Luisa Dillner asked this question in the Guardian on 28th Jan, quoting from a recent study suggesting that self-help books could treat depression better than antidepressants or therapy, relatively cheaply and without side-effects.
Now this caught my eye, because, as someone who works relationally, I just plain don’t believe it, but also because there is a mounting evidence that the therapeutic relationship is the most significant aspect of therapy, regardless of modality. I was intrigued to know how this could be bettered by a book, so I downloaded a copy of Guided Self-Help Cognitive Behavioural Therapy for Depression in Primary Care: A Randomised Control Trial, and took a look for myself.
The study recruited patients from primary care, assessed their level of depression using the BDI-II and CORE-OM questionnaire, and split them into two groups. The first group (GSH-CBT) was encouraged to use a book entitled “Overcoming Depression: a Five Areas Approach” and the second was given access to Treatment as Usual (TAU). The end results at a 12 month follow up showed that the 50% of the GSH-CBT group had achieved a 50% reduction in BD-II score, against 34% of the TAU group. That is, the GSH-CBT group was less depressed than the TAU group. Hmm, sounds conclusive, but let’s take a closer look.
Participants had to score 14 or above on the BDI-II to be included, so effectively in the middle of the category “Mild Mood Disturbance”. The study does not reveal the range of BDI-II scores, (how depressed participants were) or the distribution between the two groups. We do know that suicidal patients were excluded, as were those “unable to use the materials because of impaired concentration and motivation”. These are common symptoms of depression and their exclusion to me, shows some significant sample selection.
Reading on it transpires that the GSH-CBT group were also offered 2 – 4 support sessions alongside the 5 step approach of the book, in which a psychology graduate worked with them on their progress and helped them look at what might be stopping that progress. In an environment when IAPT services consider completed treatment to be as few as 2 sessions it is hard to see how this differs from the normal level of contact offered by the NHS. Luisa Dillner however in her article mentioned the comparison between self help books and therapy, so I was keen to see what therapy the TAU group was offered.
The study describes the TAU group as having access to standard treatment –
“This would usually entail monitoring, antidepressant prescription and referrals for specialist psychological therapies as recommended by national treatment guidelines” Although regular reviews were offered, there is no evidence of how many patients, or indeed if any patients in the TAU group actually received therapy sessions.
The study followed up both groups at four and at twelve months. However at the one year mark only 41% of the original participants could be contacted. Follow up data is missing therefore on 59% of the original participants, making the results less than conclusive.
In brief, I think this study involved a selected sample, did not clearly differentiate the two groups in terms of what they were offered, and draws it’s conclusion from insubstantial results. But that aside, I have one final thought;
although steps were taken to avoid bias in data analysis, the study notes that the principal author Christopher Williams also happens to be the author of the self help book used. Now, plaudits for recognising the conflict of interest, but with so many CBT self help books on the market, I have to ask, was this study really about self help, or was it about proving the benefits of Christopher William’s book?