Jouma/oq Mu=/c Therapy, XLVII (1), 2010.

27-52
@ 2010 by the American Music Therapy A.s~soclatfon

The Effects of Music Relaxation on Sleep

Quality and Emotional Measures in People
Living with Schizophrenia

Boaz Bloch, MD
Alon Reshef, MD

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Psychiatric Department, Haemek Medical Center
Afula, Israel

Limor Vadas, BA
Yamit Haliba, BA
Naomi Ziv, PhD
Department of Psychology and The Center for
Psychobiological Research, Max Stem Academic
College of Emek Yezreel

liana Kremer*, MD
Psychiatric Department, Haemek Medical Center
Afula, Israel

Iris Haimov*, PhD

Department of Psychology and The Center for
Psychobiological Research, Max Stem Academic
College of Emek Yezreel

The aim of the present study was to examine the effects of

music relaxation on insomnia and emotional measures in
people living with schizophrenia. Twenty-four people living
with schizophrenia participated in the study. The study
involved a 7-day running-in no-treatment period, followed by
a 7-day experimental period. Treatment consisted of music
relaxation played at bedtime. During each of these periods,
participants' sleep was continuously monitored with a wrist
actigraph, and participants completed a wide spectrum of
questionnaires. Results showed an improvement in sleep

*Contributed equally to this research.

The authors would like to thank Ben Shitrit Yael, Ehood Golz Adi, Shalahavich
Kiril, Tangi Royi and Tavakuli Hohit Rachel for their invaluable assistance in data
collection and data processing.
28 Journal of Music Therapy

latency and sleep efficiency after the music relaxation was

played. Likewise, music relaxation was shown to improve
participants" total psychopathology score (PANSS) as well
as their level of depression. Moreover, a significant correla-
tion was found between reduction in level of situational
anxiety and improvement in sleep efficiency. The findings
suggest the beneficial effect of music relaxation as a

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treatment both for insomnia and for emotional measures in
people riving with schizophrenia.

Introduction
Schizophrenia is a mental disorder involving disturbances in
basic mental functions such as emotions, cognition, perception,
and other aspects of behavior (Goldberg & Gold, 1005; Green,
Salomon, Brenner, & Rawlins, 2002; Heinrichs & Zakzanis, 1008;
Weickert et al., 2000). The course of the disease is often
deteriorating. Its lifetime prevalence is about 1%, with equal
distribution between men and women (American Psychiatric
Association, 1004). Schizophrenia creates enormous emotional
and economic burdens for patients, their families and society as a
whole (Mueser, Valentiner, & Agresta, 1007; Murray & Lopez,
1096). The clinical picture of schizophrenia is marked by a
mixture of two main categories of symptoms: positive symptoms
(i.e., delusions and hallucinations) and negative symptoms (i.e.,
apathy, flat affect, lack of functioning) (American Psychiatric
Association, 1004; Brekke, Long, Nesbitt, & Sobel, 1007; Mueser et
al., 1007). People living with schizophrenia have associated
neuropsychiatric and medical problems other than psychotic
symptoms, among them depressive and anxiety features and sleep
disturbances (Lykke, Morten Hesse, Austin, & Oestrich, 2008;
Monti & Monti, 2004; Zisook et al., 2006).
Specifically, insomnia, a common feature in schizophrenia, has
serious consequences for daytime functioning and quality of life
(Kane & Sharif, 2008; Monti & Monti, 2004). Insomnia is defined as
difficulty in initiating or maintaining sleep or experiencing non-
restorative sleep for at least one month (American Psychiatric
Association, 1994). In people living with schizophrenia, insomnia is
characterized by the following: decrease in sleep duration, increase
in sleep latency, difficulty in maintaining sleep throughout the
vo/. XLVl/, No. I, Spring2010 29

night including recurrent arousals and awakenings, difficulty in

going back to sleep, and daytime fatigue with exaggerated napping
throughout the day (Chouinard, Poulin, Stip, & Godbout, 2004).
Polysomnographic studies of people who have schizophrenia
tend to show disturbances both in REM (Rapid Eye Movement)
sleep and Non-REM sleep architecture, specifically a decrease in

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Slow-Wave Sleep (SWS---deep sleep) especially in Stage 4, a
decrease in REM sleep, a decrease in REM latency, and a decrease
in sleep amount (Kane & Sharif, 2008; Poulin, Daoust, & Forest,
2003). Among people who have schizophrenia, insomnia may
precede relapse or appear during exacerbated schizophrenic
episodes; it may even complicate schizophrenia to the degree that
patients can exhibit suicidal activity (American Sleep Disorders ,
Association, 1997; Van Kammen et al., 1986).
The etiology of schizophrenia is apparently, polygenic and
multifactorial, involving genetic, biochemical, biological, psycho-
logical and environmental factors. One of the major hypotheses in
understanding the pathogenesis of the disease is related to
dysregulation of the Dopamine system. In effect, excess release of
dopamine in the mesolimbic route appears to be connected to
positive symptoms, while a decrease in dopamine release in the
mesocortical route is apparently connected to negative symptoms
(Carlsson & Lindquist, 1963). A leading hypothesis regarding the
mechanisms involved in sleep disturbances in people who have
schizophrenia refers to the overactivity of the dopaminergic
system (Carlsson & Lindquist, 1963). This hypothesis is supported
by pharmacological studies showing that Dopamin2 receptor
agonists (such as bromocriptine) increase awareness and decrease
SWS and REM sleep. In addition, clinical studies have shown the
positive influence of typical antipsychotics medications, which
block the Dopamine2 receptor, on sleep induction and sleep
maintenance in people living with schizophrenia (Dzirasa et al.,
2006). In contrast, the possibility that insomnia will appear as one
of the side effects of antipsychotic medications suggest the
possibility that other neurotransmitter systems may be involved
in insomnia among people living with schizophrenia (Monti &
Monfi, 2000).
It is well known that sleep is highly important for both physical
and mental health. Human beings spend around one-third of
their lives sleeping. Sleep is required for rest, recuperation after
30 Journal of Music Therapy

effort, renewal of energy reserves, growth processes, learning

processes, memory processes and recovery of the nervous system
(Laposky, Bass, Kohsaka, & Turek, 2008; Scott, McNaughton, &
Polman, 2006). Hence, insomnia has damaging effects on health
and quality of life for people in general and for people living with
schizophrenia in particular, as manifested in negative effects on

