Active musical engagement and subjective levels of stress, anxiety and depression in the area of Piraeus

ACHAIKI IATRIKI | 2024; 43(2):74-81

Original Research Article

Maria Sourgiadaki¹, Xenophon Sinopidis², Philippos Gourzis³, Eleni Jelastopulu⁴

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¹Public Health, University of Patras, Patras, Greece
²Department of Pediatric Surgery, School of Medicine, University of Patras, Patras, Greece
³Department of Psychiatry, School of Medicine, University of Patras, Patras, Greece
⁴Department of Public Health, School of Medicine, University of Patras, Patras, Greece

Received: 08 Jan 2024; Accepted: 07 Feb 2024

Corresponding author: M. Sourgiadaki, Meg.Spilaiou 26, Aigio, 25100, Tel.: 6973359419, e-mail: mariathodoris@gmail.com

Key words: Active musical engagement, stress; anxiety, depression, DASS21, Greece

 

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Abstract

Background and Aim: Numerous studies have been conducted on the relationship between music and mental health, demonstrating its positive correlation with the promotion of well-being and prosperity. However, there is a lack of research on the impact of active musical engagement on the mental health of the population. The aim of this study was to investigate the effect of active musical engagement on the mental health of residents in Piraeus.

Methods: A cross-sectional study was conducted on a convenience sample of adults, using questionnaires distributed through social networks. The questionnaires included demographic and socio-economic questions, as well as inquiries about musical engagement and the Greek version of the DASS-21 questionnaire.

Results: A total of 377 individuals participated, of which 78% were Piraeus residents, and 61.6% of them were female. Absence of depression was reported by 65.3% of Piraeus residents, while the corresponding percentages for absence of anxiety and stress were 72.1% and 62.2%, respectively. Women exhibited higher mean scores for depression, anxiety, and stress compared to men. Individuals engaging in musical activities, either in professional or amateur capacity, lower levels of depression, anxiety, and stress compared to people who did not engage in music actively.

Conclusion: The study highlights the positive impact of active musical engagement, particularly on anxiety levels. Factors influencing depression, anxiety, and stress include gender, family status, and living arrangements.

INTRODUCTION

According to the World Health Organization (WHO), mental health is recognized as a critical component of overall well-being. It is considered one of the four domains that constitute quality of life [1], a multidimensional concept encompassing an individual’s physical health, social relationships, environmental factors and the individual’s ability to perform activities and participate in meaningful activities.

Mental health problems increased globally by 13% during the period 2007-2017, affecting 1 in 5 years lived with disability [2]. On a global scale, approximately 5% of adults suffer from depression, with serious consequences such as suicide [3,4]. Particularly in Greece, 3.8% of the population in 2019 reported experiencing depression, with women being more affected. The positive result is that a percentage of around 4.1% visited a psychiatrist or psychologist for the mental health issues they were facing [5].

Anxiety is the normal response of the human organism to stress, as a mechanism of mental defense, and is a natural part of the human experience. However, its excessive and long-standing expression can lead to generalized anxiety disorder [6,7]. The term “stress” is used to describe the effects of physical or mental pressure on the organism, with chronic stress being linked to autoimmune diseases, depression, and worsening of other psychopathological conditions [7]. Depression, as a mood disorder, is often associated with anxiety and stress and can lead to serious consequences such as suicide [7–9].

The management of the above mentioned mental disorders typically involves the use of psychotropic medication and/or psychological treatment [3,4]. However, according to modern perspectives, new, complementary approaches are also being explored, primarily through artistic engagement [10,11], recognizing it as an effective tool for regulating emotions and promoting well-being.  Engagement in artistic activities, whether receptive involvement (e.g., listening to music, attending theater, visiting museums, etc.) or active participation (e.g., playing a musical instrument, composing songs or music, singing, etc.) [12,13] has been shown to be associated with the reduction of depression and anxiety, emerging as an approach related to positive outcomes for mental health [11].

Music has been recognized as an effective tool for regulating emotions and promoting well-being [10,11]. Active musical engagement has been recognized as an accessible and effective tool for improving mental health, addressing concerns, and reducing social isolation [9–12,14–23]. It is associated with positive outcomes for individual health and well-being, as well as social functioning [24]. To our knowledge, in only two studies [14,25] the professional musician status was correlated with increased incidents of mental health disorders, as well as high rates of depression and suicides. Despite efforts to explore the correlation between music and mental well-being in the Greek context, no results have as yet been reported.

The purpose of the current study was to investigate whether adults residing in Piraeus who actively engage in music perceive themselves to have lower levels of stress, anxiety, and depression in their daily lives compared to those who are not actively involved. As a secondary objective, the study aimed to correlate and quantify the time spent on musical engagement in relation to the reduction or non-reduction of daily anxiety, stress, and depression, according to the participants’ subjective opinion.

