Journal of Religion and Health

https://doi.org/10.1007/s10943-019-00947-y

ORIGINAL PAPER

Use of Recorded Poetic Audios to Manage Levels of Anxiety

and Sleep Disorders

Andréa Cândido dos Reis1 · Carla Larissa Vidal1 ·
Kátia Alessandra de Souza Caetano2 · Haroldo Dutra Dias3

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Anxiety and sleep disorders are highly prevalent affecting millions of people world-
wide. Complementary therapies like art therapy, bibliotherapy, and music have been
used to manage these problems. The objective of this study was to evaluate levels of
anxiety and sleep disorder symptoms of participants before and after a 30-day inter-
vention of listening to short poetic audios. Thirty-one participants listened to audio-
taped messages, which associate music and literature for 30  days. Questionnaires
were answered by participants prior to the start of the study (baseline collection) and
after 30 days (final collection). Setting: the study was done in the city of Ribeirao
Preto (Sao Paulo—Brazil). Participants were 31 adults with anxiety symptoms and
sleep problems. The scores of the questionnaires were analyzed and compared by
the t test for paired samples (α = 0.05), used to evaluate possible differences in anxi-
ety and stress symptoms and sleep disturbances before and after the 30 days of inter-
vention. Significantly lower levels of anxiety and sleep disorders were found after
the 30-day intervention. This study reinforces the benefits of music and literature
for improving the quality of life of people by reducing levels of anxiety and sleep
disorder symptoms.

Keywords  Recorded audios · Anxiety · Sleep disorders

* Andréa Cândido dos Reis

andreare73@yahoo.com.br
1
Department of Dental Materials and Prosthesis, School of Dentistry of Ribeirão Preto,
University of São Paulo – FORP-USP, Av. do Café, s/n, Ribeirão Prêto, SP 14040‑904, Brazil
2
Department of Psychology and Education, Faculty of Philosophy, Sciences and Letters
of Ribeirão Preto, University of São Paulo, Ribeirão Prêto, Brazil
3
Court Judge of the State of Minas Gerais, Minas Gerais, Brazil

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 Journal of Religion and Health

Introduction

Anxiety and depression are highly prevalent, constituting 3–18% of mental dis-
orders worldwide (Ravindran and da Silva 2013; Alayarian et al. 2015) and can
lead to limited educational achievements, work difficulties, and impaired health.
People affected by anxiety and depression present irritable behavior, sleep dis-
turbances, and social phobia, which have psychological and physiological conse-
quences such as stress, failure of interpersonal relationships, reduction in quality
of life, and the occurrence of physical illnesses (Sun et al. 2015; Mason and Har-
vey 2014).
Sleep disorders affect about one-third of adults (Jespersen et al. 2015) causing
significant distress and impairment in social, occupational, and other aspects of
functioning (Wang et al. 2014). One of the most common sleep disorders affect-
ing millions of people worldwide (Wang et al. 2014) insomnia is characterized by
poor sleep quality, duration, or continuity, including difficulty falling asleep and
staying sleep, early morning awakenings, or non-restorative sleep (Morin and Jar-
rin 2013).
The first line of treatment for anxiety is pharmacotherapy. However, the use
of medicines has limitations due to the potential side effects that limit a long-
term intervention. In addition, many patients continue symptomatic despite phar-
macotherapy, and its high costs can be limiting. Thus, an alternative strategy is
mind–body interventions such as music therapy, meditation, and relaxation (Jes-
persen et al. 2015; Burns et al. 2015).
The use of art as therapy with the goal of psychosocial stabilization has gained
popularity in various fields of medicine, and been applied to all age ranges, from
children with psychiatric disorders to elderly patients with dementia (Boehm et al.
2014; Chancellor et al. 2014; Im and Lee 2014; Schouten et al. 2015). Art therapy
offers patients an alternative way of communicating and dealing with emotional
conflicts, spiritual or existential issues, experiences, and needs that are difficult to
express verbally, allowing people to express abilities or helping to relax (Boehm
et al. 2014; Baker et al. 2017).
Complementary therapies like acupuncture, transcutaneous electrical nerve
stimulation, auricular acupressure, and music have also been used to reduce pain
and anxiety (Ngee-Ming et al. 2014). Music is a non-pharmacological alternative
to promote relaxation and pain relief by activating the cingulo-frontal cortex and
causing anxiolytic effects (Yeo et  al. 2013). Musical interventions have shown
effectiveness in reducing anxiety in  situations of acute stress, such as before an
exam (Bradt et al. 2013a, 2016; Bradt and Dileo 2014) or while awaiting a medi-
cal or surgical procedure (Bradt et al. 2013b; Bradt and Teague 2018). Listening
to music is at least as effective at lowering anxiety levels as the administration of
benzodiazepines. However, no evidence is available regarding the effect of lis-
tening to spiritual relaxing messages with music in the background on anxiety
symptoms.
The therapeutic use of literature for the treatment of mental health, known
as poetry or literature therapy or bibliotherapy, is a psychotherapeutic approach

