Complementary Therapies in Medicine (2014) 22, 614—620

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevierhealth.com/journals/ctim

Exercise training and music therapy in

elderly with depressive syndrome:
A pilot study
W. Verrusio a,∗, P. Andreozzi a, B. Marigliano b, A. Renzi c,
V. Gianturco a, M.T. Pecci d, E. Ettorre a, M. Cacciafesta a,
N. Gueli a

a
Department of Cardiovascular, Respiratory, Nephrological, and Geriatric Sciences, Sapienza University of
Rome, Rome, Italy
b
Internal Medicine, Campus Bio-medico of Rome, Rome, Italy
c
Department of Dynamic and Clinical Psychology, ‘‘Sapienza’’ — University of Rome, Italy
d
‘‘Science of Aging’’ Interdepartmental Research Center — Sapienza University of Rome, Italy
Available online 6 June 2014

KEYWORDS Summary
Objective: Recent studies have thrown doubt on the true effectiveness of anti-depressants in
Anxiety;
light and moderate depression. The aim of this study is to evaluate the impact of physical train-
Depression;
ing and music therapy on a sample group of subjects affected by light to moderate depression
Exercise;
versus subjects treated with pharmacological therapy only.
Music therapy;
Design and setting: Randomized controlled study. Patients were randomized into two groups.
Elderly;
Subjects in the pharmacotherapy group received a therapy with antidepressant drugs; the exer-
Rehabilitation
cise/music therapy group was assigned to receive physical exercise training combined with
listening to music. The effects of interventions were assessed by differences in changes in
mood state between the two groups.
Main outcome measures: Medically eligible patients were screened with the Hamilton Anxiety
Scale and with the Geriatric Depression Scale. We used plasmatic cytokine dosage as a stress
marker.
Results: We recruited 24 subjects (mean age: 75.5 ± 7.4, 11 M/13 F). In the pharmacotherapy
group there was a significant improvement in anxiety only (p < 0.05) at 6-months. In the exer-
cise/music therapy was a reduction in anxiety and in depression at 3-months and at 6-months
(p < 0.05). We noted an average reduction of the level of TNF-a from 57.67 (±39.37) pg/ml to
35.80 (±26.18) pg/ml.

∗ Corresponding author at: Department of Cardiovascular, Respiratory, Nephrological, and Geriatric Sciences, Sapienza University of Rome,

Viale del Policlinico 155, 00161 Roma, Italy. Tel.: +39 3490745274.
E-mail address: walter.verrusio@uniroma1.it (W. Verrusio).

http://dx.doi.org/10.1016/j.ctim.2014.05.012
0965-2299/© 2014 Elsevier Ltd. All rights reserved.

