Women are nearly twice as likely as men to be diagnosed with depression. Some mood changes and depressive states occur with normal hormonal changes such as puberty, premenstrual, postpartum, perimenopause, and menopause, but hormonal changes alone don’t cause depression. Other biological factors are involved such as sleep disorders, anxiety, thyroid disorders, eating disorders, drug and/or alcohol misuse, and more. Inherited traits, history of trauma, poverty (women are more likely than men to live in poverty), single parenthood (more than 80% are women), history of physical or sexual abuse (an estimated 91% of rape victims are women and 9% are men), work overload, race, cultural stressors, and inequalities and can also contribute to depression. The point being, depression is clearly a women’s health issue.
Depression is one of the most disabling of diseases, causing both a personal and societal burden. The main conventional therapies for depression are pharmacotherapy and psychotherapy. The menu of natural medicine therapies includes less alcohol, nutrition, exercise, forest bathing, nutraceuticals, botanicals, homeopathy, and Chinese medicine. While some readers may already have experience with art and/or music therapy, most of us are likely unfamiliar with the increasing number of randomized controlled trials (RCT) and two Cochrane systematic reviews (1,2) on the effect of music therapy for depression. An overall result is that music therapy provides short term benefits for individuals with depression and is more effective than treatment as usual (TAU).
The authors of the current study had previously conducted a RCT using improvisational psychodynamic music therapy (IPMT) for working-aged people with depression.(3) Based on 20 biweekly music therapy sessions of 60 minutes each, clients in the IPMT and TAU group had significantly more improvement in their depression, anxiety, and general functioning compared to the TAU group. In addition, the treatment response of IPMT and TAU was almost twice as high as TAU in terms of depression, the primary outcome measure. Based on those results, the researchers hoped to gain even better results with the addition of a slow-breathing technique called resonance frequency breathing (RFB).
Resonance frequency breathing is the core element of heart rate variability biofeedback (HRVB). This method uses biofeedback equipment displaying heart and respiration patterns so that patients can learn to breathe at their resonance frequency, which typically corresponds to 4.5 to 6.5 breaths per minute in adults. When one breathes at resonance frequency, the autonomic nervous system shifts to parasympathetic dominance resulting in relaxation and lower stress levels. RFB is a simplified form of HRVB in that it does not involve any biofeedback equipment and is determined through a single breathing assessment. A meta-analysis based on 24 studies and 484 participants revealed that HRVB was associated with a large reduction in stress and anxiety (4). HRVB has also been beneficial for depression in open label studies (5,6) and in controlled studies (7,8).
The idea of listening homework is related to receptive music therapy in which listening to music is used to stimulate the verbal dialogue between client and therapist to evoke emotions, memories, images, and associations. The music can be precomposed but can also be improvised. The music is seen as a catalyst and enhancer. In the current study, there was no therapeutic guidance during the home listening as is the case in a client-patient therapeutic session, but there were opportunities to discuss the listening experiences when back in the therapy room sessions (9).
In the current study, all participants were offered 12 biweekly sessions of IIMT over a 6-week time period. Each session lasted one hour. There were three components to the therapy: 1) Every session involved identical instruments and a similar arrangement. IIMT is based on the interplay between free music improvisation and verbal discussion. Its fundamental aim is to encourage clients to engage in expressive musical interaction with the therapist. The experiences arising from this interaction are then further discussed. This improvising is understood as a symbolic representation of the mental issues and as a way to evoke emotions, images, and memories. The improvisations were digitally recorded and could be listened to anytime afterward. 2) Each client’s resonance frequency was determined before the beginning of therapy. At the beginning of each therapy session, clients in the RFB group performed 10 minutes of RFB at an inhalation/exhalation ratio of 40/60 in a seated position (this ratio has been shown to induce higher levels of relaxation). 3) Listening homework was conducted outside the therapy context based on the clinical improvisations that were created in the music therapy sessions. Clients were instructed to listen to these recordings whenever they felt like it and as often as they wanted to, although at the beginning of the trial, they were encouraged to listen to the improvisations after each session. Clients’ mean total listening time was 2 ½ hours over the course of the 6 weeks.
