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Bibliotherapy: Appraisal of Evidence for Patients Diagnosed With Cancer

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An appraisal of the evidence on the efficacy of bibliotherapy on anxiety, distress, and coping in patients with cancer is lacking in the literature. Bibliotherapy is a self-help intervention using a variety of tools, such as self-help workbooks, pamphlets, novels, and audiobooks, to improve mental health. This review identified nine original research articles that examined bibliotherapy as an intervention to alleviate the psychological issues associated with a cancer diagnosis. Data synthesis from these studies provides preliminary evidence that bibliotherapy is an acceptable and beneficial adjunct therapy for patients with cancer experiencing anxiety, depression, and ineffective coping.
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AUGUST 2018, VOL. 22 NO. 4 CLINICAL JOURNAL OF ONCOLOGY NURSING 377CJON.ONS.ORG
SUPPORTIVE CARE ASSOCIATE EDITOR JOSEPH D. TARIMAN, PhD, RN, ANPBC, FAAN
Bibliotherapy
Appraisal of evidence for patients diagnosed with cancer
Ryan Malibiran, MSN, RN, Joseph D. Tariman, PhD, RN, ANP-BC, FAAN, and Kim Amer, PhD, RN
A 36-year-old yoga trainer,
E.A., was referred to a
breast cancer specialist in
a large academic medical
center in the Midwestern
United States for further evaluation and
consultation on treatment options for her
newly diagnosed right breast cancer. Two
weeks earlier, E.A. had a routine mammo-
gram that showed a new right breast mass.
Diagnostic mammogram and ultrasound of
the right breast confirmed this mass with no
suspicious lymphadenopathy. E.A.’s right
breast mass biopsy demonstrated grade 3
infiltrating ductal carcinoma, which was
weakly estrogen receptor–positive (1%–
10%), progesterone receptor–negative, and
HER2– by immunohistochemistry and flu-
orescent in situ hybridization techniques.
The Ki-67 index of the cancer cells was
90%. A genomic test revealed a high-risk
breast cancer subtype. Magnetic resonance
imaging of the right breast showed a 3.5 cm
x 3.2 cm x 2.1 cm mass in the right breast
with no lymph node enlargement and no
cortical thickening. Positron-emission
tomography showed no metastatic disease.
E.A. appeared very anxious while waiting
for the breast cancer specialist. The oncol-
ogy nurse provided E.A. with a novel to read
to alleviate her anxiety via bibliotherapy.
Overview
Patients diagnosed with cancer often expe-
rience anxiety and distress that can affect
their overall quality of life (National Cancer
Institute, 2015). Bibliotherapy is a therapeu-
tic approach primarily used in a variety of
mental health problems, such as anxiety
and distress, in which written materials play
a central role (Glasgow & Rosen, 1978).
Bibliotherapy refers to the use of any
literature that supports good mental
health and is a versatile and cost-effective
intervention often used to supplement
other types of therapy (GoodTherapy,
2016). The National Library of Medicine
(2018) defines bibliotherapy as a form
of psychotherapy in which the patient
is given carefully selected material to
read. Bibliotherapy is often used to treat
common mental health problems, such
as stress, depression, anxiety, and psy-
chological disorders (Gots, 2016). In the
hematology/oncology practice setting,
patients may have feelings of anxiety and
distress while being screened for cancer,
waiting on results of tests, receiving a
cancer diagnosis, being treated for cancer,
or worrying that the cancer will come
back. Despite the history of therapeutic
benefits of bibliotherapy in numerous non–
cancer-related health issues, such as sexual
dysfunction (van Lankveld, 1998), anxi-
ety disorders in children and adolescents
(Amer, 1999; James, Soler, & Weatherall,
2005), and depression in older adults
(Wilson, Mottram, & Vassilas, 2008), the
efficacy of bibliotherapy in alleviating
psychosocial health problems in patients
diagnosed with cancer has not been pre-
viously examined in a systematic manner.
Objectives
The purposes of this review are to appraise
the evidence on the efficacy of bibliothera-
py for alleviating anxiety, depression, and
other psychosocial outcome variables in
patients diagnosed with cancer and to de-
scribe the patient-reported psychosocial
outcomes and their measures in research
studies involving bibliotherapy.
