Damian Sendler, M.D. – Is listening to music beneficial to one’s mental well-being? Clinical and nonclinical studies have found positive correlations between music engagement and improved quality of life, reduced depression or anxiety symptoms, and less frequent substance use, among other outcomes. It has also been suggested that some aspects of music engagement may even be associated with worse mental health outcomes, but many earlier studies were limited by small populations and methodological limitations,
Damian Jacob Sendler: People’s socio-emotional and cognitive development (e.g. socialization, personal/cultural identity, mood regulation, etc.) are influenced by music participation in all forms, including passive listening and active music-making (singing and instrument playing) [1–3]. Many studies have found positive correlations between music participation and various aspects of well-being, such as emotional competence and quality of life [4–8]. In spite of these advances that link music listening to a variety of health benefits, we still have a limited understanding of how music listening affects mental health, whether at the trait level (such as depression and anxiety symptoms, substance use behaviors), clinical diagnoses (such as associations with MDD or SUD diagnoses), or treatment.
Dr. Sendler: Musical engagement can be used as a means of promoting self-expression, developing emotional regulation and coping skills as well as building community [10–11]. Listening to music has an impact on a person’s heart rate, electrodermal activity as well as cortisol [12, 13]. The effects of music on the central nervous system (e.g., changes in autonomic activity) may be influenced by physical aspects of music (e.g., tempo) or rhythmic movements involved in making or listening to music [14], as well as by personality and context factors (e.g., shared social experiences) [15]. The neurochemical processes involved in reward processing [10, 13, 14, 16–18], as well as mental health disorders, are influenced by musical experiences as well (e.g., substance use; depression). An overall framework for studying music-mental health associations should incorporate psychological, physiological and neurochemical components. Expanding the scope of this study to include genetic and environmental risk factors, which may influence health and well-being, is our recommendation.
The hierarchical structure of psychopathology is critical to understanding mental health [19, 20]. MDD, generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and thought disorders such as bipolar disorder and schizophrenia all share many features and cluster into internalizing (MDD, GAD), externalizing (e.g., SUDs, conduct disorder), and thought disorders (e.g., bipolar disorder and schizophrenia). A lot of the comorbidity among individual disorders can be explained by these higher-order constructs, which have helped researchers to characterize the associations between psychopathology, cognition and personality. Our review is structured in a hierarchical manner. As a starting point, we review the growing body of research on the potential link between musical involvement and mental health, which shows promising results. Music participation is associated with internalizing traits, externalizing traits/behaviors, and thought disorders, among other factors. In this section, we critically examine the strengths and weaknesses of previous studies and how they might limit the conclusions drawn from this work.
Several studies have found a link between music engagement and general mental health, such as increased well-being or emotional competence, which lends support to the idea that music engagement may also be linked to better specific mental health outcomes. Emotional competence was linked to more hours of music practice and self-reported musical achievement in over 8,000 Swedish twins [5]. An analysis of 46 qualitative studies found that taking part in music-related activities improved well-being by promoting emotional regulation, self-discovery and development, distraction from stress and the development of social connections [28]. Music-related activities, such as singing or dancing with others or going to a concert, have a positive effect on people’s well-being, according to a study of more than 1,000 adults in Australia. In this sample, playing an instrument or composing music was not associated with a higher sense of well-being [4]. Infants’ and children’s early exposure to social music is associated with a variety of prosocial behaviors [6] and positive affect [7]. This includes song familiarity and synchronized movement to music. That music participation is associated with better mental health outcomes in children and adults has been shown in this study. However, the results vary depending on the type of music participation.
Internalizing disorders such as MDD, GAD, and PTSD are the most common [19, 24, 29, 30]. Research shows that music interventions are feasible and beneficial, but it is not yet rigorous enough to draw firm conclusions. A lack of appropriate control groups, few interventions with multiple sessions, and publications omitting important information about the intervention (e.g., intervention fidelity, inclusion/exclusion criteria, education status of the intervention leader) are the most serious limitations [31–33]. While musicians may be more prone to internalizing problems, correlational studies show that they use music engagement as a way to deal with these issues [34, 35].
