Anxiety

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Review article

The clinical and cost-effectiveness of selfhelp treatments for anxiety and depressive disorders in primary care: a systematic review Peter Bower, David Richards and Karina Lovell
SUMMARY Anxiety and depression are prevalent in primary care; however, current treatments differ in their availability, cost-effectiveness, and acceptability to patients. Self-help treatments (such as manualbased bibliotherapy) may be an appropriate intervention for some patients. The aim of this research was to determine the clinical and cost-effectiveness of self-help treatments for anxiety and depression in primary care by conducting a systematic review of randomised and non-randomised trials of self-help interventions for patients with anxiety and depression in primary care, from electronic database searches, correspondence with authors, and limited handsearching. Eight studies were identified, examining written interventions based mostly on behavioural principles. Although the majority of trials reported some significant advantages in outcome associated with self-help treatments, the number of included studies was limited and a number of methodological limitations were identified. There were no data concerning long-term clinical benefits or cost-effectiveness. In conclusion, self-help treatments may have the potential to improve the overall cost-effectiveness of mental health service provision. However, the available evidence is limited in quantity and quality and more rigorous trials are required to provide more reliable estimates of the clinical and cost-effectiveness of these treatments. Keywords: anxiety; depression; self-help treatment; clinical benefit; cost-effectiveness; systematic review.

Introduction
ENTAL health problems are common in primary care.1 However, only a small proportion of individuals with these disorders are referred to specialist services. For those managed in primary care, treatment options include support from the general practitioner (GP) or practice nurse, medication or referral to an on-site counsellor or psychologist.2 However, not all GPs possess the skills or enthusiasm for mental health work. Patients are often reluctant to take antidepressant medication3 and the efficacy of antidepressants in relation to depressive disorders that do not meet specific diagnostic criteria (e.g. major depression) is unclear.4 The prescription of anxiolytic medication has also been criticised, on the grounds of the likelihood of dependence,5 lowered efficacy over time, and the problems associated with their illicit sale and use. Specialist mental health professionals are only moderately more effective than routine GP care in the management of mild to moderate disorders.6,7 Given these limitations, ‘self-help’ approaches may potentially widen access to effective treatment. Although self-help is currently used in some mental health services, paradoxically this is usually after the patient has made contact with specialist professionals, which limits their availability to people passing the primary care filter.1 Greater availability of self-help treatment packages in primary care and community settings may have the potential to provide cost-effective, accessible, and appropriate treatment for a range of disorders. Self-help in mental health is available in a number of formats. Psychological treatments, such as cognitive-behaviour therapy, require that therapeutic work is done by the patient between sessions with the professional8 and standard psychological treatments are increasingly provided in written format (‘bibliotherapy’). Computerised systems have been produced that provide greater flexibility in response to the individual patient9,10 and allow information sharing with professionals around clinical progress and suicidal ideation. Using telephone and interactive voice response (IVR) means that access to a computer is not always required.11 Reviews and meta-analyses of self-help treatments such as...
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