An appraisal of the evidence on the
ecacy of bibliotherapy on anxiety,
distress, and coping in patients with
cancer is lacking in the literature. Bib-
liotherapy is a self-help intervention
using a variety of tools, such as self-
help workbooks, pamphlets, novels,
and audiobooks, to improve mental
health. This review identified nine
original research articles that exam-
ined bibliotherapy as an intervention
to alleviate the psychological issues
associated with a cancer diagnosis.
Data synthesis from these studies
provides preliminary evidence that
bibliotherapy is an acceptable and
beneficial adjunct therapy for patients
with cancer experiencing anxiety,
depression, and ineective coping.
AT A GLANCE
ɔPreliminary evidence shows that
patients with cancer can benefit
from bibliotherapy.
ɔStress reduction, relief of anxiety
and depression, and eective
coping are among the most
frequently patient-reported
outcomes of bibliotherapy.
ɔConsistent use of the same instru-
ments to measure patient-reported
outcomes and randomized, con-
trolled trials are warranted to draw
solid conclusions and establish the
causal link between bibliotherapy
and patient-reported outcomes.
KEYWORDS
bibliotherapy; anxiety;
cancer; coping; quality of life;
breast cancer
DIGITAL OBJECT
IDENTIFIER
10.1188/18.CJON.377-380
378 CLINICAL JOURNAL OF ONCOLOGY NURSING AUGUST 2018, VOL. 22 NO. 4 CJON.ONS.ORG
SUPPORTIVE CARE
TABLE 1.
STUDIES ON THE EFFICACY OF BIBLIOTHERAPY IN PATIENTS WITH CANCER
STUDY DESIGN, SAMPLE, AND SETTING TOOLS AND DATA ANALYSIS FINDINGS
Hammer et al.,
2017
Exploratory and descriptive study involving
17 self-referred cancer survivors with various
cancer diagnoses
24-week intervention called Active Book
Club with audiobook listening, walking, and
supervised book club meetings. Thematic
analysis of pre- and postintervention semi-
structured interviews and self-administered
questionnaires were used to assess mental
health and physical activity behaviors, as well
as retention, attendance, and adherence.
The authors concluded that audiobooks may
bring new meaning to physical activity and
serve as a relief from individual concerns.
Some stories aected participants negatively,
and there was a high dropout rate.
Huang et al.,
2015 Qualitative design
This study used 45 books discussing
early-stage breast cancer written for children
aged 3–12 years. Content analysis was used.
These books were found to be beneficial to
children and adults, cost eective, and helpful
to patients in terms of emotional expression.
Krebber et al.,
2017
Qualitative study with 16 patients with head
and neck and lung cancer
2 guided self-help interventions via Internet
or booklet were used. Perceived benefits were
derived from thematic analysis of qualitative
interviews.
Most patients reported that they found
the intervention to be beneficial regarding
learning what matters in life, being able to
put things in perspective, and feeling an
enhanced internal locus of control.
Moccia, 2013 Qualitative design in children with terminal
cancer
The book Milo’s Special Kite was created to
serve as a bibliotherapeutic tool for children
with terminal cancer by allowing them to
relate to the story character. Qualitative
content analysis of existing children’s books
related to death was used, and researchers
measured coping.
Results suggest that this book may optimally
support children dying of cancer and their
family members.
Roberts et al.,
2016
Descriptive, qualitative study with 18 patients
with cancer recruited from psychosocial
support cancer centers of two tertiary care
teaching hospitals in Canada
A self-help workbook, Mastering the Art
of Coping in Good Times and Bad, was
used. Content analysis was performed
using data-coding method. Acceptability
and benefits of bibliotherapy were derived
through content analysis of qualitative data
from interviews.
The workbook was acceptable as an
intervention to manage stress. 17 of 18
participants reported that they would
recommend the workbook to other patients
with cancer. The workbook reinforced
existing coping skills, positive thinking,
mindfulness, and appreciation of the impor-
tance of relationships.
Schneider
et al., 2013
Descriptive, mixed quasiexperimental and
qualitative design in 21 patients with cancer
(most had lymphoblastic leukemia) who
were undergoing or had recently completed
treatment
The book Nikki’s Day at Chemo was devel-
oped for this study, using coping strategies
for a child diagnosed with cancer. The
intervention was provided in a patient’s home
by a caseworker. Paired-samples t tests were
used to determine the change in the Child
Outcome Rating Scale.
