Complementary Therapies in Medicine 26 (2016) 141–145

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Complementary Therapies in Medicine

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Short communication

Active versus receptive group music therapy for major depressive

disorder—A pilot study
Penchaya Atiwannapat a , Papan Thaipisuttikul a,∗ , Patchawan Poopityastaporn b ,
Wanwisa Katekaew a
a
Department of Psychiatry, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
b
Music Therapy Department, College of Music, Mahidol University Salaya Campus, Nakhon Pathom, Thailand

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To compare the effects of 1) active group music therapy and 2) receptive group music therapy
Received 9 March 2015 to group counseling in treatment of major depressive disorder (MDD).
Received in revised form 18 March 2016 Design & setting: On top of standard care, 14 MDD outpatients were randomly assigned to receive 1) active
Accepted 21 March 2016
group music therapy (n = 5), 2) receptive group music therapy (n = 5), or 3) group counseling (n = 4). There
Available online 26 March 2016
were 12 one-hour weekly group sessions in each arm.
Main outcome measures: Participants were assessed at baseline, 1 month (after 4 sessions), 3 months (end
Keywords:
of interventions), and 6 months. Primary outcomes were depressive scores measured by Montgomery-
Active group music therapy
Receptive group music therapy
Åsberg Depression Rating Scale (MADRS) Thai version. Secondary outcomes were self-rated depression
Major depressive disorder score and quality of life.
Results: At 1 month, 3 months, and 6 months, both therapy groups showed statistically non-significant
reduction in MADRS Thai scores when compared with the control group (group counseling). The reduction
was slightly greater in the active group than the receptive group. Although there were trend toward better
outcomes on self-report depression and quality of life, the differences were not statistically significant.
Conclusion: Group music therapy, either active or receptive, is an interesting adjunctive treatment option
for outpatients with MDD. The receptive group may reach peak therapeutic effect faster, but the active
group may have higher peak effect. Group music therapy deserves further comprehensive studies.
© 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction toms in psychiatric patients7,8 diagnosed with schizophrenia9 or

Depression is a global crisis. More than one-third of patients
with major depressive disorder (MDD) fail to respond to
antidepressants.1,2 Moreover, cognitive therapy resulted in only
30% response rate.3 Music therapy is one possible adjunctive
therapeutic option. Music affects health through changes in 1)
reward, motivation, and pleasure; 2) stress and arousal; 3) immu-
nity; and 4) social affiliation.4 Music interventions can improve
depressive symptoms, sleep quality, global and social function-
ing in mental disorders. Music therapy can be classified as ‘active’
(re-create, improvise, or compose music) and ‘receptive’ (music
listening).5,6 There were evidences that music improve symp-
dementia.10,11 When combined with standard care, there is a sig-
nificant “dose-effect relationship” for many psychiatric symptoms
including depression12 and quality of life.13 Cochrane systematic
review14 found positive effect of music therapy measured in greater
reduction in depressive symptoms in 4 out of 5 clinical trials.
Our hypotheses were 1) music therapy improves depressive
symptoms and quality of life better than control, and 2) active
therapy results in better outcomes than receptive therapy.
2. Material and methods

This is a single-blinded randomized controlled trial comparing

∗ Corresponding author at: Department of Psychiatry, Faculty of Medicine,
Ramathibodi Hospital, Mahidol University 270, Rama 6 Rd, Thung Phaya Thai,
Ratchathewi, Bangkok 10400, Thailand.
E-mail addresses: papanthai@gmail.com, papan.jar@mahidol.edu
(P. Thaipisuttikul).
the effectiveness of music therapy (active and receptive groups)
and group counseling in MDD (Fig. 1). The study was approved by
the Institution Committee on Human Rights Related to Research
Involving Human Subjects.