MATERIALS AND METHODS

A cross-sectional quantitative study was conducted using anonymous electronic surveys through Google Forms. The sample consisted of adults aged 18 and above, healthy men and women, residents of Piraeus. Responses were collected from individuals actively involved in music and those not actively involved, allowing for a comparison of results. The number of participants was determined using the Raosoft sample size calculator, resulting in a sample size of 377 individuals. After the approval by the Ethics Committee of the University of Patras (10.07.2023/15484), and the necessary permissions were granted for using the DASS-21 questionnaire, the surveys were distributed on social media platforms and were completed between April 3, 2023, and May 5, 2023. The collected data were statistically analyzed using IBM SPSS (Superior Performance Software System) 26 for Microsoft Windows, using T-test (2 tailed), one way ANOVA test and multiple regression F-test for correlation of depression, anxiety, and stress.

The questionnaires comprised two parts. The introductory section included a paragraph informing participants about the purpose of the study and the anonymity and confidentiality of their responses. The first part of the questionnaire included 6 demographic questions and 5 questions regarding active musical engagement.

The second and final part included 21 questions related to perceived anxiety, stress, and depression using the Greek standardized DASS-21 questionnaire. This is a brief form of the DASS42 by Lovibond, S.H. & Lovibond, P.F. (1995), measuring the severity of a range of symptoms common to anxiety, stress, and depression. The Greek validated translation [26], was used after obtaining necessary permission from the authors, following the questionnaire’s usage manual [7].

During the completion of the DASS-21, the individual had to indicate the presence of a symptom during the previous week. Each item is scored from 0 (did not apply to me at all in the last week) to 3 (applied to me very much or most of the time last week). The scale has three subscales, each one consisting of 7 items designed to measure depression, anxiety, and stress.

The Depression scale assesses dysphoria, hopelessness, life devaluation, self-deprecation, lack of interest/participation, anhedonia, and inertia. The Anxiety scale evaluates autonomic nervous system arousal, skeletal muscle effects, situational anxiety, and the subjective experience of anxious feelings. The Stress scale is sensitive to levels of chronic non-specific arousal. It assesses difficulty relaxing, nervous arousal, being easily upset/disturbed, being irritable/over-reactive, and impatience [7].

Depression is considered absent when its DASS score is between 0-9, mild when 10-13, moderate when 14-20, severe when 21-27 and extremely severe when it exceeds 28+. Anxiety is considered absent when its DASS score is between 0-7, mild when 8-9, moderate when 10-14, severe when 15-19 and extremely severe when exceeds 20+, respectably. Similarly, stress is considered absent when its DASS score ranges between 0-14, mild between 15-18, moderate between 19-25, severe between  26-33 and extremely severe when exceeds 34+.

RESULTS

A total of 377 individuals aged 18 and above participated in the study, with the largest percentage (36.3%) belonging to the age group of 36-45 years. Among these participants, 78% identified themselves as residents of Piraeus (Table 1). The results of the DASS-21 for Piraeus residents indicated that 9.9% have mild depression, 10.9% moderate depression, 9.5% severe depression, and 4.4% extremely severe depression. In the anxiety subscale, 4.8% reported mild anxiety, 9.5% moderate anxiety, 6.8% severe anxiety, and 6.8% extremely severe anxiety. Regarding stress, 11.2% reported mild stress, 16.3% moderate stress, 8.2% severe stress, and 2% extremely severe stress (Fig.1). Of the Piraeus residents 61.6% were women. Women showed higher mean scores for depression, anxiety, and stress compared to men (10.42 vs 7.77, p_d=0.019; 8.14 vs 4.55, p_a=0.003; 14.53 vs 11.17, p_s=0.00, respectively) (Table 2).

Figure 1. Prevalence of Depression, Anxiety and Stress in Piraeus residents assessed by DASS-21 (n=294).

The T-test and one-way ANOVA statistical analyses revealed statistically significant differences in the occurrence of depression and stress between residents of Piraeus and those living outside Piraeus (Table 3). Additionally, they showed that widowed individuals exhibit higher scores in depression, anxiety, and stress, while married individuals have lower scores (24.40 vs 7.06; 25.20 vs 5.55; 26.80 vs 11.57, respectively; p=0.00) (Table 4). Furthermore, people living with parents or other relatives exhibited higher depression scores compared to other living arrangements (Table 5). People actively engaging in music had significantly lower anxiety levels compared to those not actively involved in music (4.11 and 5.72 vs. 7.74, respectively, with p=0.04), while no difference was observed in depression and stress levels between amateur and professional musicians (Table 6).

Regarding age, educational level, and family monthly income, no statistically significant difference was observed in the mean scores of depression, anxiety, and stress. The type of active musical engagement (singing, composing music or songs, choir, or musical group), the type of instrument (wind, percussion, or string), or the time spent on engagement per week did not play a role in any of the levels of mood disorders. According to the F-test in a multiple regression ANOVA table, it is indicated that depression, anxiety, and stress are positively correlated with each other.