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Journal of Religion and Health

that aims at providing information and strategies to readers that can be applied to
develop awareness of negative thoughts and emotions, and provide responses to
problems (Eum et al. 2014; Eum and Yim 2015). The term “bibliotherapy” was
created by Samuel Crothers in 1916, and the use of books to change behavior and
decrease human suffering has been used at least since the Middle Ages (Jack and
Ronan 2008; McKenna et al. 2010).
Recommended by the National Institute of Health and Care Excellence (NICE) in
the UK since 2009 (National Institute for Clinical Excellence 2009), bibliotherapy
is regarded as a treatment for subliminal depressive symptoms or mild to moderate
depression. Its efficacy was shown to be comparable to standard care with antide-
pressants. Thus, this therapy can be used as a complement to conventional therapies
(Eum and Yim 2015; Cuijpers et al. 2010).
When applied in a therapeutic context, bibliotherapy may comprise both fictional
and non-fictional materials. Fictional bibliotherapy (e.g., novels and poetry) is a
dynamic process where the material is actively interpreted in the light of the reader’s
circumstances. Through identification with a character in the story, the reader visu-
alizes his own problems and by empathy, the reader undergoes through a form of
catharsis, gaining hope and releasing emotional tension, which consequently leads
to insights and behavioral changes (McKenna et al. 2010).
The primary objective of this study was to evaluate the symptoms of anxiety
and sleep disorders in a sample of participants before and after listening to audio-
recorded messages for 30 days. Based on the reported benefits of music and poetry
for mental health, this research associated music and poems in the recordings. The
hypothesis of this study was that anxiety levels and symptoms of sleep disorders
would be lower after exposure to the audios for 30 days.

Method

Participants

Thirty-one participants were selected. The sample had a mean age of 46.5  years
(SD = 16.3), 77.4% (n = 24) were women and 22.6% (n = 7) were men. Regarding
schooling, 58.1% (n = 18) had a higher education, 29% (n = 9) secondary education,
6.5% (n = 2) primary education, and 3.2% (n = 1) basic education.

Procedures

Participants were asked to listen, once daily, to a message extracted from the book
“7  min with Emmanuel” sent by the WhatsApp mobile phone application. The
messages have spiritual and spiritualizing content and were listened to for 30 days.
Questionnaires were answered by participants prior to the start of the study (base-
line collection) and after 30 days (final collection).

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Measures

Demographic questionnaire: Participants answered a demographic questionnaire to

assess age, gender, and level of education, and the practice of various activities, such
as physical activity, dancing, and painting, which can affect stress levels.
Lipp’s Inventory of Stress Symptoms for Adults (Lipp 2000): This inventory was
created by Lipp and Guevava in 1994 and revised in 2000. The tool assesses stress
from two domains, psychological and physical, discriminating between participants
with and without stress symptoms. For participants experiencing stress, the stress
level is classified as alerting, the initial phase of stress; resisting, the intermediate
stage; almost exhausting, the third stage; and exhausting, the last, chronic, and most
damaging stress stage.
Beck Anxiety Inventory (BAI) (Beck et al. 1988): BAI is a self-reported inven-
tory with 21 items designed to assess the presence and severity of anxiety in adults
and adolescents. It was created by Beck and co-workers, and differentiates cogni-
tive, emotional, and physiological symptoms of anxiety. Likert scores for each item
range from 0 (not at all) to 3 (severely), and the total score provides the severity of
the symptoms varying from 0 to 63; from 0 to 9 normal or minimal anxiety; 10–18,
mild to moderate anxiety; from 19 to 29, moderate to severe anxiety; and from 20 to
63, severe anxiety.
Fletcher and Luck adapted Questionnaire (Fletcher and Luckett 1991): The ques-
tionnaire contains 38 questions regarding sleep and associated complaints. Each
question is scored from 0 to 3: never = 0, very rarely = 1, occasionally = 2, often = 3.
The total score ranges from 0 to 114, which is divided by 38; values greater than 1
indicate the presence of sleep disorder symptoms.

