What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression

ABSTRACT Background Although self-help interventions are effective in treating depression, less is known about the factors that determine effectiveness (i.e. moderators of effect). This study sought to determine whether the content of self-help interventions, the study populations or aspects of study design were the most important moderators. Method Randomized trials of the effectiveness of self-help interventions versus controls in the treatment of depressive symptoms were identified using previous reviews and electronic database searches. Data on moderators (i.e. patient populations, study design, intervention content) and outcomes were extracted and analysed using meta-regression. Results Thirty-four studies were identified with 39 comparisons. Study design factors associated with greater effectiveness were unclear allocation concealment, observer-rated outcome measures and waiting-list control groups. Greater effectiveness was also associated with recruitment in non-clinical settings, patients with existing depression (rather than those ‘at risk’), contact with a therapist (i.e. guided self-help) and the use of cognitive behavioural therapy (CBT) techniques. However, only guided self-help remained significant in the multivariate analysis [regression coefficient 0·36, 95% confidence interval (CI) 0·05–0·68, p=0·03]. In the subset of guided studies, there were no significant associations between outcomes and the session length, content, delivery mode or therapist background. Conclusions The results provide some insights into moderators of self-help interventions, which might assist in the design of future interventions. However, the present study did not provide a comprehensive description, and other research methods might be required to identify factors associated with the effectiveness of self-help.

[1]  R. Araya,et al.  Self-help books for depression: how can practitioners and patients make the right choice? , 2005, The British journal of general practice : the journal of the Royal College of General Practitioners.

[2]  R. J. Hayes,et al.  Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. , 1995, JAMA.

[3]  D. Altman,et al.  Measuring inconsistency in meta-analyses , 2003, BMJ : British Medical Journal.

[4]  H. Christensen,et al.  Delivering interventions for depression by using the internet: randomised controlled trial , 2004, BMJ : British Medical Journal.

[5]  B. Everitt,et al.  Computerized, interactive, multimedia cognitive-behavioural program for anxiety and depression in general practice , 2003, Psychological Medicine.

[6]  Julian P T Higgins,et al.  Controlling the risk of spurious findings from meta‐regression , 2004, Statistics in medicine.

[7]  Amy Przeworski,et al.  Self-help and minimal-contact therapies for anxiety disorders: Is human contact necessary for therapeutic efficacy? , 2003, Journal of clinical psychology.

[8]  P C Lambert,et al.  A comparison of summary patient-level covariates in meta-regression with individual patient data meta-analysis. , 2002, Journal of clinical epidemiology.

[9]  Daniel Bowman,et al.  The Efficacy of Self-Examination Therapy and Cognitive Bibliotherapy in the Treatment of Mild to Moderate Depression , 1995 .

[10]  Nice.  Depression: management of depression in primary and secondary care , 2005 .

[11]  Mark W. Lipsey,et al.  Design Sensitivity: Statistical Power for Experimental Research. , 1989 .

[12]  Paul Little,et al.  Importance of patient pressure and perceived pressure and perceived medical need for investigations, referral, and prescribing in primary care: nested observational study , 2004, BMJ : British Medical Journal.

[13]  G. Andersson,et al.  Delivering Cognitive Behavioural Therapy for Mild to Moderate Depression via the Internet: Predicting Outcome at 6-Month Follow-Up , 2004, Verhaltenstherapie.

[14]  Paul Little,et al.  Randomised controlled trial of effect of leaflets to empower patients in consultations in primary care , 2004, BMJ : British Medical Journal.

[15]  S. Thompson,et al.  How should meta‐regression analyses be undertaken and interpreted? , 2002, Statistics in medicine.

[16]  B. Everitt,et al.  Clinical efficacy of computerised cognitive-behavioural therapy for anxiety and depression in primary care: Randomised controlled trial , 2004, British Journal of Psychiatry.

[17]  P. Bower,et al.  The clinical effectiveness of guided self-help versus waiting-list control in the management of anxiety and depression: a randomized controlled trial , 2005, Psychological Medicine.

[18]  F. Lynch,et al.  Overcoming Depression on the Internet (ODIN): A Randomized Controlled Trial of an Internet Depression Skills Intervention Program , 2002, Journal of medical Internet research.

