The Immediate Effect of African Drumming on the Mental Well-Being of Adults With Mood Disorders: An Uncontrolled Pretest

Abstract

OBJECTIVE. This pilot study is the first to examine the effects of an occupational therapist–led African drumming group on mental well-being among adult psychiatric inpatients with mood disorders.

METHOD. We used a quasi-experimental, uncontrolled, one-group, pretest–posttest design. We collected data for six different drumming groups (N = 13) using the Stellenbosch Mood Scale, the Primary Health Questionnaire–9, the Generalized Anxiety Disorder–7 scale, and the Enjoyment of Interaction Scale.

RESULTS. Participants significantly improved on all six domains of the Stellenbosch Mood Scale, with a large clinical effect. Participants with higher self-reported anxiety and depression benefited the most. According to the Enjoyment of Interaction Scale results, all the participants enjoyed the drumming “a great deal.”

CONCLUSION. Our positive findings suggest that drumming may be an effective intervention for adults with acute mood disorders. We recommend further research that uses a control intervention.

Drumming is one of the creative activities used by occupational therapists to promote recovery in mental health (Müllersdorf & Ivarsson, 2012). We define drumming as the rhythmic beating or tapping of a variety of percussion instruments, which often occurs within a group setting. This treatment modality is being widely used within several state hospitals and private clinics in the Western Cape, South Africa. On the basis of our own experience, we believe African drumming has the potential to be a culturally relevant and highly adaptable activity to promote mental well-being.

A systematic review has provided moderate evidence that actively engaging in musical activities improves mental well-being among adult psychiatric inpatients (Carr et al., 2013). Nevertheless, in an extensive literature review, we found only two articles that evaluated drumming as an intervention with acute psychiatric inpatients. In Silverman and Marcionetti’s (2004) pretest–posttest, no-control study among psychiatric inpatients, drumming was one of the five types of music therapy that had a positive effect on mental health outcomes. However, the study did not report actual improvement on any of the measures for drumming group participants. In a subsequent randomized controlled trial, Ulrich et al. (2007) investigated the benefits of playing rhythm instruments for inpatients with schizophrenia. They found that the experimental group reported better psychosocial functioning and displayed fewer negative symptoms.

However, three studies have provided limited evidence that drumming increases positive feelings and emotions, and reduces anxiety and stress, among healthy adults. Mungas and Silverman (2014) conducted a pretest–posttest study with a control group to determine the effect of a single drumming session on the affective states of university students in Minnesota (N = 50). The study found considerable differences in improved mood between the intervention (drumming) and control (guitar-playing) groups.

In another study, Smith et al. (2014) investigated the effect of drumming as a moderate-intensity exercise on hypertension, stress, and anxiety with 35 students and middle-aged adults in South Africa. That study found an improvement in stress and anxiety status immediately after the drumming session for both groups.

Gingras et al.’s (2014) study differs because drumming was used as a receptive music activity. In their randomized controlled trial with 39 healthy participants, they found that only 15 min of listening to either drumming or meditation music while lying supine reduced salivary cortisol concentrations, and therefore levels of stress, among all participants. Similar to Silverman and Marcionetti (2004), the positive effect on stress occurred regardless of the type of music therapy.

The lack of evidence supporting the use of drumming with acute adult psychiatric inpatients suggests that further research is needed. The purpose of this pilot study was to determine whether African drumming used as a routine part of clinical practice contributed to immediate improvement in mental well-being. The following research question guided our study: “What are the immediate effects of an occupational therapy–led drumming group on mental well-being for adults with mood disorders admitted to a private clinic in the Western Cape, South Africa?”

Method

Research Design

We used a quasi-experimental, pretest–posttest design with no control group. Because of the numerous threats to internal validity inherent in this design, this design is only appropriate for use in pilot or exploratory studies, such as ours, in preparation for future research (Kielhofner, 2006).

Participant Selection

The study was conducted at one private mental health clinic in the Western Cape, South Africa. The occupational therapy program in the clinic is delivered 5.5 days/wk (Monday–Saturday) from 9:00 a.m. to 4:30 p.m. The program includes a variety of therapeutic group activities, including life skills, arts and crafts, and relaxation groups. Drumming groups are facilitated as part of the standard package of occupational therapy intervention, twice per week. Participation at all occupational therapy sessions is voluntary, and the number of participants varies each day. In addition, inpatients are treated by other multidisciplinary team members according to their individual needs. Services may include psychiatry (including drug therapy), psychology (including cognitive–behavioral therapy and other types of counseling), and mental health nursing. The maximum length of stay at the clinic is 21 days.

