An evidence review of singing-based interventions for health & wellbeing

Singing is widely accepted as the earliest form of music-making, (1, 2) spanning millennia and being practised among cultures the world over. (3) It has long brought people together, serving a communal and connective purpose, (4) rendering it “fundamental to the human experience”, (2) while also providing a means for emotional processing. (2) On an even more basic level, singing reaffirms our existence as living, breathing beings: the body itself is the instrument – “a lived, experiential structure”, (5) and singing a process that results from breathing. Not only does singing enable an embodied, felt experience, but it also triggers health-promoting physiological changes by virtue of occurring in and through the body. (6) 

Singing therefore holds great potential for supporting the health and wellbeing of individuals and communities. In the UK alone, record numbers of people are seeking out the benefits offered by singing, with over 2.1 million people taking part in choral singing every week as of 2017. (7) As such, singing is being introduced and practised in a number of settings, constituting an impactful, cost-effective health-promoting activity, (8) and yet it receives proportionally little public funding, (7) suggesting there is room for further research to drive forward evidence-based policy. 

The existing body of literature on singing is largely oriented towards subjective and mental wellbeing. More recently, however, efforts have been made to explore the physical and physiological effects of singing, (9) paving the way for an improved understanding of the interplay between mind and body phenomena, as well as building out the evidence base for the far-reaching, all-encompassing benefits potentially offered by singing.

Aims

This review aims to add to the body of evidence supporting the use of singing-based interventions for improving health and wellbeing, with a focus on examining the physiological/ biological effects of singing, and their relationship to reported impacts on wellbeing. As well as capturing the key findings in the space, the review seeks to highlight the limitations of existing research, identify opportunities for further research, and inform policy. 

[…]

Synthesis

Healthy populations (Adults)

Seven studies focusing on group singing examined its effects on neuroendocrine activity, alongside a range of subjective wellbeing measures. One study (12) showed no significant changes to stress biomarkers (cortisol, alpha-amylase), however participants did experience improvements in affect and feelings of social connectedness, particularly those exposed to 60min as opposed to 30min weekly choir sessions. This suggests psychological effects may be modulated by both singing and the duration of singing. 

Two studies investigated the effects of singing on maternal wellbeing and mother-infant closeness in mothers of newborn babies. (13, 14) Both showed significant decreases in cortisol, combined with improvements in affect, attachment and emotional closeness following 35-45min singing workshops. However, such psychological effects appear to wear off over time, (14) suggesting that any short-term improvements might be mediated by immediate physiological shifts.

One study (15) assessing the effects of varied activities on circulating endocannabinoids in a small group of women showed that singing was the only activity to produce an endogenous ‘high’, resulting in increased concentrations of two types of endocannabinoids. Singing also had a positive effect on participants’ overall mood. The study notes, however, that because participants were recruited from a local choir group, their enjoyment of singing may have played a role in their physiological and psychological responses. 

A study (16) assessing for changes in heart rate variability (HRV) in pairs of singers found that HRV becomes more synchronised during singing, even when the effects of singing on respiration (specifically respiratory sinus arrhythmia) are accounted for. HRV coupling was not, however, correlated with subjective feelings of togetherness. 

Two quasi-experimental studies compared the effects of group and solo singing in young adults, focussing on endocrine activity associated with stress and social affiliation. (17, 18) Despite mixed and at times contradictory results, they point towards a slightly stronger link between group singing and wellbeing. While all four conditions in Bowling et al. (17) (singing together and alone; speaking together and alone) resulted in decreased oxytocin and cortisol, a smaller drop in oxytocin was observed after singing. Although the observed shifts in oxytocin ran counter to the researchers’ hypothesis, singing together was still found to produce the biggest increase in affect and social connectedness.

Another similar study (18) also found that both group and solo singing led to reduced cortisol levels, while a reduction in oxytocin was observed following group singing but not solo singing. Participants in both group and solo singing conditions showed improved affect. In an attempt to explain the disconnect between feelings of social affiliation and decreases in oxytocin, the researchers conjectured that reduced stress from singing may have inhibited oxytocin secretion. 

Five studies were concerned with the effects of short bouts of solo singing in adults. Two of these explored cardiovascular and cardiorespiratory responses. (19, 20) Bernardi et al. (19) compared singing, toning (improvised vocalisations) and breathing conditions, revealing that toning had positive effects on heart rate, HRV and ventilatory efficiency, as well as slowing down breathing – thereby resulting in breathing patterns that promote cardiorespiratory health. Although singing also improved cardiovascular function, it did so to a lesser extent. Another study (20) found that slow, paced singing and breathing resulted in shifts in HRV that signal improved cardiac coherence – a measure of autonomic stability associated with reduced stress and anxiety. Singing also had a positive impact on affect. 

Three studies (21, 22, 23) investigated the effects of solo chanting on physiological measures associated with states of relaxation. Two of these (21, 22) found that chanting results in increased parasympathetic tone via shifts in HRV, therefore facilitating relaxation. Additionally, chanting led to a decrease in cortisol and improved cognitive function. (22) One study examining EEG brainwave patterns linked chanting with a widespread increase in theta brainwaves, which are associated with relaxation. (23)

[…]

Populations with/at risk of developing diagnosed health conditions

Respiratory conditions

Six studies explored the effects of singing on individuals suffering from Chronic Obstructive Pulmonary Disease, (31, 32, 33, 34) contributing evidence to support the respiratory health benefits of singing. All studies exposed participants to group singing, taking place between 1-2x a week over 8-12 weeks – with the exception of two longitudinal studies. (35, 11) One quasi-experimental study from Ireland (31) reported improvements in aerobic capacity and endurance, but no significant changes in subjective health and wellbeing or self-reported symptoms. A London case series, (35) however, showed evidence of improved COPD-related symptoms, also demonstrating that physical and physiological measures remained stable, rather than declining.

