Nurse-Implemented Music Therapy to Reduce Anxiety in Community-Dwelling Individuals with Severe Mental Illness: A Pilot Study

Round 1

Reviewer 1 Report

Thank you for submitting this paper for publication consideration. The topic is important and the authors should be commended. This study was a huge amount of work!

This study is valuable in that it measured outpatients with mental health conditions. It also used physiological measures.

The main critiques of this study is that it used a single group and had a small sample. With randomization, an adequate sample size, and a control group, these one cannot draw any conclusions from this study. 

Suggest including a statement about Ethics/IRB in the paper itself.

Although the interventionist was a music therapist, there is a lack of detail about the music therapy itself. How many years of experience did the music therapist have? What theoretical orientation guided their clinical practice? What theories guided the intervention? Was the music therapist qualified (certification, licensure, etc.) to practice in Spain?

I am assuming this was a group intervention - this needs to be made explicit in the paper. 

There was an instance wherein overstimulation was noted. How was this assessed and handled? Was the participant OK?

Was participation in the study required to receive music therapy? If so, what might the ethical implications of this be?

I am assuming that all 14 participants were in 1 group. That is a large group. How many people attended sessions? Descriptive data regarding participants/session would be helpful.

Was attendance correlated with outcome? I am not sure that this can be measured give the data set.

Was a power analysis conducted? 

Since there was no randomization, control group, and the study had a small sample, perhaps emphasizing the pilot nature of this study could help. 

The authors talked about social interaction in the discussion section. This is interesting, but there was no measure of this and the protocol did not explicitly state that social interaction was addressed. 

Another limitation of the study was the interventionist's dual training as they were a nurse and music therapist, correct?

The quote from the head of the unit is supportive but it is only a sample of 1. Was it in English or Spanish?

There is inadequate detail regarding the intervention itself. In current form, the study can not be replicated. Given the group based format of the study, how were decisions made after individually assessing each participants' music preferences?

More detail is necessary regarding the music intervention: https://www.sciencedirect.com/science/article/pii/S096522991730938X

 What type of design was used? This is not explicit in the paper. Seems like a 1 group with pre and posttests before and after each of the 10 sessions. 

I appreciate the authors' desire to conduct music therapy research and help people with mental health conditions. I would encourage the authors to present this paper at a professional conference. I hope to read more from them in the future and wish them well!

Some of the language is figurative; suggest revising so it is more literal. 

Author Response

Thank you very much for your constructive review. The answers to your questions and comments are included in the attached file. 

Author Response File: Author Response.pdf

Reviewer 2 Report

Dear authors, congratulations for your study.

However, I have some suggestions and questions for your study.

My recommendations are listed below:

1. In the introduction, the direct and indirect benefits and effects of the intervention in the target population can be mentioned.

2. The spelling error in the title order should be corrected. “2. Objective and Research Questions, 2. Materials and Methods”

3. line 71: Although pre- and post-tests were performed, information about variables that may affect anxiety, such as the number of medications or other activity programs in which the participants participated, could be provided. Why were 14 patients included in the study?

4. Line 132-156: Music therapy activities can be given in a table.

5. Line 179: "2.4. Evaluation of Vital Signs", blood pressure, pulse rate and sonulum count are evaluated as objective measurements. However, detailed information about the measurements should be given.

It is explained in the limitations that the measurements were made by the same nurse. The method should also be explained. Did the same nurse administer the questionnaires, what are the tools used for objective measurements, was the tool calibrated, what are the other measures taken to obtain safe measurements, how standardization was achieved in measurements in general should be explained.

6. “Table 2. % of users whose studied variables (mean ± SD) increased (á), stayed the same (=), or de- 223 creased (â) considering all sessions.” The title should be revised, symbols etc. should be given as a note under the table, Table 2 looks confusing in general.

7. Not all participants were able to participate in music therapy. The percentages given in the findings cause confusion. As far as I understand, the variables for each session were evaluated as percentages according to the number of participants.

8. The purpose of correlation between objective and subjective assessments is understood in the discussion section.  It can be explained with a heading in the methodology section, correlation analysis is not an answer to the main research questions, it is a finding that supports the reliability of the results.

9. line 304-309: "In summary, we have the following results:" this information is a general comment on the findings. Summary findings can be given in the discussion and in the conclusion.

