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Bibliotherapy: depression

Intervention

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 through the book and to help clarify any questions or concerns.

Indication

Patients with mild to moderate depression or subthreshold depressive symptoms, as sole or supplementary therapy.

Patients with a reading age above 12 years and who have a positive attitude towards self-help.

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.

Diagnostic criteria for depression

Based on the American Psychiatric Association’s revised fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV), depression is diagnosed by the presence of five symptoms including one or more key symptoms (see above), present most days, most of the time for at least 2 weeks.

Subthreshold depressive symptoms

Fewer than five symptoms.

Mild depression

Few, if any, symptoms in excess of the five required for the diagnosis and only minor functional impairment.

Moderate depression

Five or more symptoms and some difficulties with everyday activities.

Severe depression (bibliotherapy is NOT indicated)

Most symptoms and the symptoms markedly interfere with functioning.

Alternatively you can use the WHO’s 10th revision of the International Classification of Diseases and Related Heath Problems (ICD-10) depression diagnostic criteria, which uses the same symptoms but a threshold of four symptoms.

Precautions

  • Due to minimal patient–doctor contact, bibliotherapy alone is only suitable for patients with mild to moderate depression
  • There is no evidence to suggest that bibliotherapy alone is effective for patients with severe major depression or suicidal ideation.

Adverse Effects

No serious complications have been reported.

Infrequent

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 this only one of many options, and that if the patient does not feel it is helpful, the treatment plan can change.

Availability

The following books, recommended by the National Prescribing Service, are all in print and some are available for e-reader:

  • Feeling good: the new mood therapy, by David D. Burns. New York: HarperCollins Publishers, 1999.
  • Control your depression, by Peter Lewinsohn, Ricardo Muñoz, Mary Ann Youngren and Antoinette Zeiss. New York: Fireside, 1992.
  • Beating the blues: a self-help approach to overcoming depression, by Susan Tanner and Jillian Ball. Sydney: Susan Tanner and Jillian Ball, 1998.
  • Change your thinking: overcome stress, anxiety, and depression, and improve your life with CBT, by Sarah Edelman. San Francisco: Marlow and Company, 2007.
  • Mind over mood: change how you feel by changing the way you think, by Dennis Greenberger and Christine Padesky. New York: The Guilford Press, 1995. 
  • Dealing with depression, by Gordon Parker. Sydney: Allen & Unwin, 2004.

Costs vary from approximately $13 to $42.

A number of self-help books are available from public libraries.

Description

Patients follow a structured program from a book with the following suggested guidance:

Initial consultation

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 that 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.

Follow up session

Two weeks after the initial consultation, a 30-minute follow up is advised. Discuss with the patient any concerns or difficulties they may have had with the book and provide empathetic support. At the end of the session it is important to access the patient’s levels of motivation and acceptance of bibliotherapy. The amount of further contact should be determined from this meeting.

Ongoing contact

There is mixed evidence about how much ongoing contact is required. Most trials have maintained weekly contact with participants during treatment and a three-month follow up after treatment. Weekly maintenance does not have to involve face-to-face contact but can be done via alternative means such as phone calls and email as there has been no difference 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 four 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 time period.

Tips and Challenges

Tips

Select books that are:

  • culturally and linguistically relevant
  • 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. Note that these books were written for American readers. Beating the blues and Dealing with depression were written in Australia.

Doctors should be familiar with the material and level of the books available.

Challenges

Some patients find self-help difficult, especially at the beginning. 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, 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.

Training

  • Practitioners need to understand cognitive behavioural therapy. Practitioners need to be aware of the content in the book that they describe so they can respond to queries about specific components in the book.
  • 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.

Grading

NHMRC Level 1 evidence.

References

Consumer Resources

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