Three-year follow-up of bibliotherapy for depression

Durability of treatment effects following internet-delivered cognitive behavioural therapy for depression and anxiety delivered within a routine care setting

OBJECTIVE

To investigate post-treatment relapse and remission rates 3, 6 and 9 months after completion of an acute phase of a clinician-supported internet-delivered cognitive-behavioural therapy (iCBT) for anxiety and depressive symptoms, within a routine care setting.

METHOD

Secondary analysis from a 12-month pragmatic randomized-controlled trial delivered within the Improving Access to Psychological Therapies (IAPT) programme in England. Participants in the intervention arm were included if they met criteria for reliable recovery from depression (PHQ-9) and anxiety (GAD-7) at post-treatment assessment. Survival analysis was used to assess durability of treatment effects and determine predictors to relapse at 3-, 6- and 9-month follow-up. Hazard ratios predicting time-to-relapse were estimated with semi-parametric Cox proportional hazards model.

RESULTS

Of the 241 participants in the intervention arm, 89 participants met the criteria for reliable recovery from depression and anxiety at the post-treatment assessment. Of these 89 eligible cases, 29.2% relapsed within the 9-month period, with 70.8% remaining in remission at 9 months post-treatment. Of those who relapsed, 53.8% experienced a relapse of depression and anxiety; 7.7% experienced a relapse of depression only; and 38.4% experienced a relapse of anxiety only. Younger age, having a long-term condition, and residual symptoms of anxiety at end-of-treatment were all significant predictors of relapse.

CONCLUSIONS

This study is the first to explore the remission and relapse rates after an acute phase of iCBT treatment, within a routine, stepped-care setting. The results add to the scarce literature on the durability of the effects of iCBT treatment in routine care settings, where patients are not typically followed up after receiving a completed course of treatment.

People Searching for Meaning in Their Lives Find Literature More Engaging

Why are some people interested in complex literature and others not? This study experimentally investigated this question by assessing what cognitive traits moderated responses to literary and less-literary fictional vignettes. Specifically, participants were exposed to two variants of a celebrated literary text, one altered so as to remove overtly literary elements. A moderation analysis was performed on responses with respect to three variables: need for cognition (NC); meaning in life (measured in two subscales, search for meaning [SM] and presence of meaning [PM]); and intentionality/mentalizing ability (IM). Results showed that SM moderated interpretive response to the textual variation, such that those with increasing scores on the SM scale were increasingly more likely to rate the literary vignettes as worthy of appreciation. This result, in turn, gave grounds for a second study that investigated the role played by cloze values in identifying a text as “literary.” The latter study showed that the literary and less-literary vignettes exhibited significant differences in cloze values. Taken together, these studies suggest that differences in responsiveness to literary materials may well be driven by preexisting cognitive factors.

The long-term effects of bibliotherapy in depression treatment: Systematic review of randomized clinical trials

OBJECTIVE

Literature shows bibliotherapy can be helpful for moderate depression treatment. The aim of this systematic review is to verify the long-term effects of bibliotherapy.

METHODS

After bibliographic research, we included RCTs articles about bibliotherapy programme treatment of depression published in English language between 1990 and July 2017. All RCTs were assessed with Cochrane's Risk of Bias tool.

RESULTS

Ten articles (reporting 8 studies involving 1347 subjects) out of 306 retrieved results were included. All studies analyze the effects of bibliotherapy after follow-up periods ranging from 3months to 3years and show quiet good quality in methods and analyses. The treatment was compared to standard treatments or no intervention in all studies. After long-term period follow-ups, six studies, including adults, reported a decrease of depressive symptoms, while four studies including young people did not show significant results.

CONCLUSION

Bibliotherapy appears to be effective in the reduction of adults depressive symptoms in the long-term period, providing an affordable prompt treatment that could reduce further medications. The results of the present review suggest that bibliotherapy could play an important role in the treatment of a serious mental health issue. Further studies should be conducted to strengthen the evidence of bibliotherapy's efficacy.

