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Complementary Therapies in Clinical Practice 37 (2019) 93–101

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Complementary Therapies in Clinical Practice

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

The effectiveness of music therapy for postpartum : A and meta-analysis T

Wen-jiao Yanga, Yong-mei Baib, Lan Qinc, Xin-lan Xuc, Kai-fang Baoa, Jun-ling Xiaoa, ∗ Guo-wu Dinga, a School of Public Health, Lanzhou University, Lanzhou, 730000, China b School of Public Health, Capital Medical University, Beijing, 10069, China c School of Mathematics and Statistics, Lanzhou University, Lanzhou, 730000, China

1. Introduction rehabilitative approaches, relational approaches, and music listening, among which, music listening is the most convenient to conduct [18]. Postpartum depression usually refers to depression that occurs A systematic review and meta-analysis published in 2009 found that within one year after giving birth [1]. According to some current re- music therapy based on standard care reduced depression and search reports, the prevalence of postpartum depression is higher than in people with mental disorders [19]. Another meta-analysis also re- 10% and lower than 20% but can be as high as 30% in some regions vealed a positive effect of music therapy on the alleviation of depression [1–3]. Postpartum depression symptoms include emotional instability, and anxiety symptoms [20]. However, the efficacy of music therapy sleep disorders, poor appetite, weight loss, apathy, cognitive impair- cannot be generalized to patients with other diseases because women ment, and in severe cases, suicidal ideation [4,5]. Postpartum depres- with postpartum depression are a special group whose main symptom is sion threatens the health of the mother, as well as the physical and depression. Therefore, it is necessary to research the effectiveness of of the baby. Studies have reported that the children of music therapy on postpartum depression alone. No review or meta- mothers with postpartum depression were more likely to be under- analysis has focused on the effectiveness of music therapy for post- weight and developmentally-delayed and maternal depression has been partum depression and only a few epidemiological studies have made associated with adverse psychological outcomes in children 10 years relevant findings. In the epidemiological studies, patients suffering later. Postpartum depression may lead to chronic or recurrent depres- from postpartum depression usually listened to instrumental, soothing sion, which not only threatens human health but also causes great music, such as light music, pure music, and lullabies. After listening to burden to the caregivers of postpartum mothers [6]. the music, not only were the patients' anxiety and depression relieved Although antidepressants and are commonly used to but also sleep quality, satisfaction, and pain were improved [4,18]. relieve depressive symptoms, both of them are associated with poor However, the results of the studies were inconsistent. For example, a adherence and antidepressants may cause unwanted side effects. In recent randomized controlled trial showed that music therapy had a particular, mothers with postpartum depression may forgo anti- positive effect on reducing depression and anxiety symptoms [21], depressants to avoid exposure to their babies [7,8]. Music therapy, as while an earlier trial reported that music therapy had no significant an alternative therapy, has no obvious side effects or adverse reactions effect on anxiety relief in postpartum women [22]. Thus, evidence for [9]. It is a non-invasive treatment with good tolerance, is inexpensive, the effectiveness of music therapy for postpartum depression is still and requires little time and energy [10,11]. Music therapy has been controversial. Therefore, we quantitatively integrated all randomized found to effectively reduce negative emotions and improve physiolo- controlled studies and conducted a meta-analysis to explore the effec- gical symptoms [4,12]. Some studies have suggested that music therapy tiveness of music therapy for postpartum depression. is a special language which can affect the brain and emotional system, thus affecting cognitive, linguistic, and athletic ability [13,14]. Another 2. Methods study reported that the positive effect of music therapy was stronger when used in combination with pharmacotherapy [9]. Therefore, music 2.1. Search strategy therapy has been increasingly used in antidepressant therapy because of its effectiveness and the aforementioned advantages [15]. It has also This meta-analysis was completed with the guidance of Preferred been used to prevent and improve prenatal depression and postpartum Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) depression [16,17]. There are three categories of music therapy: [23], and it was registered in PROPESPO (CRD42019138002). Eligible

∗ Corresponding author. E-mail address: [email protected] (G.-w. Ding). https://doi.org/10.1016/j.ctcp.2019.09.002 Received 9 April 2019; Received in revised form 12 September 2019; Accepted 12 September 2019 Available online 16 September 2019 1744-3881/ © 2019 Elsevier Ltd. All rights reserved. W.-j. Yang, et al. Complementary Therapies in Clinical Practice 37 (2019) 93–101

Table 1 Research strategies for each research database.