Downloaded for Anonymous User (n/a) at Universitas Gadjah Mada from ClinicalKey.com by Elsevier on June 20, 2017.
For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved.
Exercise training and music therapy with depressive syndrome
Conclusions: Our training may potentially play a role in the treatment of subjects with mild to
moderate depression. Further research should be carried out to obtain more evidence on effects
of physical training and music therapy in depressed subjects.
© 2014 Elsevier Ltd. All rights reserved.
Introduction
Depression and anxiety are frequent disorders in the elderly.
Beyond the age of 65, the risk of falling ill with depression
increases threefold compared to the general population.1
The Food and Drug Administration (FDA) recently released
the data underlying the approval of six of the most widely
sold anti-depressants: in 47 controlled clinical studies, only
10—20% showed benefits effectively attributable to the
pharmacological action of the molecule employed, while
the placebo effect was responsible for the improved mood
of 80—90% of the subjects.2 In confirmation of this find-
ing, a recent study showed that drugs against depression
proved partially effective only in subjects suffering from
severe depression.3 In recent years, therefore, extensive
scientific evidence has thrown doubt on the true effective-
ness of anti-depressants, especially for patients affected by
light or moderate depression. And we need, especially in the
field of geriatrics, to look for new tools for the treatment of
mood disturbances.
Experience has been gained, over the last few years,
with cognitive therapy (CT). A study carried out on 240
patients suffering from moderate to severe depression
showed that, although the percentage of response to
treatment with CT overlapped, to a certain extent, with
the response to pharmaceuticals, the long-term incidence
of new episodes of depression in the group treated with
Selective serotonin reuptake inhibitors (SSRIs) was 54%,
compared to 17% among patients treated with CT.4 This
suggests not only that the effect of CT lasts longer than that
of pharmaceuticals, but that CT can produce changes which
differ from those brought about by pharmaceutical therapy,
making it a valid alternative to the use of anti-depressants.
In the field of geriatrics, other works have highlighted the
positive effect of music on treating cognitive disturbances5
and behavioral and psychological symptoms of dementia
(BPSD)6 and on a whole series of unfavorable stress-induced
circumstances, including anxiety and depression.7 Recent
research efforts examining the effects of listening to music
on the brain have discovered that music is able to increase
cerebral synaptic plasticity.8 In other words, though they
act through different mechanisms and have different
effects, both depression and music work in a shared sub-
strate of certain areas of the brain, giving rise to a series
of changes.9 The fact is that exposure to sound leads to
increased neurogenesis at the hippocampus, where neuron
impoverishment due to loss and/or scarce regeneration is
thought to be an underlying cause of a variety of mood
disturbances, including depression.10 Therefore there is a
very close link between depression and music.
Another therapeutic strategy recently proposed for the
treatment of depressed subjects is physical activity. Physical
training helps control mood disturbances, especially those
Downloaded for Anonymous User (n/a) at Universitas Gadjah Mada from ClinicalKey.com by Elsevier on June 20, 2017.
For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved.
615
of light to moderate intensity, with a level of effective-
ness comparable to that of psychological or pharmacological
therapies, especially over the long term.11
In the present study, we used plasmatic cytokine dosage
as a stress marker. Recent research has pointed to an
active role on the part of pro-inflammatory cytokines in the
regulation of synaptic plasticity, demonstrating that hyper-
activation of the immune system can be identified as part
of the pathogenesis of depression.12 Patients suffering from
mood disturbances have been found to present increases in
Interleukin 1 (IL1), Interleukin 6 (IL6) and Tumor Necrosis
Factor alpha (TNF␣), tied to a greater risk of cognitive dis-
turbances and mood depression, plus a reduced response to
therapy.13 The cytokine dosage, therefore, can be used as
a parameter for evaluating the effectiveness of a proposed
therapy.
The primary aim of this study is to determine whether
exposure to music and physical training can have a positive
effect on the mood of elderly subjects suffering from light
to moderate depression, and whether the improvement in
mood persists over time.
A secondary aim of the study is to evaluate the effec-
tive influence of aerobic physical training on the concurrent
disturbances of the subjects examined.
Materials and methods
This was a randomized controlled trial. This study included
a series of elderly subjects (n = 24; mean age: 75.5 ± 7.4;
13 females) diagnosed according to the DSM-IV criteria with
major depression with mild to moderate severity.14,15 Each
participant received information about this study in writing
and an individual verbal explanation of this study from the
researcher. Participation was entirely voluntary. Individual
participants in this study gave written informed consent and
a signed declaration of consent. This study was conducted
according to the principles expressed in the Declaration
of Helsinki and was approved by the ‘‘Science of Aging’’
Interdepartmental Research Center of Sapienza University
of Rome. We evaluated the concurrent conditions through
the Cumulative Illness Rating Score (CIRS) and its Comor-
bidity Index (CInd).16 The main diseases found in the test
group were: hypertension, obesity, diabetes mellitus, car-
bohydrate intolerance, dyslipidemia. Consistency with the
following criteria of inclusion was assessed for each patient:
diagnosis of light to moderate depression, with a Geriatric
Depression Scale (GDS) score between 5 and 12; absence of
pharmacological treatment. Patients suffering from severe
depression, or for whom physical exercise was not rec-
ommended (blood pressure — SBP — >200 mmHg and/or
diastolic blood pressure — DBP — >110 mmHg; diabetic
subjects with fasting blood glucose — FBG — >250 mg/dl;
unstable angina pectoris; arrhythmias; severe heart valves
