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Original article
Effects of music therapy on depression and duration of hospital stay of breast cancer patients after radical mastectomy
ZHOU Kai-na, LI Xiao-mei, YAN Hong, DANG Shao-nong and WANG Duo-lao Keywords: music therapy; radical mastectomy; breast cancer; depression; chemotherapy
Background Breast cancer remains the most important cancer among women worldwide. The disease itself and treatment may have a profound impact on the patients psychological well being and quality of life. Depression is common in breast cancer patients and affects the therapeutic effects as well as prolongs the duration of hospital stay. However, few studies reported the effectiveness of music therapy on depression and duration of hospital stay of female patients with breast cancer after radical mastectomy. Methods One hundred and twenty subjects were recruited to this clinical trial and randomly allocated to two groups. The experimental group (n=60) received music therapy on the basis of routine nursing care, whereas the control group (n=60) only received the routine nursing care. The whole intervention time was from the first day after radical mastectomy to the third time of admission to hospital for chemotherapy. Data of demographic characteristics and depression were collected by using the General Questionnaire and Chinese version of Zung Self-rating Depression Scale (ZSDS) respectively. One pre-test (the day before radical mastectomy) and three post-tests (the day before discharge from hospital, the second and third admission to hospital for chemotherapy) were utilized. Duration of hospital stay was calculated from the first day after radical mastectomy to the day of discharged from hospital. Results The mean depression score of all subjects was 37.196.30. Thirty-six cases (30%) suffered from depression symptoms, with 26 (72.2%) mild depression cases, 9 (25.0%) moderate depression cases, and 1 (2.8%) severe depression case. After music therapy, depression scores of the experimental group were lower than that of the control group in the three post-tests, with significant differences (F=39.13, P <0.001; F=82.09, P <0.001). Duration of hospital stay after radical mastectomy of the experimental group ((13.622.04) days) was shorter than that of the control group ((15.532.75) days) with significant difference (t=4.34, P <0.001). Conclusions Music therapy has positive effects on improving depression of female patients with breast cancer, and duration of hospital stay after radical mastectomy can be reduced. It is worthy of applying music therapy as an alternative way of nursing intervention in clinical nursing process of caring female patients with breast cancer. Chin Med J 2011;124(15):2321-2327

reast cancer is the most frequently occurring cancer among women worldwide. Global statistics show that the annual incidence of the disease is increasing, and this is occurring more rapidly in countries with a low incidence rate of breast cancer.1 Data from western countries indicate that one out of every eight women is likely to develop breast cancer, and that breast cancer is one of the leading causes of cancer death in women between the ages of 35 and 50.2,3 In China, the incidence of breast cancer in the population is lower than that in the western population, but the incidence is rising rapidly.4,5 Additionally, related reports indicate that the incidence rate of breast cancer increased 37.6% in the past two decades and the average annual growth rate was 2.3%.6 In some districts, it even surpassed the incidence rate of cervical cancer, and becomes the first malign tumor of females.7 The primary treatment modality for breast cancer is surgery, and with other adjuvant therapies such as chemotherapy, radiotherapy and hormonal therapy. However, these advanced cancer treatments also brought about the aggressiveness of the therapies which increased

the exposure of patients on treatment side-effects and lead to the secondary influences of the unhealthy mood. The patients who have radical mastectomy must confront with the indispensible stresses during their life time: impaired body image and breast loss; consequently, they would experience the negative psychological states, among which the most common one is depression. Statistics show that the prevalence rate of depression among female breast cancer patients is ranging from 3.0% to 47.6%8-13 in other countries and 34.4% to 89.5%14-19 in China. Furthermore, many other related adverse effects or symptoms can be caused by depression, such as fatigue, sleeping difficulties, digestive problems, pathological
DOI: 10.3760/cma.j.issn.0366-6999.2011.15.014 School of Nursing, Medical College of Xian Jiaotong University, Xian, Shaanxi 710061, China (Zhou KN and Li XM) Department of Public Health, Xian Jiaotong University College of Medicine, Xian, Shaanxi 710061, China (Yan H and Dang SN) Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK (Wang DL) Correspondence to: LI Xiao-mei, School of Nursing, Medical College of Xian Jiaotong University, Xian, Shaanxi 710061, China (Email: roselee8825@163.com)