Two-Year Follow-Up of Bibliotherapy and Individual Cognitive Therapy for Depressed Older Adults

This study examined the stability of treatment gains after receiving either cognitive bibliotherapy or individual cognitive psychotherapy for depression in older adults. A 2-year follow-up of 23 participants from Floyd, Scogin, McKendree-Smith, Floyd, and Rokke (2004) was conducted by comparing pre-and posttreatment scores with follow-up scores on the Hamilton Rating Scale for Depression (HRSD) and the Geriatric Depression Scale (GDS). Results indicated that treatment gains from baseline to the 2-year follow-up period were maintained on the HRSD and GDS, and there was not a significant decline from posttreatment to follow-up. There were no significant differences between the treatments on the GDS or HRSD at the 2-year follow-up; however, bibliotherapy participants had significantly more recurrences of depression during the follow-up period.

Evaluating the Effectiveness of ACT for Anxiety Disorders in a Self-Help Context: Outcomes From a Randomized Wait-List Controlled Trial

Rigorous evaluations of cognitive behavioral self-help books for anxiety in pure self-help contexts are lacking. The present study evaluated the effectiveness of an Acceptance and Commitment Therapy (ACT) self-help workbook for anxiety-related concerns, with no therapist contact, in an international sample. Participants (N=503; 94% mental health diagnosis) were randomized to an immediate workbook (n=256) or wait-list condition (n=247). Assessments at pretreatment, 12weeks, 6months, and 9months evaluated anxiety and related symptoms, quality of life, and ACT treatment processes (e.g., psychological flexibility). Participants in the wait-list arm crossed over to the workbook following the 12-week assessment. The workbook condition yielded significant improvements on all assessments from pre- to posttreatment relative to wait-list, and these gains were maintained at follow-ups. The pattern observed in the wait-list condition was virtually identical to the active treatment arm after receiving the workbook, but not before. Attrition was notable, but supplemental analyses suggested dropout did not influence treatment effects for all but one measure. Overall, findings provide preliminary support for the effectiveness of this self-help workbook and suggest ACT-based self-help bibliotherapy might be a promising low-cost intervention for people experiencing significant anxiety-related concerns.

Defining the Role of Cognitive Behavioral Therapy in Treating Chronic Low Back Pain: An Overview

Study Design Narrative review of the literature. Objectives Determine if the term cognitive behavioral therapy (CBT) is useful in clinical care and research. What literature supports these variables being relevant to the experience of chronic pain? What effects of CBT in treating these factors have been documented? What methods and platforms are available to administer CBT? Methods Chronic low back pain (CLBP) is a complex neurologic disorder with many components. CBT refers to a broad family of therapies that address both maladaptive thoughts and behaviors. There are several ways to deliver it. CLBP was broken into five categories that affect the perception of pain, and the literature was reviewed to see the effects of CBT on these variables. Results The term cognitive behavioral therapy has little use in future research because it covers such a wide range of therapies. CBT should always be defined by the problem it is intended to solve. The format and method of delivery should be defined because they have implications for outcomes. They are readily available even at the primary care level. The effectiveness of CBT is unquestioned regarding its effectiveness in treating each of the variables that affect CLBP. It is unclear why it is not more widely implemented. Conclusions CBT represents a family of therapies that are effective for a wide range of problems, many of which coexist with and influence CLBP. Each of the variables can be improved with focused CBT. Early, widespread adoption of CBT in treating and preventing CLBP is recommended. Future research and clinical care should focus on strategies to operationalize these well-documented treatments utilizing a public health approach.

Cognitive bibliotherapy and memory training for older adults with depressive symptoms

OBJECTIVES

Substantial evidence indicates that depressed participants perform more poorly than nondepressed participants on a number of memory tasks. Cognitive deficits associated with depression (i.e., poor allocation of attention, poor encoding strategies), may help explain why depressed older adults are particularly prone to evidence poorer memory performance.

