EFFECT OF MUSIC MEDICINE ON ANXIETY AND DEPRESSION IN CORONARY ARTERY BY PASS GRAFT SURGERY PATIENTS: A RANDOMISED CONTROLLED TRIAL

1. Assistant Professor, B.K.L Walawalkar Medical College, Sawarde Chiplun Maharashtra. India. 2. Professor/ HOD, Department of Physiotherapy, MCOHAS Manipal. India. 3. Chief Consultant Cardiothoracic Surgeon, Nawaloka Hospital, Colombo, Sri Lanka. 4. Associate Professor, Shri Guru Ram Rai Institute of Medical & Health Sciences, Patel Nagar Dehradun, Uttrakhand. India. 5. Professor/ HOD, Department of Physiotherapy Manipal Hospitals Bangalore. India. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 25 November 2019 Final Accepted: 27 December 2019 Published: January 2020

The prevalence of depression in patients with diagnosed CHD is quoted between 20-45%. Elevated anxiety scores have been reported for 20 to 55%. The same prevalence ratios have been found for patients undergoing CABG surgery. 5 & 6 Music has been used in different medical fields to decrease anxiety and depression. 8,9,10,11 Music is a combination of rhythmical, harmonic and melodic sounds, and many peoples, throughout history, have believed in its medicinal effects. It's a systematic intervention process in which a therapist helps patients to improve health, utilizing musical experiences and the relationships that develop through them, such as dynamic forces of change. 7 & 12 The pilot study was done on post CABG patients and according to this study, listening to music shortened the average amount of time patients spent in ICU postoperatively by more than 5 hours. 13

Aim of the Study:
The aim of the study is to find the effect of music medicine on anxiety and depression in Coronary artery bypass graft patients.

Review of Literature:
Gallagher R, McKinley S. (2007) study was done on stressors & anxiety in patient undergoing CABG .172 patients were interviewed to determine their concern and anxiety levels before surgery, before discharge & 10 days after discharge and they found that anxiety levels did not change from before to after surgery and hence they concluded that patients waiting for CABG should be routinely assessed for anxiety before the procedure and interventions to prevent or reduce anxiety should be provided. 4 Szekely A, Balog DP and Benko E, (2007) et al study was done on to find the long term effect of anxiety & depression on outcomes after cardiac surgery. Total no. of 180 patients who underwent cardiac surgery studied and followed up for 4 years. 14 Bradt J, Dileo C (2009). A Cochrane review on stress and anxiety reduction in coronary heart disease patient was done and it states that no evidence for anxiety reducing effect of music was found for the patients undergoing cardiac procedures also no evidence of effect of music for depression was found. 2

Procedure:
An approval from the time bound Ethical Committee was obtained before commencing the study. Subjects were screened for inclusion and exclusion criteria. All subjects meeting the selection criteria were given a detailed explanation about the purpose, method and benefits of the study and a written informed consent was obtained (Appendix 1 and 2). A briefing was given to the family members about the purpose and the method of the study.
Subjects enrolled in the study were assigned to 2 groups, 35 in each group (Experimental group receiving music medicine with standard care in form of chest physiotherapy & Control group with standard care alone, using block randomization. The total duration of intervention for the study was 1 month. 1. Supervised -1 week duration (hospital stay) 2. Unsupervised -4 weeks duration (home programme) Demographic data and baseline assessment of subjects was done prior to starting the intervention. (Appendix 5) Completed study (n=69) Subjects were given the following instructions prior to starting the intervention:

Flow Diagram for Randomization of Patients in the study
1. Subject's should'nt eat a heavy meal/ingest caffeine/alcohol 2hrs prior to session.
2. Subject's should'nt participate in vigorous exercise or activity 1hr prior to session. 3. To inform the experimenter of any other use of prescription or non-prescription drugs. 4. Patient can discontinue listening music at any time if he/she is not feeling comfortable.

Experimental Group
Patients were asked to fill a questionnaire related to their music preferences. (Appendix 4) Accordingly, they were provided with a collection of non-lyric Indian classical instrumental music from which they had to select one record of their choice. The factors of rhythm, tempo & pitch of the music used were taken care of. The collection was of 60-80 beats per minute, known to have relaxing effect. Patients were explained and were asked to fill self report Hospital Anxiety and Depression scale questionnaire (Appendix 3). Patients were made to lay down comfortably in supine position and baseline values of BP, RR, HR, test values at rest were measured by an independent observer (on duty nurse) who was blinded to the study.
Music was provided by means of an audio mp3 player with headphones with a collection of different types of non lyrical music (instrumental) having tempo of 60-80 beats per minute, from which patient chose the desired music.
Once the player was switched on, subjects were asked to clear their thoughts and focus their mind on the music with eyes closed for minimum of 30 minutes. Patients also received routine standard chest physiotherapy following CABG including, vibration, deep breathing exercises, incentive spirometry, active limb movements, positioning and ambulation. Patient continued listening to music and if he/she wished, after 30 minutes music player was switched off.