Participants were recruited by the occupational therapists via convenience sampling at six different drumming groups held twice per week over 3 wk. Each participant completed the research questionnaire at one of the six drumming groups held over the 6-wk period of this study. Inclusion criteria were that participants had chosen to participate in the drumming group, were inpatients at the clinic, were age 18 yr or older, and were able to give consent. Inpatients with active psychosis, who were unable to give informed consent, were excluded.

Procedure

Each drumming session lasted for 45 min. All drumming sessions were cofacilitated by the two occupational therapists working at the clinic. The occupational therapists applied Cole’s (2012) seven-step format for activity groups throughout the group program at the clinic. The drumming intervention also followed the 360 Drum/Rhythm Circle Facilitation Method (Bevil Spence, personal communication, October 2014). This process includes the following six steps:

Set up.

Introduction and warm up—Group members are introduced and familiarized with the drums using small movements. This step allows the therapist to establish the climate and therapeutic needs of the group.

Rhythm time—This step begins with the introduction of simple rhythms and methods of drumming, moving toward more complex interaction.

Expression—A space is created for individual expression using drums, participants’ voices, and other percussion instruments.

Wind up or wind down—Speed and volume are used to bring the group to the climax of the session. This step may include either energizing or relaxing the group, depending on the therapeutic needs of participants.

Closure—This step includes discussion of participants’ experiences of being in the group and how their learning can be applied to other situations.

During each drumming session, the occupational therapists adapted the rhythms, instruments, and expressive techniques to meet the therapeutic needs of the participants. We decided to capture data across multiple groups so that the way in which a group was facilitated on a single day did not become a confounding factor within the study.

Data Collection

Warr (1990) argued that the affective dimensions of depression–enthusiasm and anxiety–contentment are important contributors to well-being. For this reason, we selected the Stellenbosch Mood Scale (STEMS; Terry et al., 2003) as our primary outcome measure. This tool is a dual-language version of the Brunel Mood Scale (Terry et al., 1999, 2003), which is widely used in sport psychology. The 24-item self-report scale asks participants to best describe how they feel “right now” across six domains of Tension (α = .78), Anger (α = .73), Confusion (α = .82), Depression (α = .84), Fatigue (α = .84), and Vigor (α = .86; Terry et al., 2003). Participants rate their immediate feelings on a 5-point scale ranging from 0 (not at all) to 4 (extremely).

One advantage of this tool in our research was that it is available in English and Afrikaans, the two languages predominantly spoken by clients at the clinic. Confirmatory factor analysis supports the validity of the English and Afrikaans versions of the tool (Terry et al., 2003). In addition, the STEMS is norm referenced for South Africa (Van Wijk, 2011). The tool also takes about 3 min to complete, making it a useful measure in the clinical context of this study.

The occupational therapists distributed self-report questionnaires immediately before and after the drumming session. Before the intervention, we administered the STEMS, the Generalized Anxiety Disorder–7 scale (GAD–7; Spitzer et al., 2006), and the Primary Health Questionnaire–9 (PHQ–9; Inoue et al., 2012). Participants also completed four questions related to their exposure to drumming and music as therapeutic and leisure activities. After the intervention, participants completed the STEMS again.

They also completed the 4-item Enjoyment of Interaction Scale (Sprecher et al., 2013). Each item was rated on a 7-point scale ranging from 1 (not at all ) to 7 (a great deal ). Although this tool was initially developed for a study of initial interactions, we felt the self-report questions about laughter (“How much did you and the others laugh in the session?”) and fun (“How much fun was the session?”) added important information about their experience that was not captured by the STEMS. This tool has demonstrated good internal consistency across two studies (αs = .84 and .85, respectively; Sprecher et al., 2013). Regular interaction between the researchers and the occupational therapists throughout the research process enhanced the fidelity of the data collected.

