The fourth and final session of the "Non-pharmacological management of depression" SIGN seminar was entitled "Self help, guided and alternative/complementary therapies".  Dr George Deans, Consultant Clinical Psychologist at Aberdeen's Royal Cornhill Hospital, gave the first presentation of this session on "Alternative/complementary therapies 2".  I've already discussed the lack of good quality evidence to recommend such therapies for depression in the 4^th in this sequence of blog posts on "Alternative/complementary therapies 1".  This lack of evidence is worrying when considering how widespread the use of such approaches is likely to be.  A recent nationally representative survey of US women found 54% of those who were depressed reported past-year use of alternative and complementary medicines (Wu, Fuller et al. 2007).  The authors concluded "It is important for mental health and other health professionals to increase their own awareness of the types of complementary and alternative therapies that their patients may be using and to improve communication with their patients about the benefits and potential risks of these therapies."  A recent British Journal of Psychiatry paper on "Complementary medicines in psychiatry: review of effectiveness and safety" underlined the need for better research in this area (Werneke, Turner et al. 2006).  Mr John Coffey, Project Manager at Wishaw Hospital, went on to give a presentation on "Music, art and power therapies".  I covered the lack of evidence in these areas in the 7^th of these blog posts. 

The third presentation of this session (and the penultimate one of the day) was given by Dr Mark Storey, a Renfrewshire General Practitioner, on "Guided self help and psychoeducation".  To make a major impact on the huge amount of suffering associated with untreated and inadequately treated depression, I suspect this area is the most important that SIGN covered all day.  I wonder too about the possible value of internet-based psychoeducation as a screening tool (Houston, Cooper et al. 2001; Santor, Poulin et al. 2007).  Mark reported that SIGN proposes giving a grade A recommendation that "Self help guided by therapist input is recommended as a treatment option for patients with mild to moderate depression."  He mentioned that with no guidance, self help approaches for depression seem to produce rather modest effect sizes of about 0.4 to 0.5, whereas with some therapist guidance the effect size increases to a very respectable 0.8 - similar to the average effect size for standard psychotherapies (den Boer, Wiersma et al. 2004).  SIGN also gave a grade A recommendation that "Self help in the form of computerised CBT is recommended as a treatment option for patients with mild to moderate depression."  Since computerised CBT packages may involve more expense than bibliotherapy, it is probably worth clarifying that the two approaches - book delivered and computer delivered - are likely to be equally helpful (Gellatly, Bower et al. 2007).    

The final presentation was fittingly given by the initiator of the guideline, Ruth Lang, Information and Support Officer for the charity Depression Alliance Scotland, on "Self help groups and bibliotherapy".  There is little current good data on which to base recommendations for self help groups.  The same seems true for possible benefits of ‘virtual' internet-based groups.  In covering ‘bibliotherapy' Ruth also said that the use of prose, poetry, biography and other creative writing to treat depression was not currently supported by good quality evidence.  There is definite evidence for the value of certain kinds of creative writing for some emotional disorders (Lepore and Smyth 2002; Hawkins 2003; Gortner, Rude et al. 2006; Sloan, Marx et al. 2008), but it seems odd for SIGN to describe writing using the term "bibliotherapy" which Wikipedia, for example, describes as " ... the selection of reading material, for a client that has relevance to that person's life situation."   

As I wrote in the 1^st   of this series of 9 blog posts on the SIGN draft "Non-pharmacological management of depression" guideline, the development group deserve our congratulations and thanks for the huge amount of work they have so generously got through and the impressive job they've done.  The next major and equally important challenge is that of guideline implementation (Gilbody, Whitty et al. 2003).  The day seminar closed with a panel discussion and a request for feedback on the draft guideline - hence this series of 9 blog postings.

den Boer, P. C., D. Wiersma, et al. (2004). "Why is self-help neglected in the treatment of emotional disorders? A meta-analysis." Psychol Med 34(6): 959-71.  [PubMed] 
Gellatly, J., P. Bower, et al. (2007). "What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression." Psychological Medicine 37: 1217-1228.  [Abstract/Full Text] 
Gilbody, S., P. Whitty, et al. (2003). "Educational and organizational interventions to improve the management of depression in primary care: a systematic review." JAMA 289(23): 3145-3151. [Abstract/Free Full Text] 
Gortner, E. M., S. S. Rude, et al. (2006). "Benefits of expressive writing in lowering rumination and depressive symptoms." Behav Ther 37(3): 292-303.  [PubMed]
Hawkins, J. (2003).  "The healing power of words."  [Free Full Presentation]
Houston, T. K., L. A. Cooper, et al. (2001). "Screening the public for depression through the Internet." Psychiatric Services 52(3): 362-7.  [PubMed]
Lepore, S. J. and J. Smyth, Eds. (2002). "The writing cure: how expressive writing promotes health and emotional well-being." Washington, DC, American Psychological Association.  [AbeBooks]  [Amazon UK]
Santor, D. A., C. Poulin, et al. (2007). "Online health promotion, early identification of difficulties, and help seeking in young people." J Am Acad Child Adolesc Psychiatry 46(1): 50-9.  [PubMed] 
Sloan, D. M., B. P. Marx, et al. (2008). "Expressive writing buffers against maladaptive rumination." Emotion 8(2): 302-6.  [PubMed] 
Werneke, U., T. Turner, et al. (2006). "Complementary medicines in psychiatry: Review of effectiveness and safety." Br J Psychiatry 188: 109-21.  [PubMed] 
Wu, P., C. Fuller, et al. (2007). "Use of complementary and alternative medicine among women with depression: results of a national survey." Psychiatr Serv 58(3): 349-56.  [PubMed]