Perceptions of intrapersonal functioning
improved, and physiologic arousal decreased
immediately after the initial book reading. The
participants consistently recalled the specifics
of the coping strategies employed in the
book. Parent and child were empowered to
cope with cancer together.
Semple et al.,
2006
Descriptive, qualitative study with 28 newly
diagnosed patients with head and neck
cancer
Psychoeducational intervention program
with one-to-one therapy, group therapy, or
workbook exercises; content analysis was
used to determine preferences for psycho-
educational interventions, self-esteem, and
anxiety.
Patients preferred the more individualized
one-to-one therapy, followed closely by
workbook exercises. Group therapy was least
preferred.
Semple et al.,
2009
Quasiexperimental design in a sample of 54
patients with predetermined psychological
dysfunction; 25 participants self-selected into
the experimental group, with 29 participants
in the control group.
The Psychosocial Intervention Programme
was delivered in participants’ homes with
a minimum of 2 sessions and a maximum
of 6 sessions. Booklets were designed for
each of the 8 problem-related areas (anxiety,
depression, eating and drinking, fatigue,
appearance, speech, smoking cessation,
and finance). Questionnaires and analysis of
covariance were used to measure anxiety,
depression, coping, and quality of life with a
3-month follow-up.
Participants reported reduction in psycho-
logical distress (anxiety and depression) and
improved social functioning and quality of
life for the experimental group, which was
sustained into the 3-month follow-up period.
All participants reported that they found the
bibliotherapeutic texts to be helpful.
Note. Level of evidence for all studies was VI, except Semple et al. (2009) and Schneider et al. (2013), which were level III.
AUGUST 2018, VOL. 22 NO. 4 CLINICAL JOURNAL OF ONCOLOGY NURSING 379CJON.ONS.ORG
"Bibliotherapy refers to the use of
any literature that supports good
mental health and is a versatile
and cost-eective intervention."
Methods
This review was conducted using
Whittemore and Knafl’s (2005) inte-
grative literature review framework,
which consists of specifying the review
purpose, performing a literature search
using computerized databases, evaluat-
ing data using primary sources, analyzing
and synthesizing data, presenting the re-
sults, and arriving at a conclusion that has
evidence-based practice applications
(Whittemore & Knafl, 2005).
Integrative Literature Search
PubMed, PsycINFO®, ProQuest, and
Academic Search Complete computerized
databases were search for relevant litera-
ture. The search terms included keywords
and Medical Subject Heading (MeSH)
terms, such as bibliotherapy, anxiety, depres-
sion, coping, quality of life, and cancer. The
Boolean operators NOT and AND were
used to yield highly relevant articles. In
addition, the search was limited to peer-
reviewed articles published from 1985–2017.
Original research articles that specified
bibliotherapy as an intervention in patients
diagnosed with cancer and articles that
conveyed evidence from the opinions of
authorities or reports of expert committees
on the therapeutic effects of bibliotherapy
on patients with cancer are also included
in the final data analysis. Nine articles were
included in the final analysis.
Data Analysis
The nine original research studies includ-
ed in the data analysis are categorized
and summarized according to bibliother-
apeutic approaches, patient-reported
outcomes, effectiveness of bibliotherapy
and level of evidence using Melnyk and
Fineout-Overholt’s (2011) hierarchy of
evidence. The patient-reported outcomes
and the tools used to measure them are
presented according to the highest and
lowest frequency of reporting to identify
key outcomes associated with bibliothera-
py in patients with cancer.
Results
Of these nine studies, six used qualitative
study design. All nine studies conclud-
ed that bibliotherapy is beneficial to
patients with cancer (see Table 1). In ad-
dition, bibliotherapy is primarily studied
in terms of its association with reduced
levels of anxiety and depression and im-
proved coping skills (see Table 2). The
most commonly used tools to measure
anxiety and depression are the Hospital
Anxiety and Depression Scale (HADS)
and the Child Outcome Rating Scale
(CORS). The CORS instrument is intend-
ed to measure anxiety, depression, and
general functioning (coping) for children
aged 6–12 years.
Discussion
Overall, the studies included in this review
reported positive results. Of note, research-
ers have measured various patient-reported
outcomes using different measures. Most
of the outcomes measured are within the
psychological domain; however, there was
heterogeneity in the outcomes measured
and measures used. Future studies on
bibliotherapy in patients diagnosed with
cancer should consistently measure key
outcomes, such as anxiety, depression, and
coping, and should use the same measures
to determine the effect size of bibliothera-
py on these key outcomes.
