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August 14, 2005

BehindTheMedspeak: Bibliotherapy


Bibliotherapy — prescribing books instead of medications for depressed people — has been approved by the National Institute for Clinical Excellence, a British health agency, since last December.

Jeanne Whalen brought it to my attention with her article which appeared in this past Tuesday's Wall Street Journal.

Long story short: bibliotherapy is cheap, fast and often works.

Doctors and therapists say that part of the power of the technique lies in actually writing down the book's title on a prescription pad just as if it were a drug.

This makes patients more likely to take it seriously, follow through and buy and read the book prescribed.

Libraries are stocking up on the books most frequently prescribed, largely self–help titles.

I'm all for it.

Once upon a time, in a city on the left coast, I spent a couple years working as a family doctor.

I couldn't take it.

The reason?

95%+ of the patients I was seeing were in my office not because they had anything physically wrong with them but, rather, because they were bored, tired and/or depressed.

A doctor — especially one who's free because visits are completely covered by your company's health plan — is a pleasant diversion from work or home or family or whatever it is that's making you miserable.

After a couple years doing the general practitioner thing it became clear to me that I didn't really want to hear patients tell me why they were miserable, day after day after day.

Every night I'd go home and just sit, depressed by the endless litany of troubles I'd listened to all day.

So I went into anesthesiology where it's wham, bam, thank you ma'am as I slam home the drugs and the patient falls silent, asleep and paralyzed for the duration.

Now that's medicine. But I digress.

Of course bibliotherapy won't work if a person is really depressed, but it won't make them worse and they won't be able to read a book anyway if it's that bad: I have been there and done that — on more than one occasion.


I'm reminded, for no reason in particular but that it's book–related, of Jeanette Winterson's wonderful remark about her mother.

Winterson said that her mother was extremely put off and unhappy by her habit of reading so much when she was growing up; said her mother, "The trouble with books is that you can't tell what's in them."

So great.

On a related note, it has always interested me that looking at a jumble of computer code cannot tell you whether it's going to show a lovely landscape or a horrific murder scene: all code is unemotional on its face.

There is something much deeper here but I am not even close to being smart enough to begin to unravel it.

My thought, though, for what it's worth is, is it possible to predict the appearance of a digital photo from its computer code?

Here's the Wall Street Journal article.

    For Mild Depression, British Doctors Prescribe Books

    When some British doctors see a patient with mild to moderate depression or anxiety, they pull out their pads and prescribe a self-help book.

    Under a new program in more than a dozen counties across the United Kingdom, patients take the prescription to their local library, where they check out reserved titles such as "Overcoming Depression" and "The Feeling Good Handbook."

    Doctors say they began prescribing books out of concern that too many depressed people were either being medicated too hastily with antidepressant drugs like Prozac or going untreated.

    They also saw it as a cost-saving strategy.

    The state-run health-care system here couldn't afford one-to-one counseling for everyone -- waiting lists can run up to 18 months -- leaving medication or no treatment the remaining options.

    The programs, called "bibliotherapy" or "guided self-help," were endorsed by the National Institute for Clinical Excellence, a British health agency, in December.

    The agency warned of "overuse" of antidepressants in patients with mild depression and recommended that doctors try guided self-help or other kinds of counseling before medication.

    Bibliotherapy raises some concerns.

    Some patients fail to check out or read the books and fall through the cracks.

    And, in a few cases, severely depressed people have been directed to the self-help program when more serious treatment was needed, counselors say.

    Concerns about overuse of antidepressants -- and about how to treat the growing depression burden in general -- have been voiced in many countries, including the U.S., making the British experiment a test case for others to watch.

    "Until recently the only thing available to a physician was to write a prescription for a drug. What this does is give the physician two prescribing pads," says Neil Frude, a Cardiff University psychologist who started the self-help-book trend by setting up a program in Wales three years ago.

    Bibliotherapy, he adds, also frees up busy counselors to deal with more seriously depressed or mentally ill patients.

    In Britain, the National Heath Service covers everyone's medicines and doctor visits, free of charge.

    Bibliotherapy has been used to treat thousands of patients so far and could within a few years reach up to a quarter of a million patients nationwide, Mr. Frude estimates.