Data analysis

The t test for paired samples was used to evaluate possible differences in anxiety and
stress symptoms and sleep disturbances before and after the 30 days of intervention.
The level of significance was 0.05.

Results

A significant reduction (p < 0.05) in anxiety symptoms was observed after the inter-
vention (Table 1).

Table 1  Mean and standard Symptom Mean and SD

deviation of anxiety scores
before and after participants Anxiety
listen to the audio messages
Before 10.00 (10.227)a
After 6.84 (8.174)b

Different letters indicate a statistically significant difference

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Journal of Religion and Health

Table 2  Mean and standard  Symptom Mean and SD

deviation of sleep disorder
scores before and after the Sleep disorder
30-day intervention
Before 29.38 (15.404)a
After 25.13 (12.969)b

Different letters indicate a statistically significant difference

Fig. 1  Differences in anxiety
and sleep disorder symptoms
before and after the 30-day
intervention

There was a significant reduction in sleep disorder symptoms (p = 0.035) after the
30-day intervention (Table 2).
The change in anxiety symptoms and sleep disorders before and after the inter-
vention is also shown in Fig. 1.

Discussion

Reducing anxiety can improve vitality, quality of life, memory, and cognitive func-
tioning. (Sharma and Haider 2015) Current therapies used to treat anxiety include
antidepressants, cognitive behavioral therapy such as psychoeducation, relaxation
training, and behavioral reconstruction (Chen and Sun 1997), benzodiazepines, self-
help techniques, and lifestyle modifications.
The use of cognitive behavioral therapy and antidepressants alleviates anxiety
symptoms for 50–65% of patients; many remain symptomatic after using comple-
mentary therapies. Although effective, benzodiazepines are drugs of short-term use
as they are highly addictive (Sarris et al. 2012). Due to the lack of safe and effec-
tive treatment options for anxiety, it is imperative to search for alternative therapies,
including non-chemical options (Lin et al. 2011).
Alternative and complementary treatments for anxiety include acupuncture,
meditation, herbal supplements, homeopathic techniques, and mind–body prac-
tices such as tai chi (Chen and Sun 1997; Sarris et al. 2012) and music therapy (Lin
et al. 2011). Music therapy is a safe, well tolerated, inexpensive, and easily acces-
sible noninvasive technique that has shown to provide therapeutic benefits in a broad

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 Journal of Religion and Health

