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

https://doi.org/10.1097/JGP.0b013e3181ec8859Get 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

References (43)

  • AT Beekman et al.

    Major and minor depression in later life: a study of prevalence and risk factors

    J Affect Disord

    (1995)
  • P Cuijpers

    Bibliotherapy in unipolar depression: a meta-analysis

    J Behav Ther Exp Psychiatry

    (1997)
  • R Gould et al.

    A meta-analysis of self-help treatment approaches

    Clin Psych Rev

    (1993)
  • E Licht-Strunk et al.

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

    BMJ

    (2009)
  • AT Beekman et al.

    Review of community prevalence of depression in later life

    Br J Psychiatry

    (1999)
  • E de Beurs et al.

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

    Psychol Med

    (1999)
  • MJ Bird et al.

    Potential for community programs to prevent depression in older people

    Med J Aust

    (2002)
  • DS Charney et al.

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

    Arch Gen Psychiatry

    (2003)
  • AT Beekman et al.

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

    Arch Gen Psychiatry

    (2002)
  • MG Cole et al.

    Pathway to psychiatric care of the elderly with depression

    Int J Geriatr Psychiatry

    (1996)
  • GL Gottlieb

    Barriers to care for older adults with depression

  • P Cuijpers et al.

    Self-help interventions for anxiety disorders: an overview

    Curr Psychiatry Rep

    (2007)
  • RW Marrs

    A meta-analysis of bibliotherapy studies

    Am J Community Psychol

    (1995)
  • E van't Hof et al.

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

    CNS Spectr

    (2009)
  • J Gellatly et al.

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

    Psychol Med

    (2007)
  • M Floyd et al.

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

    Behav Modif

    (2004)
  • NL McKendree-Smith et al.

    Self-administered treatments for depression: a review

    J Clin Psychol

    (2003)
  • F Scogin et al.

    Bibliotherapy for depressed older adults: a self-help alternative

    Gerontologist

    (1987)
  • F Scogin et al.

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

    J Consult Clin Psychol

    (1989)
  • PJ van't Veer-Tazelaar et al.

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

    Arch Gen Psychiatry

    (2009)
  • H van Hout et al.

    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

    (2005)
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    This work was supported by the Netherlands Organization for Health Research and Development (ZonMw), grant number 2620.00003.

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