Background

Bibliotherapy is the prescription of literature for healing. The term was coined by American essayist and minister Samuel Crothers in a 1916 Atlantic Monthly article, in which a fictional character named Bagster prescribes books for various afflictions.[1] However, the “reading cure” was in use a century earlier, when libraries were a part of many Victorian-era psychiatric hospitals and army hospitals.[2-4] In 1802, Benjamin Rush, widely considered the founder of American psychiatry, stated, “For the amusement and instruction of patients in a hospital, a small library should by all means compose a part of its furniture.”[5] In 1853, American physician John Minson Galt outlined five reasons why reading is beneficial to psychiatric patients in his essay “On reading, recreation, and amusements for the insane.”[3,5] Bibliotherapy may include imaginative materials such as short stories, novels, and poetry, and didactic materials, which are nonfiction and instructive.[2,3,5]

Bibliotherapy has enjoyed a fresh surge of attention in the mainstream media over the past few years, with articles in the New Yorker, the National Post, and Maclean’s. Various organizations and experts have generated reading lists for patients with virtually any mental health disorder. Bibliotherapy has practical utility in medicine due to its acceptability, ease of use, low cost, and availability. It can be used alone, as adjunctive treatment, or while a patient awaits other treatment. But at the point of the clinical encounter, how is a physician to know what reading to recommend for which patient? Clinical guidelines do not recommend specific books, and there is no catalog of existing reading lists.

Objectives

The objectives of this project were to review, organize, and disseminate recommended reading for psychiatry patients and their families. The first step was to review the medical research literature for evidence for bibliotherapy, review clinical guidelines for references to recommended reading, and scan for existing patient reading lists. The next step was to review available books, organize and catalog them, and publish this catalog on a public website.

Methods

A systematic review of the medical research literature was undertaken to answer the topic question: What is the evidence for bibliotherapy for psychiatric disorders? Databases searched included all UBC Library indexes, databases, and articles, including Medline (Ovid), PubMed, and Google Scholar. Medical Subject Heading (MeSH) terms used were bibliotherapy, psychiatry, depression, anxiety, bipolar, schizophrenia, psychosis, personality disorders, borderline, dementia, and eating disorders. Systematic reviews and meta-analyses were favored. Twenty-two articles were reviewed.

Next, clinical guidelines were reviewed for references to bibliotherapy. These included the Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 depression guidelines; the CANMAT and International Society for Bipolar Disorders 2018 guidelines for the management of patients with bipolar disorder; Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress, and obsessive-compulsive disorders (2014); the Canadian schizophrenia guidelines (2017); the American Psychiatric Association clinical practice guidelines; and the National Institute for Health and Care Excellence guidelines.

A search was then undertaken for existing recommended reading lists for psychiatric patients. First, widely known groups were scanned, such as the Canadian Psychiatric Association, the Centre for Addiction and Mental Health, the Canadian Mental Health Association, the Mood Disorders Society of Canada, the Schizophrenia Society of Canada, the American Psychiatric Association, the National Institute of Mental Health, and the American Academy of Child and Adolescent Psychiatry. Then a Google search was used to determine what recommended reading lists existed for psychiatric patients. Search terms used were bibliotherapy, recommended reading, books, psychiatry, mental illness, depression, anxiety, bipolar, schizophrenia, psychosis, personality disorders, borderline, dementia, and eating disorders. Inclusion criteria required that the lists be in English; be produced by professional organizations or programs, patient advocacy groups, literary or library programs, or mental health clinicians; and have no apparent conflict of interest in the recommendations (e.g., lists by booksellers).

Books with multiple recommendations were reviewed, and a decision was made to accept or reject each book for the catalog. For books where there was uncertainty regarding suitability, another search of the medical literature with the MeSH term of the book title was undertaken for further information. Selected books were organized by illness, audience, genre, and category of evidence. The number of books in each category was limited to a maximum of six.

To disseminate the resulting catalog, the domain bibliotherapy.ca was purchased. A website was built using the Squarespace platform. The final collection of accepted books was published on the public website, named Pacific Bibliotherapy.

Results

Most robust research studies on bibliotherapy have focused on its efficacy in unipolar mild to moderate depression. A 1997 meta-analysis by Cuijpers and colleagues reported a mean effect size of 0.82 (95% CI, 0.50-1.15) for six studies comparing cognitive-behavioral therapy (CBT) bibliotherapy patients with wait list controls. Analysis of five contrast groups comparing bibliotherapy to individual therapy resulted in an effect size of 0.10 (95% CI, −0.48 to 0.28), demonstrating that bibliotherapy is as effective as individual therapy for unipolar depression.[6] Similarly, a 2004 meta-analysis of 17 studies of CBT bibliotherapy for depression reviewed by Gregory and colleagues yielded an effect size of 0.77 (95% CI, 0.61-0.94).[7] Gualano and colleagues’ 2017 systematic review of randomized clinical trials on the long-term effect of bibliotherapy in depression, looking at follow-up from 3 months to 3 years, concluded that bibliotherapy maintained its effect long term.[8] Yuan and colleagues’ 2018 meta-analysis of randomized clinical trials looking at the efficacy of bibliotherapy for depression and anxiety disorders in children and adolescents, including eight studies of 979 participants, concluded that bibliotherapy is significantly more effective than control conditions in reducing symptoms of depression or anxiety, with a standardized mean difference of −0.52 (95% CI, −0.89 to −0.15), although the evidence was more robust for depression than for anxiety.[9]

Of the guidelines reviewed, two referred to bibliotherapy. The CANMAT 2016 depression guidelines state:

“Overall, bibliotherapy has practical utility due to ease of use and low cost, may be useful for people waiting to be seen for clinical care, and remains a second-line treatment, either alone or as an adjunct to medication, ideally with clinician encouragement and monitoring.”[10]

The Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders (2014) state:

“[A] variety of self-directed or minimal intervention formats (e.g., bibliotherapy/self-help books, or internet/computer-based programs with or without minimal therapist contact) have demonstrated significant improvements in anxiety symptoms.”[11]

The Canadian guidelines state that for panic disorder and agoraphobia, bibliotherapy is “more effective than wait-list or relaxation controls, as effective as face-to-face CBT, and may be cost-effective options particularly for agoraphobic patients who are unwilling or unable to attend a clinic,” and with regard to obsessive–compulsive disorder (OCD), “[b]ibliotherapy in the form of self-help manuals delivered to patients via email has demonstrated significantly greater improvements in OCD symptoms compared with wait-list control groups in two [randomized controlled trials].”[11]

A search for existing recommended reading lists for psychiatric patients yielded 35 reading lists, summarized in the Table.

TABLE. Sources for existing recommended reading lists for psychiatric patients.

Eighty-four books with multiple recommendations were selected for review. After considering quality, appropriateness, availability, practicality, and duplication of material when compared with other books in the same category, 51 books were accepted for the catalog, and 33 were rejected. The selected books were published on www.bibliotherapy.ca [11] under seven illness categories: depression and anxiety, bipolar illness, schizophrenia, borderline personality disorder, eating disorders, dementia, and child and adolescent mental health [Figure 1 [12]]. Each illness category was divided into nonfiction and creative reading recommendations. A brief review of each book and a list linking the evidence and/or the sources of the recommendations were included for each title [Figure 2 [13]].

[12]

FIGURE 1. A screenshot of a portion of the bipolar category of the Pacific Bibliotherapy website, www.bibliotherapy.ca [14].

[13]

FIGURE 2. A screenshot of a book listing on the Pacific Bibliotherapy website, www.bibliotherapy.ca [14].

A section summarizing the major bibliotherapy research studies and clinical guideline references was included on the website, as was a section on the history of bibliotherapy.

Discussion

Bibliotherapy has been in use for centuries. Meta-analyses have demonstrated a large effect size when bibliotherapy is used to treat unipolar mild to moderate depression, and this effect has been shown to be enduring. Bibliotherapy has also been shown to be effective in reducing symptoms of depression and anxiety in children. Current Canadian guidelines for the treatment of depression and anxiety recommend bibliotherapy. A scan of current resources yielded 35 existing recommended reading lists for a wide range of mental health issues. Until now, there has been no catalog of these efforts. This project reviewed and organized these reading recommendations and published them on a website.

The website has limitations. There is a lag between a book being published, it being included on a recommended reading list, and that recommendation being reviewed and added to the website. Known resources for reading lists may add books not currently included on this website, and new resources may emerge that were not discovered on the initial scan. The website includes books on select topics but does not include books on other important subjects, such as substance use disorders or postpartum mental health, although more categories may be added in the future.

Bibliotherapy has its own limitations. Most of the evidence is for mild to moderate depression and anxiety and used CBT-based books. Exclusion criteria for most studies included comorbidities, as well as severe depression, cognitive issues, suicidality, and crisis situations.[6] Risks of the patient using bibliotherapy without professional guidance include incorrect self-diagnosis (e.g., major depressive disorder versus bipolar illness)[7] and experiencing failure when not finishing a book (e.g., phobias).[6] However, when used judiciously, bibliotherapy can be a high-quality, low-barrier form of therapy. The website www.bibliotherapy.ca [11] aims to make book prescriptions more accessible to clinicians and their patients.

Competing interests

None declared.

Acknowledgments

The author would like to acknowledge academic support from her scholarly project supervisor, Dr Marian Miller, and financial support through a UBC Psychiatry CanMEDS award.

Funding

The project received a UBC Psychiatry CanMEDS award for $678 in 2021.

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This article has been peer reviewed.

[15]

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License [15].

References

1.    Crothers SM. A literary clinic. Atlantic 1916;118:291-301.

2.    Bate J, Schuman A. Books do furnish a mind: The art and science of bibliotherapy. Lancet 2016;387(10020):742-743.

3.    Canty N. Bibliotherapy: Its processes and benefits and application in clinical and developmental settings. Logos 2017;28:32-40.

4.    Stip E, Östlundh L, Abdel Aziz K. Bibliotherapy: Reading OVID during COVID. Front Psychiatry 2020;11:567539.

5.    McCulliss D. Bibliotherapy: Historical and research perspectives. J Poet Ther 2012;25:23-38.

6.    Cuijpers P. Bibliotherapy in unipolar depression: A meta-analysis. J Behav Ther Exp Psychiatry 1997;28:139-147.

7.    Gregory RJ, Schwer-Canning S, Lee TW, Wise JC. Cognitive bibliotherapy for depression: A meta-analysis. Prof Psychol Res Pr 2004;35:275-280.

8.    Gualano MR, Bert F, Martorana M, et al. The long-term effects of bibliotherapy in depression treatment: Systematic review of randomized clinical trials. Clin Psychol Rev 2017;58:49-58.

9.    Yuan S, Zhou X, Zhang Y, et al. Comparative efficacy and acceptability of bibliotherapy for depression and anxiety disorders in children and adolescents: A meta-analysis of randomized clinical trials. Neuropsychiatr Dis Treat 2018;14:353-365.

10.    Parikh SV, Quilty LC, Ravitz P, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: Section 2: Psychological treatments. Can J Psychiatry 2016;61:524-539.

11.    Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry 2014;14 (Suppl 1):S1-S83.

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Dr Scholtens is a clinical assistant professor in the Department of Psychiatry, Faculty of Medicine, University of British Columbia.