Limitations
The studies that met the inclusion and ex-
clusion criteria in this review have small
sample sizes that limit the generalizability
of the findings. The inclusion and exclusion
criteria are arbitrarily determined, and they
may have introduced unintended selection
bias effect. The use of various measures
for a specific outcome presents serious
limitation in determining the strength of
association between bibliotherapy and its
therapeutic benefits. The consistent use of
standardized measures for anxiety, depres-
sion, and coping is recommended in future
studies to facilitate meaningful compari-
sons and draw solid conclusions.
TABLE 2.
NUMBER OF STUDIES
USING PATIENT-REPORTED
OUTCOMES ASSOCIATED WITH
BIBLIOTHERAPY AND MEASURES
USED (N = 9)
PATIENTREPORTED
OUTCOME n MEASURE
Coping skills 4 CORS
Anxiety 2 HADS, CORS
Depression 2 HADS, CORS
Self-esteem 1 CORS
Social function 1 WSAS
QOL 1 UW-QOL
Interpersonal, family,
school, and global QOL 1 CORS
Self-ecacy 1 Interview
guide
Perception of
helpfulness 1Interview
guide
Perception of support 1 Interview
guide
CORS—Child Outcome Rating Scale; HADS—Hospital
Anxiety and Depression Scale; QOL—quality of life;
UW-QOL—University of Washington QOL questionnaire;
WSAS—Work and Social Adjustment Scale
380 CLINICAL JOURNAL OF ONCOLOGY NURSING AUGUST 2018, VOL. 22 NO. 4 CJON.ONS.ORG
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Conclusion
Bibliotherapy appears to be acceptable and
beneficial in alleviating patient-reported
anxiety and depression and improving
coping skills in patients diagnosed with
cancer. Randomized, controlled trials
are lacking to establish the causal re-
lationship between bibliotherapy and
patient-reported outcomes.
Ryan Malibiran, MSN, RN, is a recent graduate,
Joseph D. Tariman, PhD, RN, ANP-BC, FAAN, is
an assistant professor, and Kim Amer, PhD, RN, is
an associate professor, all in the School of Nursing
at DePaul University in Chicago, IL. Malibiran can
be reached at malibir2@gmail.com, with copy to
CJONEditor@ons.org.
The authors take full responsibility for this content and did
not receive honoraria or disclose any relevant financial
relationships.
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... All nine studies included in the analysis concluded that bibliotherapy was beneficial for patients with cancer; however, the small sample sizes and various measures for specific outcomes limit the generalizability of the findings. Thus, the authors agreed that the strength of the association between bibliotherapy and therapeutic benefits needs standardized measurement and further comparison (Malibiran et al. 2018). ...
... The major limitation of published studies of bibliotherapeutic interventions is the relatively small sample sizes (Malibiran et al. 2018). Our findings share the same limitation, as the total number of our attendees in the three groups was 24. ...
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PurposeNovels and autopathographies that employ cancer as a central theme offer a wealth of opportunities for researching the way patients with cancer make sense of their illness and its treatment. Such literatures can also inform clinical care, because they can support patients in living with their illness. The use of novels and autopathographies for research and care in persons with cancer fits within the framework of ‘Health Humanities’, the interdisciplinary field where medicine and social science meet. This paper presents a concise overview of novels and autopathographies that explore cancer as their theme.Methods Literature searches were conducted using PubMed, major scientific journals of medicine and clinical oncology, and databases in the Health Humanities. Searches focused on novels and autopathographies where cancer is the central theme, which are available in English, and which can be considered to represent ‘high literature’.ResultsTwenty-nine books were identified. The majority of the books were written originally in English, and breast cancer and lung cancer were the most frequently discussed types of cancer. The core themes identified were giving meaning to illness; coping with medical treatment; and the psychological and social consequences of illness.Conclusion Novels and autopathographies about cancer represent an innovative base for research on living with cancer and offer rich data on how people make sense of cancer and its medical treatment. Clinical implications of this review pertain to interventions based on bibliotherapy and expressive writing. Novels and autopathographies are just part of the Health Humanities context: a wide range of art genres may prove helpful in improving the quality of life of persons with cancer.