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physical and mental health, physiological processes and funda-
mental social functioning.
Thus, insomnia treatment among people living with schizo-
phrenia is of tremendous importance (Costa e Silva, 2006). Today
a wide range of treatments are available for insomnia, including
pharmacological treatments (Morin, 1993), melatonin treatment
(Haimov et al., 1995), and a variety of psychosocial treatments,
among them sleep hygiene (Soeffing et al., 2008), cognitive
behavioral therapy--CBT (Edinger, Wohlgemuth, Radtke, March,
& Quillian, 2001), biofeedback, guided imagination (Cortoos,
Verstraeten, & Cluydts, 2006), muscle relaxation, various medita-
tion techniques (Ong, Shapiro, & Manber, 2007), and music
relaxation (Cheriniack, 2006). The first line of treatment for
insomnia is not necessarily pharmacological. Research evidence
demonstrates that a combination of cognitive behavioral therapy
and pharmacological treatment is more efficient than pharmaco-
logical treatment alone (Wallace & Mendelson, 2007). Never-
theless, the most common treatment today in clinical practice is
treatment involving hypnotic a n d / o r anxiolytic medications with
disturbing side effects that add to the drug load for treating the
disease itself (Marshall & Rathbone, 2006). Indeed, in recent years
clinicians have become increasingly aware of and exposed to a
wide range of treatments that are not pharmacological, among
them music relaxation.
The 'healing' power of music has been recognized for many
years. According to Sigmund Freud, music is the language of
inner reality, the universal tongue of personal emotions, and the
expression of the unexpressed (Banet, 1999). In the 16th and
17th centuries, music was used to treat depression (Covington,
2001). At the end of World War II, music was found to ease
distress among shell shock patients. Since then, the use of music
for therapeutic purposes has become prevalent in the United
States and worldwide (Amir, 1999), and its effect on various
mental disorders has been studied. Among the main findings were
Vol. XLVII, No. 1, Spring 2010 31

the positive effects of music relaxation in depressive disorder,

anxiety syndromes (especially situational anxiety), and dementias
(Hendricks, Robinson, Bradley, & Davis, 1999; Home-Thompson
& Grocke, 2008; Raglio et al., 2008; Twiss, Seaver, & McCaffrey,
2006; Walker & Boyce-Tillman, 2002; Ziv, Granot, Hal, Dassa, &
Haimov, 2007). Hanser and Thompson (1994) also found a

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beneficial impact of music on depression. The researchers
examined the effect of listening to music combined with stress
reduction strategies to reduce degree of depression and stress.
Thirty participants who were diagnosed as suffering from major
depression or dysthymia according to the Schedule for Affective
Disorders and Schizophrenia (SADS) were divided into three
groups: music group with therapist, music group without
therapist, and control group. Participants listened to music and
performed relaxation exercises once a day for 30 minutes to an
hour over a period of eight weeks. A significant difference
between the two music groups and the control group was found
on all measures of depression and stress. These findings support
the use of music therapy strategies for treatment of symptoms of
depression and stress among adults who suffer from these
disturbances. Previous work in our research group has shown
the superiority of music relaxation over muscle relaxation in
treating sleep and emotional variables among Post Traumatic
Stress Disorder patients (in preparation).
Several studies have demonstrated the positive effect of music
therapy among schizophrenia patients in particular. For example,
Gold, Heldal, Dahle, and Wigram (2005) summarized the
findings of four research studies that compared standard
treatment combined with music therapy to standard treatment
alone. These revealed that the combined treatment was more
effective than the standard treatment on emotional and func-
tional measures. Note that this study emphasized the effectiveness
of the combined treatment in the short term (1-3 months after
the music therapy ended) and proposed further research to
examine the effectiveness of music therapy in the long term.
Seventy-six people living with schizophrenia divided into experi-
mental and control groups participated in another study. Both
groups received standard medicinal treatment. The experimental
group was also treated with music over a period of one month,
including listening to music and actively participating by singing
32 JoumN of Music Therapy

popular songs with other patients in the group. The results were
assessed by four nurses who used scales to assess negative
symptoms. Findings showed that music therapy significantly
reduced patients' negative symptoms and social isolation, and
helped increase their interest in external events and their ability
to communicate with others (Tang, Yao, & Zheng, 1994).

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Recent evidence in the literature indicates that music is
beneficial to sleep quality. Tan (2004) found that students who
listened to pleasant and relaxing background music for 45 minutes
every night before sleep for three weeks showed significant
improvement in sleep measures, including better sleep efficiency,
shorter sleep latency, and longer sleep duration. Another study
found that elderly people reported better sleep efficiency, fewer
spontaneous arousals, improved functioning during the day and a
better general feeling overall after listening to relaxing music
(Good & Lai, 2005). Music therapy was also found to be effective
in improving sleep among older adults who suffer chronic back
pain (Kullich, Bernatzky, Hesse, Wendmer, & Likar, 2003).
The impact of music relaxation on quality of sleep and on
emotional state has not yet been studied among people living with
schizophrenia. This study examines the effect of music relaxation
on quality of sleep among people living with schizophrenia using
objective measures such as sleep efficiency, sleep latency and sleep
duration, as well as subjective reporting. The study also assesses
the influence of music relaxation on emotional measures,
including psychopathology measures, anxiety and depression
levels, and quality of life.

Method
Participants
Thirty-two participants volunteered to take part in the study. All
participants were recruited via the outpatient clinics of the
psychiatric department at Haemek Medical Center, Afula, Israel.
All of them were living independently in the community or in
rehabilitation settings (hostels). All were adults ranging from 18-
70 years old who met the DSM4-TR criteria for schizophrenia
(65.6%) or schizoaffective disorder (34.4%) (American Psychiat-
ric Association, 1994). Eight participants were excluded; seven did
not complete all stages of the study, and one experienced
Vol. XLVII, No. 1, Spring 2010 33

technical problems with the sleep measurement apparatus. Thus,

the final sample included 24 participants, mean age 45.67 +_
9.6 years, 54.2% male, with schizophrenia (54.16%) or schizoaf-
fective disorder (45.83%). All participants were assessed by their
psychiatrists to be clinically stable with respect to psychotic and
affective symptomatology. All had been taking a stable dose of
anti-psychotic drugs for at least one month prior to the start date,

