Self-help Plus Manual
Timothee Cazares
The prevalence of depression is increasing markedly in Thailand. One way of helping people with depression is to increase their resilience; good resilience is associated with positive outcomes in depression. The purpose of this study was to examine the effectiveness of a self-help manual on the resilience levels of individuals with depression living in the community in Chiang Mai Province in northern Thailand.
Fifty-six participants with a diagnosis of moderate depression were assigned randomly to either an intervention (n = 27) or control (n = 29) group by means of independent random allocation, using computer generated random numbers. Fifty-four completed the study (two were excluded shortly after baseline data collection), so an available case analysis was undertaken. The intervention group were given a self-help manual and continued to receive standard care and treatment, while the control group continued to receive standard care and treatment. Both groups were also given a short weekly telephone call from a researcher. Participants were assessed at three time points: baseline (Week 0), immediate post-test (Week 8), and follow-up (Week 12). Data were collected between October 2007 and April 2008.
The findings provide preliminary evidence supporting the use of bibliotherapy for increasing resilience in people with moderate depression in a Thai context. Bibliotherapy is straightforward to use, and an easily accessible addition to the standard approach to promoting recovery. It is incorporated readily as an adjunct to the work of mental health nurses and other professionals in promoting resilience and enhancing recovery in people with moderate depression in the community.
Depression is projected to become the major mental health problem in Thailand. For instance, the national prevalence rate of depression increased from 56 per 100,000 population in 1997 to 197 per 100,000 population in 2007 [1]. Chiang Mai, one of 13 provinces in the northern region of Thailand, has the second highest rate of depression (207 per 100,000 population) in this region [1].
Longer term outcomes of bibliotherapy have also been assessed, and have indicated that therapeutic gains from using the approach have been maintained for two [13] to three years [14] after the end of treatment. It is possible these improvements were maintained because bibliotherapy offers the opportunity to refer back to the book and re-familiarise oneself with specific skills and techniques.
Cost effectiveness of bibliotherapy has also been ascertained, though further study is needed. Bower et al. [15] conducted a systematic review of the research literature to determine the clinical and cost effectiveness of self-help treatments for anxiety and depressive disorders in primary care. The review suggested self-help treatments have the potential to improve the cost effectiveness of mental health service provision.
The quality of bibliotherapy studies has also been reported, highlighting the need for larger and better quality studies. A meta-analysis, by Anderson et al. [16], indicated that while bibliotherapy is an effective intervention for people with mild-to-moderate depression, the evidence was drawn from small studies that were, overall, of poor quality.
CBT can be used to promote resilience, which is effective in helping individuals face adversity and in promoting emotional health, like anxiety and depression [17]. It has been used successfully to promote mental health resilience in the workplace [23], and to improve resilience in adolescents with alcohol-dependent parents [24]. CBT has also been used to promote resilience by changing one's perception of the situation. This was shown in a pilot randomised controlled study which examined the effectiveness of a four-week resilience intervention programme designed to enhance resilience, coping strategies, and protective factors, and to decrease symptomatology during a period of increased academic stress [25]. The findings showed that the intervention group had significantly higher resilience scores, better coping strategies, higher scores on protective factors, and lower scores on symptomatology, such as depressive symptoms, negative effect, and perceived stress, following the intervention than the waiting list control group.
Overall, a considerable number of bibliotherapy studies have been undertaken and, of these, a significant number have focused on people with depression. However, few bibliotherapy studies for depression have been conducted outside of the United States, United Kingdom and Australia. Only one has been carried out in an Asian country. Liu et al. [26] undertook a randomised control trial of bibliotherapy in the treatment of depressive symptoms in adults in Taiwan. The results showed that those in the bibliotherapy group reported lower levels of depressive symptoms at 3-month follow-up compared to the delayed-treatment control group. Bibliotherapy, generally, is regarded as an effective and cost effective approach, though the small size and quality of some studies has been criticised. Moreover, as none of the studies reviewed have been carried out in Thai context, and only a few have examined the concept of resilience, particularly with people who have moderate depression, this study will add to the limited body of knowledge about the usefulness of this form of technology in a non-western country such as Thailand. This is important because the mental health system in this country is characterised by a disproportionate amount of resources being focused in large cities, and limited access to services in rural areas. Furthermore, while social insurance provides 93% of people with free access to essential psychotropic medication, including antidepressants, psychosocial interventions are used infrequently [27].