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Patient with breast cancer who get chemotheraphy has an side effect, one of this effect is psychological problem. The psychological problem among breast cancer patient is about depression and anxiety. The implementation of biblioteraphy has a positive effect on psychological condition. The aim of this research was to identify the effect biblioteraphy method on the level of depression and anxiety of breast cancer patient. The method was used quasy experimental pretest-postest with intervention control group design. The sampel was 32 respondents using purposive sampling technique wich divided into 2 groups, the intervention group received biblioteraphy story telling method and pray of Prophet Ayyub Alaihisalam while the control group without intervention.The evaluation of psychological aspect depression and anxiety used Hospital Anxiety Depression Scale (HADS) in bahasa. The analysis of depression and anxiety changes measured using independent t-test. The result: There was a significant relationship between level of depression and anxiety in pre and post on respondents who received intervention and without intervention. Conclusion: the applying of intervention of biblioteraphy method with frequency as much as 5 time and maximum in 45 minutes proved in lowering level of depression and anxiety. It is suggested for applying bibliotheraphy when giving nursing care of breast cancer patient. The future research should investigate other aspect such as education and environment against level of depression and anxiety.
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Background: While the increasing number of people surviving cancer is promising, the long-term health effects warrant broad, innovative interventions. We investigated the feasibility and acceptability of a 24-week intervention called ‘Active Book Club’ comprising audio book listening, pedometer walking and supervised book club meetings. Material and methods: An exploratory and descriptive design was applied. Qualitative data included baseline and post-intervention focus group interviews as well as post-intervention individual interviews. The study also included data on retention, attendance, and adherence. Seventeen self-referred cancer survivors with various oncological and sociodemographic backgrounds were included. Results: Eight (47%) participants completed the entire intervention. Their median attendance at the book club meetings was eight [interquartile range (IQR) 6–9] of nine possible, and they reached the walking step goal in a median of 11 (IQR 7–12) of the first 12 weeks, and seven (IQR 1–10) of the last 12 weeks. The qualitative analysis revealed five themes including: Motivation and expectations (i.e. reasons for enrollment), Attentive listening (i.e. experiences of the audio book format), Affected by the story (i.e. experiences of the content of the books), Group involvement (i.e. experiences of the book club meetings) and Walking regularly (i.e. experiences of the walking program). Overall, findings revealed that while audio books may bring new meaning to physical activity and serve as a relief from own concerns, certain stories may affect some individuals negatively. The substantial dropout rate, however, suggested that modification is necessary and that patient involvement in choice of literature may be critical to enhance acceptability. Conclusion: The ‘Active Book Club’ represents a novel psychosocial intervention potentially supporting physical activity adoption and mental health in cancer survivors. However, several issues related to feasibility and acceptability including choice of literature genre, format and supervision of book club meetings need to be considered before larger scale clinical trials are initiated.
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Background: Recent results of a randomized clinical trial showed that a guided self-help intervention (based on problem-solving therapy) targeting psychological distress among head and neck cancer and lung cancer patients is effective. This study qualitatively explored motivation to start, experiences with and perceived outcomes of this intervention. Methods: Data were collected from semi-structured interviews of 16 patients. All interviews were audio-recorded and transcribed verbatim. Data were analyzed individually by two coders and coded into key issues and themes. Results: Patients participated in the intervention for intrinsic (e.g. to help oneself) and for extrinsic reasons (e.g. being asked by a care professional or to help improve health care). Participants indicated positive and negative experiences with the intervention. Several participants appreciated participating as being a pleasant way to work on oneself, while others described participating as too confrontational. Some expressed their disappointment as they felt the intervention had brought them nothing or indicated that they felt worse temporarily, but most participants perceived positive outcomes of the intervention (e.g. feeling less distressed and having learned what matters in life). Conclusions: Cancer patients have various reasons to start a guided self-help intervention. Participants appreciated the guided self-help as intervention to address psychological distress, but there were also concerns. Most participants reported the intervention to be beneficial. The results suggest the need to identify patients who might benefit most from guided self-help targeting psychological distress and that interventions should be further tailored to individual cancer patients' requirements.
