Can music improve sleep quality in adults with primary insomnia? A systematic review and network meta-analysis

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Abstract

Background

Primary insomnia is one of the most common issues for adults. However, whether to use music intervention as a non-pharmacological method of treatment, as well as which treatment should be preferred, is still a matter of controversy. Therefore, we aimed to compare and rank music interventions and no-music controls for primary insomnia patients.

Methods

A network meta-analysis was used to identify evidence from relevant clinical trials. We searched PubMed, Embase, the Cochrane Library, and the China National Knowledge Infrastructure Library for publications up to May 2017, pertaining to music intervention for primary insomnia patients. The prespecified primary outcome was sleep quality (scored by the PSQI and overall), and the secondary outcomes were sleep onset latency and sleep efficiency. We did pairwise meta-analyses using the random-effects model, later completing the random-effects network meta-analyses. The study was registered with PROSPERO, number CRD42017064750.

Results

We deemed 20 trials to be eligible, involving 1339 patients and 12 intervention arms. For PSQI scores, all intervention arms were statistically more effective than the usual care, with patients ranking listening to music as the best means of intervention (SMD: −0.61, 95%CrI: −1.01 to −0.20). For overall sleep quality, only music-associated relaxation was statistically more effective than the patients’ usual care (−0.28, −0.48 to −0.08). In terms of sleep onset latency, music-associated relaxation and listening to music had significant advantages (−0.26, −0.64 to −0.09, and −0.28, −0.53 to −0.02); listening to music and music with exercise displayed a tendency to improve sleep efficiency.

Conclusions

When considering the efficacy, music intervention seemed to offer clear advantages for adults with primary insomnia. Listening to music and music-associated relaxation are probably the best options to consider in the application of music intervention.

Introduction

One third of one’s lifetime is expended in sleep, and sleep is an important and indispensable part of health. Sleep disturbance has been identified as a significant and growing cause of concern for public health (Nomura et al., 2010). Characteristic of insomnia, one of the foremost sleep disturbances, as described by sleep experts, often features difficulty in initiating or maintaining sleep, early morning waking, and nonrestorative sleep (Schutte-Rodin et al., 2008). Insomnia may also be considered as a kind of sub-health state, as it causes much harm to the body, often characterized by hypertension, diabetes, or depression. Insomnia also affects the next day's work and study; in severe cases, it will lead to a decline in attention for a long time, accompanied by a reduction of the individual’s immunity and quality of life, even becoming life-threatening (Dam et al., 2008, Komada et al., 2012). Insomnia has become the second major cause of individuals’ visits to neurological clinics, ranking after headaches, and it is severe enough to become an economic burden to individuals and society, simultaneously increasing accident rates and decreasing productivity (Wade, 2011). The prevalence of insomnia worldwide is 30–35% (Roth, 2007, Yeung et al., 2004), involving up to 50% of older adults (Zahran et al., 2005). Therefore, the treatment of insomnia, especially the treatment of insomnia for elderly individuals, has attracted more and more public attention.

At present, the treatment of insomnia is still mainly drug-based therapy; however, the long-term side effects of sedative, hypnotic drug use are obvious, causing drug dependence or drug tolerance, which may also affect the hypnotic effect (DeMartinis et al., 2009). Current research shows that clinically-used, sedative, hypnotic drugs do not really improve sleep quality (Buscemi et al., 2007). As a result, the non-pharmacological management of sleep problems has become a crucial issue (Mercier et al., 2016, van Straten et al., 2017). The power of music and its nonverbal nature provides a prime communication medium in which language is diminished or abolished; furthermore, music easily elicits movements that stimulate interactions between the perception and action systems (Zhang et al., 2016, Zhang et al., 2017). As a result, music intervention has been identified by researchers as a key area of interest as it is relatively inexpensive, readily available, and can be easily implemented. Recipients can be actively engaged in a relaxation-improving intervention in which music is the key ingredient, termed “music-assisted relaxation” method, or they can passively listen to music that a therapist plays or sings or to a CD player before bedtime, considered as a “listening to music” method. Insomnia patients may sensitive to the music, and listening to music has been considered as a therapeutic strategy for insomnia patients' treatment.

Due to numerous means of classifying music intervention and small sample sizes, the effects of music are still inconclusive. To further explore this subject, we performed a network meta-analysis of all available clinical trials of the effects of music on adults with primary insomnia. Network meta-analysis is an extension of pairwise meta-analysis (head-to-head meta-analysis which only considers direct evidences) which intervention aims to combine direct and indirect evidences into a single effect size and rank all available arms, calculating estimates for interventions even if they have not been compared directly in current studies, provided that a common comparator exists (Salanti, 2012). A few pairwise meta-analyses (De Niet et al., 2009, Kligler et al., 2016, Wang et al., 2014a) have analyzed the effects of music therapy, but these analyses only considered direct evidence and did not rank which intervention arm is best. No previous reviews have provided a comprehensive overview of this subject, using network meta-analysis.

Section snippets

Search strategy and selection criteria

This systematic review was performed with an a priori established protocol (PROSPERO CRD42017064750) (PROSPERO, 2009 http://www.cdr.york.ac.uk/prospero), and the meta-analysis was performed in agreement with the preferred reporting items for the systematic reviews and meta-analyses (PRISMA) statement, the PRISMA network statement, and the Cochrane Collaboration recommendations (Cochrane handbook for systematic reviews of interventions, 2011; Hutton et al., 2015; Moher et al., 2009). Clinical

Systematic review and qualitative assessment

Overall, 214 unique citations were identified using our search strategy. A total of 20 trials (n = 1339) (Chan et al., 2010, Chan, 2011, Chang et al., 2012, de Niet et al., 2010, Feng and Wang, 2013a, Feng and Wang, 2013b, Huang et al., 2016, Lai and Good, 2005, Lai et al., 2015, Levin, 1998, Lin et al., 2016, Min et al., 2013, Shi, 2014, Shum et al., 2014, Su et al., 2013, Wang and Cheng, 2014, Wang et al., 2014b, Wang et al., 2016, Yin et al., 2015, Ziv et al., 2008) and 12 interventions

Discussion

The network meta-analysis represents the most comprehensive synthesis of data for currently available music intervention studies on adults with primary insomnia. We combined direct and indirect trials, comparing 12 different interventions and reporting on 1339 patients. First, we found that all interventions with music were significantly more effective than usual care, in reference to PSQI scores, to be the primary outcome. Listening to music before bedtime lead to superior efficacy in terms of

Conflicts of interest

The authors do not have any conflicts of interest to disclose.

Funding

The work were supported by Special project for capital health development research(No. 2014-2-5031)and Dean Innovation Fund (YNKT2014039) from the 302nd Hospital of Chinese PLA, Beijing 100039, PR China. Ethical approval

Ethical approval

The systematic review was not subject to ethical review.

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