[19]  R. Rosenthal.  The file drawer problem and tolerance for null results , 1979 .

[20]  F. Scogin,et al.  Comparative efficacy of cognitive and behavioral bibliotherapy for mildly and moderately depressed older adults. , 1989, Journal of consulting and clinical psychology.

[21]  David R. Jones,et al.  Systematic reviews of trials and other studies. , 1998, Health technology assessment.

[22]  J. Wollersheim,et al.  Group treatment of unipolar depression: A comparison of coping, supportive, bibliotherapy, and delayed treatment groups. , 1991 .

[23]  F. Scogin,et al.  Two-year follow-up of bibliotherapy for depression in older adults. , 1990, Journal of consulting and clinical psychology.

[24]  D. Bhugra,et al.  A Randomised Controlled Trial of an Educational Intervention for Depression among Asian Women in Primary Care in the United Kingdom , 2002, The International journal of social psychiatry.

[25]  F. Scogin,et al.  Cognitive bibliotherapy for mild and moderate adolescent depressive symptomatology. , 1998, Journal of consulting and clinical psychology.

[26]  S. Wessely,et al.  A systematic review of controlled trials of the effectiveness and cost-effectiveness of brief psychological treatments for depression. , 2002, Health technology assessment.

[27]  F. Scogin,et al.  Self-administered treatment in stepped-care models of depression treatment. , 2003, Journal of clinical psychology.

[28]  V D Philpot,et al.  Rehearsal of Positive Self-Statements and Restructured Negative Self-Statements to Increase Self-Esteem and Decrease Depression , 1996, Psychological reports.

[29]  J. Webster,et al.  IDentify, Educate and Alert (IDEA) trial: an intervention to reduce postnatal depression , 2003, BJOG : an international journal of obstetrics and gynaecology.

[30]  H. Christensen,et al.  Quality of web based information on treatment of depression: cross sectional survey , 2000, BMJ : British Medical Journal.

[31]  Nicholas Paxton,et al.  Parallel evaluations of new guidance materials for anxiety and depression in primary care , 1996 .

[32]  F. Scogin,et al.  The outcome of cognitive bibliotherapy with depressed adults. , 1995, Journal of consulting and clinical psychology.

[33]  Gerhard Andersson,et al.  Randomized Controlled Trial of Internet-Based Stress Management , 2003, Cognitive behaviour therapy.

[34]  P. Landreville,et al.  Effects of Cognitive Bibliotherapy for Depressed Older Adults with a Disability , 1997 .

[35]  F. Scogin,et al.  Efficacy of self-administered treatment programs: meta-analytic review , 1990 .

[36]  P. Lachenbruch.  Statistical Power Analysis for the Behavioral Sciences (2nd ed.) , 1989 .

[37]  R. Elliott,et al.  Evolving guidelines for publication of qualitative research studies in psychology and related fields. , 1999, The British journal of clinical psychology.

[38]  M. Reid,et al.  A two‐centred pragmatic randomised controlled trial of two interventions of postnatal support , 2002, BJOG : an international journal of obstetrics and gynaecology.

[39]  Mark W. Lipsey,et al.  Practical Meta-Analysis , 2000 .

[40]  R. Marrs.  A meta-analysis of bibliotherapy studies , 1995, American journal of community psychology.

[41]  L. Delbeke.  Quasi-experimentation - design and analysis issues for field settings - cook,td, campbell,dt , 1980 .

[42]  K. Lovell,et al.  MULTIPLE ACCESS POINTS AND LEVELS OF ENTRY (MAPLE): ENSURING CHOICE, ACCESSIBILITY AND EQUITY FOR CBT SERVICES , 2000 .

[43]  F. Scogin,et al.  Cognitive Therapy for Depression , 2004, Behavior modification.

[44]  P. Cuijpers,et al.  Bibliotherapy in unipolar depression: a meta-analysis. , 1997, Journal of behavior therapy and experimental psychiatry.

[45]  W. Shadish,et al.  Effects of behavioral marital therapy: a meta-analysis of randomized controlled trials. , 2005, Journal of consulting and clinical psychology.

