Does therapeutic writing help people with long-term conditions? Systematic review, realist synthesis and economic considerations

Abstract

BackgroundWriting therapy to improve physical or mental health can take many forms. The most researched model of therapeutic writing (TW) is unfacilitated, individual expressive writing (written emotional disclosure). Facilitated writing activities are less widely researched.Data sourcesDatabases, including MEDLINE, EMBASE, PsycINFO, Linguistics and Language Behaviour Abstracts, Allied and Complementary Medicine Database and Cumulative Index to Nursing and Allied Health Literature, were searched from inception to March 2013 (updated January 2015).Review methodsFour TW practitioners provided expert advice. Study procedures were conducted by one reviewer and checked by a second. Randomised controlled trials (RCTs) and non-randomised comparative studies were included. Quality was appraised using the Cochrane risk-of-bias tool. Unfacilitated and facilitated TW studies were analysed separately underInternational Classification of Diseases, Tenth Revision chapter headings. Meta-analyses were performed where possible using RevMan version 5.2.6 (RevMan 2012, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Costs were estimated from a UK NHS perspective and three cost–consequence case studies were prepared. Realist synthesis followed Realist and Meta-narrative Evidence Synthesis: Evolving Standards guidelines.ObjectivesTo review the clinical effectiveness and cost-effectiveness of TW for people with long-term conditions (LTCs) compared with no writing, or other controls, reporting any relevant clinical outcomes. To conduct a realist synthesis to understand how TW might work, and for whom.ResultsFrom 14,658 unique citations, 284 full-text papers were reviewed and 64 studies (59 RCTs) were included in the final effectiveness reviews. Five studies examined facilitated TW; these were extremely heterogeneous with unclear or high risk of bias but suggested that facilitated TW interventions may be beneficial in individual LTCs. Unfacilitated expressive writing was examined in 59 studies of variable or unreported quality. Overall, there was very little or no evidence of any benefit reported in the following conditions (number of studies): human immunodeficiency virus (six); breast cancer (eight); gynaecological and genitourinary cancers (five); mental health (five); asthma (four); psoriasis (three); and chronic pain (four). In inflammatory arthropathies (six) there was a reduction in disease severity [n = 191, standardised mean difference (SMD) –0.61, 95% confidence interval (CI) –0.96 to –0.26] in the short term on meta-analysis of four studies. For all other LTCs there were either no data, or sparse data with no or inconsistent, evidence of benefit. Meta-analyses conducted acrossallof the LTCs provided no evidence that unfacilitated emotional writing had any effect on depression at short- (n = 1563, SMD –0.06, 95% CI –0.29 to 0.17, substantial heterogeneity) or long-term (n = 778, SMD –0.04 95% CI –0.18 to 0.10, little heterogeneity) follow-up, or on anxiety, physiological or biomarker-based outcomes. One study reported costs, no studies reported cost-effectiveness and 12 studies reported resource use; and meta-analysis suggested reduced medication use but no impact on health centre visits. Estimated costs of intervention were low, but there was insufficient evidence to judge cost-effectiveness. Realist synthesis findings suggested that facilitated TW is a complex intervention and group interaction contributes to the perception of benefit. It was unclear from the available data who might benefit most from facilitated TW.LimitationDifficulties with developing realist synthesis programme theory meant that mechanisms operating during TW remain obscure.ConclusionsOverall, there is little evidence to support the therapeutic effectiveness or cost-effectiveness of unfacilitated expressive writing interventions in people with LTCs. Further research focused on facilitated TW in people with LTCs could be informative.Study registrationThis study is registered as PROSPERO CRD42012003343.FundingThe National Institute for Health Research Health Technology Assessment programme.

The “realist search”: A systematic scoping review of current practice and reporting

“…We included a total of 35 studies in our sample . Most papers reported a single realist review (27 of 35).…”

“…Most papers reported a single realist review (27 of 35). Fewer papers reported a multicomponent review that include a realist review component (n = 5) or a rapid realist review (n = 3) . We identified different models of searching from examining the overall purpose and scope of the reported searches (Table ).…”

Case management in primary care among frequent users of healthcare services with chronic conditions: protocol of a realist synthesis

“…Throughout this step, included documents about CM interventions will be reread to check if any data were missed that might help refine the theory. 47 A final middle-range theory will be developed. It will comprise multiple demiregularities based on CMO configurations, such as explanations on how and why one type of intervention works in a particular context to achieve an expected outcome among FU with chronic conditions.…”

Use of Recurrence Quantification Analysis to Examine Associations Between Changes in Text Structure Across an Expressive Writing Intervention and Reductions in Distress Symptoms in Women With Breast Cancer

“…Furthermore, they showed a significantly different development in symptoms across time [F (2,106) = 45.792, p = 0.000]. Lastly, it should be noted that all 4 samples had a BDI-symptom level at baseline that was either minimal (0-4) or mild (5)(6)(7), with only the improvers reaching a score of moderate symptoms (8)(9)(10)(11)(12)(13)(14)(15).…”

“…EWI has been widely investigated as a possible intervention to help individuals who have experienced a variety of stressful or traumatic experiences, notably including the diagnosis and treatment of cancer [3][4][5][6]. Results in this literature have been mixed, however, leading to calls for greater research attention to how and for whom EWI is efficacious [5,7].…”