616
diseases; aneurysms; any kind of severe systemic diseases),
were excluded.
Participants were randomly assigned to the pharma-
cotherapy group or the exercise/music therapy group using
computerized random numbers. Group allocation was not
communicated to the patients until the first exercise/music
session or the first prescription of the drug.
An electronic chart was filled out for each subject,
recording the following parameters at the start of the study
(W0), at the three-month point (W12), after six months
(W24) and, finally, in the exercise/music therapy group at
one month after the end of the study (W28):
- pharmacotherapy group: GDS for assessing mood; Hamil-
ton Anxiety Scale (HAS) score for evaluating anxiety;
- exercise/music therapy group: GDS and HAS; standard
laboratory techniques were used to determine, after an
overnight fast, plasma total cholesterol (TC), high-density
lipoprotein cholesterol (HDLc), triglycerides (TG), FBG
and plasmatic cytokine dosage (TNF␣, IL1, IL6). Waist cir-
cumference (WC) was measured at the level of iliac crest
with the patients standing. The body mass index (BMI) was
determined by dividing the weight (kg) by the square of
height (m).
The pharmacotherapy group subjects were assigned to
receive a antidepressant medication involving an SSRI in
9 patients (paroxetine 20 mg/die) and a specific seroto-
nergic antidepressant (NaSSA) in 2 patients (mirtazapine
30 mg/die), associated with benzodiazepine (Alprazolam) as
needed.
The exercise/music therapy group subjects were
assigned to receive physical exercise training combined
with listening to music. Each patient engaged in two
sessions of physical exercise a week, with each session
lasting approximately an hour. The routine consisted in:
warm-up of muscles, general gymnastics or postural gym-
nastics, aerobic training on stationary bicycles or treadmills,
post-workout decompression. The physical activity was mod-
erately intense so as not to exceed the target pulse rate,
meaning 75% of the maximum pulse rate for the patient
being treated (based on the theoretical maximum pulse rate
by age, or on the Borg scale).17 Blood pressure, resting heart
rate, pulse oximetry and FBG were assessed before and after
exercise. While the patients exercised, a collection of musi-
cal pieces was played. Three different play-lists were used
for the study, with the style of music selected in accor-
dance with the tastes of the patients, who were interviewed
during the recruitment phase. Three different genres were
identified: Jazz (Mt.1), Classical (Mt.2), Modern (Mt.3). The
sample group being examined was divided into 3 subgroups
of four patients each, one for each play-list. The different
songs on the various play-lists each corresponded to a spe-
cific phase of the physical training session; each session was
divided as follows:
• warm up (light exertion, slow rhythm),
• main part (moderate-intense exertion, fast rhythm),
• cool down (decompression phase, slow rhythm).
Downloaded for Anonymous User (n/a) at Universitas Gadjah Mada from ClinicalKey.com by Elsevier on June 20, 2017.
For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved.
W. Verrusio et al.
For the portion of the study involving depression, the
variations in mood were measured with the GDS, a brief
depression screening inventory composed of 15 items that
require yes or no answers. A score of 5 or more indicates
depressed individuals.18 The state of anxiety was evaluated
with the HAS. It consists of 14 items, each defined by a series
of symptoms. Each item is rated on a 5-point scale, ranging
from 0 (not present) to 5 (severe). A score of 18 or more
indicates anxiety.19
An overall description was performed for each of the con-
sidered variables. For qualitative variables, the frequencies
of each modality were determined. For quantitative vari-
ables mean and standard deviation were calculated. Mean
values were compared using Student’s t-test. The change in
the parameters between groups was compared by one-way
analysis of variance and HAS score at baseline was used as
covariate (ANCOVA), to control the effect of this variable on
outcome at 12 and 24 months (since it appeared marginally
different in the two groups). A 95% confidence intervals (CI)
was calculated. A p value below 0.05 was deemed signifi-
cant.
Results
24 patients were randomized into two groups: 12 subjects
into the pharmacotherapy group (mean age: 76.1 ± 7.1;
CInd: 2.4 ± 2.3; males/females: 4/8) and 12 subjects into
the exercise/music therapy group (mean age: 74.8 ± 8; CInd:
2.1 ± 0.7; males/females: 7/5) (Fig. 1).
All patients completed the study protocol.
The characteristics of the patients including age, Comor-
bidity Index, GDS and HAS scores were not significantly
different between the two groups at baseline.
Table 1 shows test scores in the two groups.
In the pharmacotherapy group there were minimal varia-
tions in GDS and HAS scores, however there was a significant
within group change in anxiety observed after 24 weeks com-
pared to baseline data (p < 0.05) (Fig. 2). At 3-months, we
prescribed in association therapy benzodiazepine (Alprazo-
lam) to 6 patients and we increased antidepressant dosage
in 4 patients (paroxetine, from 20 mg/die to 40 mg/die).
We also changed antidepressant therapy of 9 patients at
6-months because of side effects.
In the exercise/music group there were significant within
group reductions both in anxiety and in depression observed
after 12 and 24 weeks compared to baseline data (p < 0.05)
(Fig. 2). In general, the physical training in our study was
well tolerated and the exercise/music group did not take
any antidepressant medication during study period.
There were significant differences between the phar-
macotherapy group and exercise/music group for HAS
measurements at week 12 and at week 24 and for GDS at
week 24 (p < 0.05), although the covariate for HAS at base-
line was included (Table 1).
The cytokine dosages in the serum of the exercise/music
therapy group subjects examined pointed to a linear cor-
relation between high levels of cytokine and a high GDS
score. In fact, of the 12 patients examined, 9 presented a
average GDS score of 7.44 (±1.23) and undetectable doses
of cytokines in the blood plasma, while 3 subjects showed
a average GDS score of 11.66 (±0.57) combined with high
Exercise training and music therapy with depressive syndrome 617

