PSYCHOLOGICAL WELL-BEING IN PROFESSIONAL ORCHESTRAL MUSICIANS IN AUSTRALIA: A study of anxiety, pain, and depression Dianna T Kenny, Bronwen Ackermann, Tim Driscoll The University of Sydney Supporting sustainable careers in orchestral musicians through Occupational Health and Safety initiatives

An initiative funded by the ARC and the Australia Council for the Arts on behalf of the 8 major orchestras of Australia.

Introduction Australia has eight full-time professional symphonic and pit orchestras located in each of the capital cities of Australia Their musicians represent the country’s most elite orchestral musicians Study motivated by the Strong Report (2005) that showed very high injury rates and escalating workers’ compensation costs for professional musicians High frequency (60% - 90%) of self-reported musculoskeletal pain

Introduction Mental health of professional musicians is not well understood; hence, their mental health needs are often poorly managed International surveys report high rates of music performance anxiety and performance-related pain Health behaviours such as substance and alcohol use have not been systematically studied Strong (2005) identified a NEED for OCCUPATIONAL GUIDELINES FOR ORCHESTRAL MUSICIANS

Sample characteristics (n=377, 70% participation) 184 males (49%) 192 females (51%) Mean age of musicians: 42.1 years (SD=10.3; Range=18-68 years)

Numbers and percentages of musicians in each age group % <30 62 16.5 31-40 103 27.4 41-50 130 34.6 51+ 81 21.5 TOTALS 376 100

Sample Distribution #Seven musicians were aged between 18 and 24 years # 47 musicians were aged between 55 and 69 years #No gender differences within age groups

Instrument group membership % Trumpet, French horn, trombone, bass trombone, tuba 58 15.4 Piccolo, flute, oboe, clarinet, cor anglais, bassoon, contrabassoon 67 17.8 Cello, double bass, harp 70 18.5 Violin, viola 169 44.8 Percussion, tympani 12 3.2 Total 377 100

Baseline assessment K-MPAI PRIME-ED STAI-T ADD SPIN AUDIT CSE

Psychosocial Profile 33% musicians screened positive for a diagnosis of social phobia 32% screened positive for depression 30% regularly used Beta Blockers to manage their anxiety 22% answered ‘yes’ to a question screening for post-traumatic stress disorder 14% reported unsafe patterns of alcohol consumption 6% smokers

Inter-correlations among the psychological tests STAI-T K-MPAI ADD CSE SPIN .569*** .619*** .404*** -.526*** ASI .277 .548*** .166 -.358*   .712*** .498*** -.749*** .574*** -.711*** -.496***

Predictors of severity of MPA (K-MPAI) Severity of MPA is affected by the severity of other underlying anxiety conditions

Means, SD, minimum and maximum scores, F tests and p values for STAI-T, K-MPAI, ASI and ADD by sex Anxiety measure Sex  Mean SD Sig. K-MPAI male 75.95 36.30 0.001 female 91.15 43.33 Total 83.73 40.72 STAI-T 52.33 10.54 0.004 55.71 11.88 54.08 11.37 SPIN 12.92 9.67 17.17 11.45 15.09 10.81 ADD 1.84 1.30 2.33 1.37   2.09 1.35

Means, SD, minimum and maximum scores, F tests and p values for STAI-T, K-MPAI, ASI and ADD by age group Anxiety measure Age group Mean SD Sig. K-MPAI <= 30 93.5 39.1 0.037 31 - 40 79.0 35.9 41 - 50 87.0 45.1 51+ 76.0 Total 83.5 40.8 STAI-T 55.6 12.5 0.056 51.6 8.9 55.2 12.7 54.2 10.7 54.1 11.4 SPIN 17.8 11.0 0.014 13.5 8.8 16.3 11.8 13.0 10.8 15.1 ADD 2.18 1.38 0.001 2.02 1.20 2.19 1.45 1.91 1.37 2.09 1.35

Association between alcohol frequency, K-MPAI, and age Test Alcohol frequency N Mean SD sig. K-MPAI every day 17 104.0 40.3 0.05 5-6 days 89 83.7 40.1 3-4 days 96 83.3 40.0 1-2 days 77 89.7 44.0 less than 1-2 days 55 73.5 35.7 Total 334 84.3 40.7   Age 49.5 10.9 0.001 88 44.1 9.2 41.7 10.5 78 37.9 9.7 41.6 10.4 41.8 10.3

Age, K-MPAI, STAI-T, SPIN and ASI scores by depression category Factor Depression category Number Mean SD Sig. Age Yes to 2Q 63 41.3 10.1 .821 Yes to 1Q 54 41.8 11.7 No to 2Q 247 42.2 10.0 K-MPAI 64 120.4 42.3 0.001 91.8 29.1 249 74.9 36.1 STAI-T 66.5 13.2 56.8 8.9 50.3 8.6 SPIN 61 22.5 13.4 53 15.6 9.7   240 13.0 9.3

Self-rated causes of MPA FNE 68% Repertoire 61% Bad performance experience 78% Pressure from others 61%

Anxiety, depression, pain Depressed patients with musculoskeletal pain report more psychosocial stressors and more severe anxiety than comparable non-depressed patients with musculoskeletal pain (Poleshuck et al., 2009). Depressed patients with pain report more severe pain than non-depressed patients with pain. GAD + MDD = 78% pain GAD only = 59% pain No GAD or MDD = 28% pain Anxiety [MPA] Depression [PRMD] Pain Somatiz-ation Chronic pain

Treatment In depressed patients with pain, treatment that focuses on pain Mx is not effective until depression treated Increases in pain associated with increases in depression severity Increases in pain severity associated with increased depression (Kroenke et al., 2011). Number pain complaints a better predictor of depression than scales of pain severity and persistence (Godfrey, 2007).