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and all were in stable physical health. The study was approved by
the hospital Helsinki Committee, and all participants gave their
informed consent before entering the study.
Too/,
Evaluations included sleep assessment, emotional condition
assessment, clinical assessment and personality evaluation.
Sleep Parameters
A miniature actigraph worn on the wrist (Mini Motionlogger,
Ambulatory Monitoring, Inc. Ardsley, NY) was used to evaluate
sleep quality objectively, making it possible to monitor sleep
under natural circumstances with minimal distortions. The
actigraph measures wrist activity using a'piezoelectric element
and translates wrist movements into an electrical signal that is
digitized and memorized. Actigraphy has been well validated
against polysomnography in trials with people with sleep disorders
and without sleep disorders (Lichstein et al., 2006). The
actigraphs collected data in one-minute epochs (activity level
was sampled at 10-second intervals and summed across 1-minute
intervals) and stored the data at amplifier setting. 18 (i.e.,
manufacturer's technical code for frequency band pass 2 to
3 Hz, high gain, and high threshold). This working mode is the
standard mode for sleep-wake scoring (Ancoli-Israel et al., 2003;
Martin et al., 2006). Actigraphic raw data were translated to sleep
measures using the Actigraphic Scoring Analysis program for an
IBM-compatible personal' computer (W2 scoring algorithm)
provided by the manufacturer (Ambulatory Monitoring, Inc.).
These sleep measures have been validated against polysomnog-
raphy, with agreement rates for minute-by-minute sleep-wake
identification of over 90% (Sadeh, Hauri, Kripke, & Lavie, 1995).
Actigraphic sleep measures included time in bed (total number
of minutes from bedtime to wake time), total sleep time (total
34 Joumal of Music Therapy

number of minutes defined as sleep), sleep latency (time to fall

asleep from bedtime), and sleep efficiency index (percentage of
total sleep time out of total time in bed).
In addition, for the purpose of evaluating sleep quality, all
participants completed two questionnaires that subjectively
evaluated their sleep patterns: (a) a quantitative questionnaire--

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the Mini Sleep Questionnaire (MSQ) (Zomer, Peled, Rubin, &
Lavie, 1985), and (b) a qualitative questionnaire--the Technion
Sleep Questionnaire (Haimov, Breznitz, & Shiloh, 2006).

Clinical and emotional assessments

Patients were interviewed by a psychiatrist and answered two
questionnaires aimed at measuring their clinical morbidity: (a)
Positive and Negative Syndrome Scale (PANSS) (Kay, Opler, &
Lindenmayer, 1987), and (b) Brief Psychiatric Rating Scale
(BPRS) (Overall & Gorham, 1962).
Depression level was assessed through the Beck Depression
Inventory (BDI) (Beck & Steer, 1987). The BDI is a 21-item self-
report questionnaire. The 21 items correspond to symptoms such
as mood, pessimism, and suicidal ideas. Participants rate each
item on a four-point Likert scale ranging from 0 (absent) to 3
(severe). The recommended cutoff of 17 is used to define
depression; higher scores indicate greater depression. The BDI is
an internally consistent and valid measurement (Beck, Steer, &
Garbin, 1988).
Anxiety level was assessed by the State-Trait Anxiety Inventory
(STAI) (Spielberger, Gorusch, & Lushene, 1970). The STAI is a
40-item self-report measure consisting of two 20-item scales; the
first scale measures state anxiety, defined as a transitory emotional
state or condition, and the second measures trait or character-
ological anxiety. The STAI has demonstrated high internal
consistency and high test-retest reliability (Spielberger et al.,
1970; Tyano et al., 2006).
In order to assess the participants' present state ofanhedonia, we
used the Snaith-Hamilton Pleasure Scale (SHAPS). The SHAPS
includes 14 items, each with a set of four response categories:
Definitely Agree (= 1), Agree (= 2), Disagree (= 3), and Definitely
Disagree (= 4). A higher total score indicates higher levels of state
anhedonia (Snaith et al., 1995). The Quality of Life Enjoyment and
Satisfaction Questionnaire (Q-LES-Q) (Endicott, Nee, Harrison, &
VOI. XLVII, No. 1, Spring 2010 35

Blumenthal, 1993) was used to measure patients' general satisfac-

tion with their life. The Quality of Life Enjoyment and Satisfaction
Questionnaire is a self-report instrument. Responses are scored on a
fwe-point scale (ranging from ~not at all or never" to "frequently or
all the time"), with higher scores indicating greater enjoyment and
satisfaction with specific life domains.

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To assess subjective quality of life, we used the Schizophrenia
Quality of Life Scale (SQLS) (Wilkinson et al., 2000). The SQLS, a
self-report 30-item questionnaire for measuring quality of life
specific to patients with schizophrenia, has good reliability and
validity (Kaneda, Imakura, Fujii, & Ohmori, 2002). It comprises
three scales: (a) psychosocial, (b) motivation/energy and (c)
symptoms/side effects. Lower scores indicate higher levels of
subjective quality of life.

Personality assessment
The Tridimensional Personality Questionnaire (TPQ) was used
to assess personality trait. The TPQ is a 98-item questionnaire that
assesses the three temperament dimensions of novelty seeking
(NS---34 questions), harm avoidance (HA--34 questions), and
reward dependency (RDm30 questions) (Cloninger, 1987). In
keeping with Cloninger's analyzes, two questions (no. 61 and
no. 71) were excluded from scoring due to nonspecificity
(correlations with multiple factors) (Cloninger, Przybeck, &
Svrakic, 1991). The total score for each dimension was calculated.
Test-retest correlations were found to be moderately high
(Cloninger et al., 1991).

Relaxation CD
Music relaxation disk. T h e music relaxation disk was a CD or
cassette containing music composed specifically for the study. A
male voice is heard, explaining the recording contains music for
relaxation. Participants are asked to lie down comfortably, to close
their eyes, listen to the music, and imagine they are in a pleasant
place. The place can either be a real place they remember or an
imaginary place in which they feel at ease. The music then starts
playing. The music is a modal harmonic progression in Am/C,
played in largo tempo (52 bpm) in moderate volume with no
dynamic changes throughout. A harp plays arpeggiated chords
starting from a repetition of Am four times, going through G-F-
36 Journal of Music Therapy

Em-F-Em and back to Am, with each chord playing twice. While
the chord progression is played, a piano sound plays a melody
composed of diatonic notes of the chords mentioned above. After
about 3 rains, 2 s of chimes are heard. The chord then changes to
C around the 4th minute and continues for a minute, with 2 s of
bird and cascading water effects. The progression moves to Am-C-

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Am-C-F-Dm and back to C, with each chord played twice. Around
the 6th minute, a violin is added, playing long diatonic notes, in
addition to the piano. The first chord progression is then
repeated, ending on Am. The whole sequence's duration is
10 rains, and it is repeated four times, creating a total duration of
40 mins.

Experimental design
The current study was a within-subject design study, with
baseline and treatment condition. The study comprised a seven-
day running-in no-treatment period, followed by a seven-day
experimental period. The participants were asked to listen to the
CD (free-field, without headphones) when they went to bed at
their desired bedtime. During each of the periods, participants'
sleep was continuously monitored with a wrist actigraph (Ambu-
latory Monitoring, Inc.). At the end of each of the periods,
participants were asked to complete a broad spectrum of
questionnaires monitoring sleep quality indices, psychopathology,
depression, anxiety, quality of life and life satisfaction.

