1. health and fitness

Does therapeutic writing help people with long term conditions?
Systematic review, realist synthesis and economic considerations
Meads C1 Nyssen OP2, Wong G2, Higgins A1, Steed L2, Bourke L2, Ross CA3, Hayman S4, Field V5, Lord J1, Greenhalgh T2, Taylor SJC2
1 Health Economics Research Group, Brunel University 2 Centre for Primary care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of
London 3 Cumbria Partnership NHS Foundation Trust 4 Medical Foundation for the Care of Victims of Torture 5 Freelance experienced therapeutic writing practitioner
Background: Long-term medical conditions (LTCs) cause
reduced health-related quality of life and considerable health
service expenditure. Therapeutic writing (TW) has potential to
improve physical and mental health in people with LTCs, but its
effectiveness is not clear. The aim of this project is to establish
the clinical and cost-effectiveness of therapeutic writing in
LTCs, and to evaluate context and mechanisms by which it
might work, through realist synthesis. Research findings are
compared to the UK clinical experience of therapeutic writing
practitioners.
Systematic review
Results: We included 63 clinical trials and one
observational study. Most were conducted in USA and
assessed adults patients. Studies had up to 507
participants, but ~half included fewer than 50 patients
in each arm. Only five were in facilitated writing, many
used either standard emotional disclosure writing1 or an
adapted version. Other TW types included positive
writing, enhanced meaning writing, song, poetry and
Internet chat forums. Studies reported mainly
psychological, physical and quality of life outcomes, with
172 instruments used and more than 300 different
outcome measures reported. Follow-up was mostly
between 1-3 months. Studies were categorised by
facilitated/ unfacilitated TW then by ICD-10 code. Most
frequently investigated were breast cancer (8 studies)
and HIV (6 studies).
Synthesis: Very few meta-analyses were possible
because of heterogeneity. The forest plot on depressive
symptoms in any LTC up to 17 weeks suggests no
significant difference for TW compared to controls.
Methods: Selection of studies: any comparative study in any language of TW
compared to no writing, waiting list, attention control or placebo writing in
patients with any diagnosed LTCs reporting at least one of the following;
relevant clinical outcomes; quality of life; health service use; psychological,
behavioural or social functioning; adherence or adverse events. Search
strategy: to January 2015 in 22 medical databases (including Medline,
Embase, PsychInfo, The Cochrane Library and Science Citation Index) and for
the realist review further purposive and iterative searches through
snowballing techniques. Data synthesis systematic review: narrative and
tabular with meta-analysis where 3 or more studies reported the same
outcome. Realist review: RAMESES methodological standards were followed
to extract and test middle-range theories about the links between context,
mechanisms and outcomes. Programme theory was developed and refined
through consultation with TW practitioners and from data in included
studies. Extensive consultation with TW practitioners was conducted. De
novo economic modelling was not possible due to lack of information –
costs and resource use were estimated.
Realist review
Two distinct TW models were identified:
• For unfacilitated (individual) TW, the main
mechanisms and contexts were difficult to clarify as
specific theoretically-derived variables were usually
not tested within the studies - unfacilitated TW was
treated like a ‘black box’ . It was unclear as to why
participants would have wanted to do this or what
they would gain from it.
• For the facilitated (group) TW, the mechanisms were
complex, involving the forming of relationships and
the group acting as an audience for personal
narratives. It did not treat TW as a standard, onesize-fits-all intervention but let participants engage in
different ways and at different times with the group
and the writing activity, in a way that suited them.
Economic considerations
No full economic evaluations were found. Nine studies reported on
resource use, covering a wide range of disease areas and
populations. Meta-analysis of health centre visits is shown below:
Reference: 1. Pennebaker J, Beall SK. Confronting a traumatic event: Toward an understanding of inhibition and disease.
Journal of Abnormal Psychology 1986;95(3):274-81
Conclusions: Effectiveness of emotional disclosure TW interventions in LTCs is not so clear as would have been expected from
reading textbooks about this intervention. Most interventions evaluated did not mirror those currently used by professional TW
practitioners in clinical practice. Further research is needed that evaluates interventions employed in clinical settings, using
cluster RCT or stepped wedge designs.
Funding Acknowledgement:
This project was funded by the National Institute for Health Research HTA programme (project number 11/70/01)
Department of Health Disclaimer:
The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health.