METHOD

The present study compared the impact of two self-administered treatment protocols, cognitive bibliotherapy for depression plus memory training (CBT + MT) and cognitive bibliotherapy alone (CBT), to a wait-list control condition on measures of memory functioning and depression in a group of older adults experiencing depressive symptoms and memory complaints.

RESULTS

Results provide partial support for CBT as a treatment for depressive symptoms; however, memory training augmentation did not produce improvements.

CONCLUSION

Suggestions for improving retention of older adults in self-administered treatments are discussed.

Reading group rehabilitation for patients with psychosis: a randomized controlled study

OBJECTIVE

Group reading activities are often reported to be helpful in a variety of psychiatric conditions. However, data on the effects of structured reading rehabilitation activities, in both hospital and community settings for patients with psychosis, are still scarce. Our aim was to investigate the effects on clinical status, disability, psychosocial functioning and cognitive functioning of a structured group reading activity, in a sample of hospitalized patients with psychosis.

METHODS

We enrolled 41 consecutive patients with psychosis and randomly assigned them to a structured group reading programme. For all included patients, we psychometrically evaluated clinical symptomatology, psychosocial functioning and disability, as well as cognitive functioning. All evaluations were repeated at a 6-month follow-up. Repeated-measure multiple analyses of variance were used to test the effect of the group reading activities on the clinical, psychosocial and cognitive measures.

RESULTS

We found that, after 6 months from discharge, structured group reading activities induced a statistically significant improvement of cognitive (p < 0.007) and psychosocial (p < 0.008) functioning in patients with psychosis and reduced their disability (p < 0.005), with respect to the control group. Furthermore, such programmes are easy to implement and were perceived as extremely 'interesting' and 'useful' by patients with psychosis.

CONCLUSIONS

Rehabilitation programmes focusing on group reading activities should be regarded as a valid psychosocial rehabilitation tool for psychotic patients with severe mental disability.

KEY PRACTITIONER MESSAGE

A structured group reading programme induced a significant symptomatological cognitive and psychosocial amelioration in hospitalized patients with psychosis. The improvement was sustained also at the 6-month follow-up, with respect to the control group. Structured group reading activities are perceived, by severely ill psychiatric patients, as highly useful, interesting and pleasant, while they are relatively easy to implement.

Evaluation of a cognitive behavioural self-help manual for reducing depression: a randomized controlled trial

The prevalence of depression is increasing in Thailand. We used a randomized controlled trial to examine the effectiveness of a self-help programme in reducing depression in people with depression in Chiang Mai Province in Thailand. Fifty-six individuals diagnosed with moderate depression participated. They were assigned randomly to an intervention (n= 27) or control (n= 29) group. The intervention group were given a self-help manual along with standard care and treatment, while the control group continued to receive standard care and treatment. Both groups were also given a short weekly telephone call. The findings showed statistically significant differences between the groups, and within the intervention group, in their depression levels. Between baseline and post-test, a sharp decrease in depression was evident in the intervention group, whereas the level of depression increased in the control group. Between post-test and follow-up, a decrease was apparent in depression in both groups. However, the intervention group showed a much lower level of depression than the control group. The results support the use of bibliotherapy as an adjunct to mental health nurses' and other professionals' work in caring for people with moderate depression in the community.

TRIAL REGISTRATION

http://www.ANZCTR.org.au/ACTRN12611000905965.aspx.

Evaluation of a bibliotherapy manual for reducing psychological distress in people with depression: a randomized controlled trial

AIM

This article reports a study to evaluate the efficacy of a self-help manual in reducing psychological distress in individuals with moderate depression.

BACKGROUND

The prevalence of depression in Thailand is increasing markedly (e.g. from 56-197 per 100,000 population between 1997-2007).

DESIGN

We conducted a randomized controlled trial with 54 outpatients with depression in Chiang Mai Province in Thailand.

