Abstract

Background

A growing body of research has found that participating in choir singing can increase positive emotions, reduce anxiety and enhance social bonding. Consequently, group singing has been proposed as a social intervention for people diagnosed with mental health problems. However, it is unclear if group singing is a suitable and effective adjunct to mental health treatment. The current paper systematically reviews the burgeoning empirical research on the efficacy of group singing as a mental health intervention.

Methods

The literature searched uncovered 709 articles that were screened. Thirteen articles representing data from 667 participants were identified which measured mental health and/or wellbeing outcomes of group singing for people living with a mental health condition in a community setting.

Results

The findings of seven longitudinal studies, showed that while people with mental health conditions participated in choir singing, their mental health and wellbeing significantly improved with moderate to large effect sizes. Moreover, six qualitative studies had converging themes, indicating that group singing can provide enjoyment, improve emotional states, develop a sense of belonging and enhance self-confidence in participants.

Conclusion

The current results indicate that group singing could be a promising social intervention for people with mental health conditions. However, these studies had moderate to high risk of bias. Therefore, these findings remain inconclusive and more rigorous research is needed.

Introduction

Recent studies indicate that engaging in singing groups has a wide range of benefits which have the potential to improve mental health and wellbeing.1,3 Participants in established choirs report benefits including positive affect, social support and cognitive stimulation.4 Studies have found that while people are engaged in group singing, they experience increased positive emotions and immune functioning, as well as decreased negative emotions including anxiety.5,7 Singing in groups is also reported to enhance social bonding,8 which predicts improvements in anxiety and mental wellbeing.9,10 These impacts may in part be due to music aiding emotion regulation and social connectedness.7,8

Based on these findings, choirs for people experiencing mental health conditions have been established with the hope that participating in group singing could help to reduce symptoms.11 This has coincided with a developing practice in the UK of arts-on-referral that involves GPs and other health professionals referring clients to arts community programmes, such as singing, poetry, drama, craft and painting groups.12 These programmes are used to support recovery from health issues through providing access to increased social supports and engagement in meaningful activities. Recent research on arts-on-referral has shown that while engaging in arts programmes participants’ mental wellbeing significantly increases.12 Arts programmes may be particularly helpful in mental health as it could address the social disadvantage and isolation, which often co-occurs with mental health conditions.13 Social isolation and loneliness are significant perpetuating factors of mental health conditions and are associated with higher levels of depression and suicidality.14,15 Gaining social support through new social group memberships has been found to significantly reduce the risk of depression relapse.16 Therefore, referring clients to arts programmes, such as choir singing, may facilitate therapeutic goals, such as developing social support and confidence. However, for referrers it is important to know the evidence behind programmes before encouraging clients to participate. This paper focuses on providing a review of the current literature on the impact of participating in community group singing on mental health symptoms and wellbeing in clinical populations.

Arts-based interventions for mental health have been attracting increasing interest by policy makers,17 however, it is unclear if group singing is a suitable intervention for people with mental health conditions, or if there are contraindications to participating in music interventions.18,19 There is a growing number of studies examining community choirs for adults with mental health conditions.11,20,21 Thus far, there have been no systematic reviews specifically on the therapeutic impacts of group singing specifically for mental health conditions. Recent reviews on music therapy, indicate that when music therapy is added to the treatment of depression and schizophrenia, people can experience greater symptom improvement,18,19 however, it is yet to be established if community group singing can have similar outcomes.

Existing systematic reviews have found that community music and singing activities can promote mental health in people who are not diagnosed with a mental health condition. For example, it has been concluded that there is strong evidence that engaging in music and singing activities decreases depression, anxiety and loneliness in older people; and moderate evidence that engaging in music and singing activities enhances wellbeing and decreases depression in young adults, marginalized groups and people with chronic physical health conditions.2,3 Music interventions may also help people diagnosed with cancer, coronary heart disease and chronic obstructive pulmonary disease to manage anxiety.22–24 Although literature reviews have concluded that singing is a promising intervention for psychological and social functioning, methodological issues in the literature and the lack of a systematic theoretical model have also been acknowledged.1–3,25

The current systematic review is the first to focus on the mental health impacts of group singing for people experiencing mental health conditions, including substance abuse. This review aimed to assess the viability of choir singing to improve mental health and wellbeing in people with a mental health condition. It also reviewed the methodology used in this research to make recommendations for future research in this emerging field.

Methods

Inclusion criteria

Participants

This literature review focused on people living with mental health conditions, therefore the participants in the studies must either have reported a mental health diagnosis, including substance use disorders, or score in the clinical range on mental health measures. Studies with participants who experienced other cognitive or neurological conditions were not included (e.g. dementia, intellectual disabilities). Participants were aged 18 years old or over. There were no limits on gender or ethnicity.

Intervention

This review assessed the effects of participating in a community singing group, therefore, the intervention used in the studies predominately involved group singing. Only interventions undertaken in community settings were included. Singing interventions implemented in a hospital or clinical context were excluded, as this review focused on non-clinical settings. Interventions were excluded if they involved other music modalities, additional therapy or singing individually, however, the groups could be facilitated by musicians, music educators or music therapists.

Methodology

Studies with quantitative and qualitative methodologies exploring the impact of participating in a choir were included. Quantitative studies were confined to longitudinal studies which assessed participants’ mental health or wellbeing. These studies included a baseline measure when the participants started the singing intervention. Participants were then assessed after several weeks or months during which the participants had taken part in the singing intervention. Whether or not studies had a randomized control group was considered in the assessment of the quality of their methodology. Control or comparison samples included other interventions, treatment as usual or a waiting list control. Studies using experimental designs that measured effects of a single choir session, such as effects on emotional states, were excluded.

Outcomes

We extracted outcome measures relating to mental health and wellbeing, including validated measures of anxiety, depression, mental wellbeing, general mental health or quality of life. Self-report outcome measures, diagnostic interviews and observational measures were included. State self-report or physiological measures of emotions were excluded as the literature review focused on long-term outcomes. The measures of mental health used by the studies in this review were (see Supplementary appendix for references):

  • Clinical outcomes in routine evaluation (CORE)

  • Beck Depression Inventory II (BDI-II)

  • Brief Symptom Inventory (BSI)

  • Indigenous risk impact screen

  • Edinburgh Postnatal Depression Scale

The measures of mental wellbeing and quality of life included:

  • Warwick-Edinburgh Mental Wellbeing Scale

  • World Health Organisation Quality of Life—BREF

  • Quality of Life Enjoyment and Satisfaction Questionnaire

In relation to qualitative studies, outcomes were the themes generated from the analysis.

Searches

Before commencing our searches, we pre-published our protocol on PROSPERO for methodological transparency (PROSPERO Record ID =60115). We used multiple strategies to identify studies. First, electronic bibliographic databases were searched. The following databases were used: Scopus, Web-of-Science, PsycINFO, MEDLINE (Ovid), CINAHL, PubMed, The Cochrane Library and Google Scholar. The search strategy included terms related to group singing (‘choir’, ‘singing group’, ‘group singing’), mental health and wellbeing (‘mental health’, ‘anxiety’, ‘depression’, ‘wellbeing’, ‘well-being’). Second, we conducted a manual search of relevant journals from 1990 to 2017. The searches began at 1990 as only one study relating to choir singing (from 1989) had been identified prior to 1997 in the database searches. These journals included ‘Psychology of Music’, ‘Musicae Scientiae’, ‘Journal of Music Therapy’ and ‘Arts and Health’. Third, we checked references in sources found and previous literature reviews. Fourth, we contacted researchers in the field to identify relevant unpublished studies and work in progress. The search through databases and other sources found 709 records.

Data extraction (selection and coding)

Initially titles and abstracts of the articles yielded during the literature searches were screened by the first author to decide if the study related to a group singing intervention with mental health or wellbeing outcomes for adults. Of the 709 records, 464 were excluded as they did not relate to the review topic. An additional 140 were removed as they were duplicates. The remaining 105 full-text articles were screened by the first author in relation to eligibility criteria. All authors reviewed the extracted information to decide which papers meet the inclusion criteria. See figure 1 for flow chart of record screening.

