Self-help books for people with depression: A scoping review

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Self-help books for people with depression: A scoping reviewRachel Richardson a; David A. Richards a; Michael Barkham b

a Department of Health Sciences, University of York, York b Centre for Psychological Services Research,University of Sheffield, Sheffield, UK

Online Publication Date: 01 October 2008

To cite this Article Richardson, Rachel, Richards, David A. and Barkham, Michael(2008)'Self-help books for people with depression: Ascoping review',Journal of Mental Health,17:5,543 — 552

To link to this Article: DOI: 10.1080/09638230802053334

URL: http://dx.doi.org/10.1080/09638230802053334

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Self-help books for people with depression: A scopingreview

RACHEL RICHARDSON1, DAVID A. RICHARDS1, &

MICHAEL BARKHAM2

1Department of Health Sciences, University of York, York, and 2Centre for Psychological Services

Research, University of Sheffield, Sheffield, UK

AbstractBackground: There has been little research into self-help books for people with depression, despite theapparent plethora of such titles. As an initial step, we undertook a scoping review of available books.Aim: To identify the number of self-help books for people with depression or mixed anxiety anddepression that are available in the UK and to describe their principle characteristics.Methods: We located publicly available self-help books for people with depression or mixed anxietyand depression. We extracted data from the books we located that included descriptive information(including the psychological approach used), readability statistics and popularity measures.Results: We analysed data from 97 books. These publications were diverse in both structure andcontent. Structure and readability data illustrated that many potential readers may have difficulty usingsome of them. Popularity proved to be an unreliable way of locating books that would fulfil NICEguidance for a CBT based self-help programme.Conclusions: Many of the available books are complex to read in terms of literacy levels and maypresent additional problems given the concentration problems of people with depression. There is norelationship between popularity and a book being evidence-based or readable.

Keywords: Self-help books, depression

Introduction

Depression is a significant cause of personal distress, social disability and economic cost for

patients, families and society at large (Layard, 2006). The condition is highly prevalent: at

any one time more than 10% of the British population are suffering from depression alone or

mixed anxiety and depression (Office for National Statistics, 2001). We know that patients

would often prefer talking treatments to medication (Rogers et al., 1993, p. 124). However,

despite the fact that the National Institute for Health and Clinical Excellence (NICE) has

recognized that psychological therapies are as effective as antidepressants for most

depression (NICE, 2004), the majority of patients do not have access to talking treatments.

A recent survey published by the Office for National Statistics showed that only 9% of

people assessed as having a neurotic disorder were having counselling or therapy (Office for

National Statistics, 2001).

Correspondence: Rachel Richardson, Research Fellow, Area 4, Seebohm Rowntree Building, Department of Health Sciences,

University of York, York YO10 5DD, UK. Tel: þ44 (0)1904 321863. E-mail: [email protected]

Journal of Mental Health,

October 2008; 17(5): 543–552

ISSN 0963-8237 print/ISSN 1360-0567 online � Shadowfax Publishing and Informa UK Ltd.

DOI: 10.1080/09638230802053334

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This unsatisfactory situation has led to calls for the development of increased open access

to psychological therapies focussing on self-management rather than traditional therapy

(Lovell & Richards, 2000). This direction has been reflected in both policy, for example the

Expert Patients Programme (Department of Health, 2001) and the National Service

Framework for Mental Health (Department of Health, 1999), and clinical guidelines, for

example the NICE clinical guideline on depression (NICE, 2004). The NHS has responded

to this challenge with various initiatives whereby self-help materials are made available to

patients. These include ‘‘books on prescription’’ schemes where a range of self-help books

are ‘‘prescribed’’ by a health professional and borrowed from a local library (Dobson, 2003).

Importantly, this policy direction reflects a patient-driven agenda, with self-help strategies

cited by patients as being an important part of managing mental health problems (Faulkner

& Layzell, 2000).

