Abstract
BACKGROUND: Mental health dementia wards care for people with dementia experiencing the most acute and complex distress but research into psychosocial interventions to manage symptoms is limited. Music therapy may be helpful, but access and practice vary. A novel music therapy intervention (MELODIC) was co-designed for these wards, informed by programme theory for music therapy with people with advanced dementia in institutional care. This theory should be refined for mental health dementia wards. METHODS: A co-designed realist evaluation was conducted using mixed methods data from the MELODIC feasibility study with two National Health Service (NHS) mental health dementia wards. MELODIC was delivered on each ward for four weeks. Realist interviews were conducted post-intervention. Interventionist diaries and study documentation were recorded. Quantitative data, including patient, staff and family outcomes and routinely collected data, were gathered twice both pre- and post-intervention. Template analysis was conducted in NVivo to refine, test and adapt the initial programme theory. This was consolidated with previous research and stakeholder consultations. RESULTS: The mid-range theory outlines the intervention components and contextual elements required for music therapy to trigger changes in patient, staff and family reasoning and behaviour which lead to observable outcomes. A qualified music therapist can assess and attune to individual unmet needs, supporting a short-term reduction in distress and improved sense of personhood. Additionally, the therapist works collaboratively with staff and families, with reciprocal communication, structures for knowledge exchange and support from management. This enables staff and families to use personalised music in their individual practice to support patient care and create a more therapeutic ward atmosphere, facilitating a positive change in ward culture and approach to distress management over time. CONCLUSIONS: This realist evaluation provides theory for how and why the MELODIC music therapy intervention can reduce distress and improve personhood for patients on NHS mental health dementia wards, with positive associated outcomes for staff and families. Further research should establish the efficacy and effectiveness of the intervention, with continued iterative refinement of the programme theory. TRIAL REGISTRATION: ISRCTN86317609, registration date 25/04/2025. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13690-026-01865-8.