METHOD

Participants were assigned randomly to an intervention or control group. The intervention group participants were given a self-help manual in addition to standard care and treatment while the control group received standard care and treatment. Psychological distress was measured with the Kessler Psychological Distress Scale. Data were collected between October 2007-April 2008.

RESULTS

The findings showed statistically significant differences between both groups in their levels of psychological distress (e.g. tiredness, hopelessness, restlessness). At post-test, the distress scores of the intervention group were lower than those in the control group. Between post-test and 1-month follow-up, distress scores continued to decrease steadily in the intervention group but only decreased slightly in the control group.

CONCLUSION

The findings affirm the benefits of bibliotherapy or self-help therapy in book form in helping to reduce psychological distress in people with moderate depression. The approach is easy to use and can be incorporated as an adjunct to standard care and treatment. Bibliotherapy can be used by community mental health nurses and other clinicians to reduce psychological distress and promote recovery in people with moderate depression.

Effectiveness of a self-help manual on the promotion of resilience in individuals with depression in Thailand: a randomised controlled trial

BACKGROUND

The prevalence of depression is increasing markedly in Thailand. One way of helping people with depression is to increase their resilience; good resilience is associated with positive outcomes in depression. The purpose of this study was to examine the effectiveness of a self-help manual on the resilience levels of individuals with depression living in the community in Chiang Mai Province in northern Thailand.

METHODS

Fifty-six participants with a diagnosis of moderate depression were assigned randomly to either an intervention (n = 27) or control (n = 29) group by means of independent random allocation, using computer generated random numbers. Fifty-four completed the study (two were excluded shortly after baseline data collection), so an available case analysis was undertaken. The intervention group were given a self-help manual and continued to receive standard care and treatment, while the control group continued to receive standard care and treatment. Both groups were also given a short weekly telephone call from a researcher. Participants were assessed at three time points: baseline (Week 0), immediate post-test (Week 8), and follow-up (Week 12). Data were collected between October 2007 and April 2008.

RESULTS

The findings showed statistically significant differences between the intervention and the control group, and within the intervention group, in their resilience levels. Simple main effects analyses of group within time showed a significant difference between both groups at follow-up (p = 0.001), with the intervention group having a higher resilience score than the control group. Simple main effect of time within the intervention group showed a significant increase in resilience scores from baseline to post-test time points (p < 0.001), from baseline to follow-up (p < 0.001), but not from post-test to follow-up (p = 0.298).

CONCLUSIONS

The findings provide preliminary evidence supporting the use of bibliotherapy for increasing resilience in people with moderate depression in a Thai context. Bibliotherapy is straightforward to use, and an easily accessible addition to the standard approach to promoting recovery. It is incorporated readily as an adjunct to the work of mental health nurses and other professionals in promoting resilience and enhancing recovery in people with moderate depression in the community.

TRIAL REGISTRATION

http://www.ANZCTR.org.au/ACTRN12611000905965.aspx.

A 3.5-year follow-up of Internet-delivered cognitive behavior therapy for major depression

BACKGROUND

Internet-delivered cognitive behavior therapy (ICBT) for major depression has been tested in several trials, but only with follow-ups up to 1.5 years.

AIM

The aim of this study was to evaluate the outcome of ICBT 3.5 years after treatment completion.

METHODS

A total of 88 people with major depression were randomized to either guided self-help or e-mail therapy in the original trial. One-third was initially on a waiting-list. Treatment was provided for eight weeks and in this report long-term follow-up data were collected. Also included were data from post-treatment and six-month follow-up. A total of 58% (51/88) completed the 3.5-year follow-up. Analyses were performed using a random effects repeated measures piecewise growth model to estimate trajectory shape over time and account for missing data. Results Results showed continued lowered scores on the Beck Depression Inventory (BDI). No differences were found between the treatment conditions. A large proportion of participants (55%) had sought and received additional treatments in the follow-up period. A majority (56.9%) of participants had a BDI score lower than 10 at the 3.5-year follow-up.

CONCLUSIONS

People with mild to moderate major depression may benefit from ICBT 3.5-years after treatment completion.