Nonetheless, there remain considerable issues to be resolved in the use of self-help as an

intervention for common mental health problems. First, reviewers have conflicting opinions

regarding the efficacy of self-help, opinions which are often a result of definitional

differences, particularly in regard to the amount of therapeutic support patients should

receive when undertaking a programme of self-help (Bower et al., 2001; Cuijpers, 1997;

Lewis et al., 2003). A recent review has noted, however, that whilst guided self-help for

depression may be effective, ‘‘pure’’ self-help is not supported by the current evidence

(Gellatly et al., 2007).

Second, there is the issue of whether self-help materials should be considered as

separate products analogous to a group of drugs such as SSRIs or a type of therapy such

as cognitive behaviour therapy (CBT). This is a critical issue since results from trials of

one self-help product can only be generalized if all self-help manuals and materials are

regarded as a single class of product. This has recently been illustrated by guidance in

the UK on the adoption of computerized cognitive behaviour therapy systems for

depression – a form of self-help. NICE ruled that randomized trial evidence from the

testing of one product (Beating the Blues) could not be generalized to others, despite the

class argument that all were based on an identical CBT model (NICE, 2006). According

to Anderson et al. (2005) only two self-help books have been evaluated in randomized

controlled trials and are available to members of the public: Managing anxiety and

depression (Holdsworth & Paxton, 1999) and Feeling good – the new mood therapy (Burns,

1999). We are also aware of one other book, What should I do? A handy guide to

managing depression and anxiety (Kennedy & Lovell, 2002) that has been evaluated in a

randomized controlled trial (Mead et al., 2005). There are, however, many more such

products available in both general circulation and specifically recommended by mental

health professionals.

Third, there is the difficulty arising from the abundance of books available. People seeking

a self-help book are faced with an array of material and most people with depression will not

have access to advice from a specialist mental health professional on which resource might

be best for them. People may use bestseller lists to select products. However these are self-

fulfilling: best selling books are automatically recommended above other products,

prompting more sales and high sales do not necessarily mean that a book is a useful

resource.

A final difficulty is the integration of ‘‘specific’’ and ‘‘common’’ factors into self-help

materials. We have recently pointed out (Richardson & Richards, 2006) that although the

efficacy of specific CBT techniques and their ability to be manualized has led them to be

translated into self-help formats, the independent agency of the therapeutic alliance has been

given little attention in these materials. There is considerable evidence that a strong

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therapeutic alliance can have a positive impact on patient outcomes (Norcross, 2002).

Hence, it is reasonable to hypothesize that books that can engage the reader are likely to

produce better outcomes. However self-help books may vary in their degree of engagement

with the reader.

These issues make it extremely difficult for both the public and professionals to choose

and recommend appropriate self-help books. Books adopt differing theoretical perspectives.

Even when efficacious techniques are included in a book, if they are delivered without

attention to the therapeutic alliance, the material may not be as engaging as it might have

been. For mental health professionals, if the class argument is not accepted, any evidence of

efficacy from certain books may not be used as a reason to prescribe another. Currently there

are no recommendations based on a systematic appraisal of the content and style of self-help

books. Therefore, we set out to analyse the nature of self-help books readily available to the

public in the UK. The first stage of this work was a scoping review to identify the number

and nature of self-help books. We describe this work below.

Aim

To identify the number of self-help books for people with depression or mixed anxiety and

depression that are available in the UK and to describe their priniciple characteristics.

Methods

Inclusion criteria

We included self-help books according to the following criteria:

. Availability. Books had to be available for loan from any UK library, or to download

from a publicly accessible website. We excluded materials that could only be accessed

by patients through consultation with a health professional.

. Audience. In order to identify books that had the widest possible relevance we specified

that books had to be aimed at a general adult audience and not targeted at a specific age

group, gender, ethnic or religious group.

. Language. Only those written in English were included.

. Approach. Books had to be based around psychological approaches. We interpreted

this as books whose content originated from one of the ‘talking therapies’ i.e were based

on a body of literature drawing upon psychological theory or theories. We excluded

books based on, for example, dietary supplements.

