Archives of Psychiatric Nursing xxx (2016) xxx–xxx

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Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

Effects of Relaxation Exercises and Music Therapy on the Psychological

Symptoms and Depression Levels of Patients with Schizophrenia
Funda Kavak a, Süheyla Ünal b, Emine Yılmaz c,⁎
a
Faculty of Health Sciences, Department of Psychiatric Nursing, Inonu University, Malatya, Turkey
b
Faculty of Medicine, Department of Psychiatry, Inonu University, Malatya, Turkey
c
Faculty of Health Sciences, Department of Psychiatric Nursing, Bingol University, Turkey

a b s t r a c t

Purpose: This study aims to identify the effects of relaxation exercises and music therapy on the psychological
symptoms and depression levels of patients with chronic schizophrenia.
Materials and methods: This semi-experimental study was conducted using pre- and post-tests with a control
group. The study population consists of patients with schizophrenia who regularly attended community mental
health centers in the Malatya and Elazığ provinces of Turkey between May 2015 and September 2015. The study's
sample consists of 70 patients with schizophrenia (n = 35 in the control group; n = 35 in the experimental
group) who were selected randomly based on power analysis. The “Patient Information Form,” the “Brief
Psychiatric Rating Scale (BPRS)” and the “Calgary Depression Scale for Schizophrenia (CDSS)” were used for
data collection. Patients in the experimental group participated in relaxation exercises and music therapy 5
times a week for 4 weeks. The experimental group of 35 persons was divided into three groups of approximately
10–12 individuals in order to enable all participants to attend the program. No intervention was applied to the
patients in the control group. The data were evaluated using percentage distribution, arithmetic means, standard
deviations, Chi-square and independent samples t-tests.
Results: The study found that patients in the experimental group showed a decrease in total mean scores on the
BPRS and CDSS; the difference between the post-test scores of the experimental group and the post-test scores of
the control group was statistically significant (p b 0.05). The practice of relaxation exercises and music therapy
was proven to be effective in reducing schizophrenic patients' psychological symptoms and levels of depression.
Conclusion: Relaxation exercises and music therapy can be used as a complementary therapy in the medical
treatment of patients with chronic schizophrenia.
© 2016 Elsevier Inc. All rights reserved.

Schizophrenia is a cluster of chronic symptoms that generally starts
during youth and negatively affects individuals' affection, thinking,
perceptions, behaviors and social relationships. The illness causes loss
of competence, and sufferers are prone to relapses. According to epide-
miological research carried out by the World Health Organization
(WHO), more than 26 million patients suffer from schizophrenia world-
wide. Both Turkish and global statistics suggest that schizophrenia has a
very high prevalence and is becoming an important public health prob-
lem (Kwon & Gang, 2013; Möller, Hasan, & Falkai, 2015; Van Os & Kapur,
2009). In Turkey, schizophrenia has a rate of incidence of 8.9% (Binbay
Tolga, 2011).
Even though pharmacological treatment is the first option in the
treatment of schizophrenia, it has limitations as a result of the chronic
progress of the disease and patients' relapses, deficiency of insight and
cognitive losses; indeed, in some cases, patients experience ongoing
⁎ Corresponding Author: Emine Yılmaz.
E-mail addresses: funda-kavak@hotmail.com (F. Kavak), suheyla.unal@inonu.edu.tr
(S. Ünal), emine.tog@hotmail.com (E. Yılmaz).
negative symptoms despite medication (Ventura, Wood, Jimenez, &
Hellemann, 2013). A number of studies have emphasized the
importance of multi-model care, which involves psychosocial
interventions being made in addition to pharmacological treatment
(Pazvantoğlu, 2014).
Relaxation exercises and music therapy are among the methods
used in the multidisciplinary treatment of patients with schizophrenia.
The aim of relaxation exercises is to enable individuals to examine
their entire body as soon as possible; more specifically, such exercises
encourage patients to recognize tension in their bodies, control their
muscles, decrease that tension and finally relax (Bulfone, Quattrin,
Zanotti, Regattin, & Brusaferro, 2009; Demir & Okanli, 2013; Georgiev,
Probst, & De Hert, 2012; Vancampfort, De Hert, & Skjerven, 2012;
Yildirim, 1991). The application potential of relaxation exercises is in-
creased by their efficiency, flexibility and low cost. The exercises also
have minimal side effects, which means they are accompanied by a
lower risk than psychotropic drugs. Relaxation exercises are an alterna-
tive method of treatment that targets both the body and the mind (Lafçi,
2009; Paikkat, Singh, & Singh, 2012; Vadas, Bloch, & Haliba, 2008).
Music-aided relaxation exercises are especially effective in decreasing

