Gastroenterology Unit, Hospital Universitario de la Princesa, Instituto de Investigación, Sanitaria Princesa (IP), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.
Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
Health Technol Assess. 2016 Apr;20(27):vii-xxxvii, 1-367. doi: 10.3310/hta20270.
Writing 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.
Databases, 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).
Four 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 under International 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.
To 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.
From 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 across all of 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.
Difficulties with developing realist synthesis programme theory meant that mechanisms operating during TW remain obscure.
Overall, 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.
This study is registered as PROSPERO CRD42012003343.
The National Institute for Health Research Health Technology Assessment programme.
改善身心健康的写作疗法有多种形式。最具研究性的治疗性写作模型（TW）是未经引导的个体表达性写作（书面情感披露）。引导性写作活动的研究较少。
数据库，包括 MEDLINE、EMBASE、PsycINFO、Linguistics and Language Behaviour Abstracts、Allied and Complementary Medicine Database 和 Cumulative Index to Nursing and Allied Health Literature，从创建到 2013 年 3 月进行了搜索（2015 年 1 月更新）。
四位 TW 从业者提供了专业建议。研究程序由一位审查员进行，并由第二位审查员检查。包括随机对照试验（RCT）和非随机对照比较研究。使用 Cochrane 偏倚风险工具评估质量。未经引导和引导的 TW 研究根据国际疾病分类第十版章节标题分别进行分析。在可能的情况下，使用 RevMan 版本 5.2.6（RevMan 2012，Cochrane 协作组织，北欧 Cochrane 中心，丹麦哥本哈根）进行荟萃分析。从英国国民保健制度的角度估计成本，并准备了三个成本效益案例研究。根据真实主义和元叙事综合：不断发展的标准指南进行真实主义综合。
综述 TW 对长期疾病（LTCs）患者的临床有效性和成本效益，与不写作或其他对照相比，报告任何相关的临床结果。进行真实主义综合，以了解 TW 如何发挥作用以及对谁有效。
从 14658 条独特的引文，审查了 284 篇全文论文，并最终纳入了 64 项研究（59 项 RCT）进行有效性审查。五项研究检查了引导性 TW；这些研究非常异构，存在不明确或高偏倚风险，但表明引导性 TW 干预可能对个体 LTCs 有益。59 项研究检查了未经引导的表达性写作，这些研究的质量存在差异或未报告。总体而言，在以下情况下，很少或没有证据表明任何益处：人类免疫缺陷病毒（六）；乳腺癌（八）；妇科和生殖泌尿系统癌症（五）；心理健康（五）；哮喘（四）；银屑病（三）；慢性疼痛（四）。在炎症性关节炎（六）中，在四项研究的荟萃分析中，疾病严重程度在短期时间内有所降低[n=191，标准化均数差（SMD）-0.61，95%置信区间（CI）-0.96 至-0.26]。对于所有其他 LTCs，要么没有数据，要么数据稀疏，没有或不一致的益处证据。在所有 LTCs 上进行的荟萃分析没有证据表明未经引导的情感写作对短期（n=1563，SMD -0.06，95%CI -0.29 至 0.17，存在大量异质性）或长期（n=778，SMD -0.04 95%CI -0.18 至 0.10，异质性较小）随访的抑郁有任何影响，或对焦虑、生理或基于生物标志物的结果有任何影响。一项研究报告了成本，没有研究报告成本效益，12 项研究报告了资源使用情况；荟萃分析表明药物使用减少，但对健康中心就诊没有影响。干预措施的估计成本较低，但没有足够的证据来判断成本效益。真实主义综合研究结果表明，引导性 TW 是一种复杂的干预措施，群体互动有助于感知益处。目前尚不清楚谁可能最受益于引导性 TW。
发展真实主义综合计划理论的困难意味着 TW 期间运作的机制仍然不清楚。
总体而言，在长期疾病患者中，未经引导的表达性写作干预的治疗有效性或成本效益证据很少。进一步研究针对长期疾病患者的引导性 TW 可能会有所帮助。
本研究已在 PROSPERO CRD42012003343 注册。
英国国家卫生研究院卫生技术评估计划。