. Content. Books had to offer more than just information about depression. Authors had

to offer specific advice and/or self-help strategies.

There was no restriction on publication date.

Search

We have described the search methods used in detail elsewhere (Richardson & Richards,

2006). Our aim was to identify as many as possible of the books available in the UK that

would meet our inclusion criteria. Briefly, we searched on-line bookshops, the British

Library catalogue, patient and professional websites, and the lists from ‘Books on

Prescription’ schemes.

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Data extraction and analysis

We extracted and analysed:

(1) Descriptive information on: the year of publication of the latest edition; geographic base

of author; number of chapters; average length of each chapter; psychological model used;

the use or not of case histories; level of interactivity through the extent that books

included worksheets to fill in or exercises to complete by the reader; use of research

evidence categorized as ‘formal’ for those books that included references to research

papers in the text and a formal reference list, ‘informal’ for those books that

mentioned research evidence but did not include a reference list and ‘none’ for those

that did not include either of these.

(2) Readability statistics expressed as reading age. We scanned a page of text from the first

five pages of each book and then analysed the readability using the Flesch-Kincaid

Grade Level. We then added 5 to the figure obtained to convert the result into a

reading age figure.

(3) Popularity of the included books was assessed using Amazon sales rankings for

depression as a proxy measure of popularity.

One reviewer extracted the data and discussed this with a second reviewer where areas of

uncertainty were clarified.

Results

We were able to identify and extract data from 97 self-help books for depression. The result

of the search is shown in Figure 1.

Initial appraisal of titles and descriptions available on each book led to a pool of over 300

books that potentially met our inclusion criteria. After de-duplication, 190 books remained,

which we tried to obtain through the University of York’s Interlending Document Supply

Service, linked to the British Library. We were unable to obtain 65 of these books through

UK libraries, as they were unavailable for loan. From the remaining pool of 125 books that

we were able to obtain via the web or public libraries, a further 32 were excluded, as they did

not meet our inclusion criteria. A summary of the reasons for exclusion is shown in Table I.

Unfortunately, applying our inclusion criteria that books had to be available from libraries

resulted in several books being excluded that appeared in the top 200 of the Amazon ‘‘Best-

selling’’ list of books about depression. We therefore compromised and purchased all six

books that potentially met our inclusion criteria and that appeared in the ‘‘top 200’’ of the

Amazon list. Two of these were excluded for not meeting inclusion criteria. One book was in

fact a general discussion about depression and not self-help; the other had a religious focus.

Descriptive information

Figure 2 shows the results of the analysis of data on the year of publication. Fifty-six percent

had been published since 2000. Figure 3 shows the results of the analysis of data on the

psychological model used. By far the predominant orientation was eclectic with only 19

books based on CBT models alone and another five using rational emotive behaviour

therapy (REBT). Books classified as ‘eclectic’ presented advice from more than one school

of psychology, or their primary orientation was unclear. These books, even if they contained

some elements of CBT, would not have met NICE guidance for a self-help programme

546 R. Richardson et al.

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based on CBT. In terms of the geographic base of the author, 47 (48%) books were written

by UK authors and 44 (45%) by US authors. Only 6(6%) were written outside these two

countries. Books varied greatly in chapter number and length: the median number of

chapters was 14 (range 3–92). The median chapter length was 14 pages (range 2–37) and the

interquartile range 9–18 pages. Although the chapter length of 37 pages represents an

outlier, an average chapter length of 14 pages may still test the concentration span of a

person with depression. We classed just over half (53) as interactive and the vast majority

Figure 1. Search results.

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(85) used case histories. Books were fairly equally split between the ‘formal’, ‘informal’, and

‘none’ research categories. Just over a third (34) included references to research papers in

the text and a formal reference list, 27 mentioned research evidence but did not include a

reference list and 36 did neither.

