IntroductionSchizophrenia is a seve

Introduction
Schizophrenia is a severe mental disorder characterized by long duration, bizarre delusions, hallucinations, negative symptoms, and affective symptoms (Os & Kapur, 2009). Recently, 0.4% of the adult population was diagnosed as schizophrenia, and the median lifetime incidence was reported to be 15.2 per 100,000 (McGrath, Saha, Chant, & Welham, 2008). Schizophrenia is a treatable disorder, treatment being more effective in its initial stages. It is important for the patients to adhere to their treatment to yield better management of the disorder (World Health Organization, 2012).

During the recurrence of this long-term condition, chronic schizophrenia is accompanied by disorders of drive and volition, cognition, and affect, in addition to psychiatric symptoms (i.e., delusions or hallucinations). Chronic schizophrenia patients experience abnormal thinking and cognitive functioning (reality distortion), emotional difficulty (lack of responsiveness), and a decrease in social and problem-solving skills; thus, these individuals have serious dysfunction in self-management and social activities, making full recovery less likely (Kim, 2007; Os & Kapur, 2009; Stephane et al., 2008). Currently, antipsychotic medications are very important for the treatment of schizophrenia. However, impaired cognitive function and social dysfunction may continue even after drug treatment. Impaired cognitive function might be the cause of negative emotions and social dysfunction. Therefore, it is necessary to complement medication with psychosocial interventions. Recently, the development of effective treatments for targeting these cognitive deficits has been a priority.

Music therapy is one of the psychosocial interventions that can manage schizophrenic psychiatric symptoms and regression, as well as bring about improved social interaction and neurophysiologic function (Gold et al., 2009, Jung, 2011, Möesler et al., 2011, Peng et al., 2010). Music therapy can also affect physiological responses and activities within the nervous system, endocrine system, and cardiovascular system, consequently leading to mental and bodily stabilization, improved emotion, cognitive function and positive behaviors (Blood and Zatorre, 2001, Boso et al., 2006; Jung; Urich, Houtmans & Gold, 2007). In particular, music therapy can affect electroencephalography (EEG) brainwave activity, which is closely related to cerebral function (Fachner et al., 2013, Yang et al., 2012). According to Lundy-Ekman (2009)), the frontal lobe of the cerebral cortex is in charge of high-level cognitive, emotional, and mental functions, while the parietal lobe is for somatosensory function and spatial perception. In addition, the temporal lobe is in charge of auditory information processing, memory, and emotional function; the occipital lobe is for visual information processing and recognizing objects. Previous studies have reported that auditory stimulation of music acts on the cerebral cortex and limbic system through the thalamus and hypothalamus (Blood & Zatorre; Boso et al.). Of note is that in psychosocial aspects, music therapy by using musical interaction as a means of communication and expression can reduce psychotic symptoms, negative emotion (i.e., depression, anxiety) and the behavioural patterns of people with mental disorders (Gold et al.; Jung; Urich et al.).

Several studies have been conducted on the use of music therapy for patients with schizophrenia. Most previous studies, however, have focused on providing a short-term, single music activity, mainly for acute patients, utilizing small sample size, or examining the effects of psychotic symptoms solely by patients' self-assessments (Gold et al., 2009; Peng et al., 2010). Few data assess the outcome of music therapy by objective physiologic measures (Mӧesler et al., 2011). For chronic patients with schizophrenia who have frontal lobe damage and serious cognitive impairment resulting from chronic progression of the disorder, EEG would be more appropriate for assessing changes in cerebral functions as a result of music therapy.

Therefore, the present study developed the group music therapy by combining passive music therapy (listening to music) and active music therapy (playing musical instruments) based on previous studies. This paradigm was implemented with chronic schizophrenia patients to determine the effect of the therapy on behavior, physiological responses and cognitive function through EEG measurement. EEG is a noninvasive, useful neuroscience research method for measuring the functional state of the cerebrum in real time. As the EEG analyzes and quantifies the waveforms that occur on the surface of the brain, this method enables the analysis of human brain functions (i.e., thinking, cognition, emotion, & behavior). The present study aimed to explore if music could be utilized as a differentiated therapeutic intervention in clinical situations and community settings.