http://dx.doi.org/10.1016/j.ctim.2016.03.015
0965-2299/© 2016 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.
0/).
142 P. Atiwannapat et al. / Complementary Therapies in Medicine 26 (2016) 141–145
Fig. 1. Flow chart of study participants.
2.1. Subjects
Outpatients, age 18–65, with ICD-10 diagnosis of MDD were
eligible. A score of ≥7 on the Montgomery-Åsberg Depression
Rating Scale (MADRS) Thai version15 was required. Eligibility did
not include medication status and music skills. Participants were
allowed to continue taking psychiatric medications and seeing
psychiatrists during the study. Exclusion criteria included severe
depression with repeated suicidal behavior/psychotic symptoms
or need hospitalization, substance abuse/dependence, hearing or
communication problems and treatment with psychotherapy or
electroconvulsive therapy. Participants were randomly assigned to
active group, receptive group, and counseling group using drawing
lots 1:1:1 randomization.
2.2. Interventions
Both active and receptive groups received a weekly 1-h ses-
sion for 12 sessions. Each session contained 3 phases: opening
(10–15 min), one or two main interventions (35–45 min), and clos-
ing (5–10 min). All sessions were facilitated by board-certified
(MT-BC) music therapist (PP) and a music therapy assistant.
2.3. Active therapy group
Sessions began with group singing. The main interventions were
1) instrument choir playing, including anklung, tone bars and hand
bells 2) song writing and group performance and 3) improvisation
using percussion such as maracas, egg shakers and rhythm sticks.
The sessions ended with group singing and instruments playing.
2.4. Receptive/passive therapy group
Sessions began with music listening. The main interventions
were 1) lyric analysis including sharing thoughts and comments,
2) song writing, facilitated by music therapist, but participants
selected words of their choice and 3) drawing while listening to
the music. Sessions ended with music and relaxation. Active music
making behaviors were not actively reinforced.
2.5. Control (counseling) group
Control group was designed to reduce the confounding effect of
group therapy. Individuals participated in a weekly 1-hour group
counseling for 12 sessions facilitated by senior psychiatry resident
(PA). Group interventions focused on problem-solving and improve
coping skills.
2.6. Outcome assessment
Assessments were conducted at baseline, 1-month (after 4 ses-
sions), 3-month (end of interventions), and 6-month (3 months
after interventions). All rating scales and questionnaires were
in Thai language. One well-trained psychiatric nurse who evalu-
ated patients’ outcomes, including MADRS rating, was blinded to
assigned interventions. The primary outcome was the change from
baseline in MADRS Thai depression total score.15,16 The secondary
outcomes were the change from baseline in self-rated depression
score (Thai Depression Inventory—TDI)17 and quality of life (Thai
version of the Short Form Health-related Quality of Life Survey—SF-
36 Thai).18,19
2.7. Statistical analysis
Results were analyzed using STATA version 13. The efficacy anal-
yses used an intention-to-treat group with all randomly assigned
patients who had at least one post-baseline assessment. ANOVA
and Kruskal-Wallis tests were used for continuous outcomes,
Fisher’s exact test for dichotomous outcomes. For all statistical
analyses, p-values < 0.05 were considered significant. Imputation
is not recommended for missing data due to small number of par-
ticipants.
 P. Atiwannapat et al. / Complementary Therapies in Medicine 26 (2016) 141–145 143

Table 1
Baseline characteristics of 14 patients randomized to active group music therapy, receptive group music therapy, or standard care alone (control group).

Characteristics Active group (n = 5) Receptive group (n = 5) Control group (n = 4) P valuea

Age: years, mean (SD) 41.6 (11.15) 54.4 (6.73) 55.25 (10.21) 0.09
Female, n (%) 4 (80) 3 (60) 4 (100) 0.73
Married, n (%) 1 (20) 3 (60) 2 (50) 0.53
Employed, n (%) 5 (100) 2 (40) 2 (50) 0.15
Diagnosisb , n (%) 1.00
Mild depressive episode 1 (20) 3 (60) 3 (75)
Moderate depressive episode 2 (40) 1 (20) 0 (0)
Severe depressive episode 2 (40) 1 (20) 1 (25)
Duration of depression: years, mean (s.d.) 9.48 (12.56) 8.95 (11.59) 8.77 (13.09) 0.90
Age of onset of depression: years, mean (s.d.) 32.12 (13.65) 45.45 (13.95) 46.48 (11.54) 0.22
Medical comorbidity, n (%) 2 (40) 3 (60) 3 (75) 0.80
Musical background (self-reported), n (%) 1.00
Sings 1 (20) 2 (40) 1 (25)
Plays an instrument 1 (20) 0 (0) 0 (0)
Both 1 (20) 0 (0) 0 (0)
Current medication (self-reported), n (%)
SSRIs 5 (100) 2 (40) 1 (33.33) 0.15
SNRIs 0 (0) 2 (40) 0 (0) 0.30
Any other antidepressant medication 0 (0) 3 (60) 2 (66.67) 0.15
Psychiatric test scores, mean (s.d.)
MADRS Thai 27.2 (11.90) 20.6 (11.19) 16.25 (13.20) 0.33
Thai Depression Inventory 31.2 (11.61) 24.8 (10.80) 19.5 (12.37) 0.35
SF-36 Thai
All 8 dimensions 40.81 (20.80) 46.42 (20.79) 53.59 (28.64) 0.70
Physical functioning 71.0 (29.03) 67.0 (19.87) 55.0 (38.30) 0.68
Role-physical 35.0 (41.83) 30.0 (41.08) 68.75 (47.32) 0.49
Role-emotional 33.34 (33.35) 13.32 (18.24) 58.33 (50.01) 0.28
Vitality 25.0 (17.68) 46.0 (19.17) 51.25 (13.15) 0.08
Mental health 29.6 (18.46) 46.0 (24.58) 51.0 (13.22) 0.24
Social functioning 45.0 (42.02) 57.5 (32.60) 46.88 (18.75) 0.79
Bodily pain 57.5 (32.60) 62.5 (25.00) 50.0 (39.53) 0.87
General health 30.0 (27.39) 49.0 (23.83) 47.5 (32.27) 0.59