Readability

There was a wide range of reading ages represented by our book sample, from less

than 10 years to 17 and over (the upper limit of the Flesh-Kincaid Grade Level

converted into a reading age). The median reading age of the books was 14.5 with a range

from 9.2–17.0.

Table I. Reasons for exclusion of self-help books.

Reason for exclusion Number (%)

Only offering information 19 (20)

Not based on psychological model 4 (4)

Not self-help for people with depression 4 (4)

Aimed at specific group 4 (4)

Earlier edition of included book 3 (3)

Total 34 (100)

Figure 2. Year of publication of included books.

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Popularity

Table II shows the distribution of included books according to Amazon sales rankings. Just

under 50% of the books are in the Amazon top 500 with seven books occurring in the top

10. There are many other books listed under the Amazon depression ranking including

those concerning bipolar disorder, postnatal depression, complementary therapy for

depression and economic depression.

CBT versus Non- CBT Books

Given the focus on CBT in NICE guidelines we undertook some comparisons of the

characteristics of CBT/REBT versus non-CBT/REBT books. We did not find any difference in

the average chapter length of CBT/REBT versus non-CBT/REBT books (Independent

Samples T Test¼ 0.060, CI: –4.085 to 4.331, p¼ 0.953) nor in the average reading age

(Independent Samples T Test¼71.287, CI:71.667 to 0.371, p¼ 0.206). This would

suggest that books based on CBT/REBT models are no more difficult to read than books based

in other models. We also found that CBT/REBT books were no more likely to make overt use

Figure 3. Psychological model of included books.

Table II. Popularity: Amazon sales ranking.

Rank Number of books

1–500 46

501–1000 3

1001–1500 3

1501–2000 3

2001–2500 0

2501–3000 8

3001–3500 14

3501–4000 3

4000þ 0

Not listed 17

Total 97

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of research than books based on other models (Chi-Square¼ 0.002, p¼ 0.964). However, not

unexpectedly, we found that CBT/REBT books were more likely to be interactive (Chi-

Square¼ 10.594, p¼ 0.001). We also analysed the position of CBT/REBT based self-help

books in the Amazon sales ranking. Twelve of these 24 books appeared in the top 500

positions, although seven were not listed at all in this category.

Discussion

We found 97 self-help books for depression that met our inclusion criteria, 93 of which could

be obtained from UK libraries. Whilst all purporting to be self-help books, these publications

are extremely diverse in both structure and content. Some of the techniques used (e.g., CBT)

have been the subject of rigorous clinical research whereas many of the others have not.

Indeed, despite the apparent growth in the rate of publication of self-help books since the year

2000 (although this could also be partly due to books published earlier going out of print),

there remain far fewer CBT books than one might expect.

Structure and readability data, including the average chapter length and the range of

reading ages required by these books, illustrate that many potential readers may have

difficulty using some of them. Even for people with a high reading age, an average chapter

length of 14 pages would require a span of concentration that may well be beyond people

with depression. The readability data is even more troubling. The majority of the books

require a reading age greater than 12 with 40% in the 15–17þ age range. To put this into

context A Tale of Two Cities (Dickens) has been calculated to have a reading age of 13 and

the Times Educational Supplement a reading age of 17 (Johnson, 1998, p. 7). The House of

Commons Public Accounts Committee recently estimated that there are about 12 million

people in employment with literacy skills at level 1 or below, which is equivalent to the level

expected of children 11 year old and younger (Public Accounts Committee, 2006). It is,

therefore, clear that due to literacy skill or because of the impact of the depression itself a

large proportion of adults would find the majority of currently available self-help books for

depression difficult to read. Similar difficulties are likely to be experienced for people whose

first language is not English. Books may be widely accessible, but their ability to be utilized

by the people they are aimed at may thus be limited. Interestingly, we did not find that CBT

based books were any more readable than books based on other psychological models. Being

based on an evidence-based model is no guarantee of superior readability.