    Most cases of depression and anxiety are diagnosed at the general physician's office, where the average visit in Britain lasts just seven minutes.

    In nearly 100 physicians' offices in Devon, a county in southwest England, doctors now send mildly to moderately depressed patients down the hall to a mental-health worker, who tries to determine the core problem.


    Then the mental-health worker prescribes a self-help book and meets four more times with the patient to discuss the book and its exercises and ensure that the treatment is working.

    Sami Al-Haboubi, a 23-year-old mental-health worker in Devon, lets patients talk about what's troubling them and asks a list of 14 questions that help score the person's level of depression or anxiety.

    One woman says she came to see Mr. Al-Haboubi recently for panic attacks brought on by a stressful work environment.

    The attacks would leave her hyperventilating and feeling she couldn't cope with anything.

    The woman had struggled with depression, including suicidal thoughts, in her teens and had taken Prozac but says she didn't want to go on medication again for the panic attacks.

    "The doctor told me I could go to counseling, but there would be a wait, or that Sami could help me quickly," she said in a phone interview in which she asked to remain anonymous.

    Mr. Al-Haboubi prescribed "Overcoming Anxiety" by Helen Kennerley.

    Some of the book's suggestions for dealing with panic -- including breathing and muscle-relaxation exercises -- helped calm some of the woman's symptoms, she says.

    The book gives people space to record times that they experience negative thoughts and explains how to keep those thoughts in check.

    The woman had four visits with Mr. Al-Haboubi and says she found this crucial to her therapy.

    Over time, her panic attacks lessened and she says she's looking into more long-term counseling to better understand the deep-seated causes.

    Mr. Al-Haboubi isn't a fully trained counselor -- Devon's mental-health workers have undergraduate degrees in psychology or a related field and take an additional one-year training course that qualifies them to administer bibliotherapy.

    Mr. Al-Haboubi keeps a stack of self-help books and his laptop in the trunk of his car, traveling among three doctors' offices to meet patients.

    Many of the books are from the "Overcoming" series published by London-based Constable & Robinson Ltd., including "Overcoming Panic" and "Overcoming Childhood Trauma."

    During the first session, Mr. Al-Haboubi says, he explains to patients that "what they're going to get is not what people typically think of as counseling -- it's not ongoing, it's not just us sitting here talking. We use self-help books," he says.

    He emphasizes that some of the onus will be on the patient working through the book and its exercises with Mr. Al-Haboubi as a guide.

    Because he writes down the book prescription, patients are more likely to take it seriously and get the book, he says.

    If a patient doesn't follow through, he says he reminds them that he can't do much for them if they won't do the reading.

    In other regions like Wales, where books are prescribed without follow-up visits, doctors and counselors acknowledge they don't even necessarily know when patients don't fill the prescription.

    Libraries are stocking up on the prescribed books, and some patients are also buying them.

    Constable & Robinson says world-wide sales its most popular "Overcoming" books will grow 20 percent to 25 percent this year thanks to bibliotherapy, with most of those sales coming from Britain.

    Dr. Frude says other publishers are also vying to get on the lists of approved books, which doctors in each region generally compile.

    Paul Farrand, a psychologist at the University of Plymouth and head of the Devon program, says bibliotherapy has led to "significant improvements" for patients.

    He acknowledges that sometimes patients in need of more serious treatment are wrongly referred to the self-help scheme but says that in those cases the mental-health worker refers the patient back to the physician.

    Mr. Al-Haboubi says he has had to stop his sessions a few times to call in the physician out of concern that a patient was at risk of self-harm or suicide.

    Mr. Al-Haboubi also sees patients who are taking antidepressants.

    One recent patient says he was putting so much pressure on himself to perform his job perfectly that he would become hugely stressed over the slightest mistake and end up quitting.

    The cycle had left the man depressed and out of work.

    His doctor prescribed antidepressants, which he says made him feel better within a few weeks, and sent him to Mr. Al-Haboubi, who realized the man had a self-esteem problem and prescribed "Overcoming Low Self-Esteem" by Melanie Fennell.

    The patient has taken a less-stressful job and says he is feeling better.

August 14, 2005 at 12:01 PM | Permalink


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