INTRODUCTION
Psychological morbidity is a very common consequence of cancer. It has been estimated that between 30 and 50% of patients show a moderate to high level of distress during the course of their illness (Zabora et al., Reference Zabora, BrintzenhofeSzoc and Curbow2001; Carlson et al., Reference Carlson, Angen and Cullum2004). Anxiety, depression, and adjustment to disorders are the most typical manifestation of psychological suffering associated with a diagnosis of and treatment for cancer (Akechi et al., Reference Akechi, Okuyama and Sugawara2004; Singer et al., Reference Singer, Szalai and Briest2013). Mitchell et al. (Reference Mitchell, Chan and Bhatti2011) reviewed 94 studies in which patients were assessed by a psychiatric interview for mood disorders. They concluded that some form of mood disorder can be detected in 30–40% of cancer patients. Several negative consequences have been correlated with distress in cancer patients, including: poor quality of life (Brown et al., Reference Brown, Kroenke and Theobald2010), long-term hospital stays (Prieto et al., Reference Prieto, Blanch and Atala2002), reduced compliance with treatments (DiMatteo et al., Reference DiMatteo, Lepper and Croghan2000; Berry et al., Reference Berry, Blonquist and Hong2015), higher risk of suicide (Breitbart et al., Reference Breitbart, Rosenfeld and Pessin2000; Leung et al., Reference Leung, Li and Devins2013), and reduced survival (Kissane, Reference Kissane2009; Pinquart & Duberstein, Reference Pinquart and Duberstein2010). In this sense, to identify effective interventions to address patient distress is one of the highest priorities in clinical psycho-oncology.
After prayer, music is the most common self-administered strategy used by patients to cope with illness (Zaza et al., Reference Zaza, Sellick and Hillier2005), and music interventions have been widely used during different phases of the disease: diagnostic procedures (Danhauer et al., Reference Danhauer, Vishnevsky and Campbell2010), surgery (Li et al., Reference Li, Yan and Zhou2011), chemotherapy (Ferrer, Reference Ferrer2007), radiotherapy (Chen et al., Reference Chen, Wang and Shih2013), and palliative care (Gallagher et al., Reference Gallagher, Lagman and Walsh2006; Archie et al., Reference Archie, Bruera and Cohen2013). Most of the evidence supports the beneficial effects of music interventions in reducing anxiety, depression, and perception of pain in cancer patients. Moreover, music may also have an effect on improving heart rate, respiratory rate, and blood pressure (Bradt et al., Reference Bradt, Dileo and Grocke2011).
Music interventions in the literature are subcategorized into music therapy (MT) and music medicine (MM) (Dileo, Reference Dileo1999). Music therapy is a process that includes assessment, treatment, and evaluation, and it is based on the relationship between a trained music therapist and a patient. The intervention is tailored to the characteristics of the patient and can include: listening to live improvised or prerecorded music, composing and performing music, and combining music with other experiences (e.g., art or imagery interventions). The purpose of MT is to improve patient well-being in various domains, including relationships, adjustment to disease, and sense of control, among others.
Conversely, in MM interventions, patients passively listen to music, usually prerecorded music provided by hospital staff. An example in oncology is listening to relaxing music through headphones during chemotherapy. The main difference with MT is the absence of a therapeutic relationship with a therapist. Moreover, the intervention is not preceded by an assessment of the patient and does not include an evaluation or discussion of the experience with a professional.
A pilot study was recently conducted with 31 cancer patients in order to compare the effectiveness of MM and MT. These results did not demonstrate any significant differences between the two treatments in terms of improving psychological outcomes (i.e., anxiety, mood, and relaxation) and pain (Bradt et al., Reference Bradt, Potvin and Kesslick2015). More research is requited in the field of oncology to determine which one of these interventions is more effective in cancer patients.
The oncology unit at Massa Carrara hospital in Tuscany, Italy, has since 2009 been promoting a new sort of experience called “Donatori di Musica” (“Music Givers”), which is aimed at organizing and managing live concerts in the oncology departments of participating hospitals (Toccafondi et al., Reference Toccafondi, Bonacchi and Mambrini2013). Despite the fact that the Music Givers interventions are closely related to MM interventions (i.e., the musicians are not music therapists and do not have a therapeutic relationship with the patients), it has evolved into a specific and repeatable format.
The main features of Music Givers are the following:
1. The intervention is divided into two phases: a live concert followed by a buffet (Table 1).
2. Continuity/regularity: Music Givers are not limited to occasional happenings but include regular weekly concerts performed at the same place on the ward, on the same day of the week, and at the same hour. It is a concert season that begins in September and ends in July.
3. Quality: To ensure high-quality standards, the participants have a reputation for being senior musicians who are selected by the art commission of the Music Givers organization.