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worry, prolonged arousal, lowered immune functioning, feelings of helplessness and pessimism.20 Therefore, it is very necessary to provide effective measures to assist female patients with breast cancer to deal with these secondary manifestations of depression, so that rehabilitation can be achieved smoothly and stably. Music therapy is one of the common adjuvant therapeutic methods in cancer care.21 In 2005, the American Music Therapy Association defines music therapy as the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program. It can be carried out not only by professional music therapists, but also unpaid carers, volunteers and performing musicians in a variety of nursing care settings; even when music therapists are not available, music has been championed as a nursing intervention.22 The purpose of the music therapy is to improve, maintain, remediate, or prevent one or more of the clinical issues in clients, as specified in their needs for habilitation and rehabilitation.23 It is capable of addressing various human domains simultaneously due to the multidimensional phenomenon of music and the function of improving the listening environment for the patients. Research on the effects of music therapy on cancer patients with various diagnoses has revealed numerous benefits. It has been effective in evoking positive emotions and memories, improving sense of self and mood, enhancing psychological well-being and decreasing psychological symptoms such as depression, anxiety, fear, etc. Related studies also indicate that relaxed music listening (one of the common implementation methods of music therapy) has been benefit for the patients in increasing comfort and relaxation, relieving self-reported pain, reducing anxiety and depression, lowering treatment-related distress, and decreasing nausea and vomiting.24 The efficacy of music therapy in providing these benefits has been confirmed by cancer patients with well documented outcomes;25-28 however, Clark et al29-31 reported that music therapy has no obvious effects on relieving depression. In spite of this, few nursing researches have been performed on the use of music therapy in female patients with breast cancer after radical mastectomy. To this end, the purpose of this clinical trial is to study the effects of music therapy on depression of female patients with breast cancer after radical mastectomy; meanwhile, the alteration of duration of hospital stay after music therapy was also explored. METHODS Participants Target population was female patients with breast cancer hospitalized in Surgical Oncology Center of the First Affiliated Hospital of Medical College, Xian Jiaotong University. Subjects were included if they were female,

aged 2565, had pathologic diagnosis of breast cancer and needed to have radical mastectomy, including modified radical mastectomy and extensive radical mastectomy. If the subjects were allergic to sound, or have the voice sensitivity of epilepsy or not prefer to music listening, they would be excluded. Written consent form was signed up only by those who would receive music therapy in order to guaranty their compliance, reduce the lost to follow-up and contamination. Sample size and randomization One hundred and twenty subjects were recruited into this clinical trial. The randomization procedure was performed with 120 random numbers produced by computer and all subjects were randomly allocated into two groups: an experimental group (n=60) with receiving music therapy and a control group (n=60) with no intervention. The sample size was calculated based on the parameters of depression (measured by Zung Self-rating Depression Scale, ZSDS) in other related research on cancer patients,29,32-33 among which the largest sample size was selected. It was calculated that 100 subjects (50 in each group of the study) were needed to detect the difference between the two groups with a power of 80% at the 5% level of statistical significance. The sample size was increased to 120 subjects to allow for just over 20% drop out rate. Questionnaires Questionnaires used in this study involve the General Questionnaire and Chinese version of ZSDS. Both have been shown to be reproducible, sensitive to change and are easy to complete. The General Questionnaire was applied to collect demographic data, which include age, occupation, education level, residence, monthly income, marital status, age of the first suffering from breast cancer, etc., a total of 15 items. Chinese version of ZSDS was utilized to assess the depression state. The ZSDS is a 20-item self-report measure of the symptoms of depression. The subjects rate each item with regard to how they have felt during the preceding week using a 4 point Likert scale, with 4 representing the most unfavorable response. The sum of the 20 items, after correcting for the 10 items that are reverse-scored, produces a raw score that is converted into a self-rating depression score (termed the SDS index) by utilizing the formula ZSDS Index=Raw Score/80. The scope of ZSDS Index was from 0.251.0. These index scores are then categorized into 4 levels to offer a global clinical impression: 1: with normal range, no significant psychopathology (SDS Index: below 0.50); 2: presence of minimal to mild depression (SDS Index: 0.500.59); 3: presence of moderate to marked depression (SDS Index: 0.600.69); and 4: presence of severe to extreme depression (SDS Index: 0.70 and above).34 Scores are not meant to offer strict diagnostic