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Objective Examine the content of children’s books and summarize the main issues related to communication with young children about maternal cancer, especially breast cancer. Methods A search of English books discussing early-stage (breast) cancer and written for children aged 3–12 years was conducted on the Amazon.com Web site. Each of 45 identified books was analyzed independently by two of three coders using inductive qualitative content analysis. Results The main contents of these books included cancer-related knowledge, impacts of maternal cancer, and coping strategies. The concept of (breast) cancer and its treatment was introduced in plain language and some common misunderstandings were clarified. The consequences of maternal cancer were highlighted. Conclusions These books are beneficial to children and adults. However, impacts on school life, children’s concerns about financial burdens, and instructions about age-appropriate use of the books have been neglected. Additional studies should be undertaken to explore the value of these books.
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This article describes the combined effect of 12 controlled studies of bibliotherapy for sexual dysfunctions, comprising data on 397 participants, who were treated in 16 bibliotherapy groups. A mean effect size of 0.68 SDs at posttreatment was found (0.50 when weighted for sample size). This effect eroded at follow-up. No influence on effect size was found for either bibliotherapy implementation characteristics or study methodology. Studies were largely limited to bibliotherapeutic administration of the directed practice approach to orgasmic disorders. The efficacy of bibliotherapy has not yet been investigated sufficiently for evaluation of its use for other sexual dysfunctions or for its comparison with other therapeutic approaches for sexual dysfunctions.
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To identify whether bibliotherapy will help children with short stature and diabetes discuss their feelings and to explore themes that may help children cope with short stature and diabetes. Twenty-seven children, referred to a pediatric endocrinologist, aged 7-16 years, participated in interviews after reading a work of fiction. A semi-structured interview guide was used in both groups to elicit feelings about the work of fiction, feelings of self-esteem, and attitudes toward the condition. Children freely discussed their feelings about school experiences and condition-related issues. Several themes emerged from data analysis including the child's development of compensatory attributes, responses to teasing, and management of diabetes. This study confirmed that bibliotherapy is an effective nursing intervention in children with short stature and diabetes. Bibliotherapy can be used by nurses to facilitate open discussion between nurses, children, and families.
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Purpose/objectives: To determine the acceptability of a self-help workbook, Mastering the Art of Coping in Good Times and Bad, for patients with cancer. . Research approach: Descriptive, qualitative. . Setting: Participants were recruited from the psychosocial support cancer centers of two tertiary care teaching hospitals in Montreal, Quebec, Canada. . Participants: 18 individuals diagnosed with cancer. . Methodologic approach: A semistructured interview guide with open-ended questions was used to gather feedback from participants about the workbook. . Findings: 18 participants completed the interviews from which the data emerged. Two main categories were identified from the respondents' interviews regarding the acceptability of the workbook. The first category focuses on content, whereas the other focuses on recommendations. Interviewees specified the following content as most helpful. Conclusions: Bibliotherapy gives patients access to knowledge to help them cope and engage in their own self-management. The workbook Mastering the Art of Coping in Good Times and Bad may be an acceptable means of helping them manage their stress. . Interpretation: Bibliotherapy is not only cost-effective and easy to administer but also an acceptable minimal intervention.
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Reviews the current status of self-help behavioral treatment manuals. Organizing concepts and strategies for the development and evaluation of such programs are described. Programs that have been published or empirically tested for the treatment of phobias, smoking, obesity, sexual dysfunctions, assertiveness, child behavior problems, study skills, and physical fitness, as well as general instructional texts, are reviewed. It is concluded that the validation of available self-help behavior therapy manuals is extremely variable at the present time. It is suggested that future research evaluate manuals under conditions of intended usage, recruit clinically relevant Ss, employ follow-through and cost-effectiveness indices, include appropriate controls and follow-up assessments, and attempt to identify S or other clinical predictors of treatment outcome. The clinical and ethical issues raised by self-help programs are also briefly considered. (5 p ref)