Music interventions (including both music therapies administered by board-certified music therapists and other music interventions) have been shown to reduce depression, anxiety, and PTSD symptoms in randomized controlled trials [26, 27, 33, 36]. More than two-dozen studies found that music intervention groups were significantly less depressed than control groups, including nine studies that included active non-music intervention control groups (e.g., reading, “conductive-behavior” psychotherapy, and antidepressant drugs). It has been found that listening to music can reduce one’s level of self-reported anxiety in healthy people [26]. There were only four studies that were relevant to a review of music-based PTSD treatment studies [36]. Recent studies [37–39] support these findings, such as a randomized controlled trial that found that older adults who practiced musical improvisation exercises had lower levels of depression than those who engaged in light gymnastic activities [39].
Some studies have found effects even when comparing this work to traditional behavior therapies, which is encouraging [40, 41]. The number of studies comparing music therapy to other forms of treatment is small. Dialectic and cognitive behavior therapies [42, 43] have been incorporated into some music interventions but few directly compare how the inclusion of music enhances traditional behavioral therapy. As for the role of music in other non-music therapies, such as mindfulness, it’s not clear what role it plays. [43, 44]. For this reason, more systematic studies linking music to traditional therapies are urgently required. These studies will help identify the music interventions that use similar mechanisms (e.g., building coping mechanisms and community) as traditional therapies, as well as the ones that complement or sync with other approaches (e.g., by adding structure, reinforcement, predictability, and social context to traditional approaches).
It was found that the promising effects of music therapy were limited by small sample sizes and methodological shortcomings, including the lack of reporting of adverse events, exclusion criteria and possible confounders, and the characteristics of patients who were lost to follow-up [33]. Additionally, the study’s source population (e.g., selection of patients and proportion agreeing to participate in the study) was not adequately reported, and interviewers were not adequately masked when conducting the post-test. The results of all the studies which included these characteristics showed significant positive effects on mood. However, there was some evidence that therapies with active music participation, structured sessions and multiple sessions (i.e. four or more). Studies have focused on passive interventions like listening to music [26, 27]. As no direct comparison has been made between active (e.g. singing) and passive interventions [27], more research is needed to determine whether therapeutic effects are stronger with more engaging and active interventions.
Music’s role in emotional self-regulation has been studied correlatively. Particularly neurotic individuals appear to use music to help regulate their emotions [34, 35], with beneficial effects of music engagement on emotion regulation and well-being driven by cognitive reappraisal [45].. It is also possible that listening to music can reduce the link between neuroticism and depression in adolescents [46].
Individuals’ use of music activities to regulate their emotions has been studied using validated self-reported instruments in recent studies [47–50]. Adults’ subjective well-being, psychological well-being, and social well-being were all improved when they listened to music to control their anger and anxiety [50]. Music listening as a form of entertainment has been linked to lower levels of depression and anxiety in adolescents and undergraduates [51]. Adolescents who engage in “healthy” music use (i.e., listening to music to relax and connect with others) are more likely to be happy and satisfied at school [49]. As a result, “unhealthy” music engagement (e.g., “hiding” in music to block others out) was associated with lower well-being (e.g., happiness, school satisfaction, and greater depression and rumination) as well as higher levels of stress. According to other studies, valence plays an important role in these associations, with people who listen to happier music when they are feeling down reporting that music has a greater ability to influence their mood than those who listen to sad music when feeling down [52, 53].
These findings support the idea that people who are already suffering from depression, anxiety, or stress use music as a therapeutic tool to manage their emotions, and that some strategies are more effective than others when looking at associations between music and well-being and mental health. These correlational effects may not necessarily reflect causal associations, but may be due to bidirectional influences, as suggested by claims that musicians may be at greater risk for internalizing problems [54–56]. For example, participation in the arts may be more strongly associated with self-esteem in those with higher education [58], so demographic and socioeconomic factors must also be taken into account in these associations [57].
There needs to be a better understanding of whether or not musicians (both professional and non-professional) are already at a higher risk of internalizing issues. Professional musicians in Norway (N = 6372) were found to have a higher level of neuroticism than the general population [56]. Using text mining of medical records, another study of musicians (N = 9803) compared to controls (N = 49015) found that musicians have a higher risk of MDD (OR = 1.21), anxiety disorders (OR = 1.25) and posttraumatic stress disorder (PTSD) (OR = 1.13) [55]. Another study found no correlation between musician status and depression symptoms [5] while another found mixed results [59]. Professional and amateur musicians, for example, reported more symptoms of burnout in a study of 10,776 Swedish twins [54]. Both amateur musicianship and professional musicianship were found to have no significant impact on depression and anxiety diagnoses.