Data Analyzes
A paired t test was used, with each of the measures taken serving
as the d e p e n d e n t variables. Moreover, Pearson's correlation was
used to compare different measures. All tests were two-tailed, with
p-values of less than 0.05 considered to be significant. Data are
presented as mean + SD.

Results
Objective sleep measures as recorded by the actigraph
A paired-sample t test was conducted to compare objective
measures of sleep in the two experimental conditions. The four
d e p e n d e n t variables recorded by the actigraph were time in bed,
total sleep time, sleep latency, and sleep efficiency.
Vol. XLVII, No. 1, Spring 2010 37

A
80

I 40
i

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~ P<0.011

_l
O.
_S2o
(n

Baseline Followingmusic relmmllon

~' 84
i
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s..
Q.
|
76
p

Followingmusic relaxation
F m u ~ 1.
Objective sleep measures recorded by the acdgraph for the two experimental
conditions: (A) sleep latency, (B) % of sleep efficiency.

No significant differences were found in time in bed and in

total sleep time following music relaxation compared with
baseline measures [t(23) < 1; 503.99 +_ 110.9 vs. 500.06 "4-
105.5; t(23) = -1.45, p > 0.16; 419.43 "4- 139.2 vs. 433.19 +_
127.2; respectively]. However, a significant difference was found
in sleep latency (t(23). = 2.77, p < 0.01), showing shorter sleep
latency when music relaxation was played (Figure 1A). These
findings show that when music relaxation was played, the
participants' sleep latency did not meet the criteria for insomnia,
that is, sleep latency shorter than 31 mins.
38 Joumal of Music Therapy

For sleep efficiency, a significant difference was found (t(23) =

-3.479, p < .002), showing that sleep efficiency was higher when
music relaxation was played (Figure 1B). Thus, after music
relaxation at bedtime, the participants' sleep efficiency did not
meet the criteria for insomnia, that is, sleep efficiency higher than
85%.

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Subjective sleep questionnaires
A paired-sample t test was used to compare subjective sleep
measures in the two phases of the study, for the Mini Sleep
Questionnaire and for the Technion Sleep Questionnaire
separately. Analysis revealed a marginal significant difference in
the subjective insomnia sub-scale of the Mini Sleep Questionnaire
on the following questions: Question 1 ("difficulty falling
asleep"), Question 2 ("waking up early in the morning"), and
Question 7 ("waking up during the night") (t(23) = 1.97, p <
0.06). This result reflects a reduction in the number of reported
complaints of subjective insomnia after music relaxation (4.36 _+
0.8) compared with the baseline level (4.49 -+ 0.9).
Moreover, a significant difference (t(23) = 2.13, p < .004) was
found for the subjective complaints of difficulties in falling asleep
(average of item 1 in the MSQ), showing a reduction in reported
sleep latency after music relaxation (3.88 + 2.2) compared with
baseline level (4.63 - 1.0).
No significant effects of music relaxation condition were found
for the relevant questions in the Technion Sleep Questionnaire.

Subjective measures: depression, anxiety, quality of life, pleasure and

life satisfaction
A paired-sample t test was conducted to compare participants'
subjective measures with and without music relaxation at bedtime.
The dependent variables were the average scores on the Beck
Depression Inventory, the State Anxiety Inventory Scale, the
Schizophrenia Quality of Life Scale (SQLS), the Quality of Life
Enjoyment and Life Satisfaction Questionnaire (Q-LES-Q) and
the SnaithoHamilton Pleasure Scale (SHAPS).
A significant difference was found in depression level (t(23) =
2.96, p < 0.007), revealing a lower level of depression after music
relaxation compared with participants' baseline level (Figure 2).
No significant differences were found for anxiety level (t(23) <
Vol. XLVII, No. 1, Spring 2010 39

i 2O

16

12

s
!

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|4
Q.
8 o
Baseline Followingmusicrelaxation
F m u ~ 2.
Depression level (BDI) in the two experimental conditions.

1), quality of life level (t(23) = -1.46, p > 0.15), life satisfaction
(t(23) = 1.28, p > .21) or pleasure level (t(23) = -1.45, p >
0.16).

Subjective measures recorded by the Brief Psychiatric Rating Scale

A paired-sample t test conducted to compare subjective
measures recorded by the Brief Psychiatric Rating Scale revealed
that music relaxation decreased the general psychopathology
score [(t(23) = 2.41, p < 0.02); Figure 3], with participants
scoring lower following music relaxation compared with their
baseline score.

P<O.o2

ii4o
o ,-

Q.

io Baseline Followingmusicrelaxation
Fm~,z 3.
General psychopathology as assessed by the Brief Psychiatric Rating Scale (BPRS)
in the two experimental conditions.
40 Joumal of Music Therapy

Four dependent variables were also tested: mean anxiety, mean

depression, mean tension and distractibility level. After music
relaxation, participants exhibited a lowered anxiety level [(t(23)
= 2.50, p < 0.02); Fig 4A], tension level [(t(23) = 3.14, p <
0.005); Figure 4B] and distractibility level [(t(23) = 2.32, p <
0.02); Figure 4C]. However, no significant difference was found

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for depression level (t(23) < 1).

Subjective measures as recorded by the Positive and Negative

Syndrome Scale
A significant difference was found in the total psychopathology
score (t(23) = 2.28, p < 0.03) with participants scoring lower on
total psychopathology after music relaxation compared with their
baseline level (Figure 5A).
Moreover, a significant difference was found for positive
symptoms as well (t(23) = 3.71, p < 0.001). Participants
exhibited fewer positive symptoms after music relaxation com-
pared with their baseline level (Figure 5B). Interestingly, no
significant difference was found for the negative symptoms (t(23)
= 1.55, p > 0.14); Figure 5C. Moreover, a significant difference
was found in the general psychopathology score (t(23) = 2.01, p
< 0.05), with participants generally scoring lower on general
psychopathology after music relaxation compared with their
baseline level (Figure 5D).
Relationships between objective sleep measures and personality and
emotional measures
To understand how the effects found on the objective sleep
measures related to personality and emotional measures, we
performed correlations for each of the measures (calculated as
the difference between relaxation score, i.e., music relaxation,
and baseline). Among the emotional measures and personality
features, the only significant correlation was found between
improvement in objective sleep efficiency and reduction in
situational anxiety [(rp = -.49, p < 0.015); Figure 6].