With access to the internet becoming ever more ubiquitous, searching online book sellers

may become an ever more frequent means by which people find product information, even if

they subsequently purchase or borrow such products elsewhere. The included books in our

study spanned a wide range of positions on the ‘best-selling’ depression sales rankings on

Amazon, with some not listed at all. Although some of the CBT-based books appear in high

positions on the Amazon.co.uk ‘‘bestsellers’’ list, many do not appear at all. Relying on sales

figures-based popularity indices to identify an evidence-based book is not a reliable method.

Indeed, sales listings are self-reinforcing, independent of actual book quality or usability.

The average browser would be unlikely to scroll through more than a few pages of results

from an online bookstore and therefore those books at the top of the list listed in the first few

screens are likely to remain the ones selected for potential use.

Limitations

The major limitation of this review is that we had to exclude 59 of the 190 books identified

as potentially meeting the inclusion criteria, as we they were not obtainable from public

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libraries. However, it is likely that several of these books would have failed to meet the

inclusion criteria once they had been obtained, so the deficit may not be that significant. We

are also confident that we have reviewed the most popular self-help books by obtaining all

those highest in the Amazon rankings.

It has sometimes proved difficult to apply the inclusion criteria relating to offering advice

rather than just information. There may be some books amongst those excluded whose

authors might argue that advice is offered and we had to make some difficult decisions.

Where we were in serious doubt, we erred towards including books. We are also not

implying that books just giving information about depression are unimportant and do not

have a therapeutic effect. However, we selected our inclusion criteria to try to find the books

that specifically offer self-help and thus might fall within the remit of the NICE guidelines

(NICE, 2004).

Conclusion and implications

The UK market for self-help books for depression is large and well supplied with a variety of

books, giving the consumer an apparently wide choice. However, on closer inspection, our

study has demonstrated that making a choice from such a large number of books is difficult.

. Many of the available books are complex to read in terms of literacy levels.

. Books may present additional problems given the concentration problems of people

with depression.

. There is no relationship between sales popularity and a book being evidence-based or

readable.

. Few books have been empirically tested.

Sales rankings are very influential in the commercial market but these are unrelated to

quality in terms of either an evidence-based (CBT) product or a readable one. Books are

never classified by either of these two criteria. Some readable and evidence based books

appear low down or not at all on sales rankings. Equally, whilst some evidence based books

appear high in the rankings, their readability statistics may render them unsuitable for many

potential readers. Libraries stock books that are popular or recommended by professionals.

In the same manner as the general public, professionals have little appraisal evidence with

which to recommend books. Indeed, lists used by ‘books on prescription schemes’ merely

tend to be very similar if not duplications of those used in other areas.

Given our findings, it is clearly inappropriate to apply the class argument, whereby all self-

help books for depression are considered to have similar therapeutic effects. This cannot be

true, even where books have the same psychological orientation, since they may vary along

so many other dimensions. The results of trials generated by one book, therefore, cannot be

generalized to others. Despite the proliferation of self-help books and the promotion of such

as a crucial element of modern mental health care (Rogers et al., 2004), we appear to have

little evidence with which to justify selection and use of specific self-help books more widely.

This has worrying implications for the people with depression who purchase and use these

books. We require an urgent research effort to develop and evaluate the use of specific

products in both a guided and self-managed form, similar to that currently being undertaken

in the UK for computerized CBT. These products should be developed to pay attention not

only to their core evidence base but also to their ease of use – including their readability,

their structure and their approach to engage readers. We need to replace the current

situation with one with a solid, and specific, evidence base.

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Declaration of interest: The authors report no conflicts of interest. The authors alone are

responsible for the content and writing of the paper.

References

Anderson, L., Lewis, G., Araya, R., Elgie, R., Harrison, G., Proudfoot, J., Schmidt, U., Sharp, D., Weightman, A.

& Williams, C. (2005). Self-help books for depression: How can practitioners and patients make the right

choice? British Journal of General Practice, 55, 387–392.