DISCUSSION

The overall results of the study both agree and disagree with various studies from the existing literature. Our study showed that women report higher levels of symptoms of anxiety, stress and depression than men. This statistically positive correlation between gender and mood disorders is in agreement with data previously reported [27], especially when discussing gender and stress [25]. Furthermore, in line with prior research [28], it is suggested that women tend to participate more in creative activities (including active musical engagement) to regulate their emotions, while men are  inclined  to use music for cognitive purposes [29]. This could also possibly account for the elevated levels of depression, stress, and anxiety observed in women in our current study.

Additionally, the higher scores in women are consistent with the existing literature [27], which indicates that female professional musicians commonly experience more frequent mental health issues, possibly due to challenges such as gender discrimination, lower compensation compared to male counterparts, and the juggling of family responsibilities. Our study indicates this also.

Furthermore, there is agreement between the study results and other research [29], which suggests that certain mental health disorders, such as anxiety disorders, depression, bipolar disorder, etc., are likely explained by common genetic or environmental factors. In the current study, a possible connection might exist between living arrangements and the levels of depression, stress, and anxiety, especially for individuals still living with parents or relatives, who exhibit higher rates. This could be attributed to the sense of responsibility for caring for these relatives or the perceived inability to achieve independence.

The results of the current research  are consistent  with studies indicating that family status plays a role in self-reported symptoms of depression, stress, and anxiety, particularly for individuals who are widowed [11,23]. Both literature and our study suggest that active musical engagement benefits an individual’s mental health, providing protection against stress and depression. Simultaneously, it fosters a sense of purpose in life, boosts self-confidence, enhances positive overall life emotions, and provides post-bereavement support, while significantly reducing anxiety symptoms.

Education in performing artistic activities and regular engagement in them are associated with an individual’s ability to use artistic activities for emotion regulation and mental health management [27,30]. Musical engagement, including active music creation (playing an instrument, singing), influences social and emotional development throughout an individual’s life [31],  improving mood symptoms and cognitive functions [32]. The current study’s results are consistent with the finding that professionals and amateur musicians have lower levels of the studied emotional disorders, as they are the ones regularly engaged in music, although the time of engagement does not play a role in the rates among musicians.

Another study has suggested that individuals, especially women, with lower socio-economic status use artistic creative activities to regulate their emotions [33], which does not seem to be the case in the present study. In contrast, in this research, symptoms of depression, anxiety, and stress do not appear to be associated with economic and educational demographic factors. Moreover, musical studies and knowledge in Greece is costly to the family budget and therefore tends to be directed towards higher social classes.

Other studies [10–12] have demonstrated that individuals who actively engage in music report  lower anxiety levels, which is in complete agreement with the results of the present study, as statistically significant differences in anxiety levels were observed between people actively engage in music, compared to people who do not. Although there was no statistically significant difference in depression and stress levels, a trend of lower percentages in professionals and amateur musicians was noted.

The results of our study seem to be at odds with a study [14] which suggests that individuals who actively play a musical instrument (but not necessarily professionally) may have a somewhat increased risk of mental health problems. There seems to be some inconsistency in the beneficial effects of music on daily life and mental health between professional musicians and the high rates of depression and suicides among them, possibly due to the highly competitive and stressful professional environment, something that has not been observed in our research Moreover, our results contradict with the results of a previous study [25], which indicated that musical education did not reduce the relationship between mood regulation related to music and psychopathology..

According to all the above, marital status plays a role in all disorders, as well as gender, with women having higher levels as opposed to men. Being Piraeus’ citizens possibly leads to lower levels of depression and stress and living with parents or other relatives may lead to higher levels of depression, probably because of lack of independence. Age, educational level and monthly family income did not correlate with the levels of mood disorders.

To conclude, musical engagement seems to play a role in decreasing anxiety and could be protective against symptoms of depression and stress. Active music engagement seems to be a promising way to enhance an individual’s mental health and well-being, resulting in their total everyday function.

LIMITATION

Given that the study sample is not random but convenience-based, inherent bias in the study implies that the sample is unlikely to be representative of the population. As a result, generalizations from the sample to the studied population should be made with caution. The questionnaires were distributed and answered electronically, so only individuals with access to electronic devices and social media accounts could participate. A future prospective, longitudinal randomized controlled trial study could answer reliably whether musical engagement could be beneficial on mood disorders. Additional emphasis on objective measures, such as blood pressure and heart rate, during interactions with music is necessary to ascertain its beneficial effects in daily life and its potential as a complementary method of mood regulation.

Acknowledgements: We thank all the people who took the time to fill in the questionnaire, Dr. Lyrakos for giving the permission to use the validated Greek version of DASS-21 and all the professors of Department of Public Health, School of Medicine, University of Patras, for the given opportunity to finish the MSc on Public Health. 

Conflict of interest disclosure

None to declare

Declaration of funding sources

This research was conducted as part of a master’s thesis, and there was no funding for its completion.

Author contributions

Conceptualization, M.S. and E.J.; methodology, M.S. and E.J.; data curation, analysis, and interpretation M.S.; writing – original draft preparation, M.S.; writing – review and editing, M.S. and E.J.; supervision, E.J., X.S., P.G.; All authors have read and agreed to the published version of the manuscript.

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