Findings such as these can still support the idea that music-making is beneficial and therapeutic even if musicians are at a higher risk (e.g., depression medication use is elevated in individuals with depressive symptoms because it is a treatment). Disentangling these links may require clinical samples, and a broader deployment of measures that capture emotion regulation strategies and motivations for engaging with music will help shed light on whether high-risk individuals engage with music in qualitatively different ways than others [51, 57]. [57, 57] For example, if people who are genetically or environmentally at risk for mental health issues choose to participate in music therapy because they believe it is beneficial, this could shed light on these questions.
Damian Jacob Markiewicz Sendler: Music therapy has been shown to benefit patients with SUDs in a variety of ways, including the reduction of withdrawal symptoms and stress, the ability to feel emotions without the desire to use drugs or alcohol, and the enhancement of patient motivation and enjoyment in treatment sessions [62–64]. (for a systematic review, see [65]). These studies, too, would benefit from larger samples, better controls, and higher reporting standards, just like the ones that looked at people’s ability to internalize traits.
Damian Sendler
Studies on the effectiveness of music therapy for ADHD are of the same quality. These treatments have been shown to improve reading comprehension in ADHD patients by decreasing inattention [66], lowering mood [67], and reducing negative emotions [68]. It’s possible that some children with ADHD find music distracting, while others are better able to focus when listening to music [69].
Musical interventions for impulsivity and conduct disorder have received scant attention, and the results have been mixed. If you’re looking for an example, a music therapy study of 251 children found that free improvisation had a significant impact on communication skills in children above the age of 13 [70]. There was no control group in another study that found that music therapy improved social skills and problem behaviors in 89 students with social/emotional problems [71]. There are conflicting results from smaller studies (N 20) on disruptive behaviors and aggression.
There are few studies on the correlation between externalizing traits and correlational studies. There have been a number of studies looking at the link between music listening habits and substance use [74–77]. Music genres are influenced by cultural and socioeconomic factors that change over time, so these studies do not provide strong evidence of a link between music engagement and substance use. A large study of electronic medical records in the United States [55] found no correlation between musicianship and higher rates of internalizing diagnoses like “tobacco use disorder,” “alcoholism,” “alcohol-related disorders,” or “substance addiction and disorders.” However, in sex-segregated analyses, female musicians were found to be significantly less likely to develop an addiction to tobacco (OR = 0.85). As a result, there is less evidence that musicians are more prone to externalizing their problems than those in other professions.
Externalizing, some studies have shown that children with ADHD have a poor sense of rhythm, which raises the possibility that working on rhythm skills could have an effect on ADHD. Because of its regular, predictable rhythmic beat, music may serve as a useful scaffold (e.g., for attention). If these associations with music rhythm are also observed for measures of musical engagement, especially in larger population studies, it will be important to investigate further. Musicians were found to be less impulsive than non-musicians in some studies, but these studies did not compare musicians to the general population [80, 81].
People with schizophrenia and bipolar disorder have participated in music therapy studies. It has been found that music therapy in combination with standard treatment for schizophrenia (and similar disorders) improves general mental health, reduces negative symptoms of schizophrenia, and enhances social functioning [82]. General functioning and positive symptoms of schizophrenia were unaffected. Comments mirrored those outlined in the previous paragraphs. Even though attrition bias was low in most studies, the vast majority of studies (>75 percent) had a high risk of bias from selection bias, performance bias, detection bias, and reporting bias. It is imperative that these studies provide more information about their study selection, blinding procedure, and outcomes.
Music therapy has been shown to have similar benefits for patients with psychosis and thought disorders [83, 84]. (e.g., one study did not include a control group). Music therapy has the potential to treat bipolar disorder symptoms and alleviate subthreshold symptoms in early stages of the disorder, according to a 2021 review that did not find any more recent studies on the subject.