Purpose of study
The purpose of the study was to examine the effect of the group music therapy on brain waves, cognitive function, and behavior among patients with chronic schizophrenia.


Methods

Study design
A quasi-experimental pretest-posttest design was used with nonequivalent control group. The experimental group participated in the group music therapy twice a week for 7 weeks while continuing their standard treatment. The control group received nursing care including psychopharmacology, routinely provided in the hospitals.


Setting and sample
Participants were recruited from the inpatient ward in a psychiatric facility in a metropolitan city with the following inclusion criteria: (a) those who had been diagnosed with schizophrenia by a psychiatrist based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association, 2000) criteria for more than 2 years since the diagnosis, (b) adults over 20 years of age and who understood the purpose of this study and agreed to participate with a written consent, given the agreement from their parents or guardian, (c) those who had no acute psychotic symptoms and were able to perform verbal communication, (d) those who had no problem with hearing or doing other activities, (e) and those who did not have dementia or other brain injuries that may affect the outcome variables.

To determine the sample size, a significance level of .05, power of .80, and an effect size of .79 were set. The effect size was based on the meta-analysis with music therapy for cognitive function (Jung, 2011). Using the G*power 3.0 program (Faul, Erdfelder, Buchner, & Lang, 2009), the required sample was 16 patients for each group. Thus, 33 patients for the experimental group and 35 for the control group were selected, considering the potential dropouts. There were a total of four psychiatric wards in two separate buildings. The experimental and control groups were assigned according to the wards in which they were located to prevent the contamination of the treatment. The ward settings are relatively similar in terms of the types of therapy provided and man power allocation.

During the data collection process, 5 from the experimental group and 8 from the control group dropped out due to discharge from the hospital or declining to undergo the EEG measurement. Our final sample included 55 participants: 28 from the experimental group and 27 from the control group (19% dropout rates).


Ethical consideration
The present study was conducted after receiving approval (08-03) from the institutional review board at the school of medicine of the university. The recruitment of research participants was conducted through individual interviews with chronic schizophrenia inpatients that met the selection criteria. When the potential participants agree to take part in the study upon the agreement of their legal guardians, we asked them to sign the consent form. The purpose and procedures of the study were explained, including voluntary participation and withdrawal, as well as anonymous data collection solely for research purposes. Upon obtaining participants' written consent forms, the study proceeded.


Measurements

Brain wave
Brain wave was assessed by EEG spectra with a PolyG-1 (LAXTHA, Daejeon, Korea) by a trained professional researcher. Electrodes were attached to cortical sites on participants' prefrontal lobe (Fp1, Fp2), frontal lobe (F3, F4), temporal lobe (T3, T4) and parietal lobe (P3, P4) according to the international 10/20 system. Among several types of EEG waveforms, including the α, β, γ, δ and θ waves, only the α and β waves were measured since they are the key indicators of brain arousal and relaxation that showed significant results in previous studies (Kim, 2004, Lee, 2011, Lee, 2004, Ray and Cole, 1985; Yang et al., 2012). EEG measurement time varied depending on the purpose of the study and characteristics of participants. In this study, we recorded EEG waves for 6 minutes as required for obtaining stable waveforms, based on previous studies (Fachner et al., 2013; Yang et al.) and the results of pilot study from five patients with schizophrenia. Six minutes of EEG was recorded across eight channels before the experiment (at rest), and right after the experiment. Data were then converted through a fast Fourier transform. Finally, relative α wave and relative β waveforms were obtained and analyzed.


Cognitive function
Cognitive function was measured using the Mini-Mental State Examination (MMSE), a brief questionnaire developed by Folstein, Folstein, and McHugh (1975)). Lee and Shin (1993)) evaluated the validity and reliability of it for the Korean population with mental disorders. The MMSE is widely used in clinical practice as a tool to measure cognitive function among diverse populations, including those with schizophrenia. The MMSE consists of 19 questions with a total possible score of 30, and includes the following subcategories: orientation

ผลลัพธ์ (ไทย) 1:

