Off to a good start. Are self-help interventions effective for people with comorbid physical and mental health problems?

The ideal treatment for common mental health problems in those with chronic physical illness would have to be reliable, easy to deliver, inexpensive and accessible by a group of people whose physical impairment may affect treatment adherence. NICE guidelines (CG90 Depression; the treatment and management of depression in adults) recommend self-help interventions (SHIs) based on principles of Cognitive Behavioural Therapy (CBT) for mild to moderate depression. If effective, this treatment has the potential to tick all of the boxes above for those with mild to moderate mental health problems and chronic physical illnesses.

SHIs can be delivered in a number of ways, including via manuals, patient information sheets, or via the internet and provided with or without professional support. A recent systematic review published in Clinical Psychology Review evaluated self-help via written information for people with depression, anxiety and physical illness (Matcham et al, 2014).

Methods

The authors used an appropriate search strategy to identify 29 papers for the systematic review. Twenty five studies were suitable for meta-analysis. Inclusion criteria were:

SHIs used written material only and had less than 60 mins contact time with a non-mental health professional
Participants had 1 or more physical illness (defined as a physical health problem with a biological basis)
Randomised controlled trials (RCTs)
Depression, anxiety and/or distress measured as an outcome variable (not at baseline)

The primary outcome of interest was assessed and reported depression, anxiety or distress. Using sub-group analysis, the authors were able to unpick more specific information about what type of intervention showed benefit for which patient group. They also examined the secondary outcomes of; acceptability (assessed by drop-out rates from the intervention), changes in physical function, quality of life (QoL), knowledge about conditions and cognitions (such as self-efficacy, helplessness and coping strategies).

This study examined written information with little contact time, which was a low intensity, accessible and relatively cheap intervention

Results

4,739 patients were included in the systematic review covering wide a range of physical conditions including cancer, stroke and heart disease.

Primary analysis

Primary outcomes were assessed with standardised mean differences (SMDs) and 95% confidence intervals (CIs). Primary analysis showed that SHIs significantly reduced depression (SMD -0.13, 95% CI; -0.25 to -0.02), but not anxiety (-0.10 95% CI; -0.24 to 0.05) or distress (-0.14 95% CI; -0.40 to 0.12)

In the subgroup analysis, the strongest evidence in favour of SHIs for depression was when the intervention contained stress management material (SMD= -0.21, 95% CI; -0.38 to -0.04).

SHIs with information content alone or disease self-management tended to be ineffective for depression, anxiety and distress.

There was also evidence of benefit for:

Patients with heart disease
When outcomes were measured between 5-12 weeks
When some professional guidance was provided
And when the mean age was 40-50 years

Secondary analysis

SHIs had equivocal impact on the outcomes. Improvements in:

Function were seen in 6/12 studies
QoL were seen in 5/11 studies
Knowledge was seen in 6/10 studies
Cognitions were seen in 4/8 studies
Fewer patients withdrew from the control groups than the intervention (OR = 1.36, 95% CI 1.01 to 1.82, p=0.04), but this difference disappeared when studies with a high risk of bias were excluded.

The strongest evidence in favour of SHIs for depression was when the intervention contained stress management

Limitations

The heterogeneity of the studies and the sensitivity analyses has made interpretation complicated. There is a risk that over analysis has increased the chances of rejecting a true finding. The use of subgroup analysis has been useful though, as it provided closer examination of methodological aspects that might affect the results. However, even though the studies recorded baseline psychological measures, subgroup analysis to examine whether baseline severity of depression or anxiety affected outcomes was not conducted.

Conclusions

The authors said that:

Provision of written self-help materials may help ameliorate distress in some circumstances.

They also recommend that SHIs are of most value in primary care where there are high levels of comorbidity with milder mental illness and long-waiting lists for CBT. One of the major strengths of this paper is that by looking at written information with little contact time, it examined a low intensity, accessible and relatively cheap intervention, which would fit in well in primary care.

The elements of the SHIs that showed the most promise were:

Stress management using relaxation exercises
Goal setting
Cognitive restructuring

These techniques are also used in CBT, which is a useful treatment for common mental health problems in the physically ill. However, many people in this population find the prospect of psychological work daunting, too emotionally challenging and might favour less intense strategies. SHIs could be a starting point for these individuals in addressing their mental health problems and may give them the confidence to embark on more in-depth therapy.