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Childhood and adolescent anxiety disorders are relatively common, occurring in between 5-18% of all children and adolescents. They are associated with significant morbidity and impairment in social and academic functioning, and when persistent, there is a risk of depression, suicide attempts and substance abuse in adulthood. There is accumulating evidence for the efficacy of cognitive behavioural therapy (CBT), with a number of randomised controlled trials (RCTs) suggesting benefit. To determine whether CBT is an effective treatment for childhood and adolescent anxiety disorders in comparison to waiting list or attention controls. Search of the Cochrane Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register, which includes relevant randomised controlled trials from the bibliographic databases - The Cochrane Library ( to January 2004), EMBASE, (1970-2004) MEDLINE (1970-2004) and PsycINFO (1970-2004). We also searched the references of all included studies and relevant textbooks, and contacted authors in order to identify further trials. . Each identified study was assessed for possible inclusion by two reviewers independently. Inclusion criteria consisted of randomised controlled trials of CBT versus waiting list/attention controls in children (more than six years of age) and adolescents (under the age of 19 years) with a DSM (Diagnostic Statistical Manual) or ICD (International Classification of Diseases) anxiety diagnosis; and excluding simple phobia, obsessive compulsive disorder and post-traumatic stress disorder. Each study was required to conform to the principles of CBT through use of a protocol and comprising at least eight sessions of CBT. The methodological quality of included trials was assessed by two reviewers independently. The dichotomous outcome of remission of anxiety diagnosis was pooled using relative risk (RR) with 95% confidence intervals. Means and standard deviations of anxiety symptom continuous scores were pooled using the standardised mean difference (SMD). Heterogeneity was assessed and intention-to-treat (ITT) analyses undertaken. The presence of publication bias was assessed using funnel plots. Thirteen studies with 498 subjects and 311 controls met the inclusion criteria and were included in the analyses. The studies involved community or outpatient subjects only, with anxiety of only mild to moderate severity. ITT analyses showed a response rate for remission of any anxiety diagnosis of 56% for CBT versus 28.2% for controls (RR 0.61,95%CI 0.53 to 0.69), with no evidence of heterogeneity. The number needed to treat (NNT) was 3.0 (95%CI 2.5 to 4.5). For reduction in anxiety symptoms, the SMD was -0.58 (95% CI 0.76 to -0.40) with no significant heterogeneity indicated. Individual, group and family/parental formats of CBT produced fairly similar outcomes. Cognitive behavioural therapy appears an effective treatment for childhood and adolescent anxiety disorders in comparison to waiting list or attention control. There was no evidence for a difference between an individual, group or parental/family format. CBT can be recommended for the treatment of childhood and anxiety disorders, although with only just over half improving, there is a need for further therapeutic developments.
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The aim of this paper is to distinguish the integrative review method from other review methods and to propose methodological strategies specific to the integrative review method to enhance the rigour of the process. Recent evidence-based practice initiatives have increased the need for and the production of all types of reviews of the literature (integrative reviews, systematic reviews, meta-analyses, and qualitative reviews). The integrative review method is the only approach that allows for the combination of diverse methodologies (for example, experimental and non-experimental research), and has the potential to play a greater role in evidence-based practice for nursing. With respect to the integrative review method, strategies to enhance data collection and extraction have been developed; however, methods of analysis, synthesis, and conclusion drawing remain poorly formulated. A modified framework for research reviews is presented to address issues specific to the integrative review method. Issues related to specifying the review purpose, searching the literature, evaluating data from primary sources, analysing data, and presenting the results are discussed. Data analysis methods of qualitative research are proposed as strategies that enhance the rigour of combining diverse methodologies as well as empirical and theoretical sources in an integrative review. An updated integrative review method has the potential to allow for diverse primary research methods to become a greater part of evidence-based practice initiatives.
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Cognitive behaviour therapy (CBT) is a widely practiced and approved form of psychotherapy for many psychosocial difficulties. As the efficacy of CBT is recognized, its demand has increased and today exceeds the availability of qualified practitioners. Therefore, the effectiveness of delivering CBT using less labour-intensive modes than individualised therapy has been explored. These include group therapy, bibliotherapy and computer assisted therapy. Given the UK Government's impetus towards patient choice and involvement in the planning of healthcare, it was thought essential to ascertain the preferred delivery mode of patients with head and neck cancer for a CBT based intervention. Therefore, a small retrospective cohort (n= 28) of patients following treatment for head and neck cancer were sent postal questionnaires to ascertain their preferences on mode of CBT delivery. Simultaneously, the views of accredited cognitive behaviour therapists (n= 14) were determined on the optimal mode of CBT delivery to these patients. Findings indicated that patients preferred the more individualized mode of CBT delivery, namely one-to-one therapy, followed closely by bibliotherapy, with group format being the least preferred option. Professionals concurred with patients, in that one-to-one interaction was considered an optimal mode of CBT delivery, but professionals considered it equal to group therapy.