helping yourselfSophie Goodchild reports on a new project where health professionals ‘prescribe’ self-help books to people experiencing mental illness could benefit hundreds of thousands of people a year:

The local library was the last place Gill Taft would have thought of turning to for wellbeing advice, despite being a regular visitor. But that is exactly where she did find support when the pressures of caring for her elderly and blind mother, working full-time and coping with her husband’s health problems led to a nervous breakdown. Self-help books provided just the breakthrough the 59-year-old desperately needed to recover, and also helped to explain the triggers for the anxiety attacks and low moods that have overshadowed Taft’s life since adolescence.

“It [the breakdown] felt like I’d gone into a black hole – it was terrifying and I felt so isolated,” says Taft, who lives in Warwickshire with her husband. “I’ve always been a ‘yes’ person, but the books helped me understand that I can say ‘no’ to things. Now I can stand back and see I was trying to do too much, and that it was affecting me not just mentally but physically too.”

Books on Prescription
Taft is one of thousands benefiting from a new service where doctors and other professionals ‘prescribe’ selfhelp books through lending libraries from a specially selected reading list. Called Reading Well: Books on Prescription (BOP), the service was launched on June 4 across England and could help an estimated 240,000 people a year. Endorsed by the Department of Health, the pioneering national scheme is delivered by independent charity The Reading Agency in partnership with the Society of Chief Librarians and local library services.

The aim is to help people feel better through self‑help reading that follows the principles of cognitive behavioural therapy (CBT) so that people are enabled to understand and manage common mental health conditions. James Kingsland is a GP in Merseyside who believes BOP is a valuable new tool in improving wellbeing among his patients alongside medication and other psychological interventions.

“We’re all looking for new ways to help patients with mental health problems improve their self-care and general wellbeing, especially in such tough economic times,” says Dr Kingsland, who is president of the National Association of Primary Care (NAPC) and on BOP’s advisory panel.

The average 10-minute GP appointment is “rarely sufficient” for patients, he adds, so “extra tools to compliment the consultation” are necessary and welcome. The BOP scheme works within National Institute for Health and Care Excellence (NICE) guidelines, and is supported by organisations including the Royal Colleges of General Practitioners, Nursing, and Psychiatrists.

The idea of stocking library shelves with books that can be ‘prescribed’ by doctors was first piloted in Wales in 2005 and since then about 250,000 patients have benefited. It was the brainchild of Professor Neil Frude, a clinical psychologist who became frustrated at not being able to treat as many mental health patients as he would have liked. Similar self-help programmes have since been launched in Denmark and New Zealand.

Professor Frude says: “There’s very good evidence that CBT is robust and can be delivered in all sorts of ways. There might be a danger of people feeling fobbed off if there were alternative treatments which are readily accessible. But the reality is that people feel fobbed off with antidepressants. If you learn to think realistically about the world then you will have skills for life and these will prevent reoccurrences [of mental illness].”

The cost-benefits of BOP are also significant, adds Professor Frude. Mental health prescriptions already cost the NHS £1.2 billion a year. A self-help book costs about £10 and libraries will lend one around 20 times before it becomes unusable. So the BOP service works out at just 50p per head to deliver on the ground.

“It’s not only an effective treatment but the costeffectiveness is huge,” he says. What is the evidence though that such schemes work? A randomised double-blind controlled trial of BOP would be too expensive to carry out, says Professor Frude. But existing research already shows that CBT can benefit people with mild to moderate conditions such as anxiety or depression – and this can reduce the need for antidepressants.

A report by the London School of Economics (2012), for example, says the success rate of CBT is the same as drugs short-term but the effects are longer lasting. There are 30 books on the approved eading list and all have been vetted by an expert review panel with titles including Overcoming Anxiety by Helen Kennerly and the Feeling Good Handbook by David D Burns. Books on physical conditions such as chronic pain and chronic fatigue are also included.

No replacement for existing care
But there is no question of this scheme replacing existing care, according to Dr Paul Blenkiron, who is a NICE fellow and a member of BOP’s advisory panel. Instead, the consultant psychiatrist at Bootham Park Hospital in York says it is a useful addition enabling people to self-manage conditions such as social phobias, sleep problems, compulsions and binge eating through learning the skills necessary to do this.

The books can be used in different ways. For example, people can start reading one of the recommended texts while waiting to be seen for CBT sessions. Or they can be used alongside medication if their anxiety or depression is more severe.

“One of the things that people with anxiety and depression feel they get from self-help is to regain a sense of control – that they are actually doing something about it,” Blenkiron says. “It’s important to remember though that reading alone isn’t enough – it’s about putting into practice the tried and tested approaches in these books, that’s what will make the difference.”

Positive impact
Another positive impact of self-help books is that they help some patients to ‘give a name’ to their problem, points out Dr Philip Timms from South London and Maudsley NHS Foundation Trust.

“A lot of users feel very isolated and especially if they have one of the less easy to define disorders,” he says. “There are a number of things that happen with a book or a self-help leaflet. For example, a  patient said to me: ‘I feel better because I realise I’m not the only one with this problem.’ It gives them a plan, which gives them a sense of control rather than feeling at the mercy of voices or a depressive mood.”

They are also spared from telling their boss they’ve got to take time off work for a ‘doctor’s appointment’, which is an advantage for people hesitant to access conventional forms of support for fear of stigma. “If I had all the money in the world [to treat mental illness] I’d still like this programme to happen,” adds Dr Timms.

“It gives people a sense of empowerment. And it can also be more compelling when you see a condition in a book: it validates it. The important part though is to explain to patients why we’re doing this and explain they’re much more likely to benefit.”

For Gill Taft, the advantage of having a book to take away and read is that “you can go back over it in your own time, at your own speed.” Before joining the scheme, she had never had “anyone or anything really explain” why her anxiety attacks and depressive moods were occurring. Now, Taft says it makes her “feel enabled” by picking up a book from her library and learning how to do something about her illness.

“I still have good and bad days, but I know now that I don’t need to feel the way I do on the down days, or worry about what people think of me. For the first time ever, I feel like someone has understood.”

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