Damian Jacob Sendler
Music participation has been linked to improved mental health outcomes. Quality of life, happiness, social connectedness and emotional competence are all linked to music participation. The risk of mental health problems, especially internalizing and thought disorders, may be higher among those who engage in music. For example, more research is needed to clarify how “healthy” music engagement (e.g., for relaxation or social connection) leads to greater well-being or successful emotion regulation, and to test whether some individuals (e.g., those with high neuroticism) are more likely to use music as a tool to regulate emotions. To determine whether musicians are at risk because they work in an artistic field (which may have lower pay or job security), or if the same associations are observed with continuous music engagement phenotypes, will be critical in this study (e.g., hours of practice). These complex associations can be clarified using genetically informative datasets, such as testing whether musicians have a higher genetic risk for mental health problems but their music engagement reduces these risks.
Damien Sendler: Clinical diagnoses such as depression, anxiety and SUDs can be alleviated through the use of music intervention studies. Nevertheless, these studies must be expanded to include larger samples, random sampling, and active control groups in order to compare the benefits of music interventions with traditional therapies and address potential confounds. Because of these limitations, it is difficult to determine how specific factors, such as the length and depth of music training, the age of the sample, confounding variables (such as socioeconomic status), and the type of intervention influence the effectiveness (e.g., individual vs. group sessions, song playing vs. songwriting, receptive vs. active methods). The wide range of music engagement activities and measures makes it difficult to identify the specific aspects of music engagement that have the greatest impact on health and well-being [87]. Therefore, it is imperative to improve the reporting quality of studies so that researchers can more easily identify these potential moderators or confounds using systematic approaches (e.g., meta-analyses).
Psychological (e.g., building communities, developing strategies for coping) [10, 11] and specific neurobiological drivers (e.g., oxytocin, cortisol, activity of the autonomic nervous system) [12–14] have both been proposed to explain the therapeutic effects of music on mental health. As a matter of fact, it is imperative that more systematic research be conducted to compare the effects of music interventions to existing therapeutic methods and other creative activities (e.g., art). Other treatments may benefit from the use of music interventions, such as their ability to be engaging and enjoyable, their ability to provide social context and their ability to help people feel more secure [89]. It’s also true that some psychotherapeutic models (e.g., mindfulness) incorporate music into their practice, while some music therapists use existing psychotherapeutic principles [42, 90]. With better reporting standards and high-quality experimental design, it will be possible to identify which aspects of music interventions best complement or enhance standard psychotherapeutic practices (which are also heterogeneous).
We now propose a theoretical framework to help guide future research into the relationship between music engagement and mental health. This framework is meant to capture and expand on these ideas.
Music engagement and brain structure and function need to be studied in order to understand the three pathways outlined above. Music listening has a strong connection to reward centers of the brain, such as the nucleus accumbens and ventral tegmental areas, which are implicated in the reward system for all drugs of abuse [109–112] and may be linked to internalizing problems [113–115]. [104–105] The caudate’s activity can also influence rhythmic sensorimotor synchronization, money reward processing, and prosocial behavior at the same time. Emotional stimuli can influence autonomic and physiological responses (e.g., in the hypothalamus), and music listening has been shown to induce the endorphinergic response blocked by naloxone (an opioid antagonist).
Some differences in brain structure and plasticity between musicians (such as greater fractional anisotropy in corpus callosum and superior longitudinal fasciculus) and non-musicians have been observed for white matter (e.g., greater fractional anisotropy in corpus callosum) [118–121]. longitudinal studies have shown that children and adolescents who play an instrument have thicker cortical cortices in the prefrontal and parietal areas that are linked to emotion and impulse control than non-musicians [122]. Cross-sectional and longitudinal structural differences between musicians and non-musicians could be explained by genetic correlations or the effects of music training, and this is important because the existing evidence is primarily correlational in nature (Fig. 2). Increasing our knowledge of music engagement’s neural correlates and the mechanisms that drive the associations discussed above will require a closer look at these possibilities.
The biological underpinnings of musical engagement can be seen through genetic designs [123]. Understanding the role of genetic risk factors is essential to testing causal or mechanistic models related to mental health. Twin and family studies can be used to estimate genetic correlations between musical ability or engagement measures and mental health traits or diagnoses at the most basic level It is possible to test competing models or average across different candidate models [102, 124] to examine genetic associations while simultaneously quantifying environmental correlations and evaluating (bidirectional) causal associations, informing Path 1.