[46]  P. Bower,et al.  Process and Outcome of a Non-Guided Self-Help Manual for Anxiety and Depression in Primary Care: A Pilot Study , 2005, Behavioural and Cognitive Psychotherapy.

[47]  D. Wiersma,et al.  Why is self-help neglected in the treatment of emotional disorders? A meta-analysis , 2004, Psychological Medicine.

[48]  W. R. Miller,et al.  Amount of therapist contact and outcome in a multidimensional depression treatment program , 1983, Acta psychiatrica Scandinavica.

[49]  P. Bower,et al.  The clinical and cost-effectiveness of self-help treatments for anxiety and depressive disorders in primary care: a systematic review. , 2001, The British journal of general practice : the journal of the Royal College of General Practitioners.

[50]  K. Griffiths,et al.  Providing information about the effectiveness of treatment options to depressed people in the community: a randomized controlled trial of effects on mental health literacy, help-seeking and symptoms , 2003, Psychological Medicine.

[51]  R. Rahe,et al.  A Novel Stress and Coping Workplace Program Reduces Illness and Healthcare Utilization , 2002, Psychosomatic medicine.

[52]  L. Beutler,et al.  Bibliotherapy for depressed older adults: a self-help alternative. , 1987, The Gerontologist.

[53]  J. Greist,et al.  Computer-administered cognitive-behavioral therapy for depression. , 1990, The American journal of psychiatry.

[54]  N. Jacobson,et al.  A component analysis of cognitive-behavioral treatment for depression. , 1996, Journal of consulting and clinical psychology.

[55]  P. Lachenbruch,et al.  Design Sensitivity: Statistical Power for Experimental Research. , 1989 .

[56]  Kenneth F Schulz,et al.  Allocation concealment in randomised trials: defending against deciphering , 2002, The Lancet.

[57]  P. Gøtzsche,et al.  Why we need a broad perspective on meta-analysis , 2000, BMJ : British Medical Journal.

[58]  P. Grime,et al.  Computerized cognitive behavioural therapy at work: a randomized controlled trial in employees with recent stress-related absenteeism. , 2004, Occupational medicine.

[59]  G. Clum,et al.  A meta-analysis of self-help treatment approaches , 1993 .

[60]  F. Scogin,et al.  Self-administered treatments for depression: a review. , 2003, Journal of clinical psychology.

[61]  Gene V. Glass,et al.  The benefits of psychotherapy , 1980 .

[62]  S. Stuart,et al.  Use of computer‐administered cognitive‐behavior therapy with depressed inpatients , 1993 .

[63]  T. Cook,et al.  Quasi-experimentation: Design & analysis issues for field settings , 1979 .

[64]  Jacob Cohen.  Statistical Power Analysis for the Behavioral Sciences , 1969, The SAGE Encyclopedia of Research Design.

[65]  G. Andersson,et al.  Internet-based self-help for depression: randomised controlled trial , 2005, British Journal of Psychiatry.

[66]  D. A. Kenny,et al.  The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. , 1986, Journal of personality and social psychology.

[67]  P. Cuijpers,et al.  Minimal-contact psychotherapy for sub-threshold depression in primary care , 2004, British Journal of Psychiatry.

[68]  S. Hollis,et al.  What is meant by intention to treat analysis? Survey of published randomised controlled trials , 1999, BMJ.

[69]  Scott B Patten,et al.  Prevention of depressive symptoms through the use of distance technologies. , 2003, Psychiatric services.

[70]  Steve McDonald,et al.  Development of the Cochrane Collaboration’s Central Register of Controlled Clinical Trials , 2002, Evaluation & the health professions.

[71]  P. Royle,et al.  Bmc Medical Research Methodology Open Access a Simplified Search Strategy for Identifying Randomised Controlled Trials for Systematic Reviews of Health Care Interventions: a Comparison with More Exhaustive Strategies , 2005 .

[72]  M. Barkham,et al.  PHASE: a randomised, controlled trial of supervised self-help cognitive behavioural therapy in primary care. , 2003, The British journal of general practice : the journal of the Royal College of General Practitioners.

[73]  P. Salkovskis,et al.  A randomized controlled trial of the use of self-help materials in addition to standard general practice treatment of depression compared to standard treatment alone , 2005, Psychological Medicine.