Assessed for eligibility (n=24)

Excluded (n=0)

Αll participants assessed for eligibility met the

inclusion criteria

Randomized (n=24)

Allocated to Pharmacotherapy group (n=12) Allocated to Exercise/music therapy group

Received allocated intervention (n=12) (n=12)
Received allocated intervention (n=12)

Lost to follow-up (n=0) Lost to follow-up (n=0)

Continued follow up (n=12) Continued follow up (n=12)

Analysed (n=12) Analysed (n=12)

Figure 1 The study flow chart.

levels of TNF-␣. The following dosage reading, taken at 24
weeks, showed that the average level of TNF-␣ in the three
most depressed subjects had fallen from 57.67 (±39.37)
pg/ml to 35.80 (±26.18) pg/ml.
A new assessment of mood carried out 4 weeks (W28)
after the suspension of the rehabilitation program resulted
in only minimal differences in the GDS and HAS scores. For
these parameters, the difference between W24 and W28 was
minimal (GDS: −0.17 ± 0.58; HAS: 0.17 ± 1.03).
As for the secondary aim of the study, after 6 months
we observed the following in the exercise/music therapy
group: a reduction of 7 mmHg in the average systolic blood
pressure (p < 0.05) and 3 mmHg in the average diastolic blood
pressure of the group examined; a variation in the lipid level,
with average reductions of 27 mg/dl in TC (p < 0.05) and of
14.75 mg/dl in the TG; a reduction of 16.7 mg/dl in the levels
of basic FBG (p < 0.05); an average reduction of 6.2 cm in the
WC of the sample group examined (Table 2).
Discussion
The primary aim of this study is to determine whether expo-
sure to music and physical training can have a positive effect

Table 1 Anxiety (HAS) and depression (GDS) in the two groups. Values at baseline (W0), 12 weeks later (W12), 24 weeks later
(W24) and differences between groups not-adjusted and adjusted for HAS score at baseline.

Pharmacotherapy Exercise/music Differences F; p F; p

group therapy group between groups Not-adjusted Adjusted
Mean (SD) Mean (SD) [95% CI] F p F p
HAS
W0 24.2 (±5.3) 22.2 (±5.07) −2.08 [−6.51 to 2.34] 0.95 0.34 / /
W12 23.5 (±3.5) 19.6 (±4.8) −3.92 [−7.50 to −0.33] 5.14 0.03 4.55 0.04
W24 22 (±4.7) 16.5 (±2.7) −5.50 [−8.80 to −2.20] 11.92 0.00 13.33 0.00
GDS
W0 8.4 (±1.8) 8.5 (±2.2) 0.09 [−1.97 to 2.14] 0.01 0.92 / /
W12 8.6 (±2.9) 7.6 (±1.6) −1.2 [−2.84 to 0.84] 1.08 0.31 1.74.20
W24 8 (±2.5) 5.5 (±1) −2.92 [−4.39 to −0.61] 10.44 0.01 8.72 0.01
p < 0.05 = significant.