http://dx.doi.org/10.1016/j.apnu.2016.05.003
0883-9417/© 2016 Elsevier Inc. All rights reserved.

Please cite this article as: Kavak, F., et al., Effects of Relaxation Exercises and Music Therapy on the Psychological Symptoms and Depression Levels
of Patients with Schizophren..., Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.05.003
2 F. Kavak et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx
tension, anger, anxiety, depression and stress levels (Bulfone et al.,
2009). Georgiev et al. determined that 64 schizophrenic patients who
participated in relaxation exercises showed decreased levels of stress
and anxiety. Similarly, Vadas et al. found that music-aided relaxation ex-
ercises applied 30 minutes a day for 8 weeks helped 24 schizophrenic
patients to reduce their depression and anxiety levels and to increase
their sleep quality.
In several of the studies just mentioned (Bulfone et al., 2009; Vadas
et al., 2008), researchers observed that music positively affected hor-
mones like serotonin, dopamine, adrenalin and testosterone, each of
which influences the development of mental disorders and regulates
the emotional condition of individuals. Music was also found to regulate
physiological functions such as blood pressure and respiratory rhythm
and to balance ratios of oxygen and blood in the brain. Music is deeply
tied to what it means to be human and thus has multiple positive effects
when used in therapies (Lafçi, 2009; Paikkat et al., 2012). Music has
been used for therapeutic purposes in the treatment of numerous dis-
eases, including acute psychotic disorder, schizophrenia and personality
disorder (Gençel, 2006). Music therapy can take one of two forms: ac-
tive or passive. In active music therapy, individuals use musical instru-
ments, while in passive music therapy, individuals listen to music
either on stage or on tape (Aldridge, 1994). In their study of 37 patients
with schizophrenia, Ulrich, Houtmans, and Gold (2007) found that
individuals in their experimental, but not in their control, group saw a
decrease in negative symptoms after music therapy. Another meta-
analysis study found that music therapy was an efficient means of en-
couraging mental recovery in patients with schizophrenia (Gold et al.,
2005). In particular, group music therapy for schizophrenic patients
has been found to increase quality of life and to decrease negative symp-
toms (Hannibal, Pedersen, & Hestbaek, 2012; Kwon & Gang, 2013;
Ulrich et al., 2007). In their study of 67 patients with schizophrenia,
Peng, Koo, and Kuo (2010) found that music therapy decreased the psy-
chological symptoms of patients with schizophrenia. Similarly, Kwon
(Naess & Ruud, 2007) reported that music therapy applied twice a
week for 7 weeks decreased the psychotic symptoms of schizophrenic
patients and caused a positive change in their social interactions and be-
haviors. Finally, applying music therapy 30 minutes a day over the
course of a month, Sousa and Sousa (2010) studied 272 schizophrenic
patients and found that such therapy could be used alongside pharma-
cological treatment to decrease patients' symptoms and depression.
The current study is one of the rare projects that combine music
therapy and relaxation exercises. In order to fill the gap in existing
literature, this study hypothesizes that music therapy and relaxation exercises
can be simultaneously used as a complement to the pharmacotherapeutic
treatment of patients with schizophrenia.
Observing patients with chronic schizophrenia, this study was con-
ducted to determine whether music therapy and relaxation exercises
affect patients' psychological symptoms and depression levels.
The following hypotheses are advanced:
H1. : Music therapy and relaxation exercises are effective in decreas-
ing the psychological symptoms of patients with schizophrenia.
H2. : Music therapy and relaxation exercises are effective in decreas-
ing the depression levels of patients with schizophrenia.
MATERIALS AND METHODS
Quasi-experimental in nature, this study was conducted using pre-
and post-tests and a control group. The population of the study
consisted of schizophrenic patients who were registered at and regular-