spectrum of psychiatric disorders including depression, anxiety, schizophrenia,

autism, and dementia (Lin et al. 2011).
Art therapy helps overcome psychological deficiencies by providing nonverbal
experiences with sensory stimulation, symbolic movements, rhythms, and colors
that could facilitate psychological treatment (Eum and Yim 2015; Reynolds et  al.
2000) Art can improve the quality of treatment, increasing the expression of feelings
and facilitating perception (Eum and Yim 2015).
The audio-recorded messages used in the present study had literary content asso-
ciated with music. The observed reduction in anxiety symptoms and sleep disor-
ders can be attributed to the principle of bibliotherapy, a self-administered form of
treatment in which structured materials provide a means of self-improvement to help
alleviate suffering (McKenna et al. 2010; Gregory et al. 2004) Several randomized
clinical trials demonstrated the positive effects of bibliotherapy for clinical condi-
tions such as deliberate self-harm (Evans et  al. 1999), obsessive–compulsive dis-
order (OCD) (Lovell et  al. 2004), bulimia nervosa (Ghaderi and Scott 2003), and
insomnia (Morin et al. 1999).
The use of literature as therapy has several advantages such as low relapse rates,
high adherence rates, high patient acceptability, long-term benefits, few adverse side
effects, low cost, and no rebound effect after end of treatment (Frude 2004); a par-
ticularly safe treatment modality (McKenna et al. 2010).
In addition to inducing relaxation, the use of music in psychiatric disorders could
be employed as a nonverbal communication medium between patient and therapist
and used to help patients express feelings that are not articulated in other forms
(Bidabadi and Mehryar 2015).
In the present study, audio recordings contained songs associated with poems
and relaxing messages that could have led the listener to a relaxation and meditation
stage, as anxiety levels significantly decreased after 30 days of intervention. Medita-
tion and music therapy can reduce stress and depression and improve well-being and
sleep (Innes and Selfe 2014; Innes et al. 2016; Ueda et al. 2013).
Studies have shown that music can help improve sleep quality in a variety of
populations, including post-operation patients with acute sleep disorders, univer-
sity students, and elderly in the community with chronic sleep disorders (Jespersen
et al. 2015). After 30 days of listening to the spiritualized messages, the participants
of the present study presented a significant reduction (p = 0.035) in sleep disorder
symptoms. The improvement in sleep quality can be due to the reduction in anxiety
levels induced by music, which acts on the central nervous system as well as in the
limbic system. In addition, music has an effect on the modulation of endogenous
opioids and oxytocin (Bernatzky et al. 2011), contributing to its positive outcomes
on chronic sleep disorders (Jespersen et al. 2015).
The present study showed that spiritualizing audio messages associated to relax-
ing music can improve quality of life by reducing the signs and symptoms of anxi-
ety and improving the quality of sleep of listeners. These results agree with the lit-
erature that emphasize the effects of music on emotion regulatory structures of the
brain, several neurochemical systems, and neural plasticity (Raglio et al. 2015). The
literary content of the messages is based on the effect of bibliotherapy, which pro-
motes a sense of empowerment in patients involved in the activity (McKenna et al.

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Journal of Religion and Health

2010) and is associated with higher self-confidence, social support, and self-esteem,
and better quality of life, as readers feel in control of their problems (McKenna et al.
2010).

Conclusion

The use of audio-recorded 7-min spiritual messages listened to for 30 days once a
day promoted significant reduction in anxiety levels and sleep disorders.

Funding None.

Compliance with Ethical Standards 

Conflict of interest  The authors declare that they have no conflict of interest.

Ethical Approval  All procedures performed in studies involving human participants were in accordance
with the ethical standards of the institutional and/or national research committee and with the 1964 Decla-
ration of Helsinki and its later amendments or comparable ethical standards.

Informed Consent  Informed consent was obtained from all individual participants included in the study.

References
Alayarian, A., Aberbach, D., Abraham, K., et al. (2015). Cross-national comparisons of the prevalences
and correlates of mental disorders. WHO international consortium in psychiatric epidemiology. In
Handbook of working with children, trauma, and resilience: An intercultural psychoanalytic view
(Vol. 40, pp. xi–xi). Yale: World Health Organization.
Baker, F. A., Metcalf, O., Varker, T., & O’Donnell, M. (2017). A systematic review of the efficacy of
creative arts therapies in the treatment of adults with PTSD.
Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety:
Psychometric properties. Journal of Consulting and Clinical Psychology, 56(6), 893.
Bernatzky, G., Presch, M., Anderson, M., & Panksepp, J. (2011). Emotional foundations of music as a
non-pharmacological pain management tool in modern medicine. Neuroscience and Biobehavioral
Reviews, 35(9), 1989–1999.
Bidabadi, S. S., & Mehryar, A. (2015). Music therapy as an adjunct to standard treatment for obsessive
compulsive disorder and co-morbid anxiety and depression: A randomized clinical trial. Journal of
Affective Disorders, 184, 13–17.
Boehm, K., Cramer, H., Staroszynski, T., & Ostermann, T. (2014). Arts therapies for anxiety, depression,
and quality of life in breast cancer patients: A systematic review and meta-analysis. Evidence-based
complementary and alternative medicine.
Bradt, J., & Dileo, C. (2014). Music interventions for mechanically ventilated patients. Cochrane Data-
base System Review, 12, CD006902.
Bradt, J., Dileo, C., Magill, L., et al. (2016). Music interventions for improving psychological and physi-
cal outcomes in cancer patients. Cochrane Database System Review, 8, CD006911.
Bradt, J., Dileo, C., & Potvin, N. (2013a). Music for stress and anxiety reduction in coronary heart dis-
ease patients. Cochrane Database System Review, 12, CD006577.
Bradt, J., Dileo, C., & Shim, M. (2013b). Music interventions for preoperative anxiety. Cochrane Data-
base System Review, 6, CD006908.
Bradt, J., & Teague, A. (2018). Music interventions for dental anxiety. Oral Diseases, 24(3), 300–306.