Data Analysis

The researchers analyzed the data at a separate location and without input from the occupational therapists who collected the data. Data were analyzed with IBM SPSS Statistics (Version 22; IBM Corp., Armonk, NY). Differences in components of mental well-being immediately before and after the intervention were determined with paired t tests for each domain (Field, 2009). Effect sizes were calculated with Cohen’s r (Field, 2009). An effect of >.5 was considered large. We planned to establish the relationship between mental well-being after the session and enjoyment of the session. However, the Enjoyment of Interaction Scale data were so skewed that only descriptive analysis was feasible. Differences in mental well-being before the session between participants who had previously participated in drumming at the clinic and those who were drumming for the first time were analyzed with multivariate analysis of variance. The relationship between mood (depression and anxiety) over the past 2 wk and change in mental well-being was analyzed with one-way analysis of variance. The significance level for all analyses was set at .05, and confidence intervals were set at 95%.

Ethical Issues

This research was approved by the Stellenbosch University Health Research Ethics Committee (Reference S15/02/022). Permission was also granted by the board of the clinic where the research was conducted.

Results

Participant Demographics

Fourteen mental health care users agreed to participate in the study. One of these participants completed none of the STEMS items and was excluded from further analysis. The age of the remaining 13 participants ranged between 33 and 69 yr (mean [M] = 45.38, standard deviation [SD] = 11.48; Table 1). More women (n = 10) than men (n = 3) participated. Almost half the participants were of mixed ethnicity (n = 6), whereas the remaining participants were White (n = 7). All of the participants presented with a mood disorder. Nine participants were diagnosed by their medical practitioner with depression. Of these, most had a recurrent major depressive disorder (n = 7). The other 2 participants were experiencing a single episode of major depression. The other 4 participants were diagnosed with bipolar mood disorder. Of these participants, 2 were experiencing a mixed episode, and 2 were unspecified.

Table 1.

Demographic Characteristics of Adult Participants With Mood Disorders (N = 13)

Characteristic	n (%)
Gender
Male	3 (23)
Female	10 (77)
Ethnicity
Mixed ethnicity	6 (46)
White	7 (54)
Diagnosis
Bipolar mood disorder, unspecified	2 (15)
Bipolar mood disorder, current episode mixed	2 (15)
Major depressive disorder, single episode	2 (15)
Major depressive disorder, recurrent without psychosis	7 (54)
Mean age, yr (SD), range	45.38 (11.48), 33–69

Note. Percentages may not total 100 because of rounding. SD = standard deviation.

According to the GAD–7, most participants were experiencing a severe level of anxiety (M = 16, SD = 5.05, range = 5–22) immediately before the intervention. Most participants were also experiencing a severe level of depression (PHQ–9) immediately before the intervention (M = 18.77, SD = 6.72, range = 3–27). Most participants did not engage in music (n = 9) or drumming (n = 10) as part of their leisure activities, and most had not been exposed to music therapy (n = 9). Almost half the participants were attending a drumming session for the first time (n = 6).

Data Characteristics

Using the Kolmogorov–Smirnov test of normality (Field, 2009), the mean difference between scores before and after the drumming session was normally distributed. Therefore, we used parametric tests for the analysis. Analysis of the internal consistency of the scale items for our outcome measures, with Cronbach’s α, showed acceptable internal consistency for almost all measures (Bland & Altman, 1996). For the STEMS, the Tension (α = .93), Anger (α = .95), Confusion (α = .83), Depression (α = .96), and Fatigue (α = .93) subscales all showed higher internal consistency than in previous studies. However, the Vigor subscale demonstrated an unacceptably low level of internal consistency (α = .50). The PHQ–9 (α = .90), GAD–7 (α = .92), and Enjoyment of Interaction Scale (α = .77) all demonstrated an acceptable level of internal consistency.

Effect of Drumming on Mental Well-Being

There was a statistically significant difference between pretest and posttest scores on all six domains of mental well-being measured by the STEMS (Table 2). The clinical effect was also large across all six domains.

Table 2.