ly visited the Malatya and Elazığ Community Mental Health Centers be-
tween May 2015 and September 2015. The study's sample group
consisted of patients with schizophrenia who met the inclusion criteria
in the aforementioned places and between the aforementioned dates.
Using power analysis to determine the appropriate study sample, the
Please cite this article as: Kavak, F., et al., Effects of Relaxation Exercises and Music Therapy on the Psychological Symptoms and Depression Levels
of Patients with Schizophren..., Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.05.003
sample size was found to have a level of significance of 0.05, an effect
size of 0.7 and power of the population representation of 0.95; the sam-
ple size was set at 70 (35 experimental, 35 control). The experimental
group was selected from Elazığ Community Mental Health Center,
and the control group was selected from Malatya Community Mental
Health Center. Groups were allocated in this fashion to avoid possible
undue influences from subject interactions; such influences might
have arisen based on the close proximity of the medical centers and
their similar profiles.
Inclusion criteria of the study; diagnosed with schizophrenia
according to the DSM-V diagnosis criteria, open for communication
and cooperation, resides in the city center of Elazığ/Malatya and be-
tween 18 and 60 years old. Exclusion criteria of the study; patients hos-
pitalized for the first time, having other and/or additional axis 1 mental
disorders (drug or alcohol addiction) and patients with organic brain
syndrome or mental retardation.
Measures
Personal Information Form
The Personal Information Form was prepared by the researchers and
involved five questions regarding sociodemographic characteristics
of patients.
Calgary Depression Scale for Schizophrenia (CDSS)
The scale was developed by Addington, Addington, and Maticka-
Tyndale (1994) and the validity and reliability were studied by
Aydemir, Esen Danacı, and Deveci (2000). The CDSS contains 9 items
designed to measure depression in schizophrenia patients in acute
and remission stages. The interview contains eight multiple choice
questions and one question that the interviewer 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 indi-
cate minor depression and 6–7 points indicate major depression. This
shows that the CDSS is diagnostically similar to conventional classifica-
tion manuals. In this study, the Cronbach's alpha coefficient was found
to be 0.83.
Brief Psychiatric Rating Scale (BPRS)
The original 16-item BPRS (Overall & Gorham, 1962) and its modi-
fied versions are a widely used psychometric scale for assessing the se-
verity of clinical symptoms of patients with schizophrenia. The scale is
highly sensitive to change, and excellent interrater reliability can be
achieved when used by trained personnel. In this study, the 18-item
Turkish version of the BPRS was used. Only the BPRS scale was translat-
ed into Turkish and first Yanbastı was used in Turkey. Scale studies have
been performed. Because scale of validity and reliability is cross-
cultural, availability levels were too low (Aydemir, 2014). The scale
consisted of 18 items including somatic concern, anxiety, emotional
withdrawal, conceptual disorganization, guilt feelings, tension, manner-
isms and posturing, grandiosity, depressive mood, hostility, suspicious-
ness, hallucinatory behavior, motor retardation, uncooperativeness,
unusual thought content, blunted affect, excitement, and disorientation.
The scoring of each item used 0- to 4-point scale ranging from not pres-
ent to extremely severe. The items of the BPRS were further divided into
five subscales according to the results of a meta-analysis of factor anal-
yses of BPRS. (Aydemir, 2014).
Study Process
The researcher primarily gave a seminar for the experimental group
regarding how to apply the relaxation exercises and music therapy.
Then, the experimental group of 35 persons was divided into three
groups of approximately 10–12 persons in order to enable them to at-
tend the application. The application was conducted by the researcher
in an exercise hall in health center. The first group was taken into the
 F. Kavak et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx 3