Database Search Strategy

PubMed ((((“Depression, Postpartum" [Mesh]) OR ((((depressi*[Title/Abstract] OR blues [Title/Abstract] OR distress [Title/Abstract] OR bipolar [Title/Abstract] OR bi-polar [Title/Abstract] OR dysthymi* [Title/Abstract] OR [Title/Abstract]))) AND ((postpartum [Title/Abstract] OR post-partum [Title/Abstract] OR postnatal [Title/Abstract] OR “post natal” OR “post birth” [Title/Abstract] OR “after delivery” [Title/Abstract] OR “after birth” [Title/Abstract] OR puerperium [Title/Abstract] OR puerperal [Title/Abstract]))))) AND (((“Randomized Controlled Trial” [Publication Type] OR “Randomized Controlled Trials as Topic" [Mesh])) OR ((RCT [Title/Abstract] OR random [Title/Abstract] OR “controlled clinical trail” [Title/Abstract] OR placebo [Title/Abstract] OR “drug therapy” [Title/Abstract] OR trail [Title/Abstract] OR groups [Title/Abstract])))) AND ((((music [Title/Abstract] OR rhythm*[Title/Abstract] OR melod [Title/Abstract] OR sing [Title/Abstract] OR song*[Title/Abstract] OR compose [Title/Abstract] OR improvis*[Title/Abstract] OR audio [Title/Abstract] OR auditory [Title/Abstract] OR sound*[Title/Abstract] OR percussion [Title/Abstract] OR tempo*[Title/Abstract] OR acoustic [Title/Abstract] OR voice [Title/Abstract] OR vocalize [Title/Abstract]))) OR (“Music" [Mesh] OR “Music Therapy" [Mesh])) Web of Science TS: (RCT OR random OR “controlled clinical trail” OR placebo OR “drug therapy” OR trail OR groups) AND TS: (postpartum OR post-partum OR postnatal OR “post natal"OR “post birth” OR “after delivery” OR “after birth” OR puerperium OR puerperal) AND TS: (depressi* OR blues OR distress OR bipolar OR bi-polar OR dysthymi* OR melancholia) AND TS: (music OR rhythm* OR melod OR sing OR song* OR compose OR improvis* OR audio OR auditory OR sound* OR percussion OR tempo* OR acoustic OR voice OR vocalize) The Cochrane Library ((((postpartum OR postnatal OR post-partum OR puerperium OR puerperal):ti, ab, kw OR (after birth):ti ,ab, kw OR (post natal):ti, ab, kw OR (post birth):ti, ab, kw OR (after delivery):ti, ab, kw) AND ((depressi* OR blues OR distress OR bipolar OR bi-polar OR dysthymi* OR melancholia):ti,ab,kw)) OR (MeSH descriptor: [Depression, Postpartum] explode all trees)) AND ((MeSH descriptor: [Music] explode all trees) OR (MeSH descriptor: [Music Therapy] explode all trees) OR ((music OR rhythm* OR melod OR sing OR song* OR compose OR improvis* OR audio OR auditory OR sound* OR percussion OR tempo* OR acoustic OR voice OR vocalize):ti, ab ,kw)) AND ((MeSH descriptor: [Randomized Controlled Trials as Topic] explode all trees) OR ((RCT OR random OR “controlled clinical trail” OR placebo OR “drug therapy” OR trail OR groups):ti, ab, kw)) Embase ((‘music'/exp) OR (‘music therapy'/exp) OR (music:ab, ti OR rhythm*:ab, ti OR melod:ab, ti OR sing:ab, ti OR song*:ab, ti OR compose:ab, ti OR improvis*:ab, ti OR audio:ab, ti OR auditory:ab, ti OR sound*:ab, ti OR percussion:ab, ti OR tempo*:ab, ti OR acoustic:ab, ti OR voice:ab, ti OR vocalize:ab,ti)) AND (((postpartum:ab, ti OR ‘post partum':ab, ti OR postnatal:ab, ti OR puerperium:ab, ti OR puerperal:ab, ti OR ‘post natal':ab, ti OR ‘post birth':ab, ti OR ‘after delivery':ab, ti OR ‘after birth':ab,ti) AND (depressi*:ab, ti OR blues:ab, ti OR distress:ab, ti OR bipolar:ab, ti OR ‘bi polar':ab, ti OR dysthymi*:ab, ti OR melancholia:ab,ti)) OR (‘postnatal depression'/exp) AND ((‘randomized controlled trial (topic)'/exp) OR (‘randomized controlled trial'/exp) OR (rct:ab, ti OR random:ab, ti OR placebo:ab, ti OR trail:ab, ti OR groups:ab, ti OR ‘controlled clinical trail':ab, ti OR ‘drug therapy':ab,ti) CBM (“音乐"[不加权:扩展]OR"音乐疗法"[不加权:扩展]OR(音乐 OR音律 OR韵律 OR 乐曲 OR歌唱)[关键词]) AND (((产后 OR 母亲 OR 产褥期 OR 分娩)[关 键词]) AND ((抑郁 OR 忧郁)[关键词])) OR "产后抑郁"[不加权:扩展]) AND (“随机对照试验"[不加权:扩展]OR(随机对照 OR 对照 OR 随机)[关键词])