4. Empathy: The musicians do not wear formal attire. They dialogue with the public by presenting the music and explaining why they chose certain pieces. Doctors and nurses do not wear a white coat, and patients are encouraged to wear street clothes.
5. Not-for-profit: Musicians are not paid, the concerts have no admission charge, and the seats are strictly reserved for patients, their relatives, and hospital staff.
6. An oncology department that wants to host a Music Givers event must have a place where concerts can be performed.
The phases of the Music Givers intervention
Some of these features are among those recommended by patients in order to improve music interventions in oncology settings (i.e., live music on the ward, free entry, and a good-quality sound system) (O'Callaghan et al., Reference O'Callaghan, McDermott and Michael2014). This format for a music intervention has been steadily growing in popularity in Italy, now involving nearly 200 Italian and international performers. At present, eight oncology departments, located in different towns and regions, are hosting such interventions with this specific format, and several other departments have already given their consent to begin the initiative. The oncology departments that host Music Givers interventions are required to adopt and enforce the entire original format in all its aspects.
A first study was conducted that investigated the short-term effect of the Music Givers intervention on patient anxiety (Toccafondi et al., Reference Toccafondi, Bonacchi and Mambrini2016). Using the State–Trait Anxiety Inventory with the 111 inpatients who participated in the Music Givers event, we found a significant decrease in state anxiety two hours after the experience compared to two hours before. Starting from this result, we were interested in understanding whether taking part in this format could influence patients' psychological outcomes not only in the short term, but also in the days following hospitalization.
The aim of our present study was to evaluate the effectiveness of a single session of the Music Givers intervention in reducing—between admission and discharge—the levels of distress, anxiety, and depression, and in improving the psychological well-being of hospitalized cancer patients. We carried out a quasiexperimental study to investigate this effect.
METHODS
Study Sample
Our study was carried out at the medical oncology unit of Massa Carrara's AUSL 1 Hospital in Tuscany, Italy. During the period of study, participation was proposed to all patients consecutively hospitalized, regardless of site or stage of tumor. The exclusion criteria were as follows: (1), age under 18 or over 90 years, (2) cognitive impairment, (3) comorbid psychotic illness, (4) learning disabilities, (5) severe symptoms due to illness or the side effects of therapy that precluded, because of physical limitations, the ability to participate in the Music Givers intervention and/or to fill out questionnaires autonomously; and (6) a hospital stay >7 days. Particular care was exercised to avoid coercion to join the study, emphasizing that participation was totally free and voluntary and that nonadherence would not alter the care provided by the staff of the ward. Because the oncology department did not have a dedicated psychological service, patients included in the study did not receive psychological interventions during their hospitalization.
Data Collection
Patients' clinical data were provided by oncologists. The Music Givers event took place once a week (Wednesdays at 7:00 p.m.) in a space within the department of oncology. For each participating patient, we recorded whether or not the Music Givers intervention had been provided during their period of hospitalization.
The Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, Reference Zigmond and Snaith1983) was used to assess anxiety and depression. This is a multiple-choice test that includes 14 items: 7 on depression and 7 on anxiety. Answers are scored on a 4-point Likert-type scale. The total score ranges from 0 to 21 for each subscale (anxiety and depression). Psychological distress was assessed using the Distress Thermometer (DT) (Roth et al., Reference Roth, Kornblith and Batel-Copel1998), which is a rapid and simple-to-use instrument developed by The National Comprehensive Cancer Network. The patient is asked to indicate their level of distress on a 0–10 visual analogue scale and to point out possible problems in the following areas: emotional, spiritual, family, physical, and practical. Pain and fatigue were assessed by a self-reported visual analogue scale (score range = 1–10).
Patients also filled out the Multidimensional Well-Being Scale. This is a brief and practical self-report instrument used to assess patients' current well-being in five areas: physical, psychological, relationships, and spiritual, as well as overall state of well-being. Each area is represented by a 10-point line, where 1 stands for “absolute uneasiness” and 10 for “complete well-being.” This scale was developed by the authors and is currently being validated.
Statistical Analysis
The usual univariate and bivariate descriptive statistics were performed in order to compare the baseline characteristics of the two groups. Multiple regression models, including questionnaire score upon admission to the hospital and length of hospital stay, were fitted to test the effect of exposure to a Music Givers session on distress, anxiety, depression, and well-being. An intention-to-treat analysis was adopted: people who were in the hospital when the Music Givers session occurred were considered to be part of the treatment group even if they did not actually attend the concert and buffet. Analyses were performed using the STATA 12 statistical package.
Ethics
Our study received the approval of the local ethics committee of the AUSL 1 Massa Carrara Hospital. Informed consent was obtained from all included participants.