application between 9:00 and 9:40 in the morning the second group be-
tween 10:00 and 10:40 and the third group between 11:00 and 11:40.
The application was conducted as a single stage of 40 minutes for 5
days a week.
The data were collected primarily by applying ‘Patient Introduction
Form’, ‘Brief Psychiatric Rating Scale’ and ‘Calgary Scale for Depression
in Schizophrenia’ to the control group and the experimental group in
the pretest, and then no intervention was applied to the control
group. On the other hand, relaxation exercises and music therapy
were applied to the experimental group for 5 times a week for 4
weeks. Upon completion of the applications, the ‘Brief Psychiatric Eval-
uation Scale’ and ‘Calgary Scale for Depression in Schizophrenia’ were
applied again to the control group and the experimental group in the
posttest. During this process, patients in the experimental group and
the control group continued their medical treatment and doctor control.
Application of Relaxation Exercises and Music Therapy
The application of relaxation exercises and music therapy took place
over 4 weeks. The patients primarily did awareness breathing exercises
and listened to a relaxation exercise CD. Lasting for 30 minutes at a time,
the relaxation exercises involved using breathing techniques to relax
the muscles of the hands, arms, face, neck, shoulders, back, chest,
belly, thighs, calves and feet. Upon completion of the relaxation exer-
cises, patients lay back and listened to Acemi Aşiran, Hejaz and Rast
music. For the first 10 days of the study, patients listened to Hejaz; the
researchers selected this music to speed up the work of the kidneys
for drug delivery. For the last 20 days of the study, patients listened to
Acemi Aşiran and Rast music, which was intended to encourage relaxa-
tion. The music was prepared by the Group for the Research and Promo-
tion of Turkish Music (TÜMATA) and mainly involved water and nature
sounds, which have been shown to positively affect mental health.
Music therapy lasted for 20 minutes at a time. In total, the combined re-
laxation exercises and music therapy lasted 50 minutes.
Statistical Analysis
The SPSS 18.0 software package was used to assess the data.
Regarding the assessment of the data, percentage, arithmetic mean,
and standard deviation were used for distributions of patients in the ex-
perimental and control groups based on their descriptive characteris-
tics, chi-square test and independent-samples t test were used to
compare control variables among patients in the control and experi-
mental groups. While dependent-samples t test was conducted to com-
pare the pre- and posttest mean scores of the scale, the independent-
samples t test was used for comparison of mean scores of the scale
among patients in the control and experimental groups. The strength
of association was expressed as odds ratios with 95% confidence inter-
val. Cronbach's alpha was used to assess the internal consistency of
the scales. The level of significance was set at p b 0 .05.
RESULTS
In our study, 42.9% were between 29 and 39 years old, 65.7% were
male, 71.4% were single and 51.4 were secondary graduates in experi-
mental group. Among patients in the control group, 74.3% were male,
57.1% were primary school graduates, 42.9% were between 29 and 39
years old, 82.9% were single (Table 1). Analyses revealed that there
was no difference between control variables (age groups, gender, mar-
ital status, education level and income level detection) of patients in
the experimental group and in the control group, and that both groups
were similar to each other (p N 0.05).
As seen in Table 2, patients in the control group had a mean pre-test
BPRS score of 62.25 ± 5.31, while the experimental group had a mean
pre-test BPRS score of 61.91 ± 5.22. The difference between the groups'
pre-test scores was not statistically significant (p = 0.220). Results of
the post-test showed that patients in the control group had a mean
score of 62.34 ± 5.29; the difference between this score and the control
group's mean pre-test score was not statistically significant (p =
− 1.435). In contrast, patients in the experimental group had a mean
post-test score of 52.57 ± 5.79; the difference between this score and
the experimental group's mean pre-test score was statistically signifi-
cant (p = 15.579). While the decrease in BPRS scores for the experi-
mental group was 8.34, the increase in BPRS scores for the control
group was 0.7. In terms of score variations for the control and experi-
mental groups, the decrease in the experimental group's scores was sig-
nificantly statistically higher than the increase in the control group's
scores (p = 1.905).
As also seen in Table 2, patients in the control group had a mean pre-
test CDSS score of 22.05 ± 2.24, while the experimental group had a
mean pre-test CDSS score of 21.88 ± 2.04; the difference between the
mean scores was not statistically significant (p = 0.068). Results of
the post-test showed that patients in the control group had a mean
score of 22.42 ± 201; the difference between this score and the control
group's mean pre-test score was statistically significant (p = −2.721).
As for patients in the experimental group, their mean post-test CDSS
score was 14.40 ± 2.89; the difference between this score and the ex-
perimental group's mean pre-test score was also statistically significant
(p = 22.429). While the increase in CDSS scores for the control group
was 0.37, the decrease in CDSS scores for the experimental group was
7.48. In terms of score variations for the control and experimental
groups, the decrease in the experimental group's scores was
Table 1
Patients in the Experimental Group and Control Group Based on Their Descriptive
Characteristics.
Control Experimental
group group
Characteristics n % n %