Strengthening classroom emotional support for children following a family member’s death

National and international organizations have identified schools as having an unparalleled potential to offer supportive services for children’s mental health needs. This article reviews research and practice related to children’s grief and specifies strategies for classroom-based interventions. In particular, school psychologists are encouraged to assist teachers in addressing the needs of children following the death of a family member. A list of resources is included to assist school psychologists in sharing critical information with teachers, preparing them to implement suggested strategies. Additionally, two ready-to-use classroom lesson plans integrate classroom discussion and activities with grief-themed children’s literature.

Bibliotherapy as a treatment for depression in primary care

This study was designed to determine whether a physician-delivered bibliotherapy prescription would compare favorably with the prevailing usual care treatment for depression in primary care (that often involves medication) and potentially offer an alternative. Six family physicians were trained to write and deliver prescriptions for cognitive-behavioral bibliotherapy. Thirty-eight patients were randomly assigned to receive either usual care or a behavioral prescription to read the self-help book, Feeling Good (Burns, D. D. (1999). Feeling good: The new mood therapy. New York: HarperCollins). The treatment groups did not differ in terms of overall outcome variables. Patients in both treatment groups reported statistically significant decreases in depression symptoms, decreases in dysfunctional attitudes, and increases in quality of life. Although not statistically significant, the mean net medical expenses in the behavioral prescription group were substantially less. This study provided empirical evidence that a behavioral prescription for Feeling Good may be as effective as standard care, which commonly involves an antidepressant prescription.

Telemedicine for depression: a systematic review

PURPOSE

More than 14% of the population has a mood disorder, and more than 50% do not receive treatment. Information and communication technology (ICT) could improve health care. A systematic review was considered in order to know the programs that apply ICT in the management of depression and to assess their effectiveness.

CONCLUSION

There is insufficient scientific evidence regarding the effectiveness of ICT use in the management of depression. However, there is a well-founded hypothesis that videoconference produces the same results as face-to-face treatment and that self-help Internet programs could improve symptoms.

PRACTICE IMPLICATIONS

More research is needed; nevertheless, when traditional care is not possible, telemedicine could be used.

Effectiveness of bibliotherapy self-help for depression with varying levels of telephone helpline support

The effectiveness of a cognitive behavioural bibliotherapy self-help package, with varied levels of telephone support, delivered through a mental health telephone service was examined with 84 mildly to moderately depressed adults. The study compared the changes in depressive symptoms of three groups: control, self help with minimal contact and self-help with telephone assistance. Both the minimal contact and the assisted self-help groups had significant reductions in their levels of depression compared with the control group. Treatment gains were maintained at a 1-month follow-up. The potential of self-help resources such as this to be successfully disseminated and delivered through a national mental health telephone information service is discussed.

Challenges and opportunities for preventing depression in the workplace: a review of the evidence supporting workplace factors and interventions

OBJECTIVE

To explore the literature regarding prevention of depression in the workplace.

METHOD

Literature review of what the author believes are seminal articles highlighting workplace factors and interventions in preventing depression in the workplace.

RESULTS

Employees can help prevent depression by building protective factors such as better coping and stress management skills. Employees may be candidates for depression screening if they have certain risk factors such as performance concerns. Organizational interventions such as improving mental health literacy and focusing on work-life balance may help prevent depression in the workplace but deserve further study.

CONCLUSION

A strategy to prevent depression in the workplace can include developing individual resilience, screening high-risk individuals and reducing that risk, improving organizational literacy, and integrating workplace and health care systems to allow access to proactive quality interventions.

Internet-Based Mental Health Interventions

Following recent reviews of community- and practice-based mental health interventions, an assessment of Internet-based interventions is provided. Although relatively new, many Internet mental health interventions have reported early results that are promising. Both therapist-led as well as self-directed online therapies indicate significant alleviation of disorder-related symptomatology. The number of studies addressing child disorders lags behind those of adults. More research is needed to address methodological issues of Internet-based treatments.

