Medical Matters:In 1916 the word bibliotherapy (a combination of Greek words for book and healing) was coined by Samuel McChord Crothers, an American clergyman and essayist, to describe the "technique of prescribing books to patients who need help understanding their problems".
The therapeutic potential of books was recognised in ancient Greece where the door of the library at Thebes bore the inscription "Healing Place of the Soul". Depressed people have also turned to the holy books of major religions for solace and guidance. Bibliotherapy essentially provides information and encourages the reader to make changes leading to improved self-management. Enthusiasm for the 21st century use of bibliotherapy for depression should be tempered by the pursuit of sound evidence from research.
Cognitive behaviour therapy (CBT) is an effective psychological treatment for depression, but there are not enough skilled CBT therapists to satisfy public demand. If shown to be effective, CBT-based bibliotherapy could help to achieve prompt relief from suffering for many people with depression. In a recent paper in the Irish Journal of Psychological Medicine, I summarised available research about CBT-based bibliotherapy guided by a healthcare professional. I concluded that it "looks promising as a first step in the management of mild depression in some adults".
For the initial treatment of mild depression in primary care centres, the British National Institute for Health and Clinical Excellence (NICE) has recommended sleep, hygiene and anxiety management, watchful waiting, exercise, guided self-help (using appropriate written materials based on CBT and limited support from a healthcare professional over six to nine weeks), problem-solving therapy, brief CBT and counselling.
According to NICE, antidepressants are not recommended for initial treatment of mild depression. It was not within the scope of the NICE guidelines to make recommendations on specific self-help books. A recent review of randomised controlled trials in people with clinically significant emotional disorders, concluded that bibliotherapy is significantly more effective than waiting lists and may be as effective as professional treatment of relatively short duration.
Given the existence of a flourishing self-help book industry, there is a need to provide healthcare professionals, and the public, with evidence-based advice about appropriate self-help books for depression.
Hopefully, future research will measure the effectiveness of as many as possible of the currently available CBT-based self-help books for depression. Examples of such books are Mind over Mood: Change how you feel by changing the way you thinkby D Greenberger and CA Padesky; Overcoming Depressionby P Gilbert; and Overcoming Depression and Low Mood: A Five Areas Approachby C Williams.
More research is needed to clarify the true potential of guided bibliotherapy for the management of mild depression in primary care. Other challenges for research and development include identification of groups unsuited to bibliotherapy; provision of books suitable for people with different levels of education and reading abilities; bibliotherapy combined with antidepressants in moderate depression; the use of bibliotherapy in the prevention of depression in at-risk people; and consideration of the role of bibliotherapy within mainstream mental health services. Public libraries have a vital role to play in facilitating bibliotherapy.
If the evidence base for the effectiveness of guided CBT-based bibliotherapy continues to grow, widespread pursuance of this early intervention in primary care could empower many adults who suffer from mild depression, help to minimise premature prescription of antidepressant medication and reduce referrals to secondary mental health services that need to focus on people with more complex mental disorders.
Of course, patients need to be informed that there are alternative therapeutic options if guided bibliotherapy proves unacceptable or ineffective. Compared with computerised CBT, bibliotherapy based on CBT is probably less expensive, more widely available and more portable.
Early, effective intervention in mild depression will prevent progression to moderate/severe depression. Ideally, the diagnosis of mild depression should be confirmed by a GP before considering guided bibliotherapy. However, the possibility of trained "paraprofessionals" acting as bibliotherapy guides may provide an alternative therapeutic option for people reluctant to attend healthcare professionals. Participation in bibliotherapy may nurture psychological mindedness, thereby facilitating subsequent therapist-delivered psychological treatment to patients unresponsive, or partially responsive, to bibliotherapy.
If more evidence for effectiveness is forthcoming, the provision of guided CBT-based bibliotherapy for adults with mild depression in primary care, and possibly other settings, may have a significant impact on a major public health problem.
Dr Tom Foster is a consultant psychiatrist at Tyrone and Fermanagh Hospital, Omagh, Co Tyrone