Downloaded for Anonymous User (n/a) at Universitas Gadjah Mada from ClinicalKey.com by Elsevier on June 20, 2017.
For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved.
618 W. Verrusio et al.

Figure 2 Change in depression and anxiety scores. Means and standard deviation (error bars). GDS = Geriatric Depression Scale;
HAS = Hamilton Anxiety Scale. *Significant difference between the two groups.

on the mood of elderly subjects suffering from light to mod-
erate depression and whether the improvement in mood
persists over time. The results at the third and sixth month
show a twofold positive effect in the exercise/music therapy
group, reducing both depression and the symptoms of anxi-
ety in the group. We also observed progressive improvement
linked to an increase in the number of sessions, point-
ing to the possibility of a dose-dependent effect. On the
contrary, in the pharmacotherapy group we observed only
minimal variations in GDS and HAS scores at the third month
and we observed a significant reduction in anxiety only at
6-months.
We assessed whether the positive results of our training
lasted over time, subjecting the subjects of the exer-
cise/music therapy group to a new control 4 weeks after
suspension of the rehabilitation program. The results for
both depression and anxiety showed only minimal differ-
ences in the GDS and HAS scores. With regard to physical
training, our study shows that it has both a beneficial effect
on mood and a positive influence on an entire series of con-
ditions that present a high rate of morbidity in the geriatric
age bracket.
In light of these results, we hold that physical training
associated with exposure to music is capable of setting off
a series of positive effects leading to modifications in both
the depressive and anxious components of the mood.20
Nevertheless the current study faces certain limitations.
Firstly, the small size of the sample. Other studies have
analyzed the effect of music exposure or exercise training
on depression,21—23 but our study provides preliminary evi-
dence of the combined benefit of exercise and listening to
music for mood disturbances in elderly patients. For this
reason we have chosen to study two groups of patients, a
pharmacotherapy group versus an exercise/music therapy
group, exploring directly synergistic therapy. However, when
analysing our results it is not possible to disentangle the con-
tribution of each component to the overall effect. Secondly,
although the very small number of test subjects means that
the result cannot be considered statistically significant, the
variations in cytokines levels of our study are similar to
findings reported in other studies that have pointed to a cor-
relation between high levels of cytokines and depression.24
These preliminary results seem to confirm that the cytokine
dosages in the serum may potentially play a role as indi-
cator of effectiveness for evaluating the effectiveness of
a antidepressive therapy but further studies are needed to
better characterize these correlations. Thirdly, the results
of our training in the exercise/music therapy group, espe-
cially over the short term, can be attributed in part to the
placebo effect, which, nevertheless, can be used to good
advantage when treating depressed subjects, especially in
the early phases of a rehabilitation program. For the placebo
effect can encourage the depressed subject to take a more
active role in the healing process while helping to create
a good physician—patient relationship, in this way creating
ideal conditions for pursuing the therapeutic strategy over

Table 2 Side effects of antidepressant medications and secondary effects of our rehabilitation program.

Antidepressant drugs Training (value W24)

MAOIs Hypertensive crisis, flushing, nausea • Reduction of 7 mmHg in the average systolic pressure
TCAs Constipation, weight gain, sexual dysfunction, and 3.2 mmHg in the average diastolic pressure;
dizziness, memory disturbances, sedation • Average reductions of 15% in total cholesterol and of
SSRIs Dyspepsia, nausea, sexual dysfunction 10% in the triglycerides;
NASSAs Weight gain, drowsiness, dizziness, headache • Reduction of 15% in the levels of basic glycaemia;
NARI Hypotension and tachycardia, insomnia, • Average reduction of 6.2 cm in the waist
urinary retention measurements
NSRIs Dyspepsia, nausea, constipation
MAOI, monoamine oxidase inhibitors; TCA, tricyclic antidepressants; SSRIs, selective serotonin reuptake inhibitors; NASSAs, noradrenergic
and specific serotonergic antidepressants; NARI, selective noradrenaline reuptake inhibitor; NSRIs, norepinephrine serotonin reuptake
inhibitors.