Treatment of panic disorder via the Internet: a randomized trial of CBT vs. applied relaxation

A randomized trial was conducted of two different self-help programs for panic disorder (PD) on the Internet. After confirming the PD-diagnosis with an in-person structured clinical interview for DSM-IV (SCID) interview 22 participants were randomized to either applied relaxation (AR) or a multimodal treatment package based on cognitive behavioral therapy (CBT). Overall, the results suggest that Internet-administered self-help plus minimal therapist contact via e-mail has a significant medium to large effect (Cohen's d=0.71 for AR and d=0.42 for CBT). The results from this study generally provide evidence to support the continued use and development of Internet-distributed self-help programs.

Psychologic factors in scleroderma

CB interventions have been shown to reduce pain and improve psychosocial functioning in patients who have chronic illnesses, particularly chronically painful rheumatologic syndromes. These interventions are typically administered by specially trained professionals and are conducted during weekly individual or group sessions. When focused on pain and chronic illness, these interventions seem to have, at best, small effects on depression. Data from the headache literature and recent data about patients who have dental/facial pain indicate that minimal-contact CB therapy, the combination of some professional contact with audiotaped and written materials, may reduce pain in many patients, but the impact on functioning is less clear. Future studies should examine the impact of CB interventions on pain, depression, concerns about disfigurement, and physical and psychosocial functioning in scleroderma. Such knowledge is necessary for the optimal care of persons who have this debilitating illness. Although complicated, the advent of disease-specific interventions that are administered by way of the Internet may prove particularly useful in a rare illness, such as scleroderma. Psychologic factors with demonstrated relevance to scleroderma include pain, depression, and distress about disfigurement, physical function, and social function. Although these dimensions of quality of life are interrelated, pain, depression, and distress about disfigurement are common and may respond to psychologic interventions.

Self-administered treatments for depression: a review

Although there are numerous self-help books for depression, relatively few have been empirically tested. However, those that have been used in clinical trials have fared well, with an average effect size roughly equivalent to the average effect size obtained in psychotherapy studies. Computer-based treatments are being developed and appear promising as an alternative to bibliotherapy for those interested in self-administered treatments. This article provides a summary of the depression bibliotherapy literature and discusses several remaining questions such as effectiveness versus efficacy, practice applications, ethics, and future research.

Overcoming depression on the Internet (ODIN): a randomized controlled trial of an Internet depression skills intervention program

BACKGROUND

Psychoeducational programs are increasingly being delivered over the Internet. We created an Internet-based, cognitive therapy, self-help program to be used as a stand-alone intervention for mild-to-moderate depression, or as an adjunct to traditional services for more severe depression.

OBJECTIVE

To evaluate the effectiveness of a web-based intervention program to reduce depression in a randomized, controlled trial.

METHODS

In a private, nonprofit health maintenance organization, we mailed recruitment brochures to two populations: depressed adults (n = 6994) who received traditional medical services for depression, and an age/gender matched sample of nondepressed adults (n = 6996). Participants consenting to the study were randomized to either the experimental Web site (n = 144), or a no-access control group (n = 155). Participants in both groups were free to obtain nonexperimental, usual care services for their depression. All participants completed an on-line version of the Center for Epidemiological Studies Depression Scale (CES-D) at enrollment and at 4-, 8-, 16- and 32-weeks after enrollment. Mean intake scores were in the severely depressed range. 74% of participants completed at least one follow-up assessment. Unfortunately, most intervention participants accessed the Internet site infrequently.

RESULTS

We failed to find an effect for the Internet program across the entire sample. However, post-hoc, exploratory analyses revealed a modest effect among persons reporting low levels of depression at intake.

CONCLUSIONS

The negative results might have resulted from infrequent patient use of the Internet site, or a more seriously depressed sample than the intervention was intended to help. Future studies should focus on recruiting persons with mild to moderate levels of depression, and on increasing participant use of the Internet site.