RESULTS
Description of the Sample
Some 263 inpatients were invited to participate in our study, 242 (92%) of whom accepted and were asked to fill out the questionnaires both upon admission to the hospital and at discharge. Low levels of interest regarding the aim of our research and being engaged in diagnostic or therapeutic procedures were the main reasons cited by the patients who refused to participate.
Among the 242 participating patients, 103 were in the hospital when Music Givers events took place (Music Givers group). Among them, 80 participated in the concerts and buffet, and 23 did not because their medical condition did not allow them to get out of bed. The control group was composed of 139 patients, who had been hospitalized when Music Givers interventions did not take place.
Table 2 illustrates the sociodemographic and clinical characteristics of the sample. Overall, about two-thirds of patients in both groups were hospitalized for 3 days. From a clinical point of view, most patients were affected by pancreatic cancer (45.2%) and were in the metastatic phase of the disease (81.7%). Patients hospitalized when the Music Givers intervention took place reported significantly longer hospital stays. The reason for this may be due to the observational nature of the study, since a longer hospital stay made it more likely to be of assistance during a Music Givers intervention.
Basic demographic and clinical characteristics of participants
1 Patients may have received more than one treatment.
* p < 0.05.
Effects of the Intervention on Distress, Anxiety, and Depression
Upon admission to the hospital, patients showed a borderline level of distress according to the DT (Music Givers group = 4.8 ± 2.6; control group = 4.6 ± 2.9), as well as borderline HADS scores (Music Givers group: HADS–A = 7.8 ± 4.4, HADS–D = 8.0 ± 4.7; control group: HADS–A = 7.8 ± 4.2, HADS–D = 7.8 ± 4.3).
Table 3 shows that the level of distress in the Music Givers group decreased during the days spent in hospital (admission = 4.8 ± 2.6; discharge = 4.0 ± 2.6), whereas no statistically significant difference was observed in the control group (admission = 4.6 ± 2.9; discharge = 4.6 ± 3.1). Multiple regression models, adjusted for baseline level of distress and for length of hospital stay, revealed a significant difference between the intervention and control groups at discharge (p = 0.001).
Mean score (SD) of DT, HADS, and visual analogue scales upon admission to the hospital and at discharge, and estimates of adjusted effect of the intervention (multiple regression coefficient [MRC])
CI 95% = 95% confidence interval; MRC = multiple regression coefficient.
A similar trend appeared on both scales of the HADS, in which there was a reduction in the scores of patients in the Music Givers group, while an increase was observed among those in the control group. Multiple regression models, adjusted for baseline level of distress and length of hospital stay, showed a significant difference between the intervention and control groups at discharge (p < 0.001 for HADS–A and p = 0.001 for the HADS–D).
Effects of the Intervention on Visual Analogue Scales
Mean scores on the visual analogue scales, upon admission and at discharge, are reported for both the intervention and control groups in Table 3. The scores on all well-being scales for patients in the Music Givers group improved at discharge. The comparison with patients in the control group was statistically significant according to the multiple regression model, except for spiritual well-being.
The whole sample showed a moderate level of pain upon admission to the hospital (Music Givers group = 3.1 ± 2.1; control group = 3.0 ± 2.4). A similar trend was found for the fatigue scale (4.1 ± 2.4 vs. 3.9 ± 2.6). In both groups, pain decreased during hospitalization by ~1.0 and fatigue by ~0.5 points. After adjusting for score at admission and length of hospital stay, no statistically significant differences were found between the two groups in terms of pain and fatigue scores at discharge.
DISCUSSION
The findings of our study are congruent with the results of previous research on music interventions in oncology, which highlights the beneficial effects of music on hospitalized cancer patients (Archie et al., Reference Archie, Bruera and Cohen2013; Bradt et al., Reference Bradt, Dileo and Grocke2011). In our research, we demonstrated the effectiveness of the Music Givers intervention, based on a single session of live music followed by a buffet, in influencing the psychological outcomes of cancer inpatients during their hospital stay. These results indicate a significant reduction in distress, anxiety, and depression at discharge among patients hospitalized when the Music Givers event took place, compared to stable or worsened scores among patients in the control group.
Most studies in the literature that describe one session of music intervention were carried out to evaluate the effectiveness of these interventions in improving psychological outcomes during diagnostic procedures (Danhauer et al., Reference Danhauer, Vishnevsky and Campbell2010) and treatments (Ferrer, Reference Ferrer2007; Chen et al., Reference Chen, Wang and Shih2013), and/or to alleviate pain in cancer patients (Huang et al., Reference Huang, Good and Zauszniewski2010). However, in these studies, the pre–post measure of psychological variables occurred within a brief timeframe, usually over the course of a few hours (e.g., before–after a session of chemo- or radiotherapy). This same methodology was employed by us as well in a previous study of the Music Givers intervention (Toccafondi et al., Reference Toccafondi, Bonacchi and Mambrini2016). The present study adds information about the longer-term effects of a single session of music intervention in reducing the psychological suffering of hospitalized cancer patients, measured at discharge.