10. Line 333-337: The paragraph on heart rate should be revised, in the paragraph it is written that there is a decrease in HR in accordance with the literature. In general, the response of HR to music was discussed. In this study, music preferred by the participants was played, there were many group activities and activities involving isotonic muscle activity in music therapy. This may cause an increase in HR. The discussion should be revised accordingly after the method of measurements is clarified. How many minutes after the intervention was blood pressure measured? After exercise, individuals should rest for 30 minutes and blood pressure should be measured, and rest for 5 minutes for non-exertional movements. This study intervention is very different from the article discussed. It did not include only listening to music.

Good luck…

Author Response

Thank you very much for your constructive review. The answers to your questions and comments are included in the attached file.

Author Response File: Author Response.pdf

Reviewer 3 Report

Overall Comment

Overall, an interesting draft article highlighting the potential importance of music therapy nursing interventions in reducing anxiety in outpatients diagnosed with severe mental illness (SMI). This study asked a reasonable question and was conducted in a feasible manner. Most of the references are dated (24/42 are over five years old), though that could be a function of music therapy in nursing being a topic that goes in and out of interest. Although the manuscript has an interesting research question; it needs some work regarding how it is written, and the data is presented. Several issues with this study need clarification or revision. Nevertheless, the recommendations from this study are worth sharing.

Concerning issues

Introduction:

1.     Introduction needs to be rewritten, since lines 34-55 are comparing studies and follow a structure similar to the discussion section for example in line 46 “whereas our study targeted outpatients;” this compares this study to others without first presenting the methodology or the results. I suggest rewriting the introduction focusing on the what is already known and what are the gaps.

2.     Following the comment above, in the introduction section overall conceptualisation of various terms and their meaning. For example, music therapy and anxiety in individuals with SMI needs greater clarification and justification.  

Methods

3.     Evaluation of vital signs, I would like to better understand the vital signs measured meaning normal ranges and method of measuring.  

4.     Statistical analysis, I would like a better classification of which data followed normal distribution.

5.     Where applicable, did the authors perform the Bonferroni correction? 

Results

6.     In the results there is on numerous occasions the following “p<0.000” this is due to the SPSS not correctly showing the p after the fourth digit, I suggest to rephrase I to “p<0.001”.

7.     I suggest the phrase in lines 247-248: “we think happiness and euphoria after the session could slightly influence the patients’ answers” to be mover either in the discussion or limitations section.

8.     To that note in lines 254-259: Subjective Perception of Relaxation (SPR)….. I suggest move them to the methods section along with the other questionnaires used for this study.

Discussion

9.     I missed a first paragraph that would present all the main findings of the study.

10.  I would also like an evidence-based explanation for each main finding aside the comparisons to other studies.

11.   Line 322: “deeper analysis” what does this refer to?

12.  Lines 386-395, although I liked the quote, I would move it to the acknowledgments section or remove it, since it does not really add to the manuscript.

In conclusion, the paper could be amended. The paper could then help provide justification to the incorporation of music therapy interventions in individuals with SMI, because it would or might help in alleviating anxiety for some patients. Thus, the paper could be re-submitted.

Author Response

Thank you very much for your constructive review. The answers to your questions and comments are included in the attached file.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

I wish the authors well. 

Will need copyediting

Author Response

Dear reviewer,

We want to thank your constructive, helpful, and valuable reviewing work.  Thank you so much!

Best regards,

The authors

Reviewer 3 Report

I congratulate the authors for their effort in improving their manuscript, which I believe they significantly improved. However, before suggesting acceptance, I have a two minor comments. 

First, I suggest Table 1 to become supplementary material. 

Second, please check the results for confusing wording, for example "This means that the configuration of the sessions significantly influenced anxiety reduction, as illustrated in Figure 3". Significantly influenced does not suggest the flow (positive or negative) of the association and thus confuse the reader. Therefore, please check and rephrase the manuscript accordingly.

In conclusion, I think the manuscript has considerably improved, and I'm eagerly waiting for the final form, after these minor comments. 

I think the manuscript requires grammatical editing for example "In this study, we target a population of severe mental illness (SMI)...." This should have beed "targeted" since the study has already happened. Please check and fix throughout the manuscript.

Author Response

Dear reviewer,

Your constructive comments are very appreciated. 

We have corrected the issues that you pointed out.

We decided to keep Figure 1 to report the structure of the music therapy sessions in the paper itself. This has also been suggested by another reviewer.   

Thank you very much for your help in improving our work!

Best regards,

The authors