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guidelines but rather denote levels of depressive symptomology that may be of clinical significance. Overall, the ZSDS has been shown to be relatively valid and to have high internal consistency, the reliability coefficient of SDS is 0.73 (1973) and 0.92 (1986); validity coefficient of SDS is 0.84.35-37 Cronbachs Alpha reliability coefficient of ZSDS in this study is 0.72. Data collection Data were collected from March to November, 2009. Demographic data of all subjects were collected before radical mastectomy; depression scores were surveyed on the day before radical mastectomy (pre-test), the day before discharged from hospital (1st post-test), the second and third time of admission to hospital for chemotherapy (2nd and 3rd post-tests). Due to different modes of chemotherapy, the intervals are 14, 21 and 28 days, average (18.67.4) days. All subjects were asked the items of the questionnaires and the answers were documented by the data collectors, who were trained how to fill up the questionnaires and had no information about the group allocation. The primary endpoint was the scores of depression. Duration of hospital stay was calculated from the first day after radical mastectomy to the day of discharged from hospital. Intervention The experimental group Subjects of the experimental group were given an introduction of the music name and type in the music media library which was copied in the MP3 players, and music therapy (music listening was used as the method) was delivered by the researcher. The experimental group subjects selected the preferred music, controlled the music volume and listened through a headphone connected to the MP3 player. The total intervention time involve the hospital stay after radical mastectomy (average (13.62.0) days) and the two chemotherapy periods (each average (18.97.1) days). Music listening was twice a day, in the early morning (6 a.m.8 a.m.) and in the evening (9 p.m.11 p.m.), 30 minutes per time. During the time of postoperative hospital stay, the subjects who did not adhere to listen to the music would gain the assistance and encouragement from the researcher; when they were discharged from hospital, they would be followed-up by the researcher through telephone interview. The control group Subjects of the control group took part in the pre- and the three post-tests. They were not offered the information of music therapy during the period of intervention in case of contamination. Music media library The music media library, which based on the effects of different types and modes of music in treatments38,39 and according to the characteristics of Pentameter Therapy Principle and different tonality,40 was established by the