Why study pain and depression in musicians? Female Why study pain and depression in musicians? High PRMD Role of other factors? Frequency and severity of PRMD in professional musicians Complex relationships between psychological factors and pain in other populations Biomechanical factors but not job stress factors predicted PRMD (Kaufman-Cohen & Ratzon, 2011) High somatizing scores increased the odds of reporting regional pain bw 2.5 (wrist/ hand) and 5.5 (shoulder) times (Leaver, Harris & Palmer, 2011) Depression

Rationale and Additional Measures PRMD studies use pain perception, not physical measures Need objective measure of pain cf. TRIGGER POINTS (TP) TP show increased EMG activity during psychological stress; adjacent muscles remain non-responsive Psychological factors may be associated with TP pain in musicians PRMD pain, depression, MPA and SAD in professional musicians has not been previously investigated Pain perception and pain measurement

Categories of pain severity and frequency of pain Pain frequency Frequency Percent 0, never 100 26.7 1 - 2 117 31.2 3 - 4 67 17.9 5+, constantly 91 24.3 Total 375 Pain severity   <= 1, no pain 101 28.3 2 - 3 79 22.1 4 - 6 102 28.6 7+, Worst imaginable 75 21.0 357

Effects of age and sex on PRMD frequency and severity   F Sig. Sex PRMD frequency 7.27 .007 PRMD pain severity 4.19 .041 Age group 5.38 .001 3.20 .024 Sex by age group 0.25 .863 0.55 .651 Females had higher means for both PRMD frequency and severity Age group 41-50 years had higher pain reports

Cluster analyses (1) A two-step cluster analyses: K-MPAI with severity ratings of PRMD pain as inputs. The cluster quality was good (Average silhouette=0.7) and four distinct clusters were obtained. Cluster 1 Cluster 2 Cluster 3 Cluster 4 PRMD<=1 PRMD=2-3 PRMD =4-6 PRMD=7+ N=98 (27.9%) N=79 (22.5%) N=102 (29.1%) N=72 (20.5%) Mean KMPAI=78.2 Mean KMPAI=81.4 Mean KMPAI=84.6 Mean KMPAI=94.5 Linear relationship between MPA severity and PRMD severity

Cluster analyses (2) A two-step cluster analyses: Depression categories with severity ratings of PRMD pain as inputs. The cluster quality was good (Average silhouette=0.6) and four distinct clusters were obtained. Cluster 1 Cluster 2 Cluster 3 Cluster 4 DEPRESSION No to both Q Yes to 1 Q Yes to both Q N=148 (42.9%) N=86 (24.9%) N=51 (14.8%) N=60 (17.4%) PRMD Severity=1.61 PRMD Severity=6.65 PRMD Severity=4.21 PRMD Severity=4.52 No depression, no pain No depression, severe pain Moderate depression, moderate pain May be clinically depressed, moderate pain

Conclusions ANXIETY Expected sex differences on STAI and K-MPAI but not SPIN Female musicians 3x population rates for Social Phobia Convergent validity of K-MPAI demonstrated e.g., high scores associated with problem alcohol use Younger musicians more anxious than older musicians (cohort “survival” effect?) First population level data on the psychological profile of elite professional musicians in Australia Identifies significant issues regarding psychological functioning and psychosocial wellbeing Provides guidelines for preventive programs

Conclusions DEPRESSION Role of depression in MPA has not been studied Depression screening indicated that rates in orchestral musicians occurred at the higher end of general community rates Even minor depression is associated with generalized psychological suffering, health concerns, impairment in daily living activities and overall quality of life DEPRESSION Role of depression in MPA has not been studied 22% musicians reported having a PTSD experience within the past three months Kenny (2011) noted in an in depth interview study that the descriptions of some musicians’ worst music performance experiences resembled accounts by people who were suffering PTSD

Conclusions - Depression Cluster analyses of PRMD severity and MPA severity showed that increasing PRMD severity ratings mapped linearly onto increasing mean K-MPAI scores. Cluster analysis assessing relationship between PRMD severity and depression indicated that Cluster 2 members reported no depression + highest ratings for PRMD pain severity.

Conclusions Previous studies have shown this relationship with respect to anxiety and physiological arousal but not between pain and depression. Notion of “repressors” (i.e., denial of negative affect) – defensive and self-presentation bias Self-report measures unreliable because people cannot report on “unconscious” experience SOMATIZATION - emotional pain is expressed as physical pain Trigger points were sensitive to psychological phenomena (the higher MPA, the worse TP reported in females

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