Flow chart of record screening
Figure 1

Flow chart of record screening

A standardized form was used to extract data from the selected articles. The following information was extracted: sample size (and attrition rates), population (age, gender and diagnoses), intervention (setting, type of facilitator, duration and frequency), summary of outcomes and analysis of risk of bias. In addition, for quantitative studies the following was recorded: type of control or comparison group and outcome measures. Outcomes extracted included changes in the outcome variables over time, and differences between the treatment and control/comparison groups.

Half the articles (51 articles) were excluded as the study did not provide any indication of the mental health status of the participants. Mental health status was indicated in the remaining 55 studies by either diagnosis, scores on self-report measures or regular use of mental health services. Of these studies, 28 articles were excluded due to most participants not indicating mental health problems. This was established by either having a low percentage of participants with a mental health diagnosis, or only few participants scoring above clinical cut off on a self-report measure of anxiety or depression. Five of the qualitative papers did not include any formal analysis of the data. Finally, there were eight studies that were excluded as they were not conducted in a community setting (e.g. mental health facility or prison). Moreover, most of the studies excluded due to being conducted in a mental health facility, also involved other music therapy activities beyond group singing (e.g. instrument use, improvising and song writing). In the end, seven quantitative studies and six qualitative studies were included in the literature review. Due to the small number of studies and variety of self-report measures used, we were unable to aggregate the results in a meta-analysis.

Risk of bias (quality) assessment

The risk of bias assessments was conducted independently by the first two review authors. Then they were moderated by the third author and another colleague.

Quantitative studies

The Cochrane risk of bias tool was used to assess the risk of bias in the studies.26 This tool considers six domains of bias. The first two relate to the extent of selection bias. (i) Randomized sequence generation—the extent to which participants are randomly allocated to treatment or control condition. (ii) Treatment allocation concealment—the extent to which allocation was concealed from participants and researchers prior to treatment. The following four domains relate to performance bias, detection bias, attrition bias and reporting bias. (iii) Blinding of participants and personnel—the extent to which the participants and researchers are unaware of the participants’ conditions. (iv) Blinding of outcome assessment—the extent to which the assessors are unaware of the allocated conditions. (v) Incomplete outcome data—the extent of attrition, and whether the extent and reasons for attrition varied between groups. (vi) Selective reporting—the extent that certain outcomes were not reported.

Qualitative studies

To ensure that qualitative studies are of high quality, Tong, Sainsbury and Craig27 developed a 32-item checklist—Consolidated criteria for reporting qualitative research (COREQ). The quality of the qualitative papers was assessed using this checklist. This included taking measures to reduce experimenter bias (variation in researchers’ background, and no conflict of interest), sample bias (choir members declining to participate, and sample size), biased interviewing (non-leading questions, confidentiality, repeat interviews, verbatim recordings and adequate duration), biased analysis (methodological orientation, number of data coders, grounded analysis and data saturation) and reporting bias (quotations and clarity of themes).

Results

Quantitative studies

The seven studies represented data from a total of 576 participants in Australia and the UK. Overall, there were high risk of biases within all these studies. However, there were convergent results across the studies indicating that, while people participated in group singing, their mental distress decreased, and quality of life and wellbeing improved with moderate effect sizes (see table 1). Whilst these results are encouraging of using group singing in mental health community care, they should be treated with caution until more robust evidence is acquired.

Table 1

Details of quantitative studies and analysis of risk bias (Cochrane)

Clift and Morrison28Petchkovsky et al.30Grocke et al.21Sun and Buys31Clift et al.11Fancourt and Perkins32Williams et al.29,37
N42 choir21 choir+11 waitlist48 choir+25 waitlist108 choir+102 waitlist26 choir48 singing+42 play+44 TAU34 choir+25 writing
Mage6060Not reported46553546
Female (%)749160687310051
PopulationCommunity mental health service usersMajor depressive disorder diagnosis in communityCommunity mental health service usersAboriginal and Torres Strait Islander mental health service usersCommunity mental health service usersMothers with Post-Natal DepressionCommunity mental health service users
CountryUKAustraliaAustraliaAustraliaUKUKAustralia
Duration7 months8 weeks13 weeks18 months6 months10 weeks15 months
Mental health measureCORE—OMBeck Depression Inventory IIBrief Symptom InventoryIndigenous Risk Impact ScreenCORE—10Edinburgh Postnatal Depression ScaleNone used
OutcomesMental distress significantly improved during participation in the choir with a moderate effect size (d=0.44)Depression was lower after choir participation than in the control when controlling for pre-treatment scores. There was a large reduction in depression (d =0.83)Mental health did not significantly improve more when participants were participating in group singing than when they were on waitlistPercentage of people experiencing clinical levels of psychological distress significantly reduced in the choir, but did not on the waitlistMental health significantly improved during participation in the choir with a moderate effect size (d=0.39)Mothers with moderate to severe PND experienced faster improvement in symptoms when participating in singing (d=0.78) as opposed to play group or TAU
Wellbeing measureNone usedWHOQOL—BREFQoL enjoyment and satisfaction Qu.None usedWarwick-Edinburgh Mental WellbeingNone usedWarwick-Edinburgh Mental Wellbeing
OutcomesNo significant differences in QoL between choir and control after treatment, when controlling for pre-treatment scores.QoL improved significantly more during group singing than on waitlist with a moderate effect size (d=0.47)Mental wellbeing significantly improved during participation in the choir with a small effect size (d=0.29)Mental wellbeing significantly improved in the choir, and at the same rate as the creative writing group (d=0.52)
Random sequence generationHigh risk:High risk:Moderate risk:High risk:High risk:Low risk:High risk:
no control groupplanned randomized control, but then gave controls the option to join the choir.52/73 participants were randomly allocatedcomparison group were allocated based on having other commitmentsno control grouprandomized control trialno control group; participants chose to join choir or creative writing group
Treatment allocation concealmentHigh risk:Unclear risk:Unclear risk:Unclear risk:High risk:Unclear risk:High risk:
no control groupno explanation of concealmentno explanation of concealmentno explanation of concealmentno control groupno explanation of concealmentno random allocation
Blinding of participants and personnelHigh risk:High risk:High risk:High risk:High risk:High risk:High risk:
not possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blinded
Blinding of outcome assessmentUnclear risk:Unclear risk:High risk:Unclear risk:Unclear risk:Unclear risk:High risk:
use self-report measures, blinding not reportedno mention of concealment from psychiatrists undertaking clinical interviews and QEEGsdata collection was not concealed but an independent statistician analysed the datause self-report measures, blinding not reporteduse self-report measures, blinding not reporteduse self-report measures, blinding not reporteduse self-report measures, data collection was not blinded
Incomplete outcome dataModerate risk:Low risk:Moderate risk:Low risk:Moderate risk:Low risk:Moderate risk:
30% of all people participating over the year included due to participants joining and leaving at different times.100% retention rate; only one drop out before data collection began74% retention rate; reasons for attrition: family issues, other commitments, mental illness, accommodation issues and death89% retention rate62% retention rate; reasons: participants leaving the group or irregular attendance92% retention rate; no difference at baseline between attrition and retentionLow retention rate (56%); reasons: other commitments, and health; attrition not significantly different from retention at baseline
Selective reportingLow risk:Low risk:Low risk:Moderate risk:Low risk:Low riskLow risk:
reported all relevant outcomesreported all relevant outcomesreported all relevant outcomesM (SD) of MHPD not included (only % over cut-off)reported all relevant outcomesreported all relevant outcomesreported all relevant outcomes
Clift and Morrison28Petchkovsky et al.30Grocke et al.21Sun and Buys31Clift et al.11Fancourt and Perkins32Williams et al.29,37
N42 choir21 choir+11 waitlist48 choir+25 waitlist108 choir+102 waitlist26 choir48 singing+42 play+44 TAU34 choir+25 writing
Mage6060Not reported46553546
Female (%)749160687310051
PopulationCommunity mental health service usersMajor depressive disorder diagnosis in communityCommunity mental health service usersAboriginal and Torres Strait Islander mental health service usersCommunity mental health service usersMothers with Post-Natal DepressionCommunity mental health service users
CountryUKAustraliaAustraliaAustraliaUKUKAustralia
Duration7 months8 weeks13 weeks18 months6 months10 weeks15 months
Mental health measureCORE—OMBeck Depression Inventory IIBrief Symptom InventoryIndigenous Risk Impact ScreenCORE—10Edinburgh Postnatal Depression ScaleNone used
OutcomesMental distress significantly improved during participation in the choir with a moderate effect size (d=0.44)Depression was lower after choir participation than in the control when controlling for pre-treatment scores. There was a large reduction in depression (d =0.83)Mental health did not significantly improve more when participants were participating in group singing than when they were on waitlistPercentage of people experiencing clinical levels of psychological distress significantly reduced in the choir, but did not on the waitlistMental health significantly improved during participation in the choir with a moderate effect size (d=0.39)Mothers with moderate to severe PND experienced faster improvement in symptoms when participating in singing (d=0.78) as opposed to play group or TAU
Wellbeing measureNone usedWHOQOL—BREFQoL enjoyment and satisfaction Qu.None usedWarwick-Edinburgh Mental WellbeingNone usedWarwick-Edinburgh Mental Wellbeing
OutcomesNo significant differences in QoL between choir and control after treatment, when controlling for pre-treatment scores.QoL improved significantly more during group singing than on waitlist with a moderate effect size (d=0.47)Mental wellbeing significantly improved during participation in the choir with a small effect size (d=0.29)Mental wellbeing significantly improved in the choir, and at the same rate as the creative writing group (d=0.52)
Random sequence generationHigh risk:High risk:Moderate risk:High risk:High risk:Low risk:High risk:
no control groupplanned randomized control, but then gave controls the option to join the choir.52/73 participants were randomly allocatedcomparison group were allocated based on having other commitmentsno control grouprandomized control trialno control group; participants chose to join choir or creative writing group
Treatment allocation concealmentHigh risk:Unclear risk:Unclear risk:Unclear risk:High risk:Unclear risk:High risk:
no control groupno explanation of concealmentno explanation of concealmentno explanation of concealmentno control groupno explanation of concealmentno random allocation
Blinding of participants and personnelHigh risk:High risk:High risk:High risk:High risk:High risk:High risk:
not possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blinded
Blinding of outcome assessmentUnclear risk:Unclear risk:High risk:Unclear risk:Unclear risk:Unclear risk:High risk:
use self-report measures, blinding not reportedno mention of concealment from psychiatrists undertaking clinical interviews and QEEGsdata collection was not concealed but an independent statistician analysed the datause self-report measures, blinding not reporteduse self-report measures, blinding not reporteduse self-report measures, blinding not reporteduse self-report measures, data collection was not blinded
Incomplete outcome dataModerate risk:Low risk:Moderate risk:Low risk:Moderate risk:Low risk:Moderate risk:
30% of all people participating over the year included due to participants joining and leaving at different times.100% retention rate; only one drop out before data collection began74% retention rate; reasons for attrition: family issues, other commitments, mental illness, accommodation issues and death89% retention rate62% retention rate; reasons: participants leaving the group or irregular attendance92% retention rate; no difference at baseline between attrition and retentionLow retention rate (56%); reasons: other commitments, and health; attrition not significantly different from retention at baseline
Selective reportingLow risk:Low risk:Low risk:Moderate risk:Low risk:Low riskLow risk:
reported all relevant outcomesreported all relevant outcomesreported all relevant outcomesM (SD) of MHPD not included (only % over cut-off)reported all relevant outcomesreported all relevant outcomesreported all relevant outcomes
Table 1