แนะนำโรคจิตเภทเป็นโรคจิตรุนแรงโดยยาว delusions แปลกประหลาด เห็นภาพหลอน อาการลบ และผลอาการ (Os และ Kapur, 2009) ล่าสุด 0.4% ของประชากรผู้ใหญ่ถูกวินิจฉัยว่าเป็นโรคจิตเภท และมีรายงานอุบัติการณ์อายุมัธยฐานเป็น 15.2 ต่อ 100000 (McGrath บริษัทสห Chant, & Welham, 2008) โรคจิตเภทเป็นโรคคุดทะราด การเพิ่มประสิทธิภาพในขั้นตอนแรกของการรักษา มันเป็นสิ่งสำคัญสำหรับผู้ป่วยไปบำบัดให้ผลผลิตดีจัดการโรค (องค์การอนามัยโลก 2012)During the recurrence of this long-term condition, chronic schizophrenia is accompanied by disorders of drive and volition, cognition, and affect, in addition to psychiatric symptoms (i.e., delusions or hallucinations). Chronic schizophrenia patients experience abnormal thinking and cognitive functioning (reality distortion), emotional difficulty (lack of responsiveness), and a decrease in social and problem-solving skills; thus, these individuals have serious dysfunction in self-management and social activities, making full recovery less likely (Kim, 2007; Os & Kapur, 2009; Stephane et al., 2008). Currently, antipsychotic medications are very important for the treatment of schizophrenia. However, impaired cognitive function and social dysfunction may continue even after drug treatment. Impaired cognitive function might be the cause of negative emotions and social dysfunction. Therefore, it is necessary to complement medication with psychosocial interventions. Recently, the development of effective treatments for targeting these cognitive deficits has been a priority.Music therapy is one of the psychosocial interventions that can manage schizophrenic psychiatric symptoms and regression, as well as bring about improved social interaction and neurophysiologic function (Gold et al., 2009, Jung, 2011, Möesler et al., 2011, Peng et al., 2010). Music therapy can also affect physiological responses and activities within the nervous system, endocrine system, and cardiovascular system, consequently leading to mental and bodily stabilization, improved emotion, cognitive function and positive behaviors (Blood and Zatorre, 2001, Boso et al., 2006; Jung; Urich, Houtmans & Gold, 2007). In particular, music therapy can affect electroencephalography (EEG) brainwave activity, which is closely related to cerebral function (Fachner et al., 2013, Yang et al., 2012). According to Lundy-Ekman (2009)), the frontal lobe of the cerebral cortex is in charge of high-level cognitive, emotional, and mental functions, while the parietal lobe is for somatosensory function and spatial perception. In addition, the temporal lobe is in charge of auditory information processing, memory, and emotional function; the occipital lobe is for visual information processing and recognizing objects. Previous studies have reported that auditory stimulation of music acts on the cerebral cortex and limbic system through the thalamus and hypothalamus (Blood & Zatorre; Boso et al.). Of note is that in psychosocial aspects, music therapy by using musical interaction as a means of communication and expression can reduce psychotic symptoms, negative emotion (i.e., depression, anxiety) and the behavioural patterns of people with mental disorders (Gold et al.; Jung; Urich et al.).Several studies have been conducted on the use of music therapy for patients with schizophrenia. Most previous studies, however, have focused on providing a short-term, single music activity, mainly for acute patients, utilizing small sample size, or examining the effects of psychotic symptoms solely by patients' self-assessments (Gold et al., 2009; Peng et al., 2010). Few data assess the outcome of music therapy by objective physiologic measures (Mӧesler et al., 2011). For chronic patients with schizophrenia who have frontal lobe damage and serious cognitive impairment resulting from chronic progression of the disorder, EEG would be more appropriate for assessing changes in cerebral functions as a result of music therapy.Therefore, the present study developed the group music therapy by combining passive music therapy (listening to music) and active music therapy (playing musical instruments) based on previous studies. This paradigm was implemented with chronic schizophrenia patients to determine the effect of the therapy on behavior, physiological responses and cognitive function through EEG measurement. EEG is a noninvasive, useful neuroscience research method for measuring the functional state of the cerebrum in real time. As the EEG analyzes and quantifies the waveforms that occur on the surface of the brain, this method enables the analysis of human brain functions (i.e., thinking, cognition, emotion, & behavior). The present study aimed to explore if music could be utilized as a differentiated therapeutic intervention in clinical situations and community settings.

