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British Medical Bulletin 57:133-144 (2001)
© 2001 Oxford University Press
Written and computer-based self-help treatments for depression
Department of Psychological Medicine, University of Glasgow, Glasgow, UK
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Abstract |
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Top
Abstract
IntroductionPatients and health purchasers are demanding the provision of effective and accessible mental health treatments. Psychotherapeutic approaches are popular with patients, but access to specialist psychotherapy services is often limited. Other ways of offering treatment within the time and resources available to most practitioners need to be considered. One possible solution is the use of structured self-help materials that address common mental disorders such as depression. Self-help treatments are available in a variety of formats such as books, CD-ROMS, audio and videotapes. Evidence exists for their effectiveness; however, a relatively neglected area has been a discussion of the educational aspects of such materials. Self-help materials aim to improve patient knowledge and skills in self-management. They require very clear educational goals and a content and structure that is appropriate for those who use them. Such work will enhance the credibility, take-up, and effectiveness of self-help materials within clinical settings.
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Introduction |
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Depression is a common condition that is often poorly detected within both community and hospital settings1
. It is associated with significant distress and has a marked social and economic impact. Patients with co-morbid psychiatric disorders have a greater use of non-psychiatric medical resources2,3. In addition, depression is associated with a significant risk of suicide4. For these reasons, the effective detection and management of depression have been identified as priority areas within the National Service Framework for Mental Health5. This aims to improve the detection and management of depression. However, both primary and secondary care mental health services are already very busy with existing patient workloads and many non-mental health specialists admit to a lack of time and the clinical skills required to manage depression effectively. For example, a study of newly qualified doctors found that less than 12% believed that they possessed the clinical skills required to offer treatment for depression6.
Treatments for mental health problems include medication and psychosocial interventions such as counselling and the various psychotherapies. Psychological treatments are widely in demand, and have been shown to be effective7. The Department of Health has stated a preference for the delivery of psychological therapies over medication treatments where outcomes are shown to be equivalent8; however, access to specialised psychotherapy settings is often limited. The dilemma is how to offer such treatments effectively within the time and resources available within everyday clinical settings.
One possible solution is the use of structured self-help approaches.
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Definitions of self-help |
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In the context of mental health treatment, ‘self-help’ as an approach has been used to describe very varied activities including patient self-help groups and organisations and also the concept of self-care where a person uses self-help resources to improve how they feel. Self-help books are often found in the top 20 best selling books and most large bookshops have a significantly sized self-help section. An internet search of the terms ‘self+help’ reveals about 2,110,000 internet web-sites. But what is self-help? Two definitions are:
- The patient receives a standardised treatment method with which he can help himself without major help from the therapist. In (self-help) it is necessary that treatment be described in sufficient detail, so that the patient can work it through independently. Books, in which only information about depression is given to patients and their families cannot be used9.
- The use of written materials or computer programmes or the listening/viewing of audio/video tapes for the purpose of gaining understanding or solving problems relevant to a person's developmental or therapeutic needs. The goals of the (self-help approach) should be relevant to the fields of counselling and clinical psychology10.
Although patient education and self-help approaches may have some overlap in content, the goals of self-help are different from pure patient education. The crucial difference is that while patient education aims to increase patient knowledge, self-help approaches aim to increase both patient knowledge and also lead to skill gain. In particular, self-help treatments aim to help patients to learn how to self-manage their condition better. Such materials may be delivered using a range of formats including books (so-called bibliotherapy), computers, audio and videotapes, and other formats such as interactive packages accessed via telephone.
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Why use self-help? |
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There are a number of potential advantages to using self-help materials. Treatment is accessed with minimum delay and at low price. Self-help approaches are popular and acceptable to many patients. Such treatments respect patient privacy and can help avoid the stigma of formal psychotherapy. The patient can use the materials in their own time and at their own pace and this may be particularly helpful for patients who are working, or who live some distance from a practitioner. Importantly, the approach empowers the patient. The content can build upon sessions with the health care worker and can be used to re-inforce and consolidate learning. Finally, the materials allow patients to renew or update their treatment as often as they wish, and at no extra cost. It is also clear from outcome studies that self-help approaches can be effective treatments of depression.