It is notable that, at the time of admission to the hospital, both groups presented borderline-level scores on the HADS scales. At discharge, however, only patients in the Music Givers group showed a mean score under the commonly utilized threshold of 8 for HADS subscales (Bjelland et al., Reference Bjelland, Dahl and Haug2002), whereas the mean score of patients in the control group was above this limit. In this sense, Music Givers turns out to be an effective intervention to control the psychological symptoms of patients hospitalized for brief periods (approximately two-thirds of patients in our sample stayed in hospital for three days).
We also found higher well-being scores among patients in the Music Givers group at discharge, with the exception of spiritual well-being. This finding is in line with studies that evaluated the influence of music interventions on the spirituality of cancer patients. Hanser et al. (Reference Hanser, Bauer-Wu and Kubicek2005) did not find any effect on the spirituality of 70 women with metastatic breast cancer after three individual music therapy sessions. More recently, a randomized clinical trial was conducted with 113 adolescents/young adults undergoing stem cell transplantation (Robb et al., Reference Robb, Burns and Stegenga2014). After six sessions of a therapeutic music video intervention, patients showed a moderate but not significant improvement in terms of spiritual perspective and self-transcendence. The statistically significant difference on the psychological well-being scale might be attributed to the reduction among Music Givers group patients, and to the concomitantly increased symptoms of anxiety and depression in the control group. The improvement in relational well-being is congruent with the results of studies that found music intervention to be effective among cancer patients for facilitating connections between patients and family members (Teut et al., Reference Teut, Dietrich and Deutz2014), and also in promoting a better relationship between patients and staff (O'Callaghan & Magill, Reference O'Callaghan and Magill2009). We also found that the two groups differ significantly with respect to physical well-being, although no differences were found in pain and fatigue scores. The efficacy of medical treatments administered to patients during their hospital stay may explain the similar decrease of pain and fatigue in both groups. The improvement in physical well-being might be explained by the influence of Music Givers events on other variables—related to physical well-being but different from pain and fatigue—not considered in this study. Otherwise, the intervention might affect the perception of physical well-being rather than the intensity of symptomatology.
The positive results obtained with use of the Music Givers format may be explained on the basis of multiple factors. First, listening to music has been related to beneficial effects for cancer patients, including escape from worries related to the illness and treatments and the evocation of pleasant memories and imagery (Bradt et al., Reference Bradt, Potvin and Kesslick2015), as well as feelings of relaxation and happiness (O'Callaghan et al., Reference O'Callaghan, McDermott and Michael2014; Teut et al., Reference Teut, Dietrich and Deutz2014). In addition, sharing the concert and the buffet may offer an opportunity to establish better relationships between patients and staff (O'Callaghan & Magill, Reference O'Callaghan and Magill2009; Khan et al., Reference Khan, Mohamad Onn Yap and O'Neill2015), to reinforce in patients feelings of being cared for from a holistic point of view, and to promote a more positive perception of the oncology department (Moss et al., Reference Moss, Nolan and O Neill2007).
Its low cost is one factor that may facilitate replicability of the intervention presented herein on other oncology units. Indeed, the musicians are not paid, and staff do not participate as professionals. Instead, they join the event after working hours. The only costs of the intervention are the buffet and the sound system. These costs were partially defrayed by organized patients' associations in the form of assistance to the Italian oncology departments that hosted Music Givers events.
Limitations of the Study
The present study has some limitations. First, all the data came from one department of oncology in Tuscany, a region of Italy. The generalizability of these results to patients in the rest of Italy or in other countries should be explored in future studies. Second, the study did not include a qualitative investigation aimed at obtaining an in-depth understanding of the subjective experiences of patients who took part in the Music Givers intervention. Future research should also investigate these issues.
Conclusions
In conclusion, our study demonstrates the efficacy of a standardized, replicable, low-cost, and one-session music intervention, which consists of a live concert and a buffet, in reducing the psychological burden and improving the well-being of cancer patients during their hospitalization.
ACKNOWLEDGMENTS
We would like to express our gratitude to the Bianco Airone Pazienti Onlus Association (Rome, Italy) for supporting the Donatori di Musica events.
DISCLOSURES
The contributing authors hereby declare that they have no conflicts of interest, including specific financial interests and relationships or affiliations, relevant to the subject matter or materials discussed in the present manuscript.
