This review evaluated self-help books for depression and found some weak evidence to suggest that bibliotherapy, when given with additional advice, is effective in the treatment of depression. Further research is needed to support their use in the health service setting. The authors' cautious conclusion reflects the limited, short-term evidence presented in the review.

To review and update the evidence on the effectiveness of bibliotherapy in the treatment of depression.

Studies included in a previously conducted systematic review of self-help in depression were considered for inclusion (see Other Publications of Related Interest). In addition, searches of MEDLINE, CINAHL, EMBASE, PsycINFO and the Cochrane Controlled Trials Register (all from 1990 to 2003), PsiTri and the National Research Register (for ongoing studies) were conducted. The reference lists of all retrieved papers were checked, and authors and experts in the field were contacted for other published or unpublished studies.

Study designs of evaluations included in the review

Randomised controlled trials (RCTs) were eligible for inclusion.

Specific interventions included in the review

Studies of self-help written material for depression, with minimum guidance, defined as 1-hour or less of professional face-to-face contact or up to six 15-minute telephone calls, were eligible for inclusion. The studies had to compare self-help with treatment as usual or a waiting-list comparison. Specific attention was given to studies that evaluated self-help materials available to purchase. Named self-help booklets used in the included studies were 'Feeling Good', 'Control Your Depression' and 'Managing Anxiety and Depression'. All of the included studies provided additional guidance from a research worker. A description of each self-help book is given on the British Journal of General Practice website (accessed 22/05/2006 via PubMed Central). See Web Address at end of abstract.

Participants included in the review

Studies of participants aged 16 years older with a diagnosis or symptoms of depression, with or without anxiety, were eligible for inclusion. The reviewers excluded one study of adults with physical disabilities as it increased the likelihood of statistical heterogeneity. The included studies were of self-selected patients with a generally high level of education.

Outcomes assessed in the review

Studies that reported clinical symptoms, quality of life, costs or measures of acceptability to users were eligible for inclusion. The included studies assessed the outcomes at 4 weeks.

How were decisions on the relevance of primary studies made?

Two reviewers independently determined the eligibility of included studies. Any disagreements were resolved by discussion or by a third reviewer.

Each study was assessed for adequacy of random allocation concealment, percentage of follow-up, reporting of a primary outcome measure and reporting of an a priori power calculation. It was unclear how many reviewers performed the validity assessment.

The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction. The mean score and standard deviation on the Hamilton Rating Scale for Depression (HRSD) were extracted.

How were the studies combined?

Studies that evaluated the 'Feeling Good' and the 'Control Your Depression' self-help books were combined separately using a random-effects meta-analysis to calculate a standardised mean difference (SMD) for each book. The results of some studies were also tabulated and presented on the British Journal of General Practice website (accessed 22/05/2006 via PubMed Central). See Web Address at end of abstract.

How were differences between studies investigated?

Heterogeneity was assessed as part of the meta-analysis.

Eleven RCTs met the inclusion criteria. It was unclear how many participants were included in the studies.

Overall, the quality of the included studies was poor: no study reported methods used to conceal allocation or performed a power calculation, and only one study reported a primary outcome. The studies had a small sample size and included participants who were self-selected. The 'Feeling Good' self-help book was associated with a significant improvement on the HRSD at 4 weeks (SMD -1.36, 95% confidence interval, CI: -1.76, -0.96, P<0.0001), based on 6 studies (n=309). There was no evidence of statistical heterogeneity (P=0.16). A pooled analysis of these studies and 2 studies using unpublished self-help material showed a similar effect (SMD -1.28, 95% CI: -1.68, -0.88) with borderline heterogeneity (P=0.07).

The 'Control Your Depression' self-help book was associated with a non significant improvement in outcome at 4 weeks compared with waiting-list control (SMD -0.58, 95% CI: -1.40, 0.25), based on two studies.

The 'Managing Anxiety and Depression' self-help book found no significant difference between intervention and control at 1 or 3 months, based on 62 completers in one study (n=106).

There is weak evidence to suggest that bibliotherapy, based on a cognitive-behavioural approach, is effective in relieving the symptoms of depression in some people when additional advice is given. There is a need for more evidence to support its use in a health service setting.

The review question was well-defined and the inclusion criteria appeared appropriate. Several relevant sources were searched and attempts were made to identify unpublished studies. Methods were used to minimise selection bias, but it was unclear whether methods were used to minimise reviewer error and bias in the data abstraction and validity assessment processes.

Details of the results of each included study were limited, which meant that it was difficult to assess whether it was appropriate to combine the studies in a meta-analysis. The authors acknowledged the methodological limitations of the evidence provided in the included studies; their suitably cautious conclusion therefore appears appropriate.

Practice: The authors stated that using self-help as the first element in a stepped care approach in the treatment of depression would seem an appropriate option, particularly if general practitioners have received training in their use.

Research: The authors stated that evidence of cost-effectiveness of additional support would be needed before the widespread use of self-help books can be recommended. In addition, the most suitable format and presentation of materials needs to be determined.

Department of Health, Policy Research Programme.

Lewis G, Anderson L, Araya R, Elgie R, Harrison G, Proudfoot J, et al. Self-help interventions for mental health problems. Department of Health briefing. London: Department of Health; 2003.

This additional published commentary may also be of interest. Primack BA. Review: some evidence shows that self help books based on cognitive behaviour therapy can relieve depression in some patients. Evid Based Med 2006;11:8.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.