Given the increasing prevalence of depression in Thailand and the influence of resilience in people with this illness, the hypothesis of the present study was to examine whether individuals with moderate depression who took part in a bibliotherapy self-help intervention programme had greater resilience than a control group. The findings are taken from a larger study that evaluated the effect of bibliotherapy on participants' resilience, depression, and psychological distress. The findings about resilience are reported in this paper. The findings about depression [28] and psychological distress [29] are reported elsewhere.
A randomised controlled trial parallel group design was used following the CONSORT guidelines [30]. Participants were assigned by independent random allocation by a second researcher not involved in recruitment, using a computerised random number generator, to an intervention (self-help manual plus standard care and treatment) or a control (standard care and treatment) group. In addition, both groups received a 5-minute telephone call each week from the researcher. Standard care and treatment comprised involved attendance at the outpatient department for face-to-face consultations and prescription of antidepressant or a combination of antidepressant and anti-anxiety medication.
The study was carried out at participants' homes in Chiang Mai Province in northern Thailand. Participants, who were outpatients, were recruited through the outpatient department clinicians at Suan Prung Psychiatric Hospital in Chiang Mai City. Clinicians gave prospective participants brief information about the study, and in order to minimise risk, screened them for signs of relapse and suicidal thoughts/intent. If the clinicians considered prospective participants were relapsing and/or expressing suicidal thoughts/intent, they were not permitted to take part in the study. Once it was ascertained that they were not at risk of relapse and/or expressing suicidal thoughts/intent, and had expressed interest in taking part in the study, they were referred to the researcher. Thereafter, the researcher provided a detailed explanation about the study and answered questions.
A power analysis for the study was carried out using the statistical software package SPSS Sample Power (Vers. 2.0). For a power of .8 and an alpha of .05, and a confidence interval of 95% for detecting an effect size of 0.8 [32], the study could detect such an effect size with a sample of 54. Meta-analyses of bibliotherapy for depression (pretest-post-test control group design) indicated an effect size of .77 [7]. Thus, an effect size of .80 was considered an appropriate estimate for the present study. To allow for attrition, the sample size was increased to 56.
The present paper presents the findings of two self-report data collection instruments: (i) Demographic data, which contains nine items, including gender, age, marital status, occupational status, education, duration of treatment for depression, current treatment, frequency of attendance at the outpatient department, and frequency of home visits by clinical staff. (ii) Resilience Scale, which measures the degree of individual resilience. It contains 25 items rated on a 7-point Likert scale, with scores ranging from 25 to 175; higher scores reflecting greater resilience [33]. A review of 12 studies that utilised the Resilience Scale reported that it was used with a variety of age groups ranging from adolescents to the elderly, with no age-related differences reported in the scores [34]. The main racial/ethnic group studied was European American with smaller proportions of African American, Hispanic, American Indian, and Asian participants. Apart from one study [35] that found lower scores among European American participants, no differences in Resilience Scale scores were reported among racial groups in the other studies. Regarding construct validity, several of the studies initially hypothesised and subsequently reported statistically significant inverse relationships between increased resilience scores and decreased levels of stress, depression, anxiety, loneliness, and hopelessness [34]. High internal consistency has been reported with the Scale in 11 of the 12 studies (Cronbach's alpha coefficient ranging from 0.85 to 0.94). The lowest reported coefficient was .72 [35]. In the present study, the Cronbach's alpha coefficient score, at baseline, for the Resilience Scale was .94. Therefore, the internal consistency reliability of the Resilience Scale is not only acceptable across sample populations, but also rather robust.
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