Discussion
Recent research indicates that music has a positive effect on
psychological as well as neurophysiologic measures. Music
relaxation has been shown to improve mood, decrease anxiety,
Vol. XLVII, No. 1, Sprfng 2010 41

A
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~ 0.5
X
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< 0
Baseline Following music relmmtlon

E 3"
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FIGURE 4.
Subjective m e a s u r e s as assessed by the Brief Psychiatric Rating Scale (BPRS) in t h e
two experimental conditions: (A) m e a n anxiety, (B) m e a n tension, (C)
, , distractibility level. ,
42 Journal of Music Therapy

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I-

Baseline Following music relaxation

B
14
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E,"
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Baseline Following music relaxation

Fmugz 5.
Subjective measures as assessed by the Positive and Negative Syndrome Scale
(PANSS) in the two experimental conditions: (A) total symptoms, (B) positive
symptoms, (C) negative symptoms, (D) general symptoms.

induce relaxation, and improve concentration ability and sleep

quality among various populations, including people with a wide
range of psychopathologics (Covington, 2001).
The objectives of the current research were to examine the
impact of music relaxation on quality of sleep, and to study the
effect of music relaxation on emotional measures (psychopathol-
ogy measures, level of depression and anxiety) and quality of life
among people living with schizophrenia. This population was
selected based on findings and conclusions in the literature
indicating that many people living with schizophrenia suffer from
insomnia (Costa e Silva, 2006). These participants have subjec-
VOI. XLVII, No. 1, Spring 2010 43

C
211
| .
•.-- 20

Downloaded from http://jmt.oxfordjournals.org/ at University of Toronto Library on November 21, 2014

12

>- 8
m
g, 4~
;[
0
Baseline Following music relaxation
D

s|

i 24
0
Baseline Following music relaxation

FIGURE 5.
Cont/nu~,

tively reported a decrease in the amount of sleep they get, as they

are often disturbed by many thoughts before sleep, flooded by
anxiety causing them to stay awake and alert, and filled with fear
that something bad will happen to them if they fall asleep
(Chemerinski et al., 2002).
The first hypothesis of this study was that music relaxation
would objectively and subjectively improve quality of sleep among
people living with schizophrenia. We assumed that music
relaxation could relax participants and reduce anxiety and
emotional flooding by lessening the number of disturbing
thoughts during the stage of falling asleep. Moreover, since music
relaxation is a masking element, it would facilitate falling asleep in
a state of relaxation and lead to a night with fewer spontaneous
44 Journal of Music Therapy

20

y . -0.46Mx + 3.(1374
iE • R2:0.2428

i •

Downloaded from http://jmt.oxfordjournals.org/ at University of Toronto Library on November 21, 2014

=j t •. ,o
-11 -6 -1

Anxiety score (baullne - music)

FmURE 6.
Correlation between improvement in objectivesleep efficiencyand reduction in
anxiety (STAI) scale.

arousals, so that quality of sleep would improve. This hypothesis

was confirmed. The study found that music relaxation improves
sleep quality as measured by sleep efficiency and sleep latency.
These findings point to a significant improvement in sleep quality;
by the end of the study, the participants as a group were found to
no longer be suffering from insomnia according to its objective
definition (sleep efficiency > 85% and sleep latency < 30 mins).
The findings of our research are in line with the results of Good
and Lai (2005) who studied the effect of music on quality of sleep
in adults who listened to relaxing music as a treatment for 45 mins
before sleep for a period of 3 weeks. Improvement in their quality
of sleep was already observed from the first week. Moreover, the
scores indicated a better quality of sleep that improved from one
week to the next, as well as improved sleep latency, better sleep
efficiency and improved functioning throughout the day. One of
the suggested explanations for these findings is that relaxing
music created a relaxing and distracting situation that decreased
endocrine cell and sympathetic nervous system activity by
reducing noradrenalin levels. Consequently, participants' anxiety
decreased and their heart rate dropped, the rhythm of their
breathing slowed down, and their blood pressure lowered, thus
improving sleep.
Vol. XLVII, No. 1, Spring 2010 45

The current research also examined quality of sleep from a

subjective perspective. In subjective reports of sleep quality,
participants reported less difficulty in falling asleep after music
relaxation compared with the base level and greater satisfaction
with sleep quality. This finding is significant as people living with
schizophrenia tend to report difficulties in falling asleep as a

Downloaded from http://jmt.oxfordjournals.org/ at University of Toronto Library on November 21, 2014

result of disturbing thoughts flooding their heads before sleep. In
this study the subjective result is compatible with the objective
one; complaints about difficulties in falling asleep decrease,
together with an objective reduction in sleep latency.
The second research hypothesis was that music relaxation would
improve emotional measures, among them depression and anxiety
levels as well as psychopathology measures, with a beneficial
impact on quality of life as a result. This hypothesis was partly
confirmed. Music relaxation was found to significantly reduce level
of depression compared to the base level. Mei-Hsien and Mei-Feng
(2006) studied the relation between level of depression and quality
of sleep in middle-aged women. Their results showed a significant
correlation between quality of sleep and depression, so that as level
of depression rose, quality of sleep decreased and vice versa. They
proposed two explanations for the positive impact of music on
depression: first, Musical stimuli activate particular brain areas,
including the insular and cingulated cortex, the hypothalamus,
the hypocampus, the amygdale and the prefrontal cortex, which
are all linked to emotional behavior. Second, endorphins and
dopamine are released while a person listens to music, thus
improving mood and creating a pleasant feeling (Boso, Polity,
Barale, & Enzo, 2006; Wei-Chi & Hui-Ling, 2004). As mentioned,
the current research revealed that music reduces depression.
Perhaps the participants were more active throughout the day due
to this improvement in their mood and therefore were more tired
at night. ,,
The current study also found a correlation between decreased
anxiety level and improved sleep efficiency. As music relaxation
reduced the level of anxiety, sleep became more efficient. It is
interesting to note: that the situational anxiety questionnaire
revealed no significant difference in level of anxiety between the
two research conditions. It is worth mentioning that Cronbach's
alpha showed the reliability of Spielberger's state and trait anxiety
questionnaire to be low among our specific research population
46 Joumal of Music Therapy

(0.42). It may be that this questionnaire is not suitable for people

living with schizophrenia. A significant correlation was found
between decreased anxiety and improved sleep efficiency, while
no significant difference was found in level of anxiety before and
after music relaxation. This gap in the findings related to anxiety
motivated us to more specifically examine the indices characteriz-

