Bibliotherapy can be used in patients with mild to moderate depression or subthreshold depressive symptoms, as a sole or supplementary therapy.
What is depression?
Depression is characterised by one or both of the following key symptoms:
- persistent sadness or low mood
- marked loss of interest and pleasure
Associated symptoms are:
- disturbed sleep (increased or decreased)
- fatigue or loss of energy
- feelings of worthlessness or excessive guilt
- reduced concentration or indecisiveness
- agitation or slowing of movements
- change in appetite
- suicidal thoughts or acts.
There are two commonly used diagnostic criteria for depression: the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, revised fourth edition (DSM-IV-R), and the World Health Organization International Classification of Diseases and Related Heath Problems, tenth revision (ICD-10).
In the DSM-IV-R, depression is diagnosed by the presence of five symptoms, including one or more key symptoms, present most days, most of the time, and for at least 2 weeks. Subthreshold depressive symptoms are when there are fewer than five symptoms. Mild depression is when there are few, if any symptoms in excess of the five required for the diagnosis and only minor functional impairment. Moderate depression is when there are five or more symptoms and some difficulty with everyday activities. Severe depression is when most symptoms are present and the symptoms markedly interfere with functioning.
The ICD-10 uses the same symptoms as the DSM-IV, with the additional symptom of ‘loss of confidence and self-esteem’, but has a threshold of four symptoms.
What is bibliotherapy?
Bibliotherapy is a form of guided self-help. The patient works through a structured book, independently from the doctor. The role of the doctor is to support and motivate the patient as they continue working through the book and to help clarify any questions or concerns the patient may have.
Who might it be considered for?
Patients with mild to moderate depression or subthreshold depressive symptoms, as a sole or supplementary therapy. Patients need to have a reading age above 12 years and have a positive attitude toward self-help.
How is it practically done?
Patients follow a structured program from a book with the following suggested guidance:
Discuss the role of bibliotherapy with the patient and develop reasonable expectations for what is involved and what can be achieved. As bibliotherapy is a form of self directed treatment, it is important that the patient is actively involved in choosing it as a treatment option. Inform the patient that bibliotherapy is only one treatment option and that it is only suggested when it is suitable. This session should also be used to establish a relationship with the patient. It would be useful to develop a treatment and follow up plan with the patient at this stage.
Follow up session
Two weeks after the initial consultation, a 30 minute follow up consultation is advised. Discuss any concerns or difficulties the patient may have had with the book and provide empathetic support. It is important to access the patient’s level of motivation and acceptance of bibliotherapy. The amount of further contact should be determined from this meeting.
There is mixed evidence about how much ongoing contact is required. Most trials have maintained weekly contact with participants during treatment and a 3 month follow up after treatment. Weekly maintenance does not have to involve face-to-face contact, but can be done via telephone and email, as there has been no difference in outcome recorded between these modes of delivery.
The amount of contact should be determined by the patient’s situation, considering their depression severity, motivation levels and ability to understand the book.
There is no clear indication for the length of treatment. Most studies have asked patients to read the book in 4 weeks. The length of treatment should be determined between the patient and doctor, considering the barriers to being able to read the book within a set period.
What books have been used?
The following books, recommended by the National Prescribing Service, are all available in print, with some available for e-reader:
- Burns DD. Feeling good: the new mood therapy. New York: HarperCollins Publishers, 1999
- Lewinsohn P, et al. Control your depression. New York: Fireside, 1992
- Tanner S, Ball J. Beating the blues: a self-help approach to overcoming depression. Sydney: Susan Tanner and Jillian Ball, 1998
- Edelman S. Change your thinking: overcome stress, anxiety, and depression, and improve your life with CBT. San Francisco: Marlow and Company, 2007
- Greenberger D, Padesky C. Mind over mood: change how you feel by changing the way you think. New York: The Guilford Press, 1995
- Parker G. Dealing with depression. Sydney: Allen & Unwin, 2004.
What should I consider?
Due to minimal patient-doctor contact, bibliotherapy alone is only suitable for patients with mild to moderate depression. For patients with severe major depression or suicidal ideation, bibliotherapy should be used as part of a stepped care model.
No serious adverse effects have been reported. Occasionally patients report feeling rejected when receiving a book and being asked to work through it on their own. When discussing bibliotherapy as an option, doctors need to emphasise that it is only one of many options, and that if patient does not feel it is being helpful, the treatment plan can change.
National Health Medical Research Council (NHMRC) Level 1 evidence (systematic review of randomised controlled trials).
Doctors should be familiar with the material and level of the books available. Select books that are both culturally and linguistically relevant and suitable for the patient’s reading level.
‘Feeling good: the new mood therapy’ and ‘Control your depression’ were used in the bibliography effectiveness studies, with positive reductions in depression scores. ‘Feeling good’ has also been used in adolescent trials. These books were written for an American audience. ‘Beating the blues’, Change your thinking’ and ‘Dealing with depression’ were written by Australian authors.
Some patients find self help difficult, especially at the start. Reported obstacles include lack of time to read, not understanding the material, being stuck and feeling like the book is not helping. To overcome these obstacles the doctor needs to provide feedback, encouragement and motivation, and remind the patient of the benefits from putting time and effort into change.
An objection to bibliotherapy is that a loss of motivation may lead to people giving up. This concern has not been validated by reviews, which have all reported low rates of attrition. The attrition rate of bibliotherapy has been found to be lower than other psychological therapies.
Practitioners need to understand cognitive behavioural therapy. They also need to be aware of the content in the book that they prescribe so they can respond to any queries the patient may have.
Training studies of GPs in how to use self help books have found that training increased GPs’ knowledge, confidence and recommendations for self help books.
- Anderson L, Lewis G, Araya R, et al. Self-help books for depression: how can practitioners and patients make the right choice? Br J Gen Pract 2005;55:387–92
- GPNotebook: diagnostic criteria for depression (DSM-10 vs ICD-10). Available at www.gpnotebook.co.uk
- Gregory RJ, Canning SS, Lee TW, Wise JC. Cognitive bibliotherapy for depression: a meta-analysis. Prof Psychol Res Pr 2004;35:275–80.
Handbook of Non Drug Intervention (HANDI) Project Team Members include Professor Paul Glasziou, Dr John Bennett, Dr Peter Greenberg, Professor Sally Green, Professor Jane Gunn, Associate Professor Tammy Hoffman and Associate Professor Marie Pirotta.
Competing interests: None.
Provenance and peer review: Commissioned; not peer reviewed.