Downloaded for Anonymous User (n/a) at Universitas Gadjah Mada from ClinicalKey.com by Elsevier on June 20, 2017.
For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved.
Exercise training and music therapy with depressive syndrome
the long term, at which point the results will be influenced
to a lesser extent by the placebo effect.
We feel that, despite the limitations of this pilot study,
the results can have interesting implications for clinicians
in the management of light and moderate depression.
It is known that modifications in the neuro-transmission
of elderly subjects render them more vulnerable to
the extra-pyramidal and anticholinergic effects of anti-
depressant pharmaceuticals, resulting in the frequent onset
of side effects.1 This also delays the construction of a
physician—patient relationship that is important for the
management of depressed patients and requires more time
in order to find an effective therapy that is well tolerated
by the patient. On the contrary, a variety of different mech-
anisms can be identified to explain the positive effect of
physical exercise on depression: the fact that the depressed
subjects are taking care of themselves heightens their self-
reliance and esteem; the exercise leads to patients to have
more positive thoughts and plans; the alliance established
between the patient and the care-giver in ‘‘taking action’’
to cure the depression and anxiety. Moreover, the results
of the present study demonstrate the positive effect of our
training on all the risk factors linked to the metabolic syn-
drome. It is safe to say, that, even in terms of its ‘‘side
effects’’, our rehabilitation program proved to be safe and
effective (Table 2). Unlike other studies,25,26 the distinguish-
ing feature of our study is the use of the style of music
selected in accordance with the tastes of the patients and
the results show that our training had a beneficial effect,
albeit at varying levels, in each of the groups of patients
that listened to the different styles of music. Other original
element of our study is the way it has combined two such
different techniques, namely physical exercise and music
therapy. We have divided the training session in 3 phases
(warm up, main part, cool down) in order to create close
association between musical rhythm and intensity of the
activity being performed, in order to increase the synergistic
effect of physical exercise associated with music therapy.
Future studies should be randomized controlled trials of
exercise training and music therapy in depressed patients,
including a systematic investigation of possible biologi-
cal action mechanism (e.g., reduction in inflammatory
biomarkers).
Conclusions
The preliminary results allow us to state that:
• Our training may potentially play a role in the treatment
of subjects with mild to moderate depression.
• It appears that the improvement in mood may persist over
short term: at a distance of 4 weeks from the suspension
of our program, we observed that the benefits obtained
were essentially stable. In other words, our training may
serve as a tool in the rehabilitation of mood disturbances.
• Thanks to the multidimensional approach of our program,
we can treat both mood disturbances and the various
comorbid conditions that can aggravate the psycho-
physical health of elderly patients.
Downloaded for Anonymous User (n/a) at Universitas Gadjah Mada from ClinicalKey.com by Elsevier on June 20, 2017.
For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved.
619
Further research should be carried out using a larger
group of patients to obtain more evidence on effects of phys-
ical training and music therapy in rehabilitation of subjects
affected by light to moderate depression.
Conflict of interest
The authors declare that they have no competing financial
interests.
References
1. Marigliano V. Manuale breve di geriatria. Società Editrice Uni-
verso; 2007. p. 62—75.
2. Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ,
Johnson BT. Initial severity and antidepressant benefits: a meta-
analysis of data submitted to the Food and Drug Administration.
PLoS Med 2008;5(February (2)):45.
3. Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam
JD, Shelton RC, et al. Antidepressant drug effects and depres-
sion severity. A patient-level meta-analysis. J Am Med Assoc
2010;303(1):47—53.
4. DeRubeis RJ, Sigle GJ, Hollon SD. Cognitive therapy verus
medication for depression: treatment outcomes and neural