Details of quantitative studies and analysis of risk bias (Cochrane)

Clift and Morrison28Petchkovsky et al.30Grocke et al.21Sun and Buys31Clift et al.11Fancourt and Perkins32Williams et al.29,37
N42 choir21 choir+11 waitlist48 choir+25 waitlist108 choir+102 waitlist26 choir48 singing+42 play+44 TAU34 choir+25 writing
Mage6060Not reported46553546
Female (%)749160687310051
PopulationCommunity mental health service usersMajor depressive disorder diagnosis in communityCommunity mental health service usersAboriginal and Torres Strait Islander mental health service usersCommunity mental health service usersMothers with Post-Natal DepressionCommunity mental health service users
CountryUKAustraliaAustraliaAustraliaUKUKAustralia
Duration7 months8 weeks13 weeks18 months6 months10 weeks15 months
Mental health measureCORE—OMBeck Depression Inventory IIBrief Symptom InventoryIndigenous Risk Impact ScreenCORE—10Edinburgh Postnatal Depression ScaleNone used
OutcomesMental distress significantly improved during participation in the choir with a moderate effect size (d=0.44)Depression was lower after choir participation than in the control when controlling for pre-treatment scores. There was a large reduction in depression (d =0.83)Mental health did not significantly improve more when participants were participating in group singing than when they were on waitlistPercentage of people experiencing clinical levels of psychological distress significantly reduced in the choir, but did not on the waitlistMental health significantly improved during participation in the choir with a moderate effect size (d=0.39)Mothers with moderate to severe PND experienced faster improvement in symptoms when participating in singing (d=0.78) as opposed to play group or TAU
Wellbeing measureNone usedWHOQOL—BREFQoL enjoyment and satisfaction Qu.None usedWarwick-Edinburgh Mental WellbeingNone usedWarwick-Edinburgh Mental Wellbeing
OutcomesNo significant differences in QoL between choir and control after treatment, when controlling for pre-treatment scores.QoL improved significantly more during group singing than on waitlist with a moderate effect size (d=0.47)Mental wellbeing significantly improved during participation in the choir with a small effect size (d=0.29)Mental wellbeing significantly improved in the choir, and at the same rate as the creative writing group (d=0.52)
Random sequence generationHigh risk:High risk:Moderate risk:High risk:High risk:Low risk:High risk:
no control groupplanned randomized control, but then gave controls the option to join the choir.52/73 participants were randomly allocatedcomparison group were allocated based on having other commitmentsno control grouprandomized control trialno control group; participants chose to join choir or creative writing group
Treatment allocation concealmentHigh risk:Unclear risk:Unclear risk:Unclear risk:High risk:Unclear risk:High risk:
no control groupno explanation of concealmentno explanation of concealmentno explanation of concealmentno control groupno explanation of concealmentno random allocation
Blinding of participants and personnelHigh risk:High risk:High risk:High risk:High risk:High risk:High risk:
not possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blinded
Blinding of outcome assessmentUnclear risk:Unclear risk:High risk:Unclear risk:Unclear risk:Unclear risk:High risk:
use self-report measures, blinding not reportedno mention of concealment from psychiatrists undertaking clinical interviews and QEEGsdata collection was not concealed but an independent statistician analysed the datause self-report measures, blinding not reporteduse self-report measures, blinding not reporteduse self-report measures, blinding not reporteduse self-report measures, data collection was not blinded
Incomplete outcome dataModerate risk:Low risk:Moderate risk:Low risk:Moderate risk:Low risk:Moderate risk:
30% of all people participating over the year included due to participants joining and leaving at different times.100% retention rate; only one drop out before data collection began74% retention rate; reasons for attrition: family issues, other commitments, mental illness, accommodation issues and death89% retention rate62% retention rate; reasons: participants leaving the group or irregular attendance92% retention rate; no difference at baseline between attrition and retentionLow retention rate (56%); reasons: other commitments, and health; attrition not significantly different from retention at baseline
Selective reportingLow risk:Low risk:Low risk:Moderate risk:Low risk:Low riskLow risk:
reported all relevant outcomesreported all relevant outcomesreported all relevant outcomesM (SD) of MHPD not included (only % over cut-off)reported all relevant outcomesreported all relevant outcomesreported all relevant outcomes
Clift and Morrison28Petchkovsky et al.30Grocke et al.21Sun and Buys31Clift et al.11Fancourt and Perkins32Williams et al.29,37
N42 choir21 choir+11 waitlist48 choir+25 waitlist108 choir+102 waitlist26 choir48 singing+42 play+44 TAU34 choir+25 writing
Mage6060Not reported46553546
Female (%)749160687310051
PopulationCommunity mental health service usersMajor depressive disorder diagnosis in communityCommunity mental health service usersAboriginal and Torres Strait Islander mental health service usersCommunity mental health service usersMothers with Post-Natal DepressionCommunity mental health service users
CountryUKAustraliaAustraliaAustraliaUKUKAustralia
Duration7 months8 weeks13 weeks18 months6 months10 weeks15 months
Mental health measureCORE—OMBeck Depression Inventory IIBrief Symptom InventoryIndigenous Risk Impact ScreenCORE—10Edinburgh Postnatal Depression ScaleNone used
OutcomesMental distress significantly improved during participation in the choir with a moderate effect size (d=0.44)Depression was lower after choir participation than in the control when controlling for pre-treatment scores. There was a large reduction in depression (d =0.83)Mental health did not significantly improve more when participants were participating in group singing than when they were on waitlistPercentage of people experiencing clinical levels of psychological distress significantly reduced in the choir, but did not on the waitlistMental health significantly improved during participation in the choir with a moderate effect size (d=0.39)Mothers with moderate to severe PND experienced faster improvement in symptoms when participating in singing (d=0.78) as opposed to play group or TAU
Wellbeing measureNone usedWHOQOL—BREFQoL enjoyment and satisfaction Qu.None usedWarwick-Edinburgh Mental WellbeingNone usedWarwick-Edinburgh Mental Wellbeing
OutcomesNo significant differences in QoL between choir and control after treatment, when controlling for pre-treatment scores.QoL improved significantly more during group singing than on waitlist with a moderate effect size (d=0.47)Mental wellbeing significantly improved during participation in the choir with a small effect size (d=0.29)Mental wellbeing significantly improved in the choir, and at the same rate as the creative writing group (d=0.52)
Random sequence generationHigh risk:High risk:Moderate risk:High risk:High risk:Low risk:High risk:
no control groupplanned randomized control, but then gave controls the option to join the choir.52/73 participants were randomly allocatedcomparison group were allocated based on having other commitmentsno control grouprandomized control trialno control group; participants chose to join choir or creative writing group
Treatment allocation concealmentHigh risk:Unclear risk:Unclear risk:Unclear risk:High risk:Unclear risk:High risk:
no control groupno explanation of concealmentno explanation of concealmentno explanation of concealmentno control groupno explanation of concealmentno random allocation
Blinding of participants and personnelHigh risk:High risk:High risk:High risk:High risk:High risk:High risk:
not possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blindednot possible for participants to be blinded
Blinding of outcome assessmentUnclear risk:Unclear risk:High risk:Unclear risk:Unclear risk:Unclear risk:High risk:
use self-report measures, blinding not reportedno mention of concealment from psychiatrists undertaking clinical interviews and QEEGsdata collection was not concealed but an independent statistician analysed the datause self-report measures, blinding not reporteduse self-report measures, blinding not reporteduse self-report measures, blinding not reporteduse self-report measures, data collection was not blinded
Incomplete outcome dataModerate risk:Low risk:Moderate risk:Low risk:Moderate risk:Low risk:Moderate risk:
30% of all people participating over the year included due to participants joining and leaving at different times.100% retention rate; only one drop out before data collection began74% retention rate; reasons for attrition: family issues, other commitments, mental illness, accommodation issues and death89% retention rate62% retention rate; reasons: participants leaving the group or irregular attendance92% retention rate; no difference at baseline between attrition and retentionLow retention rate (56%); reasons: other commitments, and health; attrition not significantly different from retention at baseline
Selective reportingLow risk:Low risk:Low risk:Moderate risk:Low risk:Low riskLow risk:
reported all relevant outcomesreported all relevant outcomesreported all relevant outcomesM (SD) of MHPD not included (only % over cut-off)reported all relevant outcomesreported all relevant outcomesreported all relevant outcomes