13
 Journal of Religion and Health

Burns, D. S., Perkins, S. M., Tong, Y., Hilliard, R. E., & Cripe, L. D. (2015). Music therapy is associ-
ated with family perception of more spiritual support and decreased breathing problems in cancer
patients receiving hospice care. Journal of Pain and Symptom Management, 50(2), 225–231.
Chancellor, B., Duncan, A., & Chatterjee, A. (2014). Art therapy for Alzheimer’s disease and other
dementias. Journal of Alzheimer’s Disease, 39(1), 1–11.
Chen, W. W., & Sun, W. Y. (1997). Tai chi chuan, an alternative form of exercise for health promotion
and disease prevention for older adults in the community. International Quarterly of Community
Health Education, 16(4), 333–339.
Cuijpers, P., Donker, T., van Straten, A., Li, J., & Andersson, G. (2010). Is guided self-help as effective
as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-
analysis of comparative outcome studies. Psychological Medicine, 40(12), 1943–1957.
Eum, Y., & Yim, J. (2015). Literature and art therapy in post-stroke psychological disorders. The Tohoku
Journal of Experimental Medicine, 235(1), 17–23.
Eum, Y., Yim, J., & Choi, W. (2014). Elderly health and literature therapy: A theoretical review. The
Tohoku Journal of Experimental Medicine, 232(2), 79–83.
Evans, K., Tyrer, P., Catalan, J., Schmidt, U., Davidson, K., Dent, J., et al. (1999). Manual-assisted cog-
nitive-behaviour therapy (MACT): randomized controlled trial of a brief intervention with biblio-
therapy in the treatment of recurrent deliberate self-harm. Psychological Medicine, 29(1), 19–25.
Fletcher, E. C., & Luckett, R. A. (1991). The effect of positive reinforcement on hourly compliance in
nasal continuous positive airway pressure users with obstructive sleep apnea. American Review of
Respiratory Disease, 143((5_pt_1)), 936–941.
Frude, N. (2004). Bibliotherapy as a means of delivering psychological therapy. Clinical Psychology,
39(1), 8–10.
Ghaderi, A., & Scott, B. (2003). Pure and guided self-help for full and sub-threshold bulimia nervosa and
binge eating disorder. British Journal of Clinical Psychology, 42(3), 7–269.
Gregory, R. J., Schwer Canning, S., Lee, T. W., & Wise, J. C. (2004). Cognitive bibliotherapy for depres-
sion: A meta-analysis. Professional Psychology: Research and Practice, 35(3), 275.
Im, M. L., & Lee, J. I. (2014). Effects of art and music therapy on depression and cognitive function of
the elderly. Technology and Health Care, 22(3), 453–458.
Innes, K. E., & Selfe, T. K. (2014). Meditation as a therapeutic intervention for adults at risk for Alzhei-
mer’s disease–potential benefits and underlying mechanisms. Frontiers in Psychiatry, 5, 40.
Innes, K. E., Selfe, T. K., Khalsa, D. S., & Kandati, S. (2016). Effects of meditation versus music listen-
ing on perceived stress, mood, sleep, and quality of life in adults with early memory loss: A pilot
randomized controlled trial. Journal of Alzheimer’s Disease, 52(4), 1277–1298.
Jack, S. J., & Ronan, K. R. (2008). Bibliotherapy: Practice and research. School Psychology Interna-
tional, 29(2), 161–182.
Jespersen, K. V., Koenig, J., Jennum, P., et al. (2015). Music for insomnia in adults. Cochrane Database
System Review, 8, 9.
Lin, S. T., Yang, P., Lai, C. Y., Su, Y. Y., Yeh, Y. C., Huang, M. F., et al. (2011). Mental health impli-
cations of music: insight from neuroscientific and clinical studies. Harvard Review of Psychiatry,
19(1), 34–46.
Lipp, M. E. N. (2000). Manual do inventário de sintomas de stress para adultos de Lipp (ISSL) (p. 76).
São Paulo: Casa do Psicólogo.
Lovell, K., Ekers, D., Fulford, A., Baguley, C., & Bradshaw, T. (2004). A pilot study of a self-help
manual with minimal therapist contact in the treatment of obsessive–compulsive disorder. Clinical
Effectiveness in Nursing, 8(2), 122–127.
Mason, E. C., & Harvey, A. G. (2014). Insomnia before and after treatment for anxiety and depression.
Journal of Affective Disorders, 168, 415–421.
McKenna, G., Hevey, D., & Martin, E. (2010). Patients’ and providers’ perspectives on bibliotherapy in
primary care. Clinical Psychology & Psychotherapy, 17(6), 497–509.
Morin, C. M., & Jarrin, D. C. (2013). Epidemiology of insomnia: Prevalence, course, risk factors, and
public health burden. Sleep Medicine Clinics, 8(3), 281–297.
Morin, C. M., Mimeault, V., & Gagné, A. (1999). Nonpharmacological treatment of late-life insomnia.
Journal of Psychosomatic Research, 46(2), 103–116.
National Institute for Clinical Excellence. (2009). Depression: The treatment and management of depres-
sion in adults (update). Clinical Guidelines, 2009, CG90.
Ngee-Ming, G., Tamsin, D., Rai, B. P., & Somani, B. K. (2014). Complementary approaches to decreas-
ing discomfort during shockwave lithotripsy (SWL). Urolithiasis, 42(3), 189–193.