CBM = China Biology Medicine Database. studies were searched in PubMed (1966–November/2018), Embase 2.2.3. Interventions for the control group (1974–November/2018), the China Biology Medicine Database The control group was only offered standard treatment, including (1978–November/2018), the Cochrane Library (1993–November/ drug treatment, psychological treatment, and health education. 2018) and the Web of Science (1980–November/2018). There were no language restrictions. The retrieval strategy was as follows: 2.2.4. Types of outcomes and measurements Depression and anxiety were the main outcomes in the studies and #1 music OR rhythm* OR melod OR sing OR song* OR compose OR individual studies included sleep, pain, satisfaction, insight, and ma- improvis* OR audio OR auditory OR sound* OR percussion OR ternal attachment assessments. The following scales were used to tempo* OR acoustic OR voice OR vocalize measure outcomes: the Edinburg Postpartum Depression Scale (EPDS), #2 depressi* OR blues OR distress OR bipolar OR bi-polar OR dys- the visual analog scale (VAS), a self-rating depression scale (SDS), the thymi* OR melancholia State-Trait Anxiety Inventory Scale (STAI), the Hamilton Depression #3 postpartum OR post-partum OR postnatal OR “post natal"OR Scale (HAMD), the Beck Anxiety Inventory (BAI), the insight and “post birth” OR “after delivery” OR “after birth” OR puerperium OR treatment attitude questionnaire (ITAQ), Pittsburgh Sleep Quality Index puerperal (PSQI) and a maternal attachment tool. #4 RCT OR random OR “controlled clinical trail” OR placebo OR “drug therapy” OR trail OR groups #5 #1 AND #2 AND #3 AND #4 2.2.5. Types of studies We only included randomized controlled trials (RCTs) where a The specific retrieval strategies for each database are shown in control group received traditional treatment and an experimental group Table 1. We also manually searched the reference lists of included received music therapy in addition to traditional treatment. studies. 2.3. Study selection and data extraction 2.2. Inclusion criteria Duplicate studies were excluded first, then studies were excluded by 2.2.1. Types of participants reviewing titles and abstracts and by reading the full text to exclude the fi The participants were women diagnosed with postpartum depres- unquali ed studies. The reasons for exclusion were recorded. The in- sion. The age and birth delivery mode were not limited. Women diag- formation extracted included characteristics of the studies, the parti- ’ nosed with other diseases were excluded. cipants, interventions, and outcomes. First, the studies authors, pub- lication years, and countries of publication were extracted. Then, the number of participants, age, and delivery mode in both groups were 2.2.2. Interventions for the experimental group extracted. In addition, the duration, frequency, and type of music In addition to receiving traditional treatment, patients in the ex- treatment in the experimental group and treatment of the control group perimental groups listened to music, and the types of music were not were extracted. Finally, the outcomes and measurements were ex- limited. Light music, popular music, and even patient-preferred music tracted. Two researchers independently screened the literature and were acceptable. The frequency and duration of listening were also not extracted the data and a third researcher made the final decision when limited. there was no consensus.