Clift and Morrison28 were the first to conduct a quantitative evaluative study on community choirs facilitated by singing instructors for mental health service users in the UK. The mental health of 42 choir members was tracked over 7 months. These members were found to experience a moderate reduction (d = 0.44) in mental distress over that time period. Clift et al.11 followed on from this study with a sample of 26 choir members participating in similar programmes as their previous study. They replicated a moderate reduction in mental distress (d = 0.39), and additionally found a significant increase in mental wellbeing (d = 0.29).

A similar study was conducted in Australia by Williams et al.29 with a sample of 35 participants with chronic mental health conditions in a community choir run by a singing instructor. Their study found a moderate increase in mental wellbeing during the first year of taking part in the choir (d = 0.52). Williams et al.29 compared the choir sample with a creative writing group (25 participants), also comprised of people experiencing mental health conditions. They found the rate of improvement in mental wellbeing was the same for both the choir and creative writing group, indicating that the two activities provided similar benefit to participants.

Petchkovsky et al.30 recruited a sample of 32 people in the community with a diagnosis of Major Depressive Disorder. They had planned a randomized controlled trial, however, due to having a small number of participants, people on the waitlist were given the option to join the choir. Therefore, there were discrepancies between the intervention (21 participants) and control (11 participants) during the initial assessment, for example, the controls had significantly worse quality of life than the choir participants. The choir was directed by a music therapist for 8 weeks, and the focus of the programme was predominantly on singing. Their results demonstrated that choir participants’ depression reduced with a large effect size (d = 0.83). Moreover, after participating in the choir, participants’ depression was significantly lower than the control, when controlling for baseline levels of depression. They found no significant results for quality of life between the choir and waitlist participants when controlling for baseline test scores, however, the analyses were underpowered. Petchkovsky et al.30 supplemented their self-report findings with clinical diagnostic interviews by a psychiatrist and neurological markers of depression using quantitative electroencephalography (QEEG). Both of these additional outcome measures confirmed that participants involved in the choir experienced a reduction in depressive symptoms during the 8 weeks they participated in the choir.

Grocke et al.21 recruited 73 participants of mental health service users living in the community and stabilized on medication in Australia. The study used a cross-over design where all participants alternated between group singing and standard care for 13 weeks each. Standard care involved scheduled appointments with case managers and psychiatrists, as well as optional activities at the community clinic. Similar to Petchkovsky et al.30, they had planned a randomized control trial, however, due to slow recruitment in the later stages, they added a non-randomized group so there would be sufficient numbers. The intervention was primarily group singing facilitated by four music therapists, however, the therapists also composed songs with their participants. There were no significant differences in the extent to which psychiatric symptoms, measured by the Brief Symptom Inventory, decreased between when participants were in the singing group or receiving standard care. However, quality of life increased significantly more for participants when involved in group singing, than when they were on the waitlist (d = 0.47).

Likewise, Sun and Buys’31 study with 210 Australian Aboriginal and Torres Strait Islanders also used a non-randomized comparison group due to ethical constraints, meaning that participants were allocated to the waitlist if they had work and other commitments preventing their enrolment in the singing groups. Consequently, the participants on the waitlist started with better mental health. Singing instructors directed the weekly singing groups for 18 months. In the 108 people who participated in the singing groups, the proportion of people experiencing clinical mental distress significantly reduced from 54.8 to 38.3%. In the control condition, of 102 waitlist participants, there was no reduction in the proportion of people experiencing clinical mental distress (44.3% at pre-intervention and 45.7% at post-intervention).

Fancourt and Perkins32 were the first to complete a full randomized controlled trial. Their study focused on 134 women with post-natal depression in London partaking in a singing group intervention which engaged both the mothers and their babies. Participants were randomly allocated to either the singing group, creative play group (comparison) or treatment as usual (control). Both the singing and creative play groups where run by the same professional instructors to ensure consistency between the conditions. The groups were conducted over 10 weeks. Post-natal depression symptoms reduced over time regardless of what group the participants were allocated. However, among the women with moderate to severe depression symptoms (n = 75), the participants of the singing group experienced a significantly faster reduction in depression symptoms (d = 0.78) than the participants of the play group or treatment as usual.

Risk of bias

There are consistent difficulties in this line of research relating to using an appropriate randomized control group, blinding the conditions, small sample sizes and attrition. Some of these risks (such as random allocation) can be relatively easily addressed with sufficient resources. Though there have been difficulties in executing large randomized controlled trials in these studies, this methodology is ideal for inferring cause and effect. Due to the lack of randomized control groups in most of the studies reviewed, it is difficult to specify causality or effect size of the observed mental health improvements. However, even randomized control trials have self-selection limitations as participants must be willing to take part in a singing group before randomization. Detection bias could also be reduced by blinding outcome assessors. In the studies reviewed, this was not reported, although Grocke et al.21 had an independent statistician analyse the data.