machanisms. Nat Rev Neurosci 2008;9(October (10)):788—96.
5. Cacciafesta M, Ettorre E, Amici A, Cicconetti P, Martinelli V,
Linguanti A, et al. New frontiers of cognitive rehabilitation in
geriatric age: the Mozart Effect (ME). Arch Gerontol Geriatr
2010;51(November—December (3)):e79—82.
6. Raglio A, Bellelli G, Traficante D, Gianotti M, Ubezio MC, Vil-
lani D, et al. Efficacy of music therapy in the treatment of
behavioral and psychiatric symptoms of dementia. Alzheimer
Dis Assoc Disord 2008;22(April—June (2)):158—62.
7. Guétin S, Soua B, Voiriot G, Picot MC, Hérisson C. The effect
of music therapy on mood and anxiety-depression: an observa-
tional study in institutionalised patients with traumatic brain
injury. Ann Phys Rehabil Med 2009;52:30—40.
8. Kim H, Lee MH, Chang HK, Lee TH, Lee HH, Shin MC, et al.
Influence of prenatal noise and music on the spatial memory
and neurogenesis in the hippocampus of developing rats. Brain
Dev 2006;28(March (2)):109—14.
9. Rauschecker Josef P. Cortical plasticity and music. Ann N Y Acad
Sci 2001;930(June):330—6.
10. den Heijer T, Tiemeier H, Luijendijk HJ, van der Lijn F, Koudstaal
PJ, Hofman A, et al. A study of the bidirectional association
between hippocampal volume on magnetic resonance imaging
and depression in the elderly. Biol Psychiatry 2011;(June).
11. Carek PJ, Laibstain SE, Carek SM. Exercise for the treatment of
depression and anxiety. Int J Psychiatry Med 2011;41(1):15—28.
12. Khairova RA, Machado-Vieira R, Du J, Manji HK. A potential role
for pro-inflammatory cytokines in regulating synaptic plastic-
ity in major depressive disorder. Int J Neuropsychopharmacol
2009;12(May (4)):561—78.
13. Okada K, Kurita A, Takase B, Otsuka T, Kodani E, Kusama Y,
et al. Effects of music therapy on autonomic nervous sys-
tem activity, incidence of heart failure events, and plasma
cytokine and catecholamine levels in elderly patients with cere-
brovascular disease and dementia. Int Heart J 2009;50(January
(1)):95—110.
14. American Psychiatric Association. Diagnostic and statistical
manual of mental disorders. 4th ed. Washington: American Psy-
chiatric Association; 1994.
15. Lux V, Aggen SH, Kendler KS. The DSM-IV definition of severity of
major depression: inter-relationship and validity. Psychol Med
2010;40(October (10)):1691—701.
620
16. Conwell Y, Forbes NT, Cox C, Caine ED. Validation of a mea-
sure of physical illness burden at autopsy: the Cumulative Illness
Rating Scale. J Am Geriatr Soc 1993;41:38—41.
17. Borg G. Borg’s perceived exertion and pain scales. Hum Kinet
1998.
18. Ji S, Ja Y. Geriatric Depression Scale (GDS): recent evidence and
development of a shorter version. In: Clinical gerontology: a
guide to assessment and intervention. The Haworth Press Ltd.;
1986. p. 165—73.
19. Hamilton M. The assessment of anxiety states by rating. Br J
Med Psychol 1959;32(50).
20. Koelsch S, Fritz T, Cramon V, Müller DY, Friederici KAD. Inves-
tigating emotion with music: an fMRI study. Hum Brain Mapp
2006;27:239—50.
21. Ströhle A. Physical activity, exercise, depression and anx-
iety disorders. J Neural Transm 2009;116(June (6)):777—
84.
22. Zhang JM, Wang P, Yao JX, Zhao L, Davis MP, Walsh D, et al.
Music interventions for psychological and physical outcomes in
Downloaded for Anonymous User (n/a) at Universitas Gadjah Mada from ClinicalKey.com by Elsevier on June 20, 2017.
For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved.
W. Verrusio et al.
cancer: a systematic review and meta-analysis. Support Care
Cancer 2012;20(December (12)):3043—53.
23. Erkkilä J, Punkanen M, Fachner J, Ala-Ruona E, Pöntiö I, Ter-
vaniemi M, et al. Individual music therapy for depression:
randomised controlled trial. Br J Psychiatry 2011;199(August
(2)):132—9.
24. Rushaniya A, Machado-Vieira R, Du J, Manji HK. A potential role
roe pro-inflammatory cytokines in regulating synaptic plastic-
ity in major depressive disorder. Int J Neuropsychopharmacol
2009;12(May (4)):561—78.
25. Leea EJ, Bhattacharyab J, Sohnc C, Verresa R. Monochord
sounds and progressive muscle relaxation reduce anxiety and
improve relaxation during chemotherapy: a pilot EEG study.
Complement Ther Med 2012;20:409—16.
26. Cross K, Flores R, Butterfield J, Blackman M, Lee S. The effect of
passive listening versus active observation of music and dance
performances on memory recognition and mild to moderate
depression in cognitively impaired older adults. Psychol Rep
2012;111(October (2)):413—23.