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ing anxiety from the BPRS questionnaire. For the 'anxiety',
'tension' and 'distractibility' indices, the questionnaire results
revealed a significant difference between the two research
conditions. The literature demonstrates that music reduces levels
of anxiety. For example, Lee, Chung, Chan, and Chan (2005)
showed that listening to music for 30 mins before the onset of
treatment in the intensive care unit (ICU) resulted in relaxation
manifested in a decrease on physiological parameters as objective
measures of situational anxiety levels among these patients. This
finding is in line with another study that assessed influence of
music on anxiety and pain among women before undergoing a
colonoscopy procedure. The theoretical basis for choosing music
relaxation as a treatment for anxiety relies on biological insights
that music may promote relaxation through the autonomous
nervous system and through a variety of neurotransmitters,
including serotonin. The treatment is also based upon the
cognitive insight that music can change the focus of attention,
thus distracting attention from anxiety, fear and pain (Yung, Chui-
Kam, French, &Chan, 2002).
With respect to the psychopathology indices utilized in this
research, it is interesting to note that a significant improvement
was observed in levels of general psychopathology as well as of
schizophrenia symptoms after music relaxation, as indicated by
the BPRS and PANSS questionnaires respectively. The improve-
ment was particularly observed in the PANSS sub-scales reflecting
positive symptoms and the general PANSS scales demonstrating
overall non-specific symptoms. Although the current study
revealed no significant difference in negative symptoms before
and after music relaxation, previous studies indicate that music
reduces negative symptoms (Tang et al., 1994; Ulrich, Houtmans,
& Gold, 2007; Yang, Weng, Zhang, & Ma, 1998). Ulrich et al.
(2007) examined in their study the effect of music therapy on self-
esteem, psychosocial orientation, schizophrenia symptoms and
quality of life among schizophrenic research participants. The
Vol. XLVll, No. 1, Sprfng 2010 47

results showed that music therapy reduced negative symptoms,

improved interpersonal relationships and improved patients'
ability to adjust to social environments after their release from
hospital. However, the current study found no significant
differences in indices measuring quality of life and ability to
enjoy life before and after the music relaxation.

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We also examined the correlations between personality patterns
and improvement in participants' quality of sleep after music
relaxation. The study found no correlations between personality
patterns and improvement in participants' quality of sleep. Note
that the value of discussing the personal characteristics of people
living with schizophrenia is limited, primarily because schizo-
phrenia changes and distorts basic personality patterns.
To summarize, the overall findings of the current study indicate
that playing music relaxation every evening for a week improved
the quality of sleep among people living with schizophrenia
according to objective measures of sleep efficiency and sleep
latency as well as according to subjective reports of difficulties in
falling asleep. In addition, the research demonstrated the
beneficial effect of music relaxation on emotional measures,
including schizophrenia symptoms and levels of depression and
anxiety. Music relaxation was not found to have an impact on
quality of life or ability to enjoy life.
The conclusions of this study are that music relaxation
improves sleep quality and has the potential to ease schizophrenia
symptoms and reduce levels of depression and anxiety among
people living with schizophrenia.
The significance of these conclusions is that quality of sleep and
emotional measures were improved by a non-pharmacologic
treatment. People living with schizophrenia take many medications
that have various side effects, so a non-pharmacologic treatment is
quite significant. Rather than adding sleeping pills to the daily
medications taken by people living with schizophrenia, they can be
helped to fall asleep and to sleep better by playing music relaxation.
From a practical perspective, playing music relaxation offers an
effective treatment for sleep disorders. This treatment is simple,
easy to apply, inexpensive, accessible, nonintrusive and does not
require special resources. Thus, by playing music relaxation people
suffering from schizophrenia may improve the quality of their sleep
and a variety of emotional measures as well.
48 doumal of Music Therapy

Despite the support for the positive influence o f music relaxation

f o u n d in this study, these findings are limited considering that the
music relaxation was administered for a very short time, only a
week. Future studies should test the impact of increasing the time
the music is played. In addition, in the current research the
participants did not select the music, and no indicators o f patient

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preference or reaction to the music were included. These factors
may have affected the results and therefore should be included in
future studies. Another limitation is the lack of counterbalancing in
the experimental design, so there was no control for time. This also
should be considered in future studies. Moreover, random, double-
blind studies involving a control group and a larger n u m b e r o f
participants should be carried out. Future research should also be
c o n d u c t e d in populations with other psychiatric disturbances
characterized by sleep disorders.
In this pioneering study, we attempted to shed light on the
impact of relaxation music on quality of sleep and emotional
measures a m o n g people living with schizophrenia. We believe
that additional studies are required to acquire f u r t h e r knowledge
in this area.

References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders (4th ed., DSM-IV). Washington, DC: American psychiatric press.
American Sleep Disorders Association. (1997). International classificatwn of sleep
disorders, revised: diagnostic and coding manual Rochester, MN: American Sleep
Disorders Association.
Amir, D. (1999). Meat the tones. Ramat Gan: Bar Ilan University (Hebrew).
Ancoli-Israel, S., Cole, R., Alessi, C., Chambers, M., Moorcroft, W., & Pollak, C. P.
(2003). The role of actigraphy in the study of sleep and circadian rhythms.
S/eep, 26(3), 342-392.
Banet, L. (1999). Music therapy-art behind the words. Q~at byalik aach (Hebrew).
Beck, A. T., & Steer, 1L A. (1987). Beck Depression Inventory-Manual. Psychological
Coeporat/on,1-25.
Beck, A. T., Steer, R. A., & Garbin, M. (1988). Psychometric properties of the Beck
Depression Inventory: twenty-five years of evaluation. Clinical PsychologyReview,
8, 77-100.
Boso, M., Polity, P., Barale, F., & Enzo, E. (2006). Neurophysiology and
neurobiology of the music experience. Functional Neurology, 21(4), 187-191,
Brekke, J. S., Long, J. D., Nesbitt, N., & Sobel, E. (1997). The impact of service
characteristics on functional outcomes from community support programs for
persons with schizophrenia: A growth curve analysis. Journal of Consulting and
Clinical Psychology, 65(3), 464-475.
Vol. XLVII, No. 1, Spring 2010 49

Carlsson, A, & Lindquist, M. (1963). V_aects of chlorpromazine or haloperidol on

formation of 3-methoxytyramine and normetanephrine in mouse brain. Acta
Pharmacol~ ~ Toxicologica~ 20, 140-144.
Chemeriuski, E., Ho, B. C., Flaum, M., Arndt, S., Fleming, F., & Andreansen, N. C.
(2002). Insomnia as a predictor of symptom worsening following antipsychotic
withdrawal in schizophrenia. ComprehensivePsycMatry, 43(5), 393-396.
Cheriniack, P. E. (2006). The use of ahernative medicine for the treatment of
insomnia in the elderly. Psychogeriattics, 6, 21-30.