Note: a ANOVA test/Kruskal-Wallis test for continuous outcomes, Fisher’s exact test for dichotomous outcomes. b Based on Montgomery-Åsberg Depression Rating Scale
(MADRS) cut-off scores (up to 19, mild; 20–29, moderate; 30 or greater, severe).
Abbreviations: SSRIsselective serotonin reuptake inhibitors; SNRIsserotonin and norepinephrine reuptake inhibitors; MADRS ThaiMontgomery-Åsberg Depression Rating
Scale Thai version; SF-36 ThaiThai version of Short Form (36) Health-related Quality of Life Survey.

3. Results maximum change in SF-36 score from baseline was at 1 month,

and then decreased at 3 and 6 months. SF-36 decreased in the
There were 18 patients eligible. Fourteen patients signed control group (Table 2). While changes in all scores were not statis-
consent and started interventions. The number of participants ran- tically significant, graphical analysis suggested trend toward better
domized to active, receptive and control group were 5, 5 and 4, outcomes in both therapy groups than the control (Fig. 2).
respectively. Although baseline characteristics were comparable,
patients in active music therapy group were younger, had ear-
4. Discussion
lier onset of MDD, and had higher baseline MADRS and TDI scores
(Table 1).
To our knowledge, this is the first study that compared the
There was no dropout in the active music therapy group. One
effects of active and receptive group music therapy to group coun-
patient (20%) in the receptive group dropped out after the first 2
seling in MDD. The strength of this study includes the use of
sessions due to unknown reason. Two patients (50%) dropped out
one music therapy team, one blinded evaluator, and the group
in the control group (after session 1 and 3) due to lack of motiva-
counseling intervention in the control group which reduced the
tion. The average number of sessions per patient was 8 in the active
confounding effect of group meeting. Because of its relatively pas-
group (SD = 2.6, range 5–12), 7.6 in the receptive group (SD = 4.0,
sive and verbally quality, drop-out rate was higher in the control
range 2–11) and 6.8 in the control group (SD = 5.6, range 1–12).
group. The average numbers of music therapy sessions received
When dropouts were excluded, the average number of sessions
by participants (outpatients) in both types of group music ther-
in the receptive and control groups increased to 9 (SD = 2.8, range
apy were slightly lower than individual music therapy20 reported
5–11) and 11.5 (SD = 0.7, range 11–12) respectively.
previously.
At 1 month, 3 months, and 6 months, both therapy groups
The study results showed the trend congruent with our hypoth-
showed statistically non-significant reduction in MADRS Thai
esis that both music therapy groups had better improvement in
scores when compared with the control group. The reduction was
depressive symptoms and quality of life compared to control,
slightly greater in the active group than the receptive group. The
although not statistically significant. Interestingly, the effects of
receptive group may reach peak therapeutic effect faster, but the
both therapy groups seemed to maintain for at least three months
active group may have higher peak effect(Table 2).
after the end of interventions. It should be noted that only the
TDI score showed statistically non-significant reduction in
active group showed a “dose-response relationship”, as reported by
both therapy groups. Conversely, TDI score increased at every
previous systematic review and meta-analysis.13 This may reflect
follow-up assessment in the control group. SF-36 Thai score con-
the duration required to develop group cohesiveness and for
tinuously increased in the active group. In the receptive group, the
participants to be confident enough to participate in the ‘active
144 P. Atiwannapat et al. / Complementary Therapies in Medicine 26 (2016) 141–145

Table 2
Changes in primary and secondary outcomes in the active music therapy group, receptive music therapy group, and control group from baseline to 1, 3, and 6 months.

