How Effective Is Bibliotherapy for Very Old Adults With Subthreshold Depression? A Randomized Controlled Trial

doi:10.1097/JGP.0b013e3181ec8859

The American Journal of Geriatric Psychiatry

Volume 19, Issue 3, March 2011, Pages 256-265

https://doi.org/10.1097/JGP.0b013e3181ec8859 Get rights and content

Objectives

Depressive symptoms are common among elderly primary care patients, and because they encounter considerable barriers in seeking help and they often resist referral to specialized mental health facilities, it is important to look for easily accessible interventions within the primary care setting. Bibliotherapy, which has been found to be effective among younger populations, might be an attractive option. In this study, the authors investigated the effectiveness of bibliotherapy for depressive symptomatology in very old adults.

Design

Randomized controlled trial. After a 3-month period of “watchful waiting,” the participants were randomly assigned to a bibliotherapy group or a usual care group.

Setting

Thirty-three general practices in the north-western region of the Netherlands.

Participants

One hundred seventy community-dwelling adults, aged 75 and older, with subthreshold depression.

Intervention

The bibliotherapy intervention consisted of an information leaflet and a self-help manual “Coping with Depression” adapted for the elderly.

Measurements

Outcome measures after 3 months were a) change in depressive symptoms according to the Center for Epidemiologic Studies Depression Scale (CES-D) and b) the proportion of participants who scored a significant improvement on the CES-D.

Results

One hundred forty-six (85.9%) of the 170 participants completed the baseline and follow-up measurements. The authors did not find any clinically relevant and statistically significant differences between the intervention group and the control group in the severity of the depressive symptoms.

Conclusion

Bibliotherapy as a stand-alone intervention for the elderly (aged 75 years and older) did not reduce depressive symptoms more than usual care. This might indicate that bibliotherapy can only be effective for patients who are motivated and acknowledge their depression. (Am J Geriatr Psychiatry 2011; 19:256–265)

Section snippets

Design

We conducted a randomized controlled trial. After a period of watchful waiting and baseline assessment, the participants were randomized to one of two groups. The intervention group received usual care plus a cognitive behavior therapy-based bibliotherapy intervention, and the control group received usual care only. The participants were randomized with equal probability to the intervention or to usual care in blocks of four by an independent statistician, based random-number tables. The main

Study Sample

To evaluate the effects of the intervention versus usual care, 325 eligible elderly people were invited to participate, 170 of whom met all the inclusion criteria and gave informed consent. They were randomized to the bibliotherapy group (N = 86) or the usual care group (N = 84) (Fig. 1).

Baseline Characteristics

The baseline characteristics are presented in Table 1. There were no significant differences in these variables between the two groups. Of the 170 parti-cipants, 24 (14.1%) dropped out during the intervention

DISCUSSION

We could not demonstrate any clinically or statistically significant short-term effects of bibliotherapy, compared with usual care, on symptoms of depression in 170 very old adults with subthreshold depression.

Previous research has shown that bibliotherapy can be effective for depression. As described in the Introduction section, several reviews and meta-analysis have been carried out in this respect, and in general, guided self-help was found to be more effective than no treatment, with mean