Mean Pretest–Posttest Differences on the STEMS

Mental Well-Being Component	STEMS, M (SD)		M Difference	95% CI	t(11)	p	Effect Size	Correlations
Mental Well-Being Component	Pretest	Posttest	M Difference	95% CI	t(11)	p	Effect Size	Pretest Anxiety (GAD–7)	Pretest Depression (PHQ–9)
Tension	8.77 (5.05)	3.15 (3.02)	−5.62	[3.28, 7.95]	5.24	.000	.83	−.70**	−.64*
Anger	7.00 (5.12)	2.54 (3.41)	−4.47	[1.47, 7.55]	3.25	.007	.68	−.60*	−.65*
Confusion	8.08 (5.02)	2.46 (3.57)	−5.62	[3.17, 8.06]	5.00	.000	.82	−.66*	−.63*
Depression	8.62 (5.64)	2.85 (3.44)	−5.77	[3.47, 8.07]	5.46	.000	.84	−.74**	−.74**
Fatigue	9.15 (5.11)	4.54 (3.82)	−4.62	[2.47, 6.76]	4.70	.001	.80	−.35	−.31
Vigor	6.08 (3.69)	9.08 (3.35)	3.00	[−5.48, −0.52]	−2.64	.022	.61	.12	.10

Note. CI = confidence interval; GAD–7 = Generalized Anxiety Disorder–7 scale; M = mean; PHQ–9 = Primary Health Questionnaire–9; SD = standard deviation; STEMS = Stellenbosch Mood Scale.

p < .05, two-tailed. **p < .01, two-tailed.

Participants reported that they enjoyed the drumming session “a great deal” on all four components of the Enjoyment of Interaction Scale, with a total mean score of 27 (range = 23–28). No adverse events related to the drumming activity were reported.

Between-Groups Differences

Using Pearson’s correlation, we found a significant negative correlation between pretest levels of depression (PHQ–9) and anxiety (GAD–7) and mean change in Tension, Anger, Confusion, and Depression scores (see Table 2). This finding means that participants who were more anxious or depressed showed a greater improvement on these four subscales than participants who were less anxious or depressed. No relationship was found between pretest anxiety and depression and changes on either the Fatigue or the Vigor subscale (see Table 2).

We also found, using an independent t test, that there were no between-groups differences in mean change in mental well-being between men and women, t(11) = −1.19 to 0.87, ns, or between White and mixed-race participants, t(11) = −0.72 to 0.95, ns, across all six domains of the STEMS. Because of the small sample size, we were unable to analyze for differences between those who had previously been exposed to any type of music therapy (n = 4) and those who had not (n = 9). However, there were no differences between participants who had participated in previous drumming sessions at the clinic (n = 7) and those who were drumming for the first time (n = 6), t(11) = −1.58 to 0.23, ns.

Discussion

The primary finding of this study is that occupational therapy–led drumming groups contribute to immediate improvement in mood and experiences of enjoyment. Our findings strengthen Mungas and Silverman’s (2014) conclusion that drumming has a positive impact on a wide range of affective states. Moreover, our study adds to previous studies by showing that drumming can lead to substantial immediate clinical improvement in self-reported mood for adults with acute mood disorders. Given the experiences of a loss of pleasure and restriction in range of emotions that are typical of depressive disorders, we were particularly pleased to see how much the participants enjoyed the drumming session. We believe such positive experiences help to challenge the hopelessness often reported by these clients. Moreover, the finding that participants with higher levels of depression and anxiety also showed greater improvement in their mental well-being suggests that this intervention may have substantial benefits for those who are still in the acute phase of illness and find it difficult to participate in other forms of creative activity.

The structure of the group sessions contributed to the effectiveness of the intervention. In their systematic review of music therapy in acute psychiatric inpatient settings, Carr et al. (2013) recommended frequent sessions, active participation in music making, verbal discussion of experiences, consistent maintenance of contact and boundaries, and the building of therapeutic relationships. All these aspects are reflected in the structure of the drumming program at the mental health clinic where this study was conducted. Active participation is inherent in the structure of the 360° facilitation method that we used. Participants’ experiences of the session were also always discussed after the drumming. In these discussions, clear connections were made to occupational participation in the clinic or when returning home. Offering drumming groups on the same two afternoons of each week, and by the same two therapists, allowed for the building of therapeutic relationships and consistency in maintaining boundaries across the occupational therapy program.