Age group
Ethical Considerations 18–28 years 6 17.1 9 25.7
29–39 years 15 42.9 15 42.9 χ2 = 0.960
40–60 years 14 40.0 11 31.4 p N 0.05
Approval from the Ethics committee of Inonu University Faculty of
Health Sciences and legal permission from institutions where the Gender
study was conducted were taken in order to conduct the study. The pa- Male 26 74.3 23 65.7 χ2 = 0.612
Female 9 25.7 12 34.3 p N 0.05
tients included in the study were informed about the aim of the study
and their questions were answered. The patients were informed about Marital status
the fact that their information would be kept confidential and not be Married 6 17.1 10 28.6 χ2 = 1.296
Single 29 82.9 25 71.4 p N 0.05
used in any other place, and they have the right to withdraw from the
study at anytime. Patient was obtained that they voluntarily agreed to Education level
participate in the study. Primary school 20 57.1 17 48.6 χ2 = 0.516
Secondary school 15 42.9 18 51.4 p N 0.05
Since the use of human fact in the study requires protection of
individual rights, “Informed Consent Principle”, “Voluntary Basis” and Income level detection
“Protection of Confidentiality Principle” which are relevant ethical Medium 18 51.4 12 34.3 χ2 = 2.100
Fine 17 48.6 23 65.7 p N 0.05
principles were realized.

Please cite this article as: Kavak, F., et al., Effects of Relaxation Exercises and Music Therapy on the Psychological Symptoms and Depression Levels
of Patients with Schizophren..., Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.05.003
4 F. Kavak et al. / Archives of Psychiatric Nursing xxx (2016) xxx–xxx

Table 2
A Comparison of Total Pretest and Posttest BPRS and CDSS Score Mean and Score Mean for Patients in the Experimental Group and the Control Group.