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Systematic review and meta-analysis of randomised control trials of low-intensity psychological interventions for anxiety and/or depression with an active or passive control condition (e.g., waitlist, treatment-as-usual or active control) in any setting. Low intensity psychological interventions (e.g., cognitive behaviour therapy [CBT]) targeted anxiety and/or depression as primary outcomes, were primarily self-help, and included support from trained practitioners/facilitators with <6 h total contact time (typically <30 min p/contact).
Seven studies consisting of 304 older adults (65–78 years, M_age = 70, SD = 4) were identified and six included in the meta-analysis of depression outcomes and three for anxiety. A random effects meta-analysis of group differences in symptom change from pre-post treatment found evidence favouring low intensity psychological interventions over passive control groups for the treatment of depressive and anxiety symptoms, with moderate effect sizes for depression (Cohen's d = −0.62) and large effect sizes for anxiety (Cohen's d = −0.84) at post-treatment.
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Nonpharmacological interventions for subthreshold depression in adults: A systematic review and network meta-analysis
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In terms of the randomization process, 9 RCTs were rated as causing some concern because they did not explicitly mention the specific methods used for randomization (Gellis and Bruce, 2010; Hermanns et al., 2016; Morgan et al., 2012; Pan et al., 2019; Pibernik-Okanovic et al., 2009; Saisanan Na Ayudhaya et al., 2020; Thapinta et al., 2017; Woolery et al., 2004; Yamamoto et al., 2018). Other studies presented a low risk in the randomization process, including studies in which random numbers were assigned by computer (Basanovic et al., 2020; Buntrock et al., 2015; Ebert et al., 2018; Freire et al., 2015; Pols et al., 2017; Ying et al., 2022; Gellis et al., 2008), random-number tables (Joling et al., 2011; Spek et al., 2007), a sequential assignment list (Takagaki et al., 2016), sealed envelopes (Van Voorhees et al., 2009), a randomized list based on Excel (Kageyama et al., 2021), a computer-generated algorithm (Vucic Lovrencic et al., 2015), simple randomization (Gilbody et al., 2017), permuted-block randomization (Imamura et al., 2014; Willemse et al., 2004), an independent study statistician (Furukawa et al., 2012; Moldovan et al., 2013; Wong et al., 2018; Zhang et al., 2018, 2019), and others (Kageyama et al., 2021; van Aubel et al., 2020). Two studies had a high risk for bias in deviations from intended interventions (Pan et al., 2019; Thapinta et al., 2017).
Subthreshold depression (StD) is very common, with an estimated global incidence of 25%, and is associated with other clinical conditions. Nonpharmacological interventions have been demonstrated to be effective, but which one is best should be further investigated. This study aims to compare and rank the efficacy of nonpharmacological interventions in adults with StD. Ten databases were searched, and comparisons were made using a random-effects network meta-analysis using the frequentist framework. The assumption of local consistency was assessed by using the node-splitting method. The surface under the cumulative ranking curve (SUCRA) was used to separately rank each intervention. A total of 32 randomized controlled trials (RCTs) were included. The results showed that psychotherapy, as an intervention class, had significantly positive effects compared to control groups (SMD = -0.78, 95% CI: -1.06, -0.49) and had the highest rank (SUCRA, 79.0%; mean rank, 1.6). Cognitive behavioral therapy (CBT), as an individual intervention, had significantly positive effects relative to all control groups and had the highest rank (SUCRA, 82.5%; mean rank, 3.1). We speculate that psychotherapy, especially CBT, may be the most effective nonpharmacological intervention to improve StD in adults. More RCTs examining the efficacy of different nonpharmacological interventions are needed.
Cognitive, behavioural or cognitive-behavioural self-help interventions for subclinical depression in older adults: A systematic review and meta-analysis
2022, Journal of Affective Disorders
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The support was designed to check that the materials had been read, to offer practical advice and problem solve; no psychotherapeutic techniques were used. Five studies (Almeida et al., 2020; Dozeman et al., 2011; Gilbody et al., 2021; Joling et al., 2011; Van der Aa et al., 2015) had usual care as the control condition, two (Moss et al., 2012; Spek et al., 2007) used wait-lists, and one (Boen et al., 2012) used a no-treatment condition. Four studies (Dozeman et al., 2011; Joling et al., 2011; Moss et al., 2012; Van der Aa et al., 2015) used the Center for Epidemiologic Studies Depression Scale (CESD), two studies (Boen et al., 2012; Spek et al., 2007) used the Beck Depression Inventory (BDI), and two studies (Almeida et al., 2020; Gilbody et al., 2021) used the Patient Health Questionnaire (PHQ-9).
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This was a systematic review and meta-analysis of trials that used self-administrated cognitive, behavioural or cognitive-behavioural interventions for older adults with subclinical depression compared to control groups. Medline, Embase, PsycInfo and Cochrane databases were searched for relevant studies.
We analysed eight trials involving 1449 participants. A small but significant effect favouring the intervention was found at short-term [d = 0.33; 95% CI (Confidence Interval): 0.20–0.47] and at long-term (d = 0.22; 95% CI: 0.04–0.40) for depressive symptoms. None of the studies looked at the preventive effect of self-help interventions in reducing the probability of a subsequent diagnosis of major depression.
The low number of studies meant that it was not possible to test for publication bias. The absence of pre-published protocols for many of the studies meant that there is a possibility of selective reporting bias for some of the primary studies.
There is some evidence that cognitive-behavioural self-help interventions may reduce depressive symptoms in older adults with subclinical depression. However, no study examined whether the intervention had a preventative effect in reducing the likelihood of a subsequent diagnosis of major depression.
Psychotherapy adaptation in aging populations
2019, Global Mental Health and Psychotherapy: Adapting Psychotherapy for Low- and Middle-Income Countries
The elderly are often excluded from the benefits of psychotherapy, especially in low- and middle-income countries. There are many potential barriers to psychotherapy in the elderly, including the high frequency of medical comorbidities, decreased mobility, and cognitive deficits. The elderly are often unable to access psychotherapy due to structural barriers and the perceptions of patients and health-care professionals regarding this treatment modality. These obstacles can potentially be overcome using elderly-centered approaches. Possible adaptations in the elderly include making clinics more easily accessible, providing home-based treatment where appropriate, education of health professionals, and involvement of the primary caregiver. There are a number of evidence-based psychotherapeutic treatments for specific disorders that occur commonly in elderly persons. Psychotherapeutic modalities such as cognitive behavioral therapy, interpersonal therapy, problem-solving therapy, and reminiscence therapy are effective in elderly patients, and some of these approaches have been adapted for application in low- and middle-income countries.
A systematic review and meta-analysis of psychotherapy for late-life depression
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Citation Excerpt :
Four trials were included after authors supplied additional data.23,38,41,42 Since the last meta-analysis of late-life depression,7 eight trials were published.18,20,27,28,30,36,41,42 Outcome data were reported for 2,245 subjects.
To determine the efficacy of psychotherapy in late-life depression and to determine the effect of the type of control group on the magnitude of psychotherapy effects.
A systematic review and meta-analysis of randomized controlled psychotherapy trials for late-life depression.
Outpatient clinics or in subjects' home.
Subjects aged 55 years or older with acute-phase depressive disorder.
Change in depressive symptoms was measured with validated scales. Standardized mean differences (SMD) were calculated for each therapy-control contrast, as meta-analytic summaries for contrasts using a similar control, and for all contrasts combined.
The search identified 27 trials with 37 therapy-control contrasts and 2,245 subjects. Trials utilized five types of control groups (waitlist, treatment-as-usual, attention, supportive therapy, placebo). In the combined contrasts, psychotherapy was effective (SMD: 0.73; 95% confidence interval [CI]: 0.51, 0.95; z = 6.42, p <0.00001). The SMD varied widely (from 0.05 to 1.36) and significantly (χ² = 35.67, df = 4, p <0.00001) between subgroups by type of control. In five trials that compared psychotherapy with supportive therapy, the SMD was 0.39 (95% CI: 0.16, 0.61; z = 3.37, p <0.0007; I² = 0%). The SMD was 0.11 within the waitlist controls and 1.10 within the supportive therapy subgroup.
Psychotherapy is effective for late-life depression, but the magnitude of the effect varies widely with the type of control group. Supportive therapy appears to best control for the nonspecific elements of psychotherapy and is associated with considerable change itself, but few trials have utilized it as a control.
Does an outreaching stepped care program reduce depressive symptoms in community-dwelling older adults? A randomized implementation trial
2015, American Journal of Geriatric Psychiatry
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Also, given the implementation character of our study, we allowed for a wide measure of practice variation, which could explain these diverging results. Further, an analysis of elements of our first stepped care trial showed that the first guided self-help phase was not effective.42 This first step consisted of acknowledgement of symptoms, self-management, or exercise.
To examine the effects of an outreaching stepped care intervention program (Lust for Life) compared with usual care on depressive symptoms in older adults living in the community.
Randomized clinical implementation trial.
18 general practices and a home care organization in the Netherlands.
263 community-dwelling 65+-year-olds with depressive symptoms according to the Patient Health Questionnaire-9 (PHQ-9).
After three months of watchful waiting, participants could sequentially choose between the following evidence-based interventions: 1) guided self-help or an exercise program, 2) problem solving treatment or life review, and 3) a referral to their general practitioner.
The outcome measure was depression severity (PHQ-9), measured every three months over 2 years.
After the provision of the stepped care program, a significant short-term positive effect on depressive symptoms was found in the first three months after implementation, in which average PHQ-9 scores dropped from 9.34 (SE: 0.61, 95% CI: 8.14–10.5) to 7.83 (SE: 0.51, 95% CI: 6.84–8.81).
The Lust for Life program has a promising potential to relieve depressive symptoms of older adults in primary care in the short term. Providing one single clinical intervention in accordance with participants' choices instead of stepped care could be sufficient.