It is not possible within this article to review all aspects of self-help treatment; therefore, we have chosen to focus upon the treatment of depression using paper based books/manuals or computer delivered self-help packages. Interestingly, almost all studies that have examined the effectiveness of self-help treatments have used the Cognitive Behaviour Therapy (CBT) model. This has a proven effectiveness for depression11. CBT is essentially a structured and educational form of psychotherapy that aims to teach patients effective strategies for the self-management of their problems. Therefore, it provides a structure that is easily delivered using self-help formats.
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The effectiveness of written self-help materials for depression |
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Meta-analyses have drawn general conclusions about the usefulness and acceptability of the self-help approach in addressing a wide variety of clinical conditions and habitual behaviours9
,10,12,13. Most of the studies incorporated into these meta-analyses used written self-help materials although one included audiotape materials13, and another included written, audiotape, and videotape materials12. Only one of the meta-analyses looked solely at depression and this only used bibliotherapy studies9. Two of the meta-analyses observed that self-help was more effective with diagnosable problems including depression than with habitual behaviours10,12. Generally, studies comparing the outcomes of patients treated by self-help compared to face-to-face therapy have observed no significant difference in outcome9,10,12,13. Both forms of treatment had significantly better outcomes than a variety of control situations. Generally, those studies that analysed the effect of adding practitioner contact whilst the clients worked through the self-help materials did not appear to benefit from this addition10,12,13; although one meta-analysis concluded that anxious patients responded better when they had some therapist contact10. This general finding contrasts with the belief of many therapists and counsellors that supported self-help approaches are more likely to be effective than unsupported self-help treatments14,15.
One of the major problems in many of the studies is that most of the above research has been carried out on US-based non-clinical populations. Many of the participants have been recruited by advertising in the media to the general public. Participants may have been much keener to comply with treatment as a result. Not surprisingly, these studies show much lower dropout rates than are experienced in UK-based studies of self-help where dropout rates approach 50%16–18. In one UK-based study, 51 patients with symptoms of anxiety with or without concomitant depression were given a self-help booklet and audiotape as well as receiving the treatments that they would otherwise have received from their GPs16. Another 50 patients only received the regular GP interventions without any self-help. The patients who used the self-help materials achieved significantly greater reductions in levels of depression and anxiety. The difference continued at 3 months' follow-up. A subsequent study, also based in a British primary care setting, recruited 106 patients diagnosed by their GPs as suffering from anxiety, depression or a combination of the two17. No significant advantage was observed by adding self-help to the regular treatments that the GPs normally gave. The authors believed that this might have been due in part to the high dropout rate reducing the power of the study.
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The effectiveness of computer-administered self-help for depression |
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The use of computers to assist in the treatment of mental health problems has been recently reviewed14
. This review emphasised that this is a rapidly advancing field and that, at present, computerised self-help is not widely distributed to the vast majority of clinicians.
A computerised self-help cognitive-behavioural therapy (CBT) package for depression has been compared to traditional therapist-led CBT in a randomised control trial (RCT)19. In this study 36 volunteer patients who met research diagnostic criteria for major or minor depressive disorder were randomised to three groups receiving either traditional therapist-led CBT, computerised self-help, or a control option. At the end of the 6 weeks of treatment and at 2 month follow-up, the patients from the two CBT groups had improved significantly more compared to the control group. The outcome of the two treatment groups did not differ from each other at either time. It is noteworthy that the self-help provided in this study incorporated some minimal therapist contact with input at the beginning and end of each session and also there was the option for users to ask the therapist questions throughout. A subsequent randomised controlled trial allocated 22 depressed in-patients into three treatment options of 2 weeks of daily sessions of traditional therapist-led CBT, computer-instructed cognitive therapy, or in-patient care as usual20. The therapy-led patients did significantly better than the computer-led group in terms of reduction in depression rating scale scores. This trial has been criticised in that the computer programme that was used only taught cognitive techniques rather than the cognitive and behavioural approach of the therapist. Thus it may not have been a fair comparison14.
