuddalore,
Tamil Nadu, India. The design of the study was that of
a randomized control trial having experimental (n = 40)
and control groups (n = 40); total number of subjects
being eighty. The study was approved by the Institutional
Human Ethics Committee, Mahatma Gandhi Medical
College and Research Institute (MGMCRI), Puducherry,
vide letter reference no. PG DISSERTATION/2015/05
dated June 5, 2015.
The study included men and women above 65 years
having mild depression and staying at St. Mary’s Home
for the aged. Mild depression was defined as GDS‑SF[10]
score between 5 and 8. Individuals on antidepressive
medications, medications, or any other medications
affecting sleep or mood disorders, having depression with
psychotic features, having depression secondary to organic
disorders, and requiring cognitive behavioral therapy,
with hearing problems and unable to comprehend/follow
verbal instructions were excluded. Psychiatric assessment
and application of GDS were done by a psychiatrist from
Department of Psychiatry, MGMCRI, Puducherry.
Eighty subjects fulfilled the inclusion and exclusion
criteria. They were divided into experimental (n = 40)
and control (n = 40) groups by randomization by drawing
lots. Written informed consent was obtained from all the
subjects for participation in the study.
Subjects in the experimental group participated in group
singing activity conducted by one of the researchers, who
is also a music therapist. The group singing activity was
performed every day for three consecutive weeks. Duration
of each session was 30 min. Each session began with the
theme (1) de‑stressing and energizing. The other themes
were (2) self‑expression, (3) sharing and bonding, and
(4) managing emotions. In de‑stressing and energizing
theme, the researcher collected the favorite songs of
the group as a whole and initiated the singing sessions
and encouraged all the group participants to sing the
songs together, along clapping the hands and varying
the tempos gradually during a single session. Most of the
songs used were Tamil devotional songs and Bhajans.
In self‑expression, each member of the group chose
their most favorite song which they sang while playing
simple percussion instruments and also discussed with
the group why they liked that particular song. In sharing
and bonding, all the participants learned the favorite
songs of others in the group and sang together in the
group, and each participant shared his/her feelings while
singing the favorite songs of the other participants. In
managing emotions theme, the group participants sang
songs with body percussion and movements using hands
giving vent to their emotions. During each session, singing
was initiated by the music therapist researcher and the
subjects were encouraged to sing along and perform simple
movements using hands depending on the theme. The
control group received no specific intervention.
Baseline and weekly assessments of the subjects in both
groups were done using GDS‑SF[10] and UCLA Loneliness
Scale (version 3)[11] for severity of depression and loneliness,
respectively. The music therapist researcher was trained for
1 week by the Department of Psychiatry, MGMCRI, for
application of these scales to subjects. If the deterioration
in the psychological status of any subject was found during
the study, provision was made for prompt referral of
him/her to a psychiatrist for evaluation and management.
Statistical analysis of collected data was done by using
Mann–Whitney U‑test and Wilcoxon W value.

Mathew, et al.: Effect of music therapy as group singing on geriatric adults with mild depression
International Journal of Educational and Psychological Researches / Vol 3 / Issue 1 / January-March 2017
8
Results
Total eighty subjects were included in the study. Both
the experiment group and control group consisted of
forty subjects each. All subjects were above 65 years.
Each of the both groups comprised twenty males and
twenty females.
Comparison of GDS scores and UCLA Loneliness Scale
scores in both groups at the baseline and at the end of
1st, 2nd, and 3rd week are shown in Table 1.
In the intergroup comparison, GDS‑SF scores showed
continued improvement over 3 weeks in the experiment
group; the improvement being statistically significant
at end of 1st, 2nd, and 3rd week as compared to the
control group [Table 2]. Within the experiment group,
improvement in GDS‑SF scores at the end of 3 weeks
was also statistically significant (Chi‑square 52.70491,
P < 0.001). The control group showed no significant
improvement at the end of 3 weeks as compared to the
baseline (Chi‑square 1.82, P = 0.61).
As compared to the control group, UCLA Loneliness
Scale scores showed no statistically significant
improvement during initial 2 weeks in the experiment
group, but the improvement at the end of 3 weeks
was statistically significant at the end of the
3rd week [Table 2]. In the intragroup comparison,
UCLA Loneliness Scale scores in the experiment group
showed statistically significant improvement at the end
of 3 weeks as compared to baseline (Chi‑square 27.46,
P < 0.001); while the control group showed no
improvement at the end of 3 weeks (Chi‑square 0.0039,
P = 0.9999).