Downloaded from http://jmt.oxfordjournals.org/ at University of Toronto Library on November 21, 2014

Chouinard, S., Poulin, J., Sfip, E., & Godbout, R. (2004). Sleep in untreated
patients with schizophrenia: a meta-analysis. Schizophrenia Bulletin, 30(4),
957-67.
Cloninger, C. R. (1987). Neurogenetic adaptive mechanisms in alcoholism. Sc/ence,
236, 410-416.
Cloninger, C. R., Przybeck, T. R., & Svrakic, D. M. (1991). The tridimensional
personality questionnaire: US normative data. Psychological Reports, 69,
1047-1057.
Cortoos, A., Verstraeten, E., & Cluydts, R. (2006). Neurophysiological aspects of
primary insomnia: Implications for its treatment. Sleep Medicine Reviews, 10,
255--266.
Costa e Silva, J. A. (2006). Sleep disorders in psychiatry. Metabolism Clinical and
Fa/~/,nenta/, 55(2), 4O-44.
Covington, H. (2001). Therapeutic music for patients with psychiatric disorders.
Holistic Nursing Practice, 15(2), 59-69.
Dzira~, K., Ribeiro, S., Costa, R., Santos, L. M., Lin, S. C., Grosmark, A., Sotnikova,
T. D., Gainetdinov, R. R., Caron, M. G., & Nicolelis, M. A." (2006).
Dopaminergic control of sleep-wake states. The Journal of Nenroscience,
26(41), 10577-89.
Edinger, J. D., Wohlgemuth, W. K., Radtke, R. A., March, G. It., & Quillian, P,. E.
(2001). Does cognitive behavioral insomnia therapy alter dyffunctional beliefs
about sleep. S/eep, 24(5), 591-599.
Endicott, J., Nee, J., Harrison, W., & Blumenthal, R. (1993). Quality of life
enjoyment and satisfaction questionnaire: a new measure. Psychoplurrraacolog)
Bulletin, 29, 321-326.
Good, M., & Lai, H. L. (2005). Music improves sleep quality in older adults.Journal
of Advance~l Nursing, 49(3), 234--244.
Gold, C., Heldal, T. O., Dahle, T., & Wigram, T. (2005). Music therapy for
schizophrenia or schizophrenia-like illnesses. Cochrane Database of Systematic
Rev/ews, 18(2), CD004025. '
Goldberg, T. E., &Gold, J. M. (1995). Neurocognitive deficit in schizophrenia. In
S. Hirsch & D. R. Weinberger (Eds.), Schizophrenia (pp. 146-162). Oxford:
Blackwell scientific publications.
Green, A. I., Salomon, M. S., Brenner, M.J., & Rawlins, K. (2002). Treatment of
schizophrenia and comorbid substance use disorder. Current Drug Targets. CNS
and Neuroiogical Disorders, 1(2), 129-39.
Haimov, I., Breznitz, N., & Shiloh, S. (2006). Sleep in healthy elderly: Sources of
discrepancy between self-report and recorded sleep. In V. M. Kumar & H. N.
Mallick (Eds.), Clinical and Neurophysiological Aspects of Sleep (pp. 145-148),
Medimond: International Proceedings.
50 ,Journal of Music Therapy

Haimov, I., Lavie, P., Laudon, M., Herer, P., Vigder, C., & Zisapel, N. (1995).
Melatonin replacement therapy of elderly insomniacs. S/eep, 18(7), 598-603.
Hanser, B., & Thomspon, L. (1994). Effects of a music therapy strategy on
depressed older adults. Journal of Gerontology: Psychological Sciences, 49(6),
265-269.
Heinrichs, 1L W., & Zakzanis, K. IZ (1998). Neurocognitive deficit in schizophrenia:
A quantitative review of the evidence. Neuropsycholog3, 12, 426-445.
Hendricks, C. B., Robinson, B., Bradley, L.J., & Davis, IL (1999). Using Music

Downloaded from http://jmt.oxfordjournals.org/ at University of Toronto Library on November 21, 2014

Techniques to Treat Adolescent Depression. Journal of Humanistic Counseling,
Education & Development, 38(1), 39--47.
Home-Thompson, A., & Grocke, D. (2008). The Effect of Music Therapy on
Anxiety in Patients who are Terminally Ill. Journal of PaUiative Medicine, 11(4),
582-590.
Kane,J. M., & 8harif, Z. A. (2008). Atypical Antipsychotics: Sedation versus efficacy.
Journal of clinical Psychiatry, 69(1), 18--33.
Kaneda, Y., Imakura, A., Fujii, A., & Ohmori, T. (2002). Schizophrenia Quality of
Life Scale: validation of the Japanese version. PsychiatryResearch, 113, 107-113.
Kay, 3. R., Opler, L. A., & Lindenmayer, J. P. (1987). Reliability and validity of the
positive and negative syndrome scale for schizophrenics. PsychiatryResearch, 23,
99-110.
Kullich, W., Bernatzky, G., Hesse, H. P., Wendmer, F., & Likar, R. (2003). Music
therapy Impact of pain, sleep, and quality of life in law back pain. Wein Med
Wochenschr, 153(9-10), 217-221.
Laposky, A. D., Bass, J., Kohsaka, A., & Turek, F. W. (2008). Sleep and circadian
rhythms: key components in the regulation of energy metabolism. FEBS
Lettersg 582(1), 142-51.
Lee, O. K. A, Chung, Y. F. L., Chan, M. F., &Chan, W. M. (2005). Music and its
effect on the physiological responses and anxiety levels on patients receiving
mechanical ventilation: a pilot study. Journal of Chnical Nursing, 14, 609--620.
Lichstein, K. L., Stone, K. C., Donaldson, J , Nau, S. D., Soeffing, J. P., Murray, D.,
Lester, K. W., & Aguillard, R. N. (2006). Actigraphy validation with insomnia.
Steep, 29(2), 9-232.
Lykke, J., Morten Hesse, M., Austin, S. F., & Oestrich, I. (2008). Validity of the
BPRS, the BDI and the BAI in dual diagnosis patients. Addictive Behaviors, 33,
292-300.
Marshall, M.J., & Rathbone, J. (2006). Early Intervention for psychosis. Cochrane
Database of Systematic Reviews, 18(4), CD004718.
Martin,J. L., Webber, A. P., Alam, T., Harker, J. O.,Joseph~n, K. R., & Alessi, C. A.
(2006). Daytime sleeping, sleep disturbance, and circadian rhythms in the
nursing home. AmericanJournal of Geriatric Psychiatry, 14(2), 121-129.
Mei-Hsien, C., & Mei-Feng, L. (2006). Exploring the listening experiences during
guided imagery and music therapy of outpatients with depression. Journal of
Nursing Research, 14(2), 93-102.
Monti, J. M., & Monti, D. (2000). Histamine H1 receptor antagonists in the
treatment of insomnia: Is there a rational basis for use? CNS Drugs, 13(2),
87-96.
Monti, J. M., & Monti, D. (2004). Sleep in schizophrenia patients and the effects of
antipsychotic drugs. Sleep Medicine Reviews, 8, 133-148.
VOI. XLVII, No. 1, Spring 2010 51

Morin, C. M. (1993). Insomnia: psychological assessment and management. Guilford

preQ.
Mueser, K. T., Valentiner, D. P., & Agresta, J. (1997). Coping With Negative
Symptoms of Schizophrenia: Patient and Family Perspectives. Sch/zophren/a
Bu/kCin, 23(2), 329-339.
Murray, C.J., & Lopez, A. D. (1996). The g/oba/burden of diseases' injuries and risk
factors in 1990 and projected to 2020. Boston: Harvard: School of public health.