View all citing articles on Scopus

: This work was supported by the Netherlands Organization for Health Research and Development (ZonMw), grant number 2620.00003.

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Original ArticleHow Effective Is Bibliotherapy for Very Old Adults With Subthreshold Depression? A Randomized Controlled Trial

Objectives

Design

Setting

Participants

Intervention

Measurements

Results

Conclusion

Section snippets

Design

Study Sample

Baseline Characteristics

DISCUSSION

J Affect Disord

J Behav Ther Exp Psychiatry

Clin Psych Rev

Outcome of depression in later life in primary care: longitudinal cohort study with three years follow-up

BMJ

Review of community prevalence of depression in later life

Br J Psychiatry

Consequences of anxiety in older persons: its effect on disability, well-being and use of health services

Psychol Med

Potential for community programs to prevent depression in older people

Med J Aust

Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life

Arch Gen Psychiatry

The natural history of late-life depression: a 6-year prospective study in the community

Arch Gen Psychiatry

Pathway to psychiatric care of the elderly with depression

Int J Geriatr Psychiatry

Barriers to care for older adults with depression

Self-help interventions for anxiety disorders: an overview

Curr Psychiatry Rep

A meta-analysis of bibliotherapy studies

Am J Community Psychol

Self-help and Internet-guided interventions in depression and anxiety disorders: a systematic review of meta-analyses

CNS Spectr

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

Psychol Med

Cognitive therapy for depression: a comparison of individual psychotherapy and bibliotherapy for depressed older adults

Behav Modif

Self-administered treatments for depression: a review

J Clin Psychol

Bibliotherapy for depressed older adults: a self-help alternative

Gerontologist

Comparative efficacy of cognitive and behavioral bibliotherapy for mildly and moderately depressed older adults

J Consult Clin Psychol

Stepped-care prevention of anxiety and depression in late life: a randomized controlled trial

Arch Gen Psychiatry

Design and pilot results of a single blind randomized controlled trial of systematic demand-led home visits by nurses to frail elderly persons in primary care

BMC Geriatr

Original Article
How Effective Is Bibliotherapy for Very Old Adults With Subthreshold Depression? A Randomized Controlled Trial