Treatment:
Twice dailyeach music session consisting of 30 minutes. 1. Supervised-1week duration (hospital stay) 2. Unsupervised -1 month duration (post-discharge) A diary was provided to record in it if subjects have listened 30 minutes of music twice a day. Every week patients were reminded of and checked by telephone if they were continuing listening to music.

Control group:
Base line assessment of pulse rate, respiratory rate, blood pressure was done. Subjects included in this group received standard care alone as in the experimental group.
Pre and post intervention measures of anxiety, depression were taken on the 1 st day of the admission & after 1 month of follow up and HR,BP,RR were measured on the day of admission, and the day of discharge. Following discharge, subjects were given same cassette/CD so as to continue to listen music at home. .
After 1 month, subjects were asked to come for a follow-up and the HADS questionnaire for anxiety, depression was explained again and asked to fill by the patients.       Bonferroni test was done to do comparision within group from pre to discharge.Results in music group were not significant (p=0.17) but, in control group change was significant in terms of increase in heart rate from pre to discharge. (Table 7   Bonferroni test was done to do comparision within group from pre to discharge. In music group results showed highly significant from pre to discharge (p=0.00) and in control group pre to discharge it was significant (p=0.00). (Table 9)  .63 0.00* *Highly significant (P≤ 0.05) Bonferroni test was done to compare Systolic BP within groups from pre to discharge. Results in music group were highly significant from pre to discharge (p=0.00) also results in control group pre to discharge were highly significant (p=0.00) ( Table 11)    Bonferroni test for within group comparision of Diastolic BP within groups from pre discharge. Results in music group were highly significant from pre to discharge (p=0.00) also in control group pre to discharge was highly significant (p=0.00) ( Table 13)   Bonferroni test was used to see change in anxiety from pre to 1 month which showed highly significant change in music group (mean diff =6.82) (p=0.00) as compared to control group (mean diff= 0 .23) (p=0.62). (Table 15)

Depression:
Two way ANOVA for repeated measures was applied to analyze depression pre and after 1 month follow up which showed highly significant results. Difference between pre and after 1month follow up [F=14.91, p= 0.00] as well as difference between groups [F=33.53, p= 0.00] (Table 16).

Discussion:-
Our study aimed to find the effect of music medicine on anxiety, depression and the physiological variables HR,RR,BP in CABG patient. The study showed that anxiety and depression level reduced significantly in CABG patients who listened to music postoperatively and during one month of follow up as compared to control group. Physiologic measures (SBP,HR,RR,) also showed significant mean change between groups,but no significant change was seen in DBP.

Effect of Music on Anxiety & Depression
Our study showed a significant reduction in anxiety and depression levels post music intervention compared to control group. The current study used non lyrical music which was administered for 30 minutes twice daily till hospital stay by means of headphones and continued for 1 month following discharge.
In our study there were no differences at baseline for anxiety and depression between groups. Following music intervention there was a mean change of 6.8 in anxiety for HADS in music group where as this change was only 0.2 in control group. Results of our study were considered significant in accordance with mean differences of 2.1 in the earlier study. 15 Effect of Music on Physiological Variables HR, RR, BP In the current study, SBP change by 17.11 in music group and 8.4 in control group. At discharge the mean change in SBP between groups was 8.7. There was reduction in SBP in both the groups. This was similar to the earlier studies. 17,18 which was further clinically significant according to Benson that minimum change for relaxation response is when reduction in SBP is by 5mmHg. 16

Limitations:
1. Presence of nurse in the room during the music session as interruption to music intervention, also duration of music listened by patients might vary as minimum duration of music session was of 30 minutes twice daily, during hospital stay and 1 month follow up, but maximum duration of music listened by the individual subject was not calculated which might have effect on the outcome variables. 2. Reliability of patients listening music at home can also be questioned.

Conclusion:-
The study concludes that music medicine is an effective non pharmacological measure in reducing anxiety and depression along with physiological measures in patients undergoing coronary artery bypass graft surgery.