However, other limitations are more difficult to address. For instance, it is not possible to blind participants to the singing conditions to which they were allocated. This problem is inherent in any psychological or social intervention trial as participants must actively partake in these interventions.33 Therefore, participants could experience a placebo effect or otherwise be motivated to inflate the benefits of participating in these groups. Though this is an inherently difficult issue to address, methodology can be strengthened in clinical trials by understanding the mechanisms through which the treatment works, and including measures of bias to allow for post hoc adjustment of confounding effects.33

Attrition bias was also a common issue in the studies, though again this reflects a comparable problem experienced in many psychotherapy trials.34 This may occur due to positive reasons (e.g. gaining employment), or negative reasons (e.g. worsening mental health, family problems or accommodation issues). Therefore, the final sample may be experiencing more or less problems in their lives than the people who dropped out of the study. Furthermore, five out of seven of the studies had a relatively short follow-up period of 2–7 months. This makes the longevity of the impacts of choir singing difficult to determine. Despite these methodological limitations, the studies reviewed consistently demonstrate that choir participation can have a positive impact on mental health among people living with a mental health condition.

Qualitative

Outcomes

The six qualitative studies report similar themes relating to emotional, social and occupational wellbeing (see table 2). These studies included two studies by Bailey and Davidson35,36 with choirs for homeless people in Canada. These were the first studies to draw attention to the therapeutic benefits of participating in an amateur choir for people experiencing mental health issues and homelessness. Both Dingle et al.20 and Williams et al.37 explored the experience of participants in community choirs for people with chronic mental health conditions in Australia. Similarly, Plumb and Stickley38 and Shakespeare and Whieldon39 interviewed participants of community choirs in the UK. All the qualitative studies were on choirs run by singing instructors, without any focus on clinical treatment.

Table 2

Details of qualitative studies and analysis of risk bias (COREQ)

Bailey and Davidson35Bailey and Davidson36Dingle et al.20Plumb and Stickley38Shakespeare and Whieldon39Williams et al.29,37
N7821102025
Mage525247Not reportedNot reported46
% Female0%25%57%Not reported70%51%
PopulationHomeless with substance use or mental health issuesHomeless with substance use or schizophreniaCommunity mental health usersCommunity mental health usersCommunity mental health usersCommunity mental health users
CountryCanadaCanadaAustraliaUKUKAustralia
Emotional wellbeing
Enjoyment of singing6××××××
Uplift mood/reduce stress6××××××
Self-expression5×××××
Performance anxiety4××××
Diversion from worries3×××
Social wellbeing
Belonging to the group6××××××
Connection to community4××××
Social support/ acceptance4××××
Improved social functioning4××××
Occupational wellbeing
Self-efficacy/confidence6××××××
Structure/purpose5×××××
Learning/improved ability5×××××
Accomplishment5×××××
Health benefits4××××
Cognitive benefits3×××
ExperimentersModerate riskModerate riskModerate riskModerate riskModerate riskModerate risk
Documented and variation in researchers’ backgroundsBoth researchers have background in musicBoth researchers have background in musicResearchers have background in music or psychologyResearchers have background in nursing and mental healthResearchers have medical backgroundsResearchers have background in psychology
Conflict of interestResearcher independent to music directorResearcher independent to music directorResearcher independent to music directorResearcher independent to music directorResearcher independent to music directorResearcher independent to music director
SubjectsModerate riskUnclear riskLow riskUnclear riskModerate RiskLow risk
Declining to participatePeople not participating due to shyness and distrustNo explanation of non-participantsNo explanation of non-participants, majority participated.Not reportedSelf-selected, no explanation of non-participantsNone declined to participate
Sample sizeAcceptableAcceptableLargeAcceptableLargeLarge
InterviewsLow riskLow riskModerate riskModerate riskUnknown riskModerate risk
Interview questions reported and are non-leadingSemi-structured interview. Examples provided of non-leading questionsSemi-structured interview. Examples provided of non-leading questionsSemi-structured interview. Examples provided. Some questions are somewhat leading.Semi-structured interview. Examples provided. One question is somewhat leading.Semi-structured interview. No example questions reported.Semi-structured interview. Examples provided. Some questions somewhat leading
ConfidentialityIndividual interviewsIndividual interviewsIndividual interviewsIndividual interviewsIndividual interviewsIndividual interviews
Quotes recorded verbatimInterviews audio recordedInterviews audio recordedInterviews audio recordedInterviews audio recordedNot reportedInterviews audio recorded
Duration of data collectionOver an hourOver an hour20 minNot reportedNot reported10–30 min
AnalysesModerate riskModerate riskLow riskHigh riskModerate riskLow risk
Methodological orientation reportedInterpretive phenomenological analysisInterpretive phenomenological analysisThematic analysisThematic analysisThematic analysisThematic analysis
Number of data codersTwo data codersTwo data codersFour data codersOne data coderTwo data codersFour data coders
Analysis grounded in the dataData grounded analysisData grounded analysisData grounded analysisData grounded analysisData grounded analysisData grounded analysis
Data saturationNot reportedNot reportedNot reportedNot reportedNot reportedDiscussed and agreed
ReportingLow riskLow riskLow riskLow riskLow riskLow risk
Quotations reportedQuotes publishedQuotes publishedQuotes publishedQuotes publishedQuotes publishedQuotes published
Clarity of major and detail of minor themesClear detail of major and minor themesClear detail of major and minor themesClear detail of major and minor themesClear detail of major and minor themesClear detail of major and minor themesClear detail of major and minor themes
Bailey and Davidson35Bailey and Davidson36Dingle et al.20Plumb and Stickley38Shakespeare and Whieldon39Williams et al.29,37
N7821102025
Mage525247Not reportedNot reported46
% Female0%25%57%Not reported70%51%
PopulationHomeless with substance use or mental health issuesHomeless with substance use or schizophreniaCommunity mental health usersCommunity mental health usersCommunity mental health usersCommunity mental health users
CountryCanadaCanadaAustraliaUKUKAustralia
Emotional wellbeing
Enjoyment of singing6××××××
Uplift mood/reduce stress6××××××
Self-expression5×××××
Performance anxiety4××××
Diversion from worries3×××
Social wellbeing
Belonging to the group6××××××
Connection to community4××××
Social support/ acceptance4××××
Improved social functioning4××××
Occupational wellbeing
Self-efficacy/confidence6××××××
Structure/purpose5×××××
Learning/improved ability5×××××
Accomplishment5×××××
Health benefits4××××
Cognitive benefits3×××
ExperimentersModerate riskModerate riskModerate riskModerate riskModerate riskModerate risk
Documented and variation in researchers’ backgroundsBoth researchers have background in musicBoth researchers have background in musicResearchers have background in music or psychologyResearchers have background in nursing and mental healthResearchers have medical backgroundsResearchers have background in psychology
Conflict of interestResearcher independent to music directorResearcher independent to music directorResearcher independent to music directorResearcher independent to music directorResearcher independent to music directorResearcher independent to music director
SubjectsModerate riskUnclear riskLow riskUnclear riskModerate RiskLow risk
Declining to participatePeople not participating due to shyness and distrustNo explanation of non-participantsNo explanation of non-participants, majority participated.Not reportedSelf-selected, no explanation of non-participantsNone declined to participate
Sample sizeAcceptableAcceptableLargeAcceptableLargeLarge
InterviewsLow riskLow riskModerate riskModerate riskUnknown riskModerate risk
Interview questions reported and are non-leadingSemi-structured interview. Examples provided of non-leading questionsSemi-structured interview. Examples provided of non-leading questionsSemi-structured interview. Examples provided. Some questions are somewhat leading.Semi-structured interview. Examples provided. One question is somewhat leading.Semi-structured interview. No example questions reported.Semi-structured interview. Examples provided. Some questions somewhat leading
ConfidentialityIndividual interviewsIndividual interviewsIndividual interviewsIndividual interviewsIndividual interviewsIndividual interviews
Quotes recorded verbatimInterviews audio recordedInterviews audio recordedInterviews audio recordedInterviews audio recordedNot reportedInterviews audio recorded
Duration of data collectionOver an hourOver an hour20 minNot reportedNot reported10–30 min
AnalysesModerate riskModerate riskLow riskHigh riskModerate riskLow risk
Methodological orientation reportedInterpretive phenomenological analysisInterpretive phenomenological analysisThematic analysisThematic analysisThematic analysisThematic analysis
Number of data codersTwo data codersTwo data codersFour data codersOne data coderTwo data codersFour data coders
Analysis grounded in the dataData grounded analysisData grounded analysisData grounded analysisData grounded analysisData grounded analysisData grounded analysis
Data saturationNot reportedNot reportedNot reportedNot reportedNot reportedDiscussed and agreed
ReportingLow riskLow riskLow riskLow riskLow riskLow risk
Quotations reportedQuotes publishedQuotes publishedQuotes publishedQuotes publishedQuotes publishedQuotes published
Clarity of major and detail of minor themesClear detail of major and minor themesClear detail of major and minor themesClear detail of major and minor themesClear detail of major and minor themesClear detail of major and minor themesClear detail of major and minor themes
Table 2