94 W.-j. Yang, et al. Complementary Therapies in Clinical Practice 37 (2019) 93–101

2.4. Quality assessment Fig. 2. Most studies used a computer or threw dice to generate random sequences. In the study by Wang et al., the random sequence was A risk of bias (RoB) tool recommended by the Cochrane Handbook generated by the ward number, judged as high risk of bias. Two studies V.5.1.0 (Cochrane Collaboration, London, UK) was used to assess the indicated the use of allocation concealment, which was not mentioned quality of the included studies. The tool assessed the following six as- in other studies and could not be judged. Blinding was difficult to pects: random sequence generation, assignment concealment, blinding, achieve in the experimental groups and only two studies implemented participant outcomes and data integrity, no selective reporting bias, and blinding of the assessors. All seven studies had complete data sets and no other biases. According to the different answers: yes, no and unclear, no other biases. Two studies were suspected to have a moderate risk of we judged each study as low risk of bias, high risk of bias, and moderate bias in selective reporting. However, in general, the quality of these risk of bias. Studies which had less than two items with high risk of bias studies was acceptable. Moreover, after sensitivity analysis, no studies were included in this meta-analysis. We also performed a sensitivity were found to have a significant impact on heterogeneity. Due to the analysis and removed studies with a big impact on heterogeneity. If small number of studies included in this meta-analysis, it was not necessary, funnel plots were used to assess publication bias. Two re- possible to assess publication bias. searchers completed the above work independently. Differences of opinion were settled by a third researcher. 3.4. Outcomes

2.5. Data collation and analysis 3.4.1. Depression Four studies involving 763 patients described the effectiveness of We used Review Manager 5.3 software (Cochrane, London, UK) to music therapy on depression. The outcomes were measured by HAMD, perform our meta-analysis. BAI, EPDS and SDS, so SMD analysis was used. The analysis showed For continuous data, standardized mean differences (SMDs) and that music therapy had a significant effect on depression compared to 95% confidence intervals (CI) were used to synthesize data when there the control group (SMD: −0.87, 95% CI: −1.23 to-0.51, p < 0.00001; were multiple outcome measures, otherwise, mean differences (MDs) heterogeneity: χ2 = 14.09, I2 = 79%, p = 0.003). The results are and 95% confidence interval (CIs) were used. For binary data, the risk shown in Fig. 3. ratios (RR) and 95% confidence interval (CIs) were used to synthesize One trial involving 160 participators reported changes in depression the data. Heterogeneity was evaluated by P- and I2 values. In general, scores after music therapy. The results revealed that, compared to P > 0.1 and I2 ≤ 50% indicated low heterogeneity and the fixed effect traditional therapy, music therapy was more beneficial to improve model (FE) was used. I2 > 50% indicated high heterogeneity and the depression (RR: 0.73, 95% CI: 0.63 to 0.86, p = 0.01). The results are random effect model (RE) was selected. shown in Fig. 4. Three trials including 623 patients compared the number of people 3. Results who had recovered. The outcomes were measured by SAS, EPDS, and SDS. The result also showed that music had a positive effect on relieving 3.1. Literature search results depression (RR: 0.25, 95% CI: 0.12 to 0.54, p = 0.0004; heterogeneity: χ2 = 0.28, I2 = 0%, p = 0.87). The results are shown in Fig. 5. A total of 818 records were identified from five database searches and 10 studies were identified using other approaches. Duplicate cita- 3.4.2. Anxiety tions (192) were removed using the software, leaving 636 citations for Three studies including 601 patients reported the effectiveness of title and abstract screening. Of these, 579 articles were excluded fol- music therapy on anxiety and the outcomes were measured by STAI, lowing screening. Thirty-six unrelated articles were excluded by VAS, and SAS. The result demonstrated that music therapy did not re- reading the full text. The common reasons for exclusion were as follows: duce anxiety (SMD: −1.26, 95% CI: −2.81 to 0.29, p = 0.11; hetero- the intervention measures of the experimental group or the control geneity: χ2 = 93.92, I2 = 98%, p < 0.00001). The results are shown group did not meet our requirements, the studies had incomplete data, in Fig. 6. the results were presented as a figure only, or it was a retrospective Two trials involving 460 participators compared the number of study. Finally, seven studies were identified from 828 articles, with patients still experiencing serious anxiety after music therapy in the 1065 total participants [16,21,22,24–27]. The detailed retrieval pro- experimental and control groups and the outcomes were measured by cesses are shown in Fig. 1. STAI and SAS. The results showed that music therapy had no significant effect on relieving anxiety (RR: 0.38, 95% CI: 0.09 to 1.63, p = 0.20; 3.2. Study characteristics heterogeneity: χ2 = 0.01, I2 = 0%, p = 0.92). The results are shown in Fig. 7. The years of publication ranged from 2010 to 2016. The authors were from China (n = 4, 57.1%), the United States (n = 1, 14.3%), 3.4.3. Insight Korea (n = 1, 14.3%), and Iran (n = 1, 14.3%) and the studies were A study reported the effectiveness of music therapy on insight in published in English, Chinese, and Korean. There were 1065 partici- 162 patients and the outcomes were measured by ITAQ. The results pants in all, including 534 (50.1%) patients in the experimental group illustrated that patients who received music therapy had better insight and 531 (49.9%) in the control group, with ages ranging from 18 to 35. compared to the control group (MD: 5.18, 95% CI: 4.49 to 5.87, The sample size included in the different studies ranged from 60 to 400. p < 0.00001). The results are shown in Fig. 8. The delivery mode included natural birth and cesarean section. The music genre was dominated by pure music, popular music, and lulla- 3.4.4. Pain bies. The duration of the intervention was usually 30 min and the fre- One study evaluated the effectiveness of music therapy on post- quency was once a day or once every two days. The control group was partum pain in 141 patients and the outcome was measured by VAS. usually given psychological treatment (such as counseling). The specific The results showed that music therapy significantly reduced pain (MD: study characteristics were shown in Table 2. −1.13, 95% CI: −1.25 to −1.01, p < 0.00001). The results are shown in Fig. 8. 3.3. Assessing the methodological quality of the included studies 3.4.5. Sleep The quality of the RCTs included in this study is summarized in One study demonstrated the effectiveness of music therapy on