Discussion
In our study, there is a significant improvement in
GDS‑SF scores in the experiment group as compared to
control group at the end of 3 weeks. This is consistent
with results of other studies that have shown that music
therapy is useful in depressive disorders, including geriatric
depression.[12‑15]
Music has multiple and complex effects on the brain,
involving different areas of the brain and several neural
networks, involving but not limited to frontal lobe,
parietal lobe, temporal lobe, limbic system, thalami, basal
ganglia, cerebellum, and other specific areas.[16] Music
therapy improves mood in depression by modulating
various, known and unknown, neurobiological activities
Table1: Comparison of Geriatric Depression Scale‑Short
Form scores and UCLA Loneliness Scale scores for
experiment and control groups
Experiment group Control group
Mean SD Median Mean SD Median
GDS‑SF scores
Baseline 7. 8 1.137 88 . 13 0.883 8
End of 1st week 6.92 1.095 7 7.82 1.059 8
End of 2nd week 6.32 0.829 68 .1 0.9 8
End of 3rd week 5.88 0.516 6 8.1 0.9 8
UCLA loneliness
scale scores
Baseline 41.35 3.556 41 38.93 2.526 39.5
End of 1st week 38.62 3.635 38.5 38.9 2.56 39
End of 2nd week 38.08 3.269 38 38.93 2.586 39
End of 3rd week 37.45 2.66 38 38.93 2.586 39
GDS‑SF: Geriatric Depression Scale‑ Short Form, SD: Standard deviation
Table2: Comparison of mean ranks of Geriatric Depression Scale‑Short Form and UCLA Loneliness Scale scores at the
baseline and at the end of 3weeks in both groups
Experimental Control Mann-Whitney
U-test
Wilcoxon W Z P
Mean rank Sum of ranks Median Mean rank Sum of ranks Median
Baseline
GDS‑SF scores 37.58 1503 8 43.42 1737 8 683.0 1503.0 −1.184 0.236
UCLA Loneliness
Scale scores
48.56 1942.5 41 32.44 1297.5 39.5 477.5 1297.5 − 1.12 6 0.302
End of 1st week
GDS‑SF scores 32.05 1282 7 48.95 1958 8 462.0 1282.0 −3.355 0.001*
UCLA Loneliness
Scale scores
39 1560 38.5 42 1680 39 740.0 1560.0 −0.580 0.562
End of 2nd week
GDS‑SF scores 24.15 966 6 56.85 2274 8 146.0 966.0 −6.476 0.000*
UCLA Loneliness
Scale scores
3 7.15 1486 38 43.85 1754 39 666.0 1486.0 −1.298 0.194
End of 3rd week
GDS‑SF scores 21.35 854 6 59.65 2386 8 34.0 854.0 −7.648 0.000*
UCLA Loneliness
Scale scores
34.46 1378.5 38 46.54 1861.5 39 558.5 1378.5 −2.341 0.019*
*P<0.05 is statistically significant. GDS‑SF: Geriatric Depression Scale‑ Short Form, SD: Standard deviation

Mathew, et al.: Effect of music therapy as group singing on geriatric adults with mild depression
International Journal of Educational and Psychological Researches / Vol 3 / Issue 1 / January-March 2017 9
in the brain. Antidepressive effects of music therapy
are believed to be mediated by the influence of music
on the central neural serotonergic transmission and
hippocampal brain‑derived neurotrophic factor levels, but
other mechanisms are also possible.[16]
The spectrum of music therapy approaches toward geriatric
depression is broad. Active forms of music therapy
include singing including group singing, movement
therapy, instrument playing, songwriting, etc., Active
techniques help the patients to get connected with a
therapist or other people, to articulate difficult feelings,
and to enhance their own emotional awareness. In
passive (receptive) techniques, music can act as a form
of nonverbal communication and helps the patient to
relax, to reduce stress and anxiety, to ventilate suppressed
emotions, to improve sleep quality, and to improve mood
and sense of well‑being.
Singing as a music therapy has many beneficial effects
on psychology and emotional well‑being. Choir singing
has been shown to improve symptoms of depression
significantly in depressed elderly persons.[14] Apart
from relaxation benefits, active participation in choir
singing also improves many aspects of health including
emotional status, immunity, well‑being, social, and
spiritual aspects.[17,18] Singing has many positive effects
on respiratory and cardiovascular physiology, as well as
on some common geriatric neurological disorders such
as Parkinson’s disease and aphasia.[19] Thus, the positive
effect of group singing on geriatric depression seems to
be multifactorial.
Although UCLA loneliness scores for subjects in the
experiment group showed the beginning of improvement
from the 1st week, statistically significant improvement
was seen at the end of 3 weeks. This can be partly
explained by initial resistance in getting involved in group
singing activity, experienced by some of the subjects.
Moreover, it takes time to develop social and emotional
bonding among individuals in a group explaining the
delayed effect on loneliness. Although group music
therapy has many positive social and psychological
effects, we did not come across a study specifically
exploring the effect of group singing on loneliness in
geriatric depression.
There was no drop out from either of groups. No adverse
event was reported due to music therapy intervention.
Standard and validated tools were used in our study to
measure the objectives. The short version of GDS used in
our study adequately substitutes the long form of GDS.[20]
UCLA Loneliness Scale is also a validated tool with
acceptable internal consistency reliability.[21] An important
limitation is the absence of a placebo intervention in
the control group which was not feasible considering
methodology of our study involving a group intervention
in a community setup.
Financial support and sponsorship
Nil.
Conicts of interest
There are no conflicts of interest.
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