Purpose of study
The purpose of the study was to examine the effect of the group music therapy on brain waves, cognitive function, and behavior among patients with chronic schizophrenia.


Methods

Study design
A quasi-experimental pretest-posttest design was used with nonequivalent control group. The experimental group participated in the group music therapy twice a week for 7 weeks while continuing their standard treatment. The control group received nursing care including psychopharmacology, routinely provided in the hospitals.


Setting and sample
Participants were recruited from the inpatient ward in a psychiatric facility in a metropolitan city with the following inclusion criteria: (a) those who had been diagnosed with schizophrenia by a psychiatrist based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association, 2000) criteria for more than 2 years since the diagnosis, (b) adults over 20 years of age and who understood the purpose of this study and agreed to participate with a written consent, given the agreement from their parents or guardian, (c) those who had no acute psychotic symptoms and were able to perform verbal communication, (d) those who had no problem with hearing or doing other activities, (e) and those who did not have dementia or other brain injuries that may affect the outcome variables.

To determine the sample size, a significance level of .05, power of .80, and an effect size of .79 were set. The effect size was based on the meta-analysis with music therapy for cognitive function (Jung, 2011). Using the G*power 3.0 program (Faul, Erdfelder, Buchner, & Lang, 2009), the required sample was 16 patients for each group. Thus, 33 patients for the experimental group and 35 for the control group were selected, considering the potential dropouts. There were a total of four psychiatric wards in two separate buildings. The experimental and control groups were assigned according to the wards in which they were located to prevent the contamination of the treatment. The ward settings are relatively similar in terms of the types of therapy provided and man power allocation.

During the data collection process, 5 from the experimental group and 8 from the control group dropped out due to discharge from the hospital or declining to undergo the EEG measurement. Our final sample included 55 participants: 28 from the experimental group and 27 from the control group (19% dropout rates).


Ethical consideration
The present study was conducted after receiving approval (08-03) from the institutional review board at the school of medicine of the university. The recruitment of research participants was conducted through individual interviews with chronic schizophrenia inpatients that met the selection criteria. When the potential participants agree to take part in the study upon the agreement of their legal guardians, we asked them to sign the consent form. The purpose and procedures of the study were explained, including voluntary participation and withdrawal, as well as anonymous data collection solely for research purposes. Upon obtaining participants' written consent forms, the study proceeded.


Measurements

Brain wave
Brain wave was assessed by EEG spectra with a PolyG-1 (LAXTHA, Daejeon, Korea) by a trained professional researcher. Electrodes were attached to cortical sites on participants' prefrontal lobe (Fp1, Fp2), frontal lobe (F3, F4), temporal lobe (T3, T4) and parietal lobe (P3, P4) according to the international 10/20 system. Among several types of EEG waveforms, including the α, β, γ, δ and θ waves, only the α and β waves were measured since they are the key indicators of brain arousal and relaxation that showed significant results in previous studies (Kim, 2004, Lee, 2011, Lee, 2004, Ray and Cole, 1985; Yang et al., 2012). EEG measurement time varied depending on the purpose of the study and characteristics of participants. In this study, we recorded EEG waves for 6 minutes as required for obtaining stable waveforms, based on previous studies (Fachner et al., 2013; Yang et al.) and the results of pilot study from five patients with schizophrenia. Six minutes of EEG was recorded across eight channels before the experiment (at rest), and right after the experiment. Data were then converted through a fast Fourier transform. Finally, relative α wave and relative β waveforms were obtained and analyzed.


Cognitive function
Cognitive function was measured using the Mini-Mental State Examination (MMSE), a brief questionnaire developed by Folstein, Folstein, and McHugh (1975)). Lee and Shin (1993)) evaluated the validity and reliability of it for the Korean population with mental disorders. The MMSE is widely used in clinical practice as a tool to measure cognitive function among diverse populations, including those with schizophrenia. The MMSE consists of 19 questions with a total possible score of 30, and includes the following subcategories: orientation

ผลลัพธ์ (ไทย) 3:

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