researcher and experts. Two hundred and two songs (light music) were selected in the study, including Chinese classical folk music, famous world music, the music recommended by American Association of Music Therapy (AAMT) and relaxation music. All of the music files were copied in the MP3 players, which would be provided for the subjects in the experimental group. Statistical analysis All data were entried into the database established by using Epi Data, version of 3.1 (EpiData Association, Denmark), and analyzed by using SPSS 13.0 for Windows (SPSS Inc, IL, USA). Descriptive statistics summarized frequencies and percentages for categorical, mean and standard deviation for continuous variables. The two sample t-test and chi-square test were applied to detect the differences of the baseline data between the two groups. The repeated measures analysis of variance (ANOVA) was utilized to detect the between-group difference of the depression scores after music therapy. A value of P <0.05 was considered as statistically significant. RESULTS Four hundred and eighty questionnaires were issued, and 450 were retrieved and valid. At the pre-test and the first post-test, no subjects of the experimental and control group was lost; while at the second and third post-tests, 6 subjects of the experimental group and 9 subjects of the control group were lost to follow-up, due to the reason of alteration of hospital for chemotherapy. The rate of lost to follow-up was 12.5%. Demographic characteristics The demographic characteristics of the subjects are shown in Table 1. The two group subjects were similar in terms of age, occupation, education level, residence, monthly income, etc.; no statistically significant baseline differences were detected (P >0.05). There are two peaks in the age distribution of first suffering from breast cancer, one is in 2538 years, and the other is in 4365 (Figure 1). Pre-test and comparison of depression scores Of all subjects before radical mastectomy, depression score was 37.196.30; 36 cases (30.0%) suffered from depression symptoms, with 26 (72.2%) mild depression cases, 9 (25.0%) moderate depression cases, and 1 (2.8%) severe depression case. Comparison of depression scores between the two group subjects were not significantly different (t=1.06, P >0.05). The two groups were equivalent on these baseline measures. Post-tests and comparison of depression scores The post-tests of depression scores are shown in Table 2. Different measure time of the depression scores have significant differences between the two groups (F=39.13, P <0.001; F=82.09, P <0.001) (Table 3).

2324 Table 1. Demographic and baseline characteristics of the subjects

Items Experimental group n % Control group n %

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2 values

P values

Occupation 4.45 0.49 Peasants 14 23.3 14 23.3 Workers 18 30.0 17 28.3 Cadres 5 8.3 3 5.0 Teachers 8 13.3 9 15.0 Medical staffs 3 5.0 0 0 Others 12 20.0 17 28.3 Education level 5.96 0.11 Below middle school 16 26.7 14 23.3 High school 17 28.3 27 45.0 Associate degree 14 23.3 14 23.3 Baccalaureate and above 13 21.7 5 8.3 Residence 0.39 0.53 City 43 71.7 46 76.7 Countryside 17 28.3 14 23.3 Monthly income (RMB) 5.35 0.07 <1000 17 28.3 22 36.7 10003000 32 53.3 35 58.3 >3000 11 18.3 3 5.0 Terms of payment 0.23 0.89 At patients own expense 6 10.0 5 8.3 Free medical care 3 5.0 4 6.7 Others 51 85.0 51 85.0 Marital status 1.77 0.62 2 Single 1 1.7 3.3 Married 55 91.7 51 85.0 Widow 2 3.3 5 8.3 Divorce 2 3.3 2 3.3 Spousal relationship 4.97 0.29 Best 6 10.9 12 23.1 Better 31 56.4 21 40.4 General 12 21.8 13 25.0 Worse 6 10.9 5 9.6 Worst 0 0 1 1.9 Have children or not 1.48 0.69 Yes, single 35 58.3 36 60.0 Yes, two 14 23.3 16 26.7 Yes, more than three 10 16.7 6 10.0 No child 1 1.7 2 3.3 Relationship with children 1.03 0.60 Best 48 81.4 46 79.3 Better 11 18.6 11 19.0 General 0 0 1 1.7 Operation ways 0.54 0.46 Extensive radical mastectomy 3 5.0 5 8.3 Modified radical mastectomy 57 95.0 55 91.7 Chemotherapy 2.91 0.09 Yes 56 93.3 50 83.3 No 4 6.7 10 16.7 Period of chemotherapy 1.09 0.78 14 days 6 11.1 4 7.8 21 days 42 77.8 42 82.4 28 days 6 11.1 5 9.8 First suffering from BC 0.14 0.71 Yes 36 60.0 34 56.7 No 24 40.0 26 43.3 BC: breast cancer. The ages of experimental group and control group were (44.889.37) years and (45.139.48) years (t=0.15, P=0.89), while the ages of the first suffering from BC were (42.28.8) years and (42.58.3) years, respectively (t=0.14, P=0.89).

Variation trend of depression scores during follow-up periods Both the two groups depression scores were in the downtrend during the follow-up periods, but the depression score curve of the experimental group was lower than that of the control group (Figure 2).