13
Journal of Religion and Health

Raglio, A., Attardo, L., Gontero, G., Rollino, S., Groppo, E., & Granieri, E. (2015). Effects of music and
music therapy on mood in neurological patients. World Journal of Psychiatry, 5(1), 68.
Ravindran, A. V., & da Silva, T. L. (2013). Complementary and alternative therapies as add-on to phar-
macotherapy for mood and anxiety disorders: A systematic review. Journal of Affective Disorders,
150(3), 707–719.
Reynolds, M. W., Nabors, L., & Quinlan, A. (2000). The effectiveness of art therapy: Does it work? Art
Therapy, 17(3), 207–213.
Sarris, J., Moylan, S., Camfield, D. A., Pase, M. P., Mischoulon, D., Berk, M.,… & Schweitzer, I. (2012).
Complementary medicine, exercise, meditation, diet, and lifestyle modification for anxiety disor-
ders: A review of current evidence. Evidence-Based Complementary and Alternative Medicine.
Schouten, K. A., de Niet, G. J., Knipscheer, J. W., Kleber, R. J., & Hutschemaekers, G. J. (2015). The
effectiveness of art therapy in the treatment of traumatized adults: A systematic review on art ther-
apy and trauma. Trauma, Violence, & Abuse, 16(2), 220–228.
Sharma, M., & Haider, T. (2015). Tai chi as an alternative and complimentary therapy for anxiety: A
systematic review. Journal of Evidence-Based Complementary & Alternative Medicine, 20(2),
143–153.
Sun, N., Xi, Y., Zhu, Z., Yin, H., Tao, Q., Wang, H., et al. (2015). Effects of anxiety and depression on
arterial elasticity of subjects with suboptimal physical health. Clinical Cardiology, 38(10), 614–620.
Ueda, T., Suzukamo, Y., Sato, M., & Izumi, S. I. (2013). Effects of music therapy on behavioral and
psychological symptoms of dementia: A systematic review and meta-analysis. Ageing Research
Reviews, 12(2), 628–641.
Wang, C. F., Sun, Y. L., & Zang, H. X. (2014). Music therapy improves sleep quality in acute and chronic
sleep disorders: A meta-analysis of 10 randomized studies. International Journal of Nursing Stud-
ies, 51(1), 51–62.
Yeo, J. K., Cho, D. Y., Oh, M. M., Park, S. S., & Park, M. G. (2013). Listening to music during cystos-
copy decreases anxiety, pain, and dissatisfaction in patients: A pilot randomized controlled trial.
Journal of Endourology, 27(4), 459–462.

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