Nurse‐Led Music Therapy for Post‐Stroke Depression: Distinguishing Cultural Rationale From Therapeutic Mechanism

We read with interest the article by Gao and colleagues, which details the systematic development of a nurse-led five-element music therapy (FEMT) intervention for post-stroke depression using the Medical Research Council framework (Gao et al. 2025). The authors' rigorous, evidence-based approach to standardizing this complex intervention is commendable, given its history of clinical heterogeneity. The resulting six-theme protocol constitutes a valuable contribution to implementation science within traditional Chinese medicine nursing. Nevertheless, we believe a critical issue the authors raise—the cultural transferability of FEMT—requires deeper examination concerning the precise “active ingredient” of this intervention. The authors correctly note in their discussion that FEMT is rooted in traditional Chinese cultural concepts connecting the five tones to specific organs, emotions, and elemental interactions, observing that “for individuals without a background in traditional Chinese culture, the idea of associating different musical tones with specific elements… may seem abstract and difficult to comprehend” (Gao et al. 2025). While we support their emphasis on cultural sensitivity and local adaptation, we propose that the current protocol conflates two distinct therapeutic components: (1) A culture-specific therapeutic rationale, such as selecting Zhi-tone music based on the “joy suppresses sorrow” principle of TCM emotional competition theory, and (2) universal receptive music therapy mechanisms, such as listening to calming, structured auditory stimuli in a quiet environment for 30 min with guided relaxation. The network meta-analysis in the study identifies optimal “dose” parameters (> 1 time/day, > 30 min, ≤ 28 days), which are likely generalizable to many forms of receptive music therapy rather than being unique to the five-element framework. This distinction has important implications for cross-cultural implementation. Should FEMT's therapeutic benefit arise primarily from universal mechanisms—such as reducing sympathetic arousal, distracting from rumination, or modulating default mode network connectivity via preferred slow-tempo music (Legge 2015)—then its TCM-specific selection algorithm may constitute cultural packaging rather than an essential active component. Conversely, any additive benefit provided by the Wu Xing theoretical framework beyond generic music listening would require empirical confirmation. Without disentangling these components, international dissemination risks either exporting a culturally bound protocol with limited acceptability elsewhere, or inadvertently discarding therapeutically essential elements during cultural adaptation. We propose three specific steps to address this gap. First, a component-dismantling pilot study could compare the full FEMT protocol using TCM-based selection to a condition employing patient-preferred Western classical or receptive music matched for tempo and duration but lacking a TCM rationale, and to an audiobook attention control. This design would isolate any incremental benefit conferred by the five-element criteria. Second, future protocol iterations might incorporate neuroaesthetic or predictive coding frameworks (Koelsch 2014) to articulate FEMT's mechanisms in culturally neutral biological terms—for instance, reframing “Gong-tone enters the spleen to stabilize thinking” as “low-frequency, stable harmonic progressions modulate interoceptive networks”—thereby enhancing international acceptability while preserving theoretical fidelity. Third, collaboration with international teams could enable cross-cultural validation studies that explicitly measure both adherence to the TCM algorithm and participant perceptions of credibility and expectancy across different contexts (Liao et al. 2023). Adopting this mechanistic lens would shift the research focus from protocol development to clarifying the essential components underlying FEMT's efficacy. It would also strengthen the work's translational impact by identifying which elements demand faithful implementation and which permit culturally sensitive adaptation—a distinction of considerable relevance for global nursing practice. Yaru Wang: writing – original draft. The author has nothing to report. The author has nothing to report. The author has seen and approved the final manuscript. The author declares no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.