Bower, P., Richards, D., & Lovell, K. (2001). The clinical and cost-effectiveness of self-help treatments for anxiety

and depressive disorders in primary care: A systematic review. British Journal of General Practice, 51, 838–845.

Burns, D.D. (1999). Feeling good – the new mood therapy. New York: Avon Books.

Cuijpers, P. (1997). Bibliotherapy in unipolar depression: A meta-analysis. Journal of Behavioural Therapy and

Experimental Psychiatry, 28, 139–147.

Department of Health. (1999). National service framework for mental health. London: Department of Health.

Department of Health. (2001). The expert patient: A new approach to chronic disease management for the 21st century.

London: Department of Health.

Dobson, R. (2003). GPs prescribe self-help books for mental health problems. British Medical Journal, 326, 1285.

Faulkner, A. & Layzell, S. (2000). Strategies for living: a report of user-led research into people’s strategies for living with

mental distress. London: The Mental Health Foundation.

Gellatly, J., Bower, P., Hennessy, S., Richards, D., Gilbody, S. & Lovell, K. (2007). What makes self-help

interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression.

Psychological Medicine, 37, 1217–1228.

Holdsworth, N. & Paxton, R. (1999). Managing anxiety and depression. London: The Mental Health Foundation.

Johnson, K. (1998). Readability. Accessed 2 November 2006 from: http://www.timetabler.com/readable.pdf

Kennedy, A. & Lovell, K. (2005). What should I do? A handy guide to managing depression and anxiety. Southampton:

RTFB Publishing Limited.

Layard, R. (2006). The case for psychological treatment centres. British Medical Journal, 332, 1030–1032.

Lewis, G., Anderson, L., Araya, R., Elgie, R., Harrison, G., Proudfoot, J., Schmidt, U., Sharp, D., Weightman, A.,

& Williams, C. (2003). Self-help interventions for mental health problems. Bristol: University of Bristol.

Lovell, K. & Richards, D. (2000). Multiple access points and levels of entry (MAPLE): Ensuring choice,

accessibility and equity for CBT services. Behavioural and Cognitive Psychotherapy, 28, 379–391.

Mead, N., MacDonald, W., Bower, P., Lovell, K., Richards, D., Roberts, C., & Bucknall, A. (2005). The clinical

effectiveness of guided self-help versus waiting-list control in the management of anxiety and depression: a

randomized controlled trial. Psychological Medicine, 35, 1633–1643.

National Institute for Clinical Excellence. (2004). Depression: Management of depression in primary and secondary care.

Clinical Guideline 23. London: National Institute for Clinical Excellence.

National Institute for Health and Clinical Excellence. (2006). Computerised cognitive behaviour therapy for depression

and anxiety: review of Technology Appraisal 51. Technology Appraisal 97. London:National Institute for Health and

Clinical Excellence.

Norcross, J. (Ed.) (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients.

New York: Oxford University Press.

Office for National Statistics. (2001). Psychiatric morbidity amongst adults living in private households, 2000. London:

Office for National Statistics.

Public Accounts Committee. (2006). Skills for Life: Improving adult literacy and numeracy. Twenty-first report.

London: The Stationery Office.

Richardson, R. & Richards, D. (2006). Self-help: towards the next generation. Behavioural and Cognitive

Psychotherapy, 34, 13–23.

Richardson, R. & Richards, D. (2006). Designing a search strategy for locating self-help books for people with

depression. Health Information and Libraries Journal, 23, 294–295.

Rogers, A., Pilgrim, D., & Lacey, R. (1993). Experiencing psychiatry: users’ views of services. Basingstoke: The

Macmillan Press Ltd.

Rogers, A., Oliver, D., Bower, P., Lovell, K., & Richards, D. (2004). People’s understanding of a primary care-

based mental health self-help clinic. Patient Education and Counseling, 53, 41–46.

552 R. Richardson et al.

Downloaded By: [University of York] At: 10:21 16 October 2008