Downloaded from http://jmt.oxfordjournals.org/ at University of Toronto Library on November 21, 2014

Ong, J. C., Shapiro, S. L., & Manber, R. (2007). Combining Mindfulness
Meditation with Cognitive-Behavior Therapy for Insomnia: A Treatment-
Development Study. Behav/or Therapy, 39(2), 171-182.
Overall, J. E., & Gorham, D. E. (1962). The brief psychiatric rating scale.
Psydw~gical ~pom, 10, 799--812.
Poulin, J., Daoust, A. M., & Forest, (3. (2003). Sleep architecture and its clinical
correlates in first episode and neuroleptic-nafve patients with schizophrenia.
Schizophrenia RtsearcK 62, 147-153.
Raglio, A., Bellelli, G., Traficante, D., Gianotti, M., Ubezio, M. C., Villani, D., &
Trabucchi, M. (2008). Efficacy of music therapy in the treatment of behavioral
and psychiatric symptoms of dementia. AMwimerDisease and AssociatedDisorders,
22(2), 158--162.
Sadeh, A., Ham-i, P.J., Kripke, D. F., & Lavie, P. (1995). The role of actigraphy in
the evaluation of sleep disorders. S/eep, 18, 288-302.
Scott, J. P. R., McNaughton, L. R., & Polman, R. C.J. (2006). Effects of sleep
deprivation and exercise on cognitive, motor performance and mood.
Physiolo~ O' Behavior, 87, 396--408.
Snaith, R. P., Hamilton, M., Morley, S., Humayan, A, Hargreaves, D., & Trigwell, P.
(1995). A scale for the assessment of hedonic tone the Snaith-Hamihon
Pleasure Scale. The British Journal of Psychiatry, 167, 99-103.
Soeffing, J. P., Lichstein, K. L., Nau, S. D., McCrae, C. S., Wilson, N. M., Aguillard,
R. L., Lester, IL W., Andrew, J., & Bush, A.J. (2008). Psychological treatment
of insomnia in hypnotic-dependant older adults. S/eepMed/c/ne, 9, 165--171.
Spielberger, C. D., Gorusch, R. L., & Lushene, R. E. (1970). Manual for the State-
Trait Inventory (Self-Evaluation Questionnaire). Palo Alto: Consulting Psycholo-
gists Press.
Tan, L. P. (2004). The effects of background music in quality of sleep in
elementary school children.Journal of Music Therapy, 41(2), 128--150.
Tang, W., Yao, X., & Zheng, Z. (1994). Rehabilitative effect of music therapy for
residual schizophrenia. A one-month randomized controlled trial in Shanghai.
The British Journal of Psychiatry, 24, 38-44.
Twiss, E., Seaver, J., & McCaffTey, R. (2006). The effect of music listening on older
adults undergoing cardiovascular surgery. Nursing in Critical Care, 11(5),
224-231.
Tyano, S., Zalsman, G., Ofek, H., Blum, I., Apter, A., Wolovik, L., Sher, L.,
Sommerfeld, E., Harell, D., & Weizman, A. (2006). Plasma serotonin levels and
suicidal behavior in adolescents. European Neuropsychopharmacolo~, 16, 49--57.
Ulrich, G., Houtmans, T., & Gold, C. (2007). The additional therapeutic effect of
group music therapy for schizophrenic patients: a randomized study. Acta
Psychiat~ica Scandinaviwo 116, 362-370.
52 Journal of Music Therapy

Van Kammen, D. P., Van Kammen, W. B., Peters, J. L., Rosen, J., Slawsky, R. C.,
Neylan, T., & Linnoila, M. (1986). CSF MHPG sleep and psychosis in
schizophrenia. Clinical Neuropharmacology, 9(4), 575-577.
Walker, J., & Boyce-Tillman,J. (2002). Music lessons on prescription? The impact
of music lessons for children with chronic anxiety problems. Health Education,
I02(4), 172-179.
Wallace, B., & Mendelson, M. D. (2007). Combining Pharmacologic and

Downloaded from http://jmt.oxfordjournals.org/ at University of Toronto Library on November 21, 2014

Nonpharmacologic Therapies for insomnia. The Journal of Clinical Psychiatry,-
68(5), 19-23.
Wei-Chi, H., & Hui-Ling, L. (2004). Effects of music on major depression in
psychiatric inpatients. Archives of Psychiatric Nursing, 18(5), 193--199.
Weickert, T. W., Goldberg, T. E., Gold, J. M., Bigelow, L. B., Egan, M. F., &
Weinberger, D. R. (2000). Cognitive impairment in patients with schizo-
phrenia displaying preserved and compromised intellect. Archives of General
Psychiatry, 57, 907-13.
Wilkinson, G., Hesdon, B., Wild, D., Cookson, 1~, Farina, C., Sharma, V.,
Fitzpatrick, 17,.,&Jenkinson, C. (2000). Self-report quality of life measure for
people with schizophrenia: the SQI..S. The British Journal of Psychzatry, 177,
42--46.
Yang, W. Y., Weng, Y. Z., Zhang, H. Y., & Ma, B. (1998). Psychosocial rehabilitation
effects of music therapy in chronic schizophrenia. Hong Kong Journal of
Psychiatry, 8, 38-40.
Yung, P. M. B., Chui-Kam, S., French, P., &Chan, T. M. F. (2002). A controlled trial
of music and pre-operative anxiety in Chinese men undergoing transurethral
resection of the prostate. Journal of Advanced Nursing, 39(4), 352-359.
Zisook, S., Maren, N., Kasckow,J., Golshan, S., Lehman, D., & Montross, L. (2006).
Depressive symptom patterns in patients with chronic schizophrenia and
subsyndromal depression. Schizophrenia Research, 86(1-3), 226-33.
Ziv, N., Granot, A., Hai, S., Dassa, A., & Halmov, I. (2007). The effective of
background music on behavior in Alzheimer's patients. Journal of Music
Therapy, 44(4), 329-343.
Zomer, J., Peled, R., Rubin, A. H. E., & Lavie, P. (1985). Mini Sleep Questionnaire
(MSQ) for screening large populations for EDS complaints. In W. P. Koella, E.
Ruther, & H. Schulz (Eds.), S/eep (pp. 467--469). New York: Gustav Fischer
Verlag.