The physical aspect of drumming also contributed to the effectiveness of the intervention. Cole (2012) argued that a sensory–motor approach is useful in mental health group work practice. Principles of this approach (Cole, 2012) were consistently evident within the drumming method that we used (Table 3). Another study in South Africa that tracked participants’ heart rates during a drumming session concluded that drumming is a form of moderate-intensity exercise (Smith et al., 2014). The positive effects of exercise on mood are widely reported. Indeed, a review that included 39 randomized controlled trials with 2,326 participants concluded that exercise is moderately more effective than control interventions in improving symptoms of depression (Cooney et al., 2013). This finding suggests that the effectiveness of drumming in comparison with other physical activities should be considered in future research.

Table 3.

Applied Principles for Drumming Groups With a Sensory–Motor Approach

Activity	Principles
Introduction and warm up	Prepare participants psychologically and physiologically for the group by providing limited stimuli first and then gradually increasing it. This method will determine what can be tolerated by the group. Match the mood of participants to begin with and then gradually change rhythms to achieve desired aims.
Main activity	Select the drumming rhythms and actions on the basis of what you want to achieve with participants—relaxation, invigoration, energizing, distraction, or rest. Progress from simpler to more complex sensory–motor activities by progressing from simple to more complex rhythms, increasing speed and intensity of drumming, increasing the level of noise, increasing physical interaction among members of the group, and using a wider variety of instruments. Modify timing on the basis of endurance and attention span of participants.
Discussion and closure	Use discussion to • Increase awareness of the effect of different drumming rhythms on the body and emotional state. • Identify positive feelings after the release of negative emotions (e.g., anger and tension). • Problem-solve ways to manage negative emotions and to express feelings in daily life.

Note. Information in this table is based on Cole (2012).

Limitations and Implications for Future Research

Despite its limitations, this pilot study demonstrated the value of further research on the effect of occupational therapy–led drumming sessions. Our study had no control group and was conducted at one mental health clinic. Our convenience sample and data collection by therapists conducting the intervention also highlight the possibility of selection, channeling, and intervention bias (Pannucci & Wilkins, 2010). Our small sample size limited our ability to control potential confounding variables, such as the number of drumming sessions attended at the clinic before participating in the study and the length of stay at the clinic. These two variables are particularly important if data are collected over time, as we did in this study.

In future clinical trials, it would also be useful to consider data collection and analysis by a research assistant who is blind to the study hypothesis. A control group or comparison with another similar intervention, especially if randomization is possible, would significantly enhance the validity of future studies. We also recommend collecting more accurate data on previous exposure to drumming (especially during the current acute episode) or a longitudinal design that captures whether drumming sessions become more or less effective as symptoms improve. We are encouraged that statistically significant results can be achieved with a small number of participants, making future research more cost effective and feasible. Moreover, the excellent internal consistency for most subscales on the STEMS suggests that this measure is useful for further research with adult psychiatric inpatients. However, we would also recommend further confirmatory factor analysis to affirm the validity of the tool for this population.

Implications for Occupational Therapy Practice

The findings of this study have the following implications for occupational therapy practice:

Together with our study on African drumming, studies by Silverman and Marcionetti (2004) and Gingras et al. (2014) in the United States and by Ulrich et al. (2007) in Germany suggest that drumming may be a culturally relevant practice in a variety of countries.

Although previous research has suggested that a larger number of music therapy sessions are needed to have a clinically significant effect (Carr et al., 2013), our findings suggest that an improvement in mental well-being can be achieved with a single drumming session.

None of the studies we identified included occupational therapists in the delivery of drumming interventions. Because there is so little evidence to support our practice, we suggest that the procedure for our drumming groups presented here and our applied principles for drumming within a sensory–motor approach become preliminary guidelines for practice. As such, these guidelines may be more robustly tested within our own and others’ clinical practice and research.

Conclusion

Occupational therapy–led drumming groups based on the principles of a sensory–motor approach may be an effective intervention to improve positive affect and experiences of enjoyment in adults with acute mood disorders. Further research, including randomization and a control at other research sites and with adults with other mental health disorders, is recommended.

Acknowledgments

We express our deepest thanks to Bevil Spence, a master drummer and trainer, for his unfailing efforts to raise awareness of the value of drumming and for his efforts to improve our skills. The ClinicalTrials.gov identifier for this research is NCT02675712.

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The Immediate Effect of African Drumming on the Mental Well-Being of Adults With Mood Disorders: An Uncontrolled Pretest–Posttest Pilot Study