A recent method of computerised self-help has been described which uses touch-tone telephone calls to a computer-aided interactive voice response (IVR) system. One system known as ‘COPE’ is a CBT-based self-help regimen which uses an initial videotape, 9 booklets and 11 accompanying IVR telephone calls through to the IVR system that then makes recommendations to the patients based on the information they have entered21. An uncontrolled trial that tested COPE on 41 patients found that 28 (68%) completed the 12 week self-help programme with concomitant significant falls in depression rating scale scores and social adjustment scores. In common with studies that have used the IVR system for clients with obsessive compulsive disorder22, most participants made the calls to the computer outside normal office hours. This illustrates one of the great benefits of self-help – that its participation is not dependent on the working hours of the practitioner. Hand-held (palmtop) computers have been incorporated into self-help treatments of a number of anxiety disorders particularly panic23. They are capable of providing advice at critical moments as well as recording information such as symptoms or behaviours. As yet, they have found less of a niche in the treatment of depression although they could have a role in the recording of mood, thoughts and behaviours in real-time.
As with written self-help interventions, there is some controversy about the need for some face-to-face therapist input in computerised treatments. Certainly some patients find it very difficult to follow self-help regimens without some encouragement and guidance from a practitioner25. Perhaps the most important ingredient that remains largely absent from computerised self-help systems presently available is an ability to respond to the patient's non-verbal cues, misinterpreting their natural language, and, therefore, not being able to place a patient's communication into an appropriate context25. It appears that it is still extremely difficult to design a computer system that is broad-based enough to respond to all the complex needs of a patient throughout the therapy process without some assistance from a therapist14. Most packages have, therefore, opted to provide a more educational and informative input that aims to increase the patients' knowledge about depression, and teach specific skills that can be used to improve how they feel. In spite of the promising results of reported studies, computerised self-help treatment packages have failed to be adopted in everyday clinical settings and we are currently engaged in research examining the reasons for this.
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Who benefits from self-help treatments? |
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Self-help appears to benefit some patients, but not all. Some depressed patients by the very nature of the condition will not be capable of concentrating on the material15
, while the experience of failing when set the task of working through the self-help could result in increased despondency. Personality factors have also been found to predict outcome in self-help treatments for patients diagnosed with depression or dysthymia26–28. Furthermore, because of poor-eyesight or poor reading skills, some patients will not be able to use self-help unless they use a computer-based voice recogniser. The stepped care model suggests that patients will respond differently to varying types and intensities of psychosocial interventions, and that it is, therefore, sensible to provide a range of interventions perhaps ranging from self-help to long-term individual treatments29. The model has been described as a means of maximising the efficiency of resource allocation. |
Using self-help treatment in practice |
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Within health service settings, self-help materials can be offered to: (i) patients on waiting lists as they wait to be seen by secondary care based services; (ii) individual patients to support work with a health care practitioner either within primary or secondary care settings; and (iii) groups of patients to support group-based interventions.
We have looked at different ways of using self-help effectively within our own clinical setting and developed a specific self-help room to support the treatments offered within an acute adult psychiatric day hospital. This provides a centralised resource for use by staff and out-patients (including waiting list patients). Two sets of written materials are provided in the room – Mind over Mood30 and Overcoming Depression: A Five Areas Approach31; both are structured self-help materials that use a CBT model of treatment. This ensures that all staff are familiar with the content of the self-help materials used. One person uses the room at a time and books into the room for up to 1 h. Patients are encouraged to use the room once or twice a week, and to keep all their completed workbooks and worksheets so as to create their own personalised treatment pack. The room is kept neat and tidy, and has an open aspect with plants, rugs and pictures to encourage a relaxed atmosphere.