As a result, researchers can examine whether people who have a higher genetic risk for psychopathology (e.g., for MDD) have stronger associations between music engagement measures and their mental health outcomes (Path 2). People with low genetic risk for MDD, for example, are unlikely to experience many depressive symptoms regardless of how much time they spend listening to music, so the link between depressive symptoms and time spent listening to music may be weak if this population is studied. Individuals with a high genetic risk for MDD may, however, experience fewer symptoms if they engage in musical activities (i.e., a stronger negative correlation). This is in accordance with recent research showing that the heritability of depression is doubled in those who have been traumatized compared to those who have not.
There has been a rise in the number of gene–environment interaction studies that use polygenic scores (i.e., summated indices of genetic risk based on GWAS). Music rhythm appears to be highly polygenic, as evidenced by the first large-scale GWAS of a music measure [131]. Multiple large GWAS have already been conducted on internalizing and externalizing traits. Importantly, it is not necessary to examine cross-trait relationships in the same sample of traits. For example, music engagement and genetic data can still be used to examine how polygenic scores for depression predict music engagement, or how music engagement measures interact with music engagement measures to predict other study outcomes, for example. It is shown in Figure 4 how to use a GWAS to compute and apply a polygenic score to test cross-trait predictions.
Experiment design can also be guided by a study of the neural mechanisms by which music affects mental health. Even though there is a vast and sometimes tumultuous body of literature on the neural underpinnings of music listening and engagement, there is unquestionably great potential to link this to existing research on the same topic. These developments can shed light on the mechanisms that lead to effective interventions and on the individuals who stand to gain the most from them. Among many possible interactions between music and mental health, we focus on two: (1) activation of reward circuitry by music, and (2) the impact music has on dynamic patterns of neural activity.
[139] The search for neuronally based biomarkers for aspects of mental illness, which hold promise for understanding heterogeneity within disorders and identifying common mechanistic pathways, has been a central thrust in the field. Musical effects on mental health may have neuro-mechanistic mediators that can be highlighted in this paper, but a comprehensive review is beyond the scope of this paper. A treatment for MDD, for example, has been proposed to increase activity in the emotional circuitry via neurofeedback [141]. There is potential for using music as an adjuvant or as a more actively controlled output target for neurofeedback because of the emotional effects of music. It’s becoming more and more common to use magnetic resonance imaging (MRI) or magneto-electroencephalography (MEG) to measure brain activity in health and disease, with abnormalities in dynamic complexity linked to mental illness [143]. Music engagement, on the other hand, is thought to reflect and possibly influence dynamic complexity.
These neuro-mechanistic studies are not exempt from the review’s cautions [146]. Non-musical outcomes of music engagement can only be reliably supported by high-quality experimental design (involving appropriate controls and randomized design) [103]. It has been demonstrated that analyzing M/EEG activity not at the scalp level but at the source level improves the power of biomarkers and their mechanistic interpretation [147, 148] for such studies to have maximum impact. Neuronal underpinnings for music-mental health associations may be highly multivariate, just like genetic influences that typically influence a trait through numerous small individual effects [149]. While current experimentalists can prepare by adopting standards for documentation, annotation and storage of data [150], in the long term large-scale studies and large-scale standardization and aggregation promise deeper cross-domain insights. [150]
Humans have a special affinity for music, and it has a profound impact on everything we do, from how we express ourselves socially and culturally, to the way we think and feel about the world. Despite decades of research, there was no conclusive evidence that music had a positive impact on mental health or that it could be used to treat mental illness. Scoping review and framework integrated across a wide range of smaller literatures relating music engagement to mental health traits and treatment effects, though it was potentially limited by the lack of systematic literature search or formal quality evaluation of individual studies. A growing body of research suggests that people with internalizing, externalizing, or thought disorder problems may find an outlet in music, which may help regulate emotions in multiple neurobiological pathways (e.g., reward center activity). In order to better understand how music engagement relates to these mental health traits, we need to conduct more rigorous experimental intervention studies, improve reporting standards, and harness large-scale population-wide data in combination with new genetic analytic methods. To better understand how music engagement and existing risk factors interact to support mental health and well-being, we have presented a framework that shows why genetic and environmental risk factors must be considered when examining these associations.