Outcome 1-month, (n = 10)a 3-month, (n = 11)b 6-month follow-up, (n = 11)b

Mean (s.d.) Change from P value Mean (s.d.) Change from P value Mean (s.d.) Change from
baseline, meanc baseline, meand baseline, meane

MADRS Thai 0.74 0.31 0.51

Active group 20 (10.36) −11.75 16.4 (3.58) −10.8 12.8 (9.01) −14.4
Receptive group 6.5 (3.87) −10.5 11.5 (13.23) −5.5 8.75 (7.71) −8.25
Control group 15 (7.07) −6 20 (5.66) −1 19.5 (7.78) −1.5
TDI 0.11 0.62 0.77
Active group 28.25 (10.24) −6.5 22.8 (8.61) −8.4 20.6 (14.79) −10.6
Receptive group 14.75 (6.65) −6.75 13.25 (11.93) −8.25 13.5 (14.57) −8
Control group 26.5 (14.85) 5.5 21.5 (0.71) 0.5 22 (5.66) 1
SF-36 Thai 0.22 0.31 0.25
Active group 35.14 (18.55) 0.74 49.16 (14.93) 8.36 55.04 (28.90) 14.23
Receptive group 68.56 (14.36) 16.39 66.66 (29.63) 14.48 65.70 (27.60) 13.53
Control group 48.43 (10.36) −12.94 42.01 (3.10) −19.36 47.93 (4.79) −13.44

Note: a active group n = 4; receptive group n = 4; control group n = 2. b active group n = 5; receptive group n = 4; control group n = 2. c Mean difference of each patient’s psychiatric
test scores that change from baseline to 1 month. d Mean difference of each patient’s psychiatric test scores that change from baseline to 3 months. e Mean difference of each
patient’s psychiatric test scores that change from baseline to 6 months.
Abbreviations: MADRS Thai, Montgomery-Åsberg Depression Rating Scale Thai version; SF-36 Thai, Thai version of Short Form (36) Health-related Quality of Life Survey.

after the active treatment group. This may help keeping partici-
pants in the control condition interested in the study and reduce
the drop-outs.

4.1. Limitations

Our study had many limitations. First, our sample size was small
(n = 14) which limited the study statistical power. A few drop-outs,
occurred early before the first assessment, precluded any outcome
measurements for those cases. Second, participants and therapist
could not be blinded due to the nature of interventions. Third, most
participants were women (79%). Although depression is more com-
mon among women22 we cannot generalize our findings to predict
the same result for men. Fourth, we allowed participants to inde-
pendently continue their medications during the study to simulate
real clinical practice. As a consequence, medications effect could
be another confounder. Finally, non-modifiable confounders, such
as spontaneous remission, stress relief, or positive life events, can
also affect outcomes. A large sample size and effective randomiza-
tion should reduce the differences of these confounders between
groups.

5. Conclusion

Group music therapy is an interesting adjunctive treatment

Fig. 2. Mean difference of each patient’s psychiatric test scores that change from
baseline to 1 month, 3 months and 6 months.
Abbreviations: (a) MADRS Thai = Montgomery-Åsberg Depression Rating Scale Thai
version; (b) TDI = Thai Depression Inventory; (c) SF-36 Thai = Thai version of Short
Form (36) Health-related Qua lity of Life Survey.
for MDD. The receptive group may reach peak therapeutic effect
faster, but the active group may have higher peak effect. Further
researches evaluating these noninvasive interventions in MDD are
required.
Disclosure
The authors report no conflicts of interest in this work.

doing’.21 Slightly higher baseline MADRS score which reflected Acknowledgments

higher depression severity in this group can also partially con-
tribute to this delay in response. On the other hand, the response
in receptive group was noted at 1 month (after 4 sessions) then
plateaued. Because active participation was not required, its peak
effect may be reached faster.
With regard to future studies of music therapy and major
depression, the researchers might consider a wait-list control group
in which the control group will receive music therapy at some point
Many thanks to Puchong Chimpiboon for assistance in group
music therapy interventions, Pattarabhorn Wisajun for advice on
the study design, Dittapol Muntham for help in data analysis and
Dr. Iyavut Thaipisuttikul for manuscript and language check.
This study was supported by Research Grant from the Faculty
of Medicine Ramathibodi Hospital, Mahidol University Number
RF 57011.
 P. Atiwannapat et al. / Complementary Therapies in Medicine 26 (2016) 141–145
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