Comparison of duration of hospital stays after radical mastectomy After radical mastectomy, the hospitalization of the experimental group subjects were (13.622.04) days, the control group subjects were (15.532.75) days, the former was shorter than the latter, with significant

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Figure 1. Age distribution of the first suffering from breast cancer. Figure 2. Variation trend of depression score.

Table 2. Depression scores of the post-tests

Items Experimental group (n=60) Control group (n=60) 32.204.73 35.765.80 1st post-test 30.004.89 35.504.90 2nd post-test* 25.672.74 32.153.86 3rd post-test* * n=54 in the experimental group and n=51 in the control group.

Table 3. Repeated measures ANOVA of the depression score

Items Time Group Type III sum of squares 4335.77 1335.33 Mean square 1445.26 1335.33 F values 39.13 82.09 P values <0.001 <0.001

difference (t=4.34, P <0.001). DISCUSSION Of all subjects, the mean depression score was 37.196.30, 30% of subjects experienced the negative influences of depression, and the levels of depression from mild to severe were 72.2%, 25.0% and 2.8%, respectively. From the aspect of depression incidence rate, 30% in this clinical trial was higher than the results of related reports;8-10,13 meanwhile, it is lower in comparison with other related studies.11,16-18 Compared with the research of Aukst-Margetic et al12 (depression levels from mild to severe were 30.9%, 21.4% and 47.6%, respectively) and Chen et al19 (depression levels from mild to severe were 34.35%, 11.74% and 3.48%, respectively), mild and moderate depression in this trial were higher whereas severe depression was lower. These discrepancies were probably due to the different factors of sample size, instrument, measure ways and time, and so forth. In spite of this, the comparison results indicate that depression is the common negative psychological state of female patients with breast cancer, although the depression incidence rate was varied from one to the other. Results of the three post-tests and comparison indicate that depression scores of the experimental group were all lower than that of the control group, with significant differences (F=39.13, P <0.001; F=82.09, P <0.001). Such effects also demonstrate in the downtrend during the follow-up periods, and the depression score curve of the experimental group was lower than that of the control group. It illustrates that during the hospital stay after radical mastectomy, music therapy has positive influences

on improving depression; during the follow-up time of chemotherapy period, music therapy also has satisfied long-term therapeutic effects. Studies of Guetin et al41-43 have the same results that music therapy has positive effects on improving the negative psychological state of depression: subjects who received music therapy have lower depression scores than those who did not, and significant differences was detected, which strengthen the better effects of music therapy. Nevertheless, the results in this clinical trial are not consistent with the research outcome of Clark et al,29-31 who reported that music therapy has no obvious effects on improving depression. It is probably related to the different instrument, or sample size, or subjects cancer type, or music type, or measurement time, and so forth. Duration of hospital stay of the two groups were different after the intervention of music therapy: days of the experimental group subjects admitted to hospital after radical mastectomy were shorter than that of the control group with significant difference. Such discrepancy is probably due to psychological effects of music therapy on the alteration of physical status, which can improve the rehabilitation of body function, thus reduced the time of hospital stay indirectly. In this clinical trial, the data were self-reported and could have been influenced by numerous factors, such as defensiveness, misrepresentation, personal emotion and other attitudes. Accordingly, it should be considered in the light of certain limitations. First and foremost, the double-blind method was not used in this clinical trial due to the specificity of the intervention. Secondly, we investigated only from quantitative aspect which is easy to quantify the intervention effects of music therapy. Subjective experiences of the subjects for effects of music therapy need further study. Thirdly, no physical variable was utilized in this trial. Therefore, effects of music therapy on physical part need to be further explored. Fourthly, the control group was blank. Effects of different intervention time and methods of music therapy were worthy to be the control group to detect the differences among them. Finally, subjects with extensive radical mastectomy in this clinical trial only accounted for a small part. Thus, effects of music therapy on depression of such patients need further study.