Clients were randomly assigned to one of four groups: A) IIMT alone, B) IIMT + LH, C) IIMT + RFB, and D) IIMT + LH + RFB. Eligible participants were adults with a primary diagnosis of major depressive disorder. Participants were recruited in Finland and of 102 people who were initially invited for screening, 70 eligible participants remained, of which 74% were female ranging in age from 19-57 years.
The primary outcome used was the Montgomery-Asberg Depression Rating Scale (MADRS). The secondary outcome was the anxiety subscale HADS-A of the Hospital Anxiety and Depression Scale (HADS).
Results demonstrated that 12 biweekly sessions of music therapy over 6 weeks were able to significantly improve MADRS scores in all 4 groups. There was a larger effect favoring the breathing + IIMT group. Treatment effects for secondary outcomes, including anxiety and quality of life, were also significant, again, favoring the breathing + IIMT group. The listening homework enhancer did not reach a significant treatment effect.
Commentary: This study helps me to realize additional and specific therapies I could consider for my patients with major depression. While I may not find a therapist with these skills of IIMT, I can likely find a therapist who is familiar with RFB. I also may be able to use the spirit of this study in discussing the benefits of music and RFB. We can easily learn to assess and teach RFB, and I can ask questions of my patients that may lead me to how music might be therapeutic for them. It is essential to appreciate that the estimated prevalence of depression in patients with chronic diseases ranges from 9.3% to 25%. Our patients with chronic diseases such as hypertension, coronary heart disease, and diabetes have a particularly high incidence of depression as depression and cardiovascular risks are very strongly correlated. Then consider that our patients with multimorbid conditions are twice as likely to be depressed as those without multiple morbidities. In addition, many patients with chronic diseases such as fibromyalgia, chronic fatigue syndrome, chronic pain, insomnia, and more, have depression due to the long-term nature of the disease and its impact on their quality of life. Many factors lead to how chronic disease leads to depression, and how depression may lead to chronic disease. A topic for another time perhaps.
- Maratos A, Gold C, Wang X, Crawford M. Music Therapy for Depression (Review). Cochrane Database Systematic Rev. 2008: CD004517.
- Aalbers S, Fusar-Poli L, Freeman R, et al. Music therapy for depression. CochraneDatabase Systematic Review 2017; CD004517.
- Erkkila J, Punkanen M, Fachner J et al. Individual music therapy for depression: Randomised controlled trial. BJP 2011;199: 132-139.
- Goessl V, Curtis J, Hofmann S. The effect of heart rate variability biofeedback training on stress and anxiety: A meta-analysis. Psychol Med 2017; 47: 2578-2586
- Karavida M, Lehrer P, Vaschillo E, et al. Preliminary results of an open label study of heart rate variability biofeedback for the treatment of major depression. Appl Psychophysiol. Biofeedback 2007;32: 19-30.
- Siepmann M, Aykac V, Unterforfer J, et al. Piot study on the effects of heart rate variability biofeedback in patients with epression and in healthy subjects. APpl. Psychophysiol. Biofeedback 2008; 33:195-201.
- Caldwell Y, Steffen P. Adding HRV biofeedback to psychotherapy increases heart rate variability and improves the treatment of major depressive disorder. Int. J. Psychophysiol 2018; 131:96-101.
- Lin I, Fan S, Yen C, et al. Heart Rate Variability Biofeedback Increased Autonomic Activation and Improved Symptoms of Depression and Insomnia among Patients with Major Depression Disorder. Clin. Psychopharmacol. Neurosci. 2019;17:222-232.
- Erkkila J, Brabant O, Hartmann M, et al. Music therapy for depression enhanced with listening homework and slow paced breathing: A Randomised Controlled Trial. Frontiers in Psychology 2021; February Volume 12, Article 613821.