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The effectiveness of a CBT self-help room in a UK setting |
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We have evaluated the effectiveness of various aspects of the self-help room. The following briefly describes an open study evaluating the effectiveness of the CBT book Mind over Mood30
. This was offered to consecutive routine referrals with symptoms of depression and/or anxiety. Patients were all routine referrals aged 16–65 years referred from primary care to a psychiatric sector team based in inner city Leeds. The only exclusions were urgent referrals, or patients at risk of suicide or homicide, and those patients with illiteracy or marked visual impairment as identified on a standard referral form. All 42 patients referred between 19 April and 19 July 1999 who fulfilled these criteria were written to and offered a one-off brief (20 min) introduction on how to use the self-help room, and then were encouraged to attend the room to work through Mind over Mood on a weekly basis during their 6 week wait for a routine assessment interview by a team member. Baseline assessments were made of psychological distress, dysfunctional attitudes and degree of hopelessness during the period of use of the self-help manual, as well as patient satisfaction with the room and the book. Twenty-two of 42 consecutive referrals attended the room (mean 3.55 sessions, SD 1.71). The Beck Hopelessness Scale (BHS)32, the General Health Questionnaire (GHQ)33, and Dysfunctional Attitudes Scale (DAS)34, as well as measures of patient participation and satisfaction were completed at the beginning and end of the 6 week period in those patients who attended the room. Scores on all three scales fell clinically and statistically significantly over the study period. The patients generally judged that the self-help intervention was acceptable and effective, and that their knowledge in a number of key areas had been improved. Conclusions regarding effectiveness are limited by the absence of control group data; nonetheless, this study does suggest that the provision of a structured CBT self-help manual is useful for patients with low mood and anxiety on a waiting list for a psychiatric outpatient assessment. A full description of this study has been published18. |
Self-help as health technology |
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It seems clear that self-help treatment using written CBT materials can be effective; however, the study also found that the patient's experience of using the materials is also crucial. Self-help approaches are not for everyone – 48% of patients in our study chose not to take up the offer of the self-help material and the mean number of sessions attended by the 22 patients who attended their initial introductory session to the self-help room was 3.55. The concept of non take-up and dropout from treatment is not new to the health service and a significant literature has examined this. It does raise, however, the issue of how to offer self-help interventions that engage patients in treatment so that they receive the right materials, delivered using the right format and at the right pace for them35
. One interesting viewpoint on the role of self-help materials has been suggested by Dr David Richards of the University of Manchester. This sees self-help as a form of health technology – a means of delivering health care. The NHS R&D Health Technology Assessment Programme summarises health technology as covering ‘any method used by those working in health services to promote health, prevent and treat disease and improve rehabilitation and long-term care. Technologies in this context are not confined to new drugs or pieces of sophisticated equipment’ (www.hta.nhsweb.nhs.uk). Using this definition, all forms of self-help can be termed a health technology. The problem with technology, however, is how best to offer this effectively within a health care setting. Technologies can be used ineffectively without effective staff training. In addition, technology alone does not necessarily equate with user-acceptability; we need, therefore, to consider the structure and content of self-help materials to ensure that they are user-friendly and beneficial for patients.
A number of quality assessment resources can be used to ensure that self-help materials meet the patient's needs including the Help for Health Trust web-site (www.hfht.org) and the PoPPi guide36 (www.kingsfund.org.uk). Bringing together their recommendations, effective patient materials should provide:
- Accessibility: materials that are provided in an appropriate format for the target audience. The design and layout must also be simple to use and understand.
- Appropriateness: materials should be relevant to and designed for a specific target audience that is defined clearly at outset.
- Availability: materials must be made available to a wide audience. This means that materials should be delivered using different formats (e.g. CD-ROM, the internet and as books/leaflets) and include electronic versions of the information. Dissemination via a national databases such as NHS Direct on-line (www.nhsdirect.nhs.uk) is preferable to increase availability.