Scales Groups Pretest Posttest Between groups Within group

M SD M SD t p ta p

BPRS Control 62.25 5.31 62.34 5.29 tb 0.220 p N 0.05 −1.435 p N 0.05
Experimental 61.91 5.22 52.57 5.79 tc 1.905 p b 0.05 15.579 p b 0.05
CDSS Control 22.05 2.24 22.42 2.19 tb 0.068 p N 0.05 −2.721 p N 0.05
Experimental 21.88 2.04 14.40 2.89 tc 5.230 p b 0.05 22.429 p b 0.05
a
T test for dependent groups.
b
Test for independent groups (pretest).
c
Test for independent groups (posttest).

significantly statistically higher than the decrease in the control group's
scores (p = 5.230).
DISCUSSION
This section discusses the results of the current study in combination
with the findings of relevant literature. The results of this study, which
was conducted to determine the effect of relaxation exercises and
music therapy on psychological symptoms and depression level in pa-
tients with chronic schizophrenia, were discussed with the information
of relevant literature.
This study found a statistically significant decrease (p = 1.905) be-
tween mean pre- and post-test BPRS scores for the experimental
group; no statistically significant decrease was found to obtain for the
control group. These findings parallel those of the existing literature.
For instance, in their study of music therapy and schizophrenia, Peng
et al. (2010) found a decrease in the psychological symptoms of their
experimental group but not a statistically significant decrease in the
symptoms of their control group. Sousa and Sousa (2010) similarly ob-
served a significant decrease in negative and positive symptoms of the
group receiving music therapy, while Lu and Lo (2013) determined
that group music therapy for schizophrenic patients resulted in de-
creased psychological symptoms and depression. In his study of patients
with schizophrenia, Hannibal et al. (2012) determined that music pro-
duced positive results in patients and could be used as a supplementary
treatment. Meanwhile, Chen and Chu (2009) and Knöchel and Mehler
(2014) determined that relaxation decreased psychotic symptoms in
patients with schizophrenia. The results of the current study offer fur-
ther evidence that music therapy and relaxation exercises are effective
in decreasing psychological symptoms in schizophrenic patients.
In terms of the CDSS, this study also found a statistically significant
decrease between the mean pre- and post-test scores of the experimen-
tal group (p = 5.230), a decrease that was not matched in the control
group. Indeed, where the experimental group saw a decrease in mean
CDSS scores, the control group saw a slight increase between pre- and
post-test scores. In his study of schizophrenic patients, Sousa and
Sousa (2010) found that music caused a decrease in depressive symp-
toms. Moreover, in a separate study, Mössler, Chen, and Heldal (2011)
determined that music caused a decrease in depressive symptoms
such as withdrawal, blunted affection and motor retardation in patients
with schizophrenia. As regards the effect of relaxation exercises on depres-
sion, Moritz and Cludius (2015) found that schizophrenic patients undergo-
ing such exercises had decreased levels of depression, while Vadas et al.
(2008) determined that music and relaxation decrease depressive symp-
toms in patients with schizophrenia. In the current study, exposure to relax-
ation exercises and music is thought to be associated with the experimental
group's statistically significant decrease in depressive symptoms.
This study found that relaxation exercises and music therapy de-
creased the experimental group's total mean scores on the BPRS and
the CDSS. As a result of these findings, the study confirms its hypothe-
ses: namely, that relaxation exercises and music therapy decrease
both the psychological symptoms and depression levels of patients
with chronic schizophrenia.
Conclusion and recommendations
The findings of this study suggest that relaxation exercises and
music therapy should be used to supplement medication in the treat-
ment of schizophrenia-related psychotic symptoms and depression.
Medical specialists in psychiatry would benefit from being trained in re-
laxation exercises and music therapy. It could be suggested that relaxa-
tion exercises and music therapy should be used as a complementary
method in nursing practice in order to increase the effective treatment
and decrease the symptoms of schizophrenia.
Limitations
Limitations of this study include a small sample size, performing the
posttest evaluation only once, and failure to assess long-term effects.
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of Patients with Schizophren..., Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.05.003
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Please cite this article as: Kavak, F., et al., Effects of Relaxation Exercises and Music Therapy on the Psychological Symptoms and Depression Levels
of Patients with Schizophren..., Archives of Psychiatric Nursing (2016), http://dx.doi.org/10.1016/j.apnu.2016.05.003