Details of qualitative studies and analysis of risk bias (COREQ)

Bailey and Davidson35Bailey and Davidson36Dingle et al.20Plumb and Stickley38Shakespeare and Whieldon39Williams et al.29,37
N7821102025
Mage525247Not reportedNot reported46
% Female0%25%57%Not reported70%51%
PopulationHomeless with substance use or mental health issuesHomeless with substance use or schizophreniaCommunity mental health usersCommunity mental health usersCommunity mental health usersCommunity mental health users
CountryCanadaCanadaAustraliaUKUKAustralia
Emotional wellbeing
Enjoyment of singing6××××××
Uplift mood/reduce stress6××××××
Self-expression5×××××
Performance anxiety4××××
Diversion from worries3×××
Social wellbeing
Belonging to the group6××××××
Connection to community4××××
Social support/ acceptance4××××
Improved social functioning4××××
Occupational wellbeing
Self-efficacy/confidence6××××××
Structure/purpose5×××××
Learning/improved ability5×××××
Accomplishment5×××××
Health benefits4××××
Cognitive benefits3×××
ExperimentersModerate riskModerate riskModerate riskModerate riskModerate riskModerate risk
Documented and variation in researchers’ backgroundsBoth researchers have background in musicBoth researchers have background in musicResearchers have background in music or psychologyResearchers have background in nursing and mental healthResearchers have medical backgroundsResearchers have background in psychology
Conflict of interestResearcher independent to music directorResearcher independent to music directorResearcher independent to music directorResearcher independent to music directorResearcher independent to music directorResearcher independent to music director
SubjectsModerate riskUnclear riskLow riskUnclear riskModerate RiskLow risk
Declining to participatePeople not participating due to shyness and distrustNo explanation of non-participantsNo explanation of non-participants, majority participated.Not reportedSelf-selected, no explanation of non-participantsNone declined to participate
Sample sizeAcceptableAcceptableLargeAcceptableLargeLarge
InterviewsLow riskLow riskModerate riskModerate riskUnknown riskModerate risk
Interview questions reported and are non-leadingSemi-structured interview. Examples provided of non-leading questionsSemi-structured interview. Examples provided of non-leading questionsSemi-structured interview. Examples provided. Some questions are somewhat leading.Semi-structured interview. Examples provided. One question is somewhat leading.Semi-structured interview. No example questions reported.Semi-structured interview. Examples provided. Some questions somewhat leading
ConfidentialityIndividual interviewsIndividual interviewsIndividual interviewsIndividual interviewsIndividual interviewsIndividual interviews
Quotes recorded verbatimInterviews audio recordedInterviews audio recordedInterviews audio recordedInterviews audio recordedNot reportedInterviews audio recorded
Duration of data collectionOver an hourOver an hour20 minNot reportedNot reported10–30 min
AnalysesModerate riskModerate riskLow riskHigh riskModerate riskLow risk
Methodological orientation reportedInterpretive phenomenological analysisInterpretive phenomenological analysisThematic analysisThematic analysisThematic analysisThematic analysis
Number of data codersTwo data codersTwo data codersFour data codersOne data coderTwo data codersFour data coders
Analysis grounded in the dataData grounded analysisData grounded analysisData grounded analysisData grounded analysisData grounded analysisData grounded analysis
Data saturationNot reportedNot reportedNot reportedNot reportedNot reportedDiscussed and agreed
ReportingLow riskLow riskLow riskLow riskLow riskLow risk
Quotations reportedQuotes publishedQuotes publishedQuotes publishedQuotes publishedQuotes publishedQuotes published
Clarity of major and detail of minor themesClear detail of major and minor themesClear detail of major and minor themesClear detail of major and minor themesClear detail of major and minor themesClear detail of major and minor themesClear detail of major and minor themes
Bailey and Davidson35Bailey and Davidson36Dingle et al.20Plumb and Stickley38Shakespeare and Whieldon39Williams et al.29,37
N7821102025
Mage525247Not reportedNot reported46
% Female0%25%57%Not reported70%51%
PopulationHomeless with substance use or mental health issuesHomeless with substance use or schizophreniaCommunity mental health usersCommunity mental health usersCommunity mental health usersCommunity mental health users
CountryCanadaCanadaAustraliaUKUKAustralia
Emotional wellbeing
Enjoyment of singing6××××××
Uplift mood/reduce stress6××××××
Self-expression5×××××
Performance anxiety4××××
Diversion from worries3×××
Social wellbeing
Belonging to the group6××××××
Connection to community4××××
Social support/ acceptance4××××
Improved social functioning4××××
Occupational wellbeing
Self-efficacy/confidence6××××××
Structure/purpose5×××××
Learning/improved ability5×××××
Accomplishment5×××××
Health benefits4××××
Cognitive benefits3×××
ExperimentersModerate riskModerate riskModerate riskModerate riskModerate riskModerate risk
Documented and variation in researchers’ backgroundsBoth researchers have background in musicBoth researchers have background in musicResearchers have background in music or psychologyResearchers have background in nursing and mental healthResearchers have medical backgroundsResearchers have background in psychology
Conflict of interestResearcher independent to music directorResearcher independent to music directorResearcher independent to music directorResearcher independent to music directorResearcher independent to music directorResearcher independent to music director
SubjectsModerate riskUnclear riskLow riskUnclear riskModerate RiskLow risk
Declining to participatePeople not participating due to shyness and distrustNo explanation of non-participantsNo explanation of non-participants, majority participated.Not reportedSelf-selected, no explanation of non-participantsNone declined to participate
Sample sizeAcceptableAcceptableLargeAcceptableLargeLarge
InterviewsLow riskLow riskModerate riskModerate riskUnknown riskModerate risk
Interview questions reported and are non-leadingSemi-structured interview. Examples provided of non-leading questionsSemi-structured interview. Examples provided of non-leading questionsSemi-structured interview. Examples provided. Some questions are somewhat leading.Semi-structured interview. Examples provided. One question is somewhat leading.Semi-structured interview. No example questions reported.Semi-structured interview. Examples provided. Some questions somewhat leading
ConfidentialityIndividual interviewsIndividual interviewsIndividual interviewsIndividual interviewsIndividual interviewsIndividual interviews
Quotes recorded verbatimInterviews audio recordedInterviews audio recordedInterviews audio recordedInterviews audio recordedNot reportedInterviews audio recorded
Duration of data collectionOver an hourOver an hour20 minNot reportedNot reported10–30 min
AnalysesModerate riskModerate riskLow riskHigh riskModerate riskLow risk
Methodological orientation reportedInterpretive phenomenological analysisInterpretive phenomenological analysisThematic analysisThematic analysisThematic analysisThematic analysis
Number of data codersTwo data codersTwo data codersFour data codersOne data coderTwo data codersFour data coders
Analysis grounded in the dataData grounded analysisData grounded analysisData grounded analysisData grounded analysisData grounded analysisData grounded analysis
Data saturationNot reportedNot reportedNot reportedNot reportedNot reportedDiscussed and agreed
ReportingLow riskLow riskLow riskLow riskLow riskLow risk
Quotations reportedQuotes publishedQuotes publishedQuotes publishedQuotes publishedQuotes publishedQuotes published
Clarity of major and detail of minor themesClear detail of major and minor themesClear detail of major and minor themesClear detail of major and minor themesClear detail of major and minor themesClear detail of major and minor themesClear detail of major and minor themes

The qualitative studies in this review either used interpretive phenomenological analysis or thematic analysis to process interview data. There was considerable consensus between the studies on the types of perceived benefits that participants with mental health issues experience in a singing group. In particular, enjoyment of singing, experiencing improved emotional states, developing a sense of belonging and self-confidence were reported in all the studies reviewed. These qualitative analyses provide a more in-depth understanding of the mechanisms by which group singing may improve mental health compared with studies using standardized scales.