Psychotherapy and combined psychotherapy/pharmacotherapy for late life depression

Over the past 20 years, numerous studies have investigated the efficacy of psychotherapy for treating late life depression and, to a lesser degree, the efficacy of psychotherapy combined with antidepressant medication. Of the intervention studies, cognitive-behavioral therapy and interpersonal psychotherapy combined with antidepressant medication have the largest base of evidence in support of their efficacy for late life depression. To a lesser degree, there is support for stand-alone interpersonal psychotherapy, brief dynamic therapy, and life review treatments. The purpose of this review is to present data on the acute and long-term effects of cognitive-behavioral therapy, interpersonal psychotherapy, brief dynamic therapy, and combined antidepressant medication and psychotherapy to discuss the generalizability of these interventions, and to discuss future research directions and the need for increased opportunities for this area of research.

Fiction, poetry and mental health: expressive and therapeutic uses of literature

People with experience as mental health clients, mental health nurses, writers and other professionals have used literature to benefit mental health service users in various ways. These include expressive writing, as well as applications in psychotherapy and counselling and to deal with specific problems and symptoms. In addition, therapeutic story-telling, bibliotherapy and poetry therapy have been used. Various benefits have been described, but some accounts do not include evidence of clinical effectiveness. However, positive treatment outcomes have been reported in research papers and other literature, with particular evidence of clinical effectiveness in some studies of bibliotherapy, therapeutic writing and poetry therapy. Further work is needed to clarify and measure the effectiveness of various expressive and therapeutic uses of literature. The authors also recommend collaboration among practitioners and the need for supporting evidence for proposals for increased resources in this field.

Who uses bibliotherapy and why? A survey from an underserviced area

OBJECTIVE

To assess which mental health therapists use bibliotherapy, their reasons for doing so, and rationale for recommending specific titles. To review the book selected most often in several categories, using prepublished criteria for reviewers of self-help books.

METHOD

We sent a survey to all therapists in a Northern Ontario community requesting information on therapist demographics, the respondent's practice, the use of bibliotherapy, and details of the book most often prescribed in various categories.

RESULTS

Of 112 surveys, 62 were returned, for a response rate of 55%. Sixty-eight percent of respondents indicated that they used bibliotherapy. The most common reason for recommending books was to encourage self-help. There was a significant relation between greater counselling experience and increased use of bibliotherapy. Three of the 5 books reviewed were based on empirical theory; only 1 met all the guidelines.

CONCLUSION

Most therapists recommend books to their clients, but there is little empirical evidence of efficacy. Counsellors should review the books recommended and discuss them with the client. Client opinion should be solicited and effectiveness measured.

Raising questions about antidepressants

Antidepressant medication has apparently become the most popular treatment for depression in the USA. Several beliefs about the efficacy of antidepressant medications prevail among mental health professionals and the public. This paper explores relevant research data and raises questions about these beliefs. Many of the common beliefs about these medications are not adequately supported by scientific data. The following issues are raised: (1) industry-funded research studies which result in negative findings sometimes do not get published; (2) placebo washout procedures may bias results in some studies; (3) there are serious questions about the integrity of the double-blind procedure; (4) the 'true' antidepressant drug effect in adults appears to be relatively small; (5) there is minimal evidence of antidepressant efficacy in children; (6) side effects are fairly common even with the newer antidepressants; (7) combining medications raises the risk for more serious complications; (8) all antidepressants can cause withdrawal symptoms; (9) genetic influences on unipolar depression appear to be weaker than environmental influences; (10) biochemical theories of depression are as yet unproven; (11) biological markers specific for depression have been elusive; (12) dosage and plasma levels of antidepressants have been minimally related to treatment outcome; (13) preliminary evidence suggests that patients who improve with cognitive-behavioral psychotherapy show similar biological changes as those who respond to medication, and (14) the evidence suggests that psychological interventions are at least as effective as pharmacotherapy in treating depression, even if severe, especially when patient-rated measures are used and long-term follow-up is considered.