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Fig. 1. Flowchart of the selection process. postpartum pain in 82 patients and the outcome was measured by PSQI. group given music therapy and the control group. The results of insight, The results indicated that music therapy promoted sleep (MD: −2.30, pain, sleep, satisfaction, and maternal attachment were also sig- 95% CI: −2.75 to −1.85, p < 0.00001). The results are shown in nificantly different, however, no significant differences in anxiety were Fig. 8. found between the two groups. Therefore, we concluded that music therapy improved postpartum depression. Moreover, music therapy 3.4.6. Satisfaction probably improved insight, pain, sleep, satisfaction, and maternal at- Only one study, with a sample size of 141, reported the effectiveness tachment but because these results were from a single study with a of music therapy on satisfaction. The outcome was measured by VAS. small sample size, the results cannot be generalized. The study found that music therapy improved the satisfaction of pa- Although only four studies included depression as an outcome, the tients (MD: 2.92, 95% CI: 2.67 to 3.17, p < 0.00001). The results are results suggested that music therapy had a significant effect on de- shown in Fig. 8. pression in postpartum mothers. This result was consistent with other studies of music therapy for the treatment of depression. The im- ff 3.4.7. Maternal attachment provement e ect of music therapy on depression accorded with the Maternal attachment was the only indicator included that measured expected conjecture and the general cognition of public. Some studies effects on the baby, instead of the mother. This outcome was included found that music promoted neuroplasticity of the human brain, which in one study of 60 patients and the outcome was measured using a may be associated with the acoustic structure of music itself [28]. A maternal attachment tool. The results showed that music therapy en- previous study used music as an acoustic stimulus to change patients' fi hanced maternal attachment (MD: 3.30, 95% CI: 1.72 to 4.88, speci c brain functions and behavioral cognition [29]. From the per- p < 0.0001). The results are shown in Fig. 8. spective of neurochemistry, music has been shown to activate marginal and marginal structures, such as the , , and the nucleus accumbens, which function abnormally in patients with severe 4. Discussion depression [18]. From the perspective of psychology, music therapy has been shown to promote transference, arouse happy , and re- 4.1. Summary of results duce negative moods [18], suggesting it would benefit recovery from postpartum depression [29,30]. Thus, music therapy has also been used This meta-analysis aimed to determine whether music therapy im- to reduce depression in patients with , , and proved the physical and psychological symptoms of women with [31–34 ]. The findings of this study provide a basis for the pro- postpartum depression. The result of continuous data and binary data motion of music therapy in the treatment of depression. assessments showed significant differences in depression between the

96 W.-j. Yang, et al. Complementary Therapies in Clinical Practice 37 (2019) 93–101 Depression (HAMD) Self-knowledge (ITAQ) (Maternal Attachment Tool) Depression (SAS) Sleep (PSQI) Anxiety (VAS) Pain(VAS) Satisfaction (VAS) Depression Depression (SDS) Drug treatment Psychological treatment Traditional Chinese medicine 2 h 1/2d 3d Health education

– Fig. 2. Summary of risk of bias assessment.