These studies focused primarily on the positive impacts of participating in group singing. However, performance anxiety was noted by most studies as a challenging aspect of group singing for people with mental health conditions. Potentially anxiety could be a barrier to some people participating in singing programmes, however, these studies also indicate that overcoming performance anxiety while participating in choir singing could be an empowering experience. Moreover, to reduce pressure on participants, the programmes place more emphasis on enjoyment than quality of the singing.

Risk of bias

The methodology of the qualitative studies reviewed tended to be sound, though this is partly due to the exclusion of qualitative studies where details were not given on how the data were processed. Strengths of the studies included that they were conducted by independent researchers, used data grounded analysis, had confidential interviews that were audio recorded, and reported both quotes and themes clearly in their articles. However, weaknesses were apparent in some of the studies which had researchers with backgrounds in only one academic discipline, insufficient coders to check reliability of the themes, leading questions in the semi-structured interview, only interviewing participants once, and not reporting if data saturation was achieved. Overall, the studies were of an acceptable quality, and demonstrated a high degree of consensus in themes found between each of the four studies. Although efforts were made to reduce experimenter bias, it can be argued that it is unavoidable for some experimenter subjectivity to influence qualitative research.

Discussion

The results of this literature review indicate that choir singing could be a promising adjunct to community-based mental health treatment. People participating in these programmes ascribed improvements in their emotional, social and occupational wellbeing to participating in group singing. Moreover, when people with mental health conditions were engaging in these programmes their mental health and wellbeing significantly improved. No contraindications for participating in these programmes have been identified by the reviewed studies, however, performance anxiety was recognized as a challenge. Therefore, to harness the benefits of group singing it is important for facilitators to be mindful of the anxiety that participants may experience.

The overall quality of evidence in this review is of moderate to high risk of bias, therefore, further research is needed to gain stronger evidence of the impacts of choir singing on mental health. This review demonstrates that this area of research is growing as publications have become more frequent in recent years. The field has been developing from exploratory qualitative studies, to more rigorous research trials. This research extends on previous findings which have found similar wellbeing benefits of choir participation for older adults, young adults and people with physical health conditions.1–3,22–24

Implications

The studies reviewed indicate that choir singing can help people with mental health conditions to overcome problems pertaining anxiety, depression and social disconnection. Despite social disadvantage and isolation contributing to the onset and maintenance of mental health conditions, there are limited evidence-based social interventions in mental health care.14 It is imperative that the social difficulties which perpetuate mental health conditions are addressed, as 14% of the global burden of disease is attributed to neuropsychiatric disorders, such as depression, anxiety, psychoses and substance use.40 There is growing evidence that arts-based interventions may be a cost-effective intervention for mental health.17 However, the cost-effectiveness of choir singing is yet to be assessed for people with mental health conditions in community-integrated settings. The current review supports that choir singing could promote mental health recovery by providing social connectedness, emotional enhancement and meaning in life. Moreover, this review demonstrates that these programmes do not need to be facilitated by mental health professionals. In fact, non-clinical groups may provide a non-stigmatizing solution to providing social support to people living with a mental health condition in the community.

Strengths and limitations of the review

This review used a comprehensive search strategy, though there may be studies in the grey literature and in the process of publication which were not identified. Thus, it is possible that publication bias may have affected the findings in this literature review. Nevertheless, through contacting authors in this area we attempted to reduce this bias. Moreover, by pre-registering our protocol on PROSPERO we were explicit in advance of our intentions. As was predicted in our protocol, there was not an adequate number of studies to conduct a meta-analysis. The limited number of studies in the area precluded reaching definite conclusions. We aimed to increase objectivity when assessing the quality of the studies by using pre-determined criteria in the Cochrane risk of bias tool for quantitative studies, and the COREQ checklist for qualitative studies. These were independently assessed by the authors to reduce bias. However, the screening of the searches was only conducted by one author. Furthermore, the review authors are also authors of five of the included studies in the review.

Future research directions

The studies reviewed provided consistent conclusions that choir singing can help people with mental health conditions improve their mental health and wellbeing, however, there were major limitations in their methodology. Most of the studies included in the review either did not have a control group or the control was not fully randomized. Therefore, there is an ongoing need to conduct more fully randomized controlled trials, such as Fancourt and Perkins,32 with a large sample. Future randomized controlled trials could test the cost-effectiveness of group singing interventions in mental health care. Furthermore, longer long-term follow-up assessments could be used to track the longevity of the impacts of choir singing and impacts on hospital admissions for psychiatric relapse. Future research could also test the consistent benefits identified in the qualitative research. For example, future studies on choirs could measure belonging, self-efficacy and purpose. Moreover, comparing choir singing and other group activities could be helpful to ascertain whether these benefits are unique to choirs or are experienced in other arts and recreational group activities.

Improvements could also be made to outcome measurement. Assessors should be blind to the participants’ conditions. Furthermore, researchers could follow Petchkovsky et al.30 by using clinical and objective assessments that could provide further information on the validity of mental health outcomes assessed by self-report questionnaires. Some of the qualitative studies have also found that participants report cognitive benefits, therefore, cognitive assessments may also be explored as an outcome measure. Overall, it would be of value to have more consistency in outcome measures used in this field, to build stronger links between studies.

Regarding the samples used, research is yet to explore if there are any differences between people with various diagnoses. It is unclear if choir singing may lead to larger or lesser impacts depending on the severity of the problems faced. Although none of studies reviewed indicated any negative impacts of choir singing, further research could explore if there are any contraindications for participating in a group singing intervention. Finally, the studies found in this review are all from English-speaking countries (Australia, UK and Canada), therefore research in more diverse cultural settings is needed. Choir singing is likely to be culturally appropriate in a wide variety of backgrounds. For instance, Sun and Buys31 had high retention rates with Aboriginal and Torres Strait Islander Australians.

In conclusion, group singing interventions for people with mental health conditions is a bourgeoning field of research. The current results are promising, indicating that many people with mental health conditions have experienced benefits to their mental health and wellbeing through participating in community singing groups. Therefore, choir singing is a viable option for arts-on-referral in mental health. However, further research is needed to determine the cost-effectiveness, how far these findings can be generalized, and to define indicators on when to refer to group singing for mental health conditions.

Acknowledgements

With thanks to Esther Coren for moderating the risk of bias analyses and providing feedback on the paper. This literature review was pre-registered on the PROSPERO database: https://www.crd.york.ac.uk/prospero/display_record.php? RecordID=60115.

Conflicts of interest: None declared.

Key points
  • Seven longitudinal studies have demonstrated that mental health and/or wellbeing improved during participation in community singing groups.

  • Participants consistently reported across six qualitative studies that group singing enhanced their positive emotions, sense of belonging and confidence.

  • These studies had a significant risk of bias and more rigorous research is needed.

  • Choir singing is a viable option for arts-on-referral in mental health.

References

1

Clift
S
,
Nicol
J
,
Raisbeck
M
, et al.
Group singing, wellbeing and health: a systematic mapping of research evidence
.
UNESCO Observ E-J
2010
;
2
:
1835
2776
.

2

Daykin
N
,
Julier
G
,
Tomlinson
A
, et al. Music, singing and wellbeing in healthy adults. What Works Wellbeing
2016
[accessed 2017 Feb 15], Available at: https://whatworkswellbeing.files.wordpress.com/2016/11/1-systematic-review-healthy-adult-music-singing-wellbeing-nov2016final.pdf (15 February 2017, date last accessed).

