Is a 63-year-old male with a past medical history of alcohol dependency, cigarette (nicotine) dependence, chronic hepatitis C, generalized anxiety disorder, hyperlipidemia, methamphetamine abuse in remission, obstructive sleep apnea, and a mood disorder a good candidate for chanting as a therapeutic intervention?

Chanting as a Therapeutic Intervention for Anxiety and Mood Disorders

This patient is a reasonable candidate for chanting as an adjunctive intervention for his generalized anxiety disorder and mood disorder, particularly given his complex psychiatric and substance use history that may limit pharmacological options.

Evidence for Music-Based and Vocal Interventions in Anxiety

Music therapy and music-based interventions demonstrate large effect sizes for anxiety reduction in clinical populations. Two meta-analyses showed substantial benefits: one reported a mean difference of -7.71 on the STAI-S scale (17 trials, N=1,381), and another showed an SMD of -0.76 for non-STAI-S measures (9 trials, N=882), both favoring music interventions over standard care 1. Importantly, music therapy delivered by trained therapists produced more consistent results than simply listening to pre-recorded music 1.

Chanting represents a specific form of vocal music therapy that combines rhythmic vocalization with focused attention, sharing mechanistic features with both music therapy and mindfulness-based interventions. While the evidence specifically examined music therapy broadly, one RCT demonstrated that listening to religious recitation (Quran) produced large treatment effects comparable to music listening in Muslim patients with cancer during chemotherapy 1, suggesting that culturally meaningful vocal/chanting practices can effectively reduce anxiety.

Patient-Specific Considerations Supporting This Approach

Substance Use History

• Your patient's history of alcohol dependency and methamphetamine abuse in remission creates significant concerns about benzodiazepine use, which should be avoided for chronic anxiety management in patients with substance use disorders 1, 2
• Substance use disorders and independent anxiety disorders are highly comorbid (prevalence 9.35% for substance use disorders, 11.08% for anxiety disorders), with positive and significant associations between them 2
• Chanting offers a non-pharmacological alternative that carries no risk of dependence or substance-related complications 1

Hepatitis C Considerations

• Patients with hepatitis C and psychiatric comorbidity can experience worsening mood and anxiety symptoms, particularly if interferon-based treatments are considered 3, 4
• Non-pharmacological interventions are particularly valuable in this population to avoid polypharmacy complications 4

Multiple Psychiatric Comorbidities

• The combination of generalized anxiety disorder, mood disorder, and substance use history places this patient in a high-risk category for medication-related complications 3
• Cognitive behavioral therapy (CBT) has the highest level of evidence for anxiety disorders and should be the primary treatment approach 5, 6, 7
• Chanting can serve as an adjunctive practice that complements CBT by providing a concrete mindfulness-based coping skill

Implementation Strategy

Integration with Evidence-Based Care

• Chanting should not replace first-line treatments but rather augment them 1
• If not already receiving treatment, initiate escitalopram 10 mg daily (preferred SSRI due to minimal CYP450 interactions) alongside CBT 5, 6
• Assess treatment response at 4 and 8 weeks using standardized instruments (GAD-7 for anxiety, PHQ-9 for depression) 5

Specific Chanting Recommendations

• Consider structured chanting sessions of 20-30 minutes duration, similar to the music therapy protocols that demonstrated efficacy 1
• Patient-selected or culturally meaningful chants may enhance engagement and effectiveness, as demonstrated with religious recitation 1
• Encourage daily practice as part of a broader stress management and relapse prevention strategy

Monitoring Parameters

• Screen for suicidality explicitly at each visit, given the high-risk profile 5
• Monitor for substance use relapse, as anxiety is a common trigger 1, 2
• Assess functional impairment using the Sheehan Disability Scale 5

Critical Pitfalls to Avoid

• Do not rely solely on chanting as monotherapy for moderate-to-severe anxiety or mood disorders 1, 5
• Do not prescribe benzodiazepines for chronic anxiety management given the substance use history 1, 6
• Do not delay evidence-based pharmacotherapy (SSRIs) or psychotherapy (CBT) while pursuing complementary approaches 5, 6
• If SSRIs are initiated, do not discontinue abruptly—taper gradually over at least 2-4 weeks to avoid withdrawal symptoms 5, 7

Treatment Duration and Adjustment

• For a first episode of anxiety, continue treatment for at least 4-12 months after symptom remission; for recurrent anxiety, longer-term treatment is beneficial 6, 7
• If symptoms are stable or worsening after 8 weeks despite good adherence, adjust the regimen by increasing medication dose, intensifying CBT, or switching medications 5, 6
• Chanting can continue indefinitely as a maintenance strategy for stress management and relapse prevention