Many studies have shown that the effects of music therapy on an- xiety were similar to those on depression. That is, because the vocal signals of music are more harmonious and less noisy than verbal ones, Type of music Time Frequency Duration Conventional treatment Outcomes patients experienced less anxiety [28,35]. Anxiety in this review in- cluded continuous data and binary data, both of which ultimately showed that music therapy did not relieve postpartum anxiety. This result was different from previous studies, which may be related to the number of studies and sample size. In this outcome, the continuous data (E/C) 41/41 Pure music 1 included 600 participants in three studies, while the binary data only included 460 participants in two studies. Specifically, Fig. 6 shows a positive effect on reducing depression in the studies by Wang et al. and Scrap et al., however, the results of Norouzi et al. were neutral. That study was based on a small sample size of 60, which may have con- tributed to the lack of significance found in that study. Furthermore, there was a large heterogeneity (I2 = 98%), which may have affected the reliability of the research results. Both the small sample size and large heterogeneity reveal the need to cautiously interpret the results of Unclearsection (28%) 30/30 Preferred 40min 1/d 8d Traditional treatment Depression (BAI) maternal Attachment Cesarean section 30/30 Lullaby 30min 1/d Unclear Kangaroo carethis meta-analysis. Anxiety (STAI) The high heterogeneity may have been related to the large differences in sample sizes of the included studies or the large differences in the duration of music intervention. For example, the duration of music intervention was three days in Wang et al.‘s study but two weeks in Scrap et al.'s study. Thus, we cannot arbitrarily re- commend abandoning music therapy for post-partum depression be- cause of one neutral result. Most of the studies we included focused more on changes in de- 35 Natural birth 70/71 Preferred 30min 1/d 2 weeks Traditional treatment Depression (EPDS) 35 Cesarean section 200/200 Pure music 30min 1/2 3d Psychological treatment Anxiety (SAS) – – pression and anxiety and less attention was paid to physical symptoms. (63.6%) C:27.33 ± 4.48 Among the seven studies, only one article examined insight, pain, sleep, satisfaction, and maternal attachment and the final results agreed with previous studies. We know from previous studies that music improved Country age Delivery mode No. of patients Iran E:29.37 ± 5.29 emotion, symptoms, and functioning by affecting neurochemical and psychological factors, so it is possible that music improved satisfaction, sleep, and insight for the same reasons [4,36,37]. Music therapy is considered to effectively relieve pain and has been widely used in

2013 surgery, postoperative recovery, palliative care, and even in [38–40]. The pain relief effect is believed to derive from stimulation of Huang et al., 2010 China Unclear Unclear 82/80 Light music 30min 1/2d 6 weeks Psychological treatment Study (author, time) Lee et al., 2010Liu et al. 2014 KoreaNorouzi et E: al., > 30 (56.7%) China C: > 30 29.24 ± 4.55 Natural birth (72%) Cesarean Serap et al., 2014 America 18 Su et al., 2014 China Unclear Unclear 80/80 Pure music 30min 2/d 6 weeks Psychological treatment Wang et al., 2016 China 25 Table 2 Descriptive summary of studies included in the meta-analysis. (E = experimental group; C = controlQuality group; Index; HAMD=Hamilton STAI=State-Trait Depression Anxiety Scale; ITAQ=Insight Inventory and Scale; Treatment SDS=Self-rating Attitude Questionnaire; Depression BAI=Beck Scale; Anxiety EPDS Inventory; = VAS=Visual Edinburg Analog Postpartum Scale; Depression PSQI=Pittsburgh Sleep Scale).

97 W.-j. Yang, et al. Complementary Therapies in Clinical Practice 37 (2019) 93–101

Fig. 3. Forest plot of the effectiveness of music therapy on depression (continuous data).

