Music Therapy

Music therapy is a clinical and scientific discipline that uses musical experience as a tool for treatment, prevention, and rehabilitation in various healthcare settings. In the context of major depressive disorder, it serves as an integrative intervention that can be combined with pharmacological and psychotherapeutic approaches to target emotional, relational, and neurobiological processes that are often impaired.

The official definition provided by the World Federation of Music Therapy describes music therapy as “the use of music and/or musical elements (sound, rhythm, melody, and harmony) by a qualified music therapist, within a therapeutic process aimed at facilitating and promoting communication, relationship, learning, mobilization, expression, organization, and other relevant therapeutic goals, to meet the physical, emotional, mental, social, and cognitive needs of the patient.”

Unlike simple music listening, music therapy is developed within a structured therapeutic relationship, where sound becomes a transformative process that facilitates the modulation and integration of emotional experience. Music becomes a privileged medium for accessing, expressing, and elaborating inner emotional states.

Neuroscientific and Neuropsychological Foundations

The neurobiological basis of music therapy is supported by numerous studies examining how music affects brain activity, mood regulation, and neuroendocrine function.

Musical listening activates a network of cortical and subcortical structures associated with emotional regulation, motivation, and affective memory, including:

• the dorsolateral prefrontal cortex, involved in cognitive control and emotional regulation;
• the anterior cingulate cortex, linked to emotional awareness and processing of psychological pain;
• the amygdala and hippocampus, key structures in emotional memory and the encoding of affective experiences;
• the mesolimbic dopaminergic system, associated with pleasure, reward, and the anhedonic aspects of depression.

Neuroimaging studies (fMRI, PET) confirm that musical experiences, even in non-musicians, synchronize these brain networks and modulate the hypothalamic–pituitary–adrenal axis, reducing cortisol levels and calming limbic overactivation.

In depression, these effects are particularly relevant: patients often show hypoactivation of the dopaminergic system, disconnection between cortical and limbic areas, and reduced affective plasticity. Music can help restore interhemispheric synchronization and amplify weak emotional signals, promoting reintegration of affective experience.

In this sense, music acts as an “intermediate stimulus” between body, emotion, and cognition, reactivating the self in an integrated and relational way.

Theoretical Frameworks

Clinical practice in music therapy is grounded in diverse but often integrable theoretical models. The main approaches include:

• Psychodynamic model: music serves as a vehicle to access unconscious and affective content; the therapeutic process centers on transference mediated by sound and symbolic elaboration;
• Humanistic-relational model: emphasizes authenticity in the therapeutic relationship, the here-and-now of musical interaction, and the patient’s expressive resources;
• Neurologic Music Therapy (NMT): uses standardized protocols based on neuroscience to pursue motor, cognitive, and affective rehabilitation goals;
• Behavioral model: applies principles of reinforcement and learning to modify dysfunctional patterns through structured musical stimuli.

In clinical work with depressed patients, elements from psychodynamic, relational, and neuroscientific models are often integrated, with the setting and techniques tailored to individual needs and psychological functioning.

Structure and Application Methods

Music therapy may be conducted in individual or group settings, typically one or two sessions per week. Each session lasts 45 to 60 minutes and takes place in a consistent and protected environment where music becomes a relational and emotional matrix.

The main application methods include:

• Receptive music therapy: the patient listens to recorded or live music performed by the therapist to elicit relaxation, emotional evocation, or memory stimulation. This may include guided imagery or post-listening discussion;
• Active music therapy: the patient engages in music-making using percussion instruments, voice, movement, or shared improvisation. The focus is on interaction, expression, and emotional regulation through sound;
• Integrated models: combine receptive and active methods within the same session or treatment plan, with gradual modulation of patient engagement.

The chosen method depends on the patient's level of activation, psychological functioning, illness phase, and shared therapeutic goals.

Clinical Indications in Depression

Music therapy is indicated in various forms and stages of depressive disorders. It can be particularly helpful in:

• major depression with reduced environmental responsiveness and emotional blunting;
• treatment-resistant depression, as an adjunct in multidisciplinary programs;
• depression with psychomotor symptoms such as internal agitation or psychomotor retardation;
• depressive disorders in patients with aphasia, speech disorders, or cognitive disabilities;
• rehabilitation and residential care settings where relational and affective support is essential.

In patients with moderate or chronic unipolar depression, music therapy may enhance behavioral activation, mood regulation, and social engagement. In depression associated with cognitive decline (e.g., dementia), music supports identity maintenance, memory recall, and reduced apathy.

Efficacy Evidence

Multiple controlled studies and meta-analyses confirm music therapy’s effectiveness in reducing depressive symptoms, particularly when administered within structured protocols by trained therapists. The Cochrane review by Aalbers et al. (2017), involving 331 patients, showed a clinically significant improvement in depression scores compared to standard care.

Additional benefits include:

• enhanced affective regulation and empathy;
• improved social and relational functioning;
• greater self-efficacy and treatment engagement;
• reduced isolation and depressive rumination.

Compared to other non-pharmacological interventions, music therapy shows equal or superior effectiveness, especially in patients with low adherence to verbal or cognitive-based therapies.

Mechanisms of Action in Depression

Music therapy acts on depression through multiple interconnected mechanisms, including:

• Mesolimbic dopaminergic activation: counters anhedonia and promotes reward processing;
• Cortico-limbic integration: facilitates emotional processing through musical experience;
• HPA axis modulation: reduces stress and restores neuroendocrine balance;
• Synaptic plasticity and neurogenesis: some studies suggest increased BDNF expression following regular music therapy sessions;
• Empathic resonance and co-regulation: shared musical experience fosters physiological and affective synchronization, enhancing the therapeutic alliance.

Music therapy is not intended to replace pharmacological or psychotherapeutic treatment in major depression but to complement them. Its efficacy is highest when integrated into a comprehensive treatment plan based on multidisciplinary evaluation and shared goals.

Main limitations include the need for trained therapists, limited standardization (except in NMT), and its dependence on patient functioning. In cases of active psychosis or severe cognitive disorganization, adaptations may be required or therapy may be contraindicated.

Conclusions

Music therapy is an evidence-based intervention offering unique tools for emotional processing, mood regulation, and motivational recovery in depressed patients. By working through the auditory channel, it can reach individuals less responsive to verbal or cognitive-based therapies.

When properly integrated into the treatment plan, music therapy can enhance adherence, subjective well-being, and the quality of the therapeutic relationship. In a person-centered framework, it is a valuable clinical resource supporting emotional transformation and healing.

References
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