Similarly, one RCT and a post-hoc analysis of the same study (32, 33) found that singing produced the same effects as physical exercise training (PET) in patients with COPD, resulting in improved exercise capacity, as well as elevated QoL. Moreover, enhancements in QoL were correlated with increased respiratory muscle strength – a measure of respiratory health, suggesting an association between objective physiological and subjective responses to singing. (33)

A cohort study from New Zealand (11) also reported improved exercise capacity in addition to a reduction in anxiety. One RCT (34) contributed further evidence towards the mental and physical benefits conferred by singing, reporting improvements in depression and balance confidence. It additionally explored differences between in-person and virtual settings, finding that although face-to-face singing was preferred by participants, both yielded comparable benefits. 

Cardiovascular conditions

Three studies examined the effects of solo singing on individuals with cardiovascular diseases. (36, 37, 38) Two RCTs from India (36, 37) evaluated the effects of regular, weekly chanting and yoga nidra on adults with hypertension over two months, making it difficult to ascertain whether any changes resulted solely from chanting. Nevertheless, both studies reported positive physiological shifts: reduced blood pressure alongside increased HDL (high-density lipoprotein, or ‘good cholesterol’), (36) and improved autonomic function – specifically HRV, as well as sleep quality, depression, stress and anxiety (37).

A quasi-experimental study from the USA, (38) which evaluated the effects of a single short bout of solo singing, also registered improvements in HRV, in addition to improved blood pressure and oxygen saturation – all of which were found to rival the effects of light exercise. The study also reported improved vascular function, with greater results being observed in patients with atherosclerosis.

Neurological conditions

Four studies evaluated the effects of singing in people with neurological conditions, taking a largely exploratory approach, and yielding imprecise findings relating to physiological responses, but encouraging results regarding wellbeing. All studies exposed participants to group singing, with only one RCT exploring the long-term effects of weekly singing. (39) Otherwise, all interventions sought to evaluate the immediate effects of a single, 1-hour bout of singing. 

Three studies were centred around people with dementia (PWD) or at risk of dementia, (39, 40, 41) and their carers. (40) One England-based quasi-experimental study (40) compared two community-based activities – choral singing and art-viewing. It reported increases in HRV in PWD during singing, but not their caregivers. Singing was also found to bolster happiness and optimism, which may be positively associated with observed increases in HRV – in line with previously cited explorations into HRV. Despite assessing biomarkers, cortisol measures were found to be inconclusive. A long-term RCT, (39) which followed older Singaporeans at risk of developing dementia over two years also revealed non-significant changes in biomarkers. However, it did report mild improvements in cognitive function as a result of group singing, compared to a mild decline in the control group.

A quasi-experimental study (41) exploring physiological responses to singing, reported increases in electrodermal activity and heart rate, thought to indicate arousal, enjoyment and engagement. It also found a correlation between changes in skin temperature, heart rate and electrodermal activity, and the tempo of songs. Despite not pointing towards clear benefits offered by singing to PWD, the study contributes towards an understanding of how PWD may respond to and experience arts activities.

The only study evaluating individuals with Parkinson’s disease (42) reported minimal physiological or motor changes following a group therapeutic singing intervention, which included breathing and articulating exercises. Despite finding no meaningful alterations in participants’ cortisol levels or motor skills, subjective wellbeing, improved, with a greater reduction in sadness among the singing group compared to an active control. This study also reported increases in heart rate as a result of singing. 

Mental health conditions

One Austrian study evaluated the effects of singing and music-listening on a small group of children and adolescents with diagnosed mental disorders, (43) with encouraging results. Singing was found to elicit a sharper decrease in cortisol, whereas listening led to improved mood and calmness. This is the first study to show that singing may result in a greater positive neuroendocrine response than music-listening. Although immune responses to singing/listening were explored, no observable changes in immunoglobulin-A (IgA) levels were found, suggesting there is room for further research in the space.

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Conclusion

The recent evidence to support the health and wellbeing outcomes of singing is wide-ranging, demonstrating it to be an impactful and generally efficacious means of effecting positive change on both a physiological and psychological level. (Figure 3) Singing has been seen to elicit positive changes in neuroendocrine activity, cardiovascular, respiratory, autonomic, cognitive and vocal function, with promising, albeit limited, evidence of its effects on immune function. Singing is also linked with improvements in mood and quality of life, increased feelings of social connectedness and emotional closeness, reduced stress, anxiety and depression, and states of relaxation – particularly in group settings. 

Observed relationships between physiological shifts and improved wellbeing help contribute towards a more complex understanding of human health, where mind and body phenomena are deeply interrelated. Asset-based interventions such as singing, which hold the power to nourish all aspects of health, should therefore be more widely leveraged and funded as a cost-effective and more comprehensive means of treating, promoting and creating health.

Recommendations

This review has identified opportunities for further research in the following areas:

• The psychobiological impacts of singing in children and adolescents, and individuals diagnosed with mental disorders 

• Explorations into different expressions and models of community singing across non-Western cultures

• A review focused on the effects of singing in more ethnically diverse populations, particularly where conditions known to benefit from singing are overrepresented

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