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Chin Med J 2011;124(15):2321-2327 al. Anxiety, depression and quality of life among Chinese breast cancer patients during adjuvant therapy. Eur J Oncol Nurs 2010; 14: 17-22. Aukst-Margetic B, Jakovljevic M, Margetic B, Biscan M, Samija M. Religiosity, depression and pain in patients with breast cancer. Gen Hosp Psychiatry 2005; 27: 250-255. Kim SH, Son BH, Hwang SY, Han W, Yang JH, Lee S, et al. Fatigue and depression in disease-free breast cancer survivors: Prevalence, correlates, and association with quality of life. J Pain Symptom Manage 2008; 35: 644-655. Xiao XL. Study of anxiety and depression of breast cancer patients after surgery and its related factors. Heilongjiang Nurs J (Chin) 2000; 6: 3-4. Chen LZ, Xie Z, Feng ZH, Huang G. Emotion measurement of anxiety and depression of breast cancer patients and the counter-measurements of traditional Chinese medicine. J Qiqihar Med Coll (Chin) 2002; 23: 886-887. Wang PL, Zhang T, Zhi YH. Study of psychological problems and intervention methods in breast cancer diagnosis and treatment. Chin J Ca Prev Treat (Chin) 2005; 12: 1961-1964. Gao CL, Zhu H, Gu JM. Psychological problems and interventions during the breast cancer treatment and nursing. Nurs J Chin Peoples Liberation Army (Chin) 2006; 23: 61-63. Wang YH, Yan CM. Study on the correlations between postoperative uncertainty in illness and anxiety, depression, coping mode in breast cancer patients. J Nurs Adm (Chin) 2007; 7: 2-3. Chen YX, Yang XM, Kuang JY, Han BX. Anxiety and depression status of patients with breast cancer and analysis of the related factors. J Bengbu Med Coll (Chin) 2009; 34: 840-842. Sharpley CF, Bitsika V, Christie DR. Helping prostate cancer patients understand the causes of anxiety and depression: comparing cancer-cansed vs. patient response events. J Mens Health 2009; 6: 345-353. Daykin N, Bunt L, McClean S. Music and healing in cancer care: a survey of supportive care providers. Arts Psychother 2006; 33: 402-413. Aldridge D. Music therapy references relating to cancer and palliative care. Br J Music Ther 2003; 17: 17-25. Dileo C, Bradt J. Medical music therapy: evidence-based principles and practices. International handbook of occupational therapy interventions. In: Soderback I, Ed. International handbook of occupational therapy. New York: Springer; 2009: 445. Bruscia K, Dileo C, Shultis C, Dennery K. Expectations of hospitalized cancer and cardiac patients regarding the medical and psychotherapeutic benefits of music therapy. Arts Psychother 2009; 36: 239-244. Cui Y, Ding YP, Chen MX. The effect of nursing intervention on negative emotional response in cancer patients. Nurs J Chin Peoples Liberation Army (Chin) 2005; 22: 28-29. Li HM, Wan YQ, Yang ZH. Effect of background music on anxiety and depression of patients during thermotherapy of cancer. Nurs J Chin Peoples Liberation Army (Chin) 2007; 24: 16-17. Cai GR, Jia LQ, Wei YL, Li PW, Zhu SJ, Yu LL. Modulation effects of music therapy assisting chemotherapy on emotion

The results of this clinical trial demonstrate that depression is common in female breast cancer patients with radical mastectomy, which can cause negative influences for the process of treatment and rehabilitation. After music therapy, depression scores of the experimental group subjects were reduced distinctly, and the long-term therapeutic effects was proved. Music therapy can be recommended as a psychosocial intervention to reduce mood disturbance in female patients with breast cancer after radical mastectomy, and worthy to be applied as an alternative way of nursing intervention in clinical nursing process of caring female patients with breast cancer.
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(Received November 27, 2010) Edited by HAO Xiu-yuan