Fig. 4. Forest plot of the effectiveness of music therapy on depression (binary data1).

Fig. 5. Forest plot of the effectiveness of music therapy on depression (binary data2).

Fig. 6. Forest plot of the effectiveness of music therapy on anxiety (continuous data).

Fig. 7. Forest plot of the effectiveness of music therapy on anxiety (binary data).

98 W.-j. Yang, et al. Complementary Therapies in Clinical Practice 37 (2019) 93–101

Fig. 8. Forest plot of the effectiveness of music therapy on insight, pain, sleep, satisfaction, and maternal attachment. endorphin release into the bloodstream, as well as by providing a me- strategy, it is possible that some applicable research was omitted. In chanism for pain distraction [41,42]. Furthermore, music therapy can addition, due to the limited number of studies, we could not assess the improve maternal attachment. From the perspective of mothers, it may risk of publication bias. be related to the improvement of individual physical and psychological conditions, which enabled them to pay more attention to babies [1,43]. 4.3. Advantages However, although the outcome was significantly different, we could not draw a credible conclusion based on a single study. Therefore, the This study first used meta-analysis to conduct an integrated analysis interpretation of this outcome should be treated cautiously and only of the effectiveness of music therapy on postpartum depression. Not used as a basis for future research. only the effectiveness of music therapy on depression and anxiety This meta-analysis illustrated that music therapy alleviated de- symptoms were evaluated, but also the effectiveness of music therapy pression in postpartum mothers and that it may also help improve in- on some physiological symptoms was analyzed. Moreover, this study sight, pain, sleep, and satisfaction. Unfortunately, this study did not included randomized controlled trials considered to be of high quality, find a significant effect of music therapy on postpartum anxiety. The with a high level of evidence. Music therapy is more and more widely studies we included did not mention side effects after music therapy, used in medicine, education, and other fields. The increased application suggesting that music therapy was an effective and safe treatment for of music therapy for post-partum depression are inseparable from the postpartum depression. increasing evidence showing that music therapy improved physiolo- gical symptoms and mental states [15,26,44]. Thus, this meta-analysis 4.2. Integrity and applicability of evidence may also be helpful for promoting the clinical application of music therapy. The overall quality of this meta-analysis is presented in Fig. 2. Ex- cept for one research study that did not strictly implement random 4.4. Limitations sequencing, the quality of the other studies was acceptable. Re- grettably, this meta-analysis was based on a small sample of a few However, there were some deficiencies in this study. The sample studies with limited numbers of participants. Specifically, the sample size of this meta-analysis was small and may have produced invalid sizes of insight, pain, sleep, satisfaction and maternal attachment were results and increased the likelihood of contingent results. Additionally, too small. Therefore, analyses of larger and more representative sam- depression is considered to be a disease prone to recurrence. ples are needed. Moreover, although we found that music therapy had a Consequently, it is difficult to ensure that the current disease was positive effect on postpartum depression, in the actual application adequately treated. It is often necessary to continue treatment for six process, it may vary depending on the type of music, personal char- months after remission to maintain long-term therapeutic effectiveness acteristics of patients, and the listening venue. Although the selected [ 45]. Our research data was usually acquired after music therapy. studies were retrieved from the literature according to a detailed Therefore, the long-term effectiveness of music therapy for postpartum

99 W.-j. Yang, et al. Complementary Therapies in Clinical Practice 37 (2019) 93–101 depression is uncertain. In addition, there were many differences in the review of the literature, Harv. Rev. 23 (5) (2015) 377–393. included studies, such as the intervention duration, frequency, type of [9] M.J. Poulsen, J. Coto, Nursing music protocol and postoperative pain, Pain Manag. Nurs. 19 (2) (2018) 172–176, https://doi.org/10.1016/j.pmn.2017.09.003 Epub music, severity of depression, and delivery mode [35]. However, the 2017 Nov 16. limitation of sample size prevented analysis in this study. [10] F.B. Haslbeck, H.U. Bucher, D. Bassler, C. Hagmann, Creative music therapy to promote brain structure, function, and neurobehavioral outcomes in preterm in- fants: a randomized controlled pilot trial protocol, Pilot and Feasibility Studies 3 4.5. Future research (2017) 36, https://doi.org/10.1186/s40814-017-0180-5. eCollection 2017. [11] R. Blackburn, T. 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