- Legibility: so that text/content is clearly presented. For example, in depression concentration is often impaired. Providing an appropriate font size and line spacing, clear chunking of text into sections and the use of shading can aid the user's ability to use the materials effectively. Legibility tools can be used. In addition, the words and sentences used in materials should be kept short and medical/psychological jargon minimised. Readability tests such as the Flesch or that of the Plain English campaign (www.plainenglish.co.uk/freepub.html) can be helpful.
- User involvement: in order to meet patient needs, the target audience for the materials should be involved in the production of the content.
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The Overcoming Depression Course |
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This course of 10 structured CBT workbooks was initially funded for development by a NHS Health Authority. It aims to offer ready access to the evidence-based CBT treatment for depression and to provide this in an accessible, jargon-free form. Each workbook has been tested within a collaborative group of GPs, psychologists, practice nurses, CPNs, and others who have used the workbook with patients and have offered feedback that has then been used to improve their content. The reading age of each workbook is 11–14 years (most aged 11–12 years). The development of the materials meet the criteria for producing effective patient materials as described above, and provide a structured step-by-step approach that supports 1:1 work with the practitioner. The structure of the Overcoming Depression Course is summarised in Figure 1.
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The course workbooks include a single entry workbook that helps the patient self-assess current problems (situation, relationship and practical problems, altered thinking, mood, physical symptoms and behaviour). This then helps the patient and their health care practitioner to decide which of workbooks 2–9 should be chosen for use. Finally, a single exit workbook teaches effective strategies for relapse prevention. The materials are designed to support work by the health care practitioner and as many or as few of the materials as are relevant to the patient or practitioner may be used. Patients are seen once every 1–3 weeks for monitoring.
Users are encouraged to take time reading and responding to questions in the workbooks. They are invited to answer all the questions asked and to Stop, Think and Reflect on their answers. The materials are aimed at patients with mild-to-moderate depression in primary or secondary care, who have a reading age of 12 years or over. They provide very clear targets for change and aim to help improve:
- extreme/unhelpful thinking
- poor problem solving/lack of assertiveness skills
- problems of reduced activity
- unhelpful behaviours (such as drinking excessively)
- problems such as poor sleep/insomnia
- the patient's ability to take antidepressants (if prescribed)
The materials are available in a range of delivery formats including as a book31, via the web37 and as an interactive CD-ROM for use by patients38. Together, the different formats of delivery offer patients access to the same materials in ways that address the different personal preferences and skills of patients/practitioners. In addition, a range of accompanying written and CD training materials for practitioners provide staff training in using the approach. Several health authorities have set up training courses in the approach and a trainer's manual will shortly be available to support such training. This is seen as crucial in supporting the use of the materials, so that they can be used effectively by practitioners who are familiar with their content.
In order to provide ready access to materials, a license for unlimited photocopying for use with patients and in training is provided with the book, and six of the ten workbooks are available free of charge from the web-site www.calipso.co.uk
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Key points for clinical practice |
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- Self-help approaches offer a potentially important and useful way of providing ready access to effective psychosocial interventions
- Most self-help approaches use the Cognitive Behaviour Therapy approach and a strong evidence base supports the effectiveness of this form of psychotherapy, and its effectiveness as a structured self-help approach
- Delivery may be by more traditional book or tape-based formats, or by more modern approaches such as by interactive CD-ROMs or via the Internet
- Patients are all very different and providing materials that meet these different needs is important
- With the increasing focus on the use of technology to deliver self-help treatments, there is a need to re-visit the basics of patient engagement to ensure that computer-based and written self-help materials provide materials that are developed with the patient in mind and that such materials are delivered by trained practitioners who are able to use them effectively and appropriately with the patients they treat35
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Acknowledgements |
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Figure 1 is reproduced with permission of Dr CJ Williams and University of Leeds Innovations.
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Footnotes |
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Correspondence to: Dr Chris Williams, Department of Psychological Medicine, Academic Centre, Gartnavel Royal Hospital, 1055 Great Western Road, Glasgow G12 0XH, UK
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