3

Daykin
N
,
Julier
G
,
Tomlinson
A
, et al. Music, singing and wellbeing for adults living with diagnosed conditions. What Works Wellbeing,
2016
. Available at: https://whatworkswellbeing.files. wordpress.com/2016/11/2-systematic-review-diagnosed-conditions-music-singing-wellbeing.pdf (15 February 2017, date last accessed).

4

Clift
S
,
Hancox
G
.
The significance of choral singing for sustaining psychological wellbeing: findings from a survey of choristers in England, Australia and Germany
.
Music Perf Res
2010
;
3
:
79
96
.

5

Kreutz
G
,
Bongard
S
,
Rohrmann
S
, et al.
Effects of choir singing or listening on secretory immunoglobulin A, cortisol, and emotional state
.
J Behav Med
2004
;
27
:
623
35
.

6

Sanal
AM
,
Gorsev
S
.
Psychological and physiological effects of singing in a choir
.
Psychol Music
2014
;
42
:
420
9
.

7

Dingle
GA
,
Williams
E
,
Jetten
J
,
Welch
J
.
Choir singing and creative writing enhance emotion regulation in adults with chronic mental health conditions
.
Br J Clin Psychol
2017
;
56
:
443
57
.

8

Keeler
JR
,
Roth
EA
,
Neuser
BL
, et al.
The neurochemistry and social flow of singing: bonding and oxytocin
.
Front Neurosci
2015
;
9
:
518
.

9

Pearce
E
,
Launay
J
,
Machin
A
,
Dunbar
RIM
.
Is group singing special? Health, well-being and social bonds in community-based adult education classes
.
J Community Appl Soc Psychol
2016
;
26
:
518
33
.

10

Stewart
NAJ
,
Lonsdale
AJ
.
It’s better together: the psychological benefits of singing in a choir
.
Psychol Music
2016
;
44
:
1240
54
.

11

Clift
S
,
Manship
S
,
Stephens
L
.
Further evidence that singing fosters mental health and wellbeing: the West Kent and Medway project
.
Ment Health Soc Inclusion
2017
;
21
:
53
62
.

12

Crone
DM
,
Sumner
RC
,
Baker
CM
, et al.
‘Artlift’ arts-on-referral intervention in UK primary care: updated findings from an ongoing observational study
.
Eur J Public Health
2018
;
28
:
404
9
.

13

Corrigan
PW
,
Markowitz
FE
,
Watson
AC
.
Structural levels of mental illness stigma and discrimination
.
Schizophr Bull
2004
;
30
:
481
91
.

14

Tew
J
,
Ramon
S
,
Slade
M
, et al.
Social factors and recovery from mental health difficulties: a review of the evidence
.
Br J Soc Work
2012
;
42
:
443
60
.

15

Stickley
A
,
Koyanagi
A
.
Loneliness, common mental disorders and suicidal behavior: findings from a general population survey
.
J Affect Disord
2016
;
197
:
81
7
.

16

Cruwys
T
,
Dingle
GA
,
Haslam
C
, et al.
Social group memberships protect against future depression, alleviate depression symptoms and prevent depression relapse
.
Soc Sci Med
2013
;
98
:
179
86
.

17

All-Party Parliamentary Group on Arts, Health and Wellbeing
. Inquiry Report Creative Health: The Arts for Health and Wellbeing. 2nd edn.
2017
, http://www.artshealthandwellbeing.org.uk/appg-inquiry/Publications/Creative_Health_ Inquiry_Report_2017_-_Second_Edition.pdf (20 April 2018, last date accessed).

18

Aalbers
S
,
Fusar-Poli
L
,
Freeman
RE
, et al.
Music therapy for depression
.
Cochrane Database of Syst Rev
2017
;
11
:
CD004517
. Art. No.: CD004517.

19

Geretsegger
M
,
Mössler
KA
,
Bieleninik
Ł
, et al.
Music therapy for people with schizophrenia and schizophrenia-like disorders
.
Cochrane Database of Systc Rev
2017
;
5
, Art. No.: CD004025.

20

Dingle
G
,
Brander
C
,
Ballantyne
J
,
Baker
FA
.
‘To be heard’: the social and mental health benefits of choir singing for disadvantaged adults
.
Psychol Music
2013
;
41
:
405
21
.

21

Grocke
D
,
Bloch
S
,
Castle
D
, et al.
Group music therapy for severe mental illness: a randomized embedded-experimental mixed methods study
.
Acta Psychiatr Scand
2014
;
130
:
144
53
.

22

Bradt
J
,
Dileo
C
,
Magill
L
,
Teague
A
.
Music interventions for improving psychological and physical outcomes in cancer patients
.
Cochrane Database Syst Rev
2016
;
8
, Art. No.:
CD006911
.

23

Bradt
J
,
Dileo
C
,
Potvin
N
.
Music for stress and anxiety reduction in coronary heart disease patients
.
Cochrane Database Syst Rev
2013
;
12
, Art. No.:
CD006577
.

24

Lewis
A
,
Cave
P
,
Stern
M
, et al.
Singing for lung health—a systematic review of the literature and consensus statement
.
NPJ Prim Care Respir Med
2016
;
26
:
16080
.

25

Reagon
C
,
Gale
N
,
Enright
S
, et al.
A mixed-method systematic review to investigate the effect of group singing on health related quality of life
.
Complement Ther Med
2016
;
27
:
1
11
.

26

Higgins
JPT
,
Green
S
. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.0. The Cochrane Collaboration,
2008
.

27

Tong
A
,
Sainsbury
P
,
Craig
J
.
Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups
.
Int J Qual Health Care
2007
;
19
:
349
57
.

28

Clift
S
,
Morrison
I
.
Group singing fosters mental health and wellbeing: findings from the East Kent “singing for health” network project
.
Ment Health Soc Inclusion
2011
;
15
:
88
97
.

29

Williams
E
,
Dingle
G
,
Jetten
J
,
Rowan
C
. Identification with arts-based groups improves mental wellbeing in adults with chronic mental health conditions. PsyArXiv
2018
, doi:10.17605/OSF.IO/ZHM7U.

30

Petchkovsky
L
,
Robertson-Gillam
K
,
Kropotov
J
,
Petchkovsky
M
.
Using QEEG parameters (asymmetry, coherence, and P3a novelty response) to track improvement in depression after choir therapy
.
Adv Ment Health
2013
;
11
:
257
67
.

31

Sun
J
,
Buys
N
.
Effects of community singing program on mental health outcomes of Australian Aboriginal and Torres Strait Islander people: a meditative approach
.
Am J Health Promot
2016
;
30
:
259
63
.

32

Fancourt
D
,
Perkins
R
.
Effect of singing interventions on symptoms of postnatal depression: three-arm randomised controlled trial
.
Br J Psychiatry
2018
;
212
:
119
21
.

33

Button
KS
,
Munafò
MR
.
Addressing risk of bias in trials of cognitive behavioral therapy
.
Shanghai Arch Psychiatry
2015
;
27
:
144
8
.

34

Swift
JK
,
Greenberg
RP
.
Premature discontinuation in adult psychotherapy: a meta-analysis
.
J Consult Clin Psychol
2012
;
80
:
547
59
.

35

Bailey
BA
,
Davidson
JW
.
Adaptive characteristics of group singing: perceptions from members of a choir for homeless men
.
Music Sci
2002
;
6
:
221
56
.

36

Bailey
BA
,
Davidson
JW
.
Effects of group singing and performance for marginalized and middle-class singers
.
Psychol Music
2005
;
33
:
269
303
.

37

Williams
E
,
Dingle
G
,
Calligeros
R
, et al. Enhancing mental health recovery by joining art-based groups: a role for self-categorisation. PsyArXiv
2018
; doi:10.17605/OSF.IO/ZS8MB.

38

Plumb
L
,
Stickley
T
.
Singing to promote mental health and well-being
.
Ment Health Pract
2017
;
20
:
31
6
.

39

Shakespeare
T
,
Whieldon
A
.
Sing your heart out: community singing as part of mental health recovery
.
Med Humanit
2017
; doi:10.1136/medhum-2017-011195.

40

Prince
M
,
Patel
V
,
Saxena
S
, et al.
No health without mental health
.
Lancet
2007
;
370
:
859
77
.

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