Title: Does therapeutic writing help people with long term conditions? Systematic review realist synthesis and economic modelling
Funder: Department of Health (England)

Abstract: ObjectivesOur proposal will follow the key steps involved in establishing whether there are any benefits of therapeutic writing for people with long-term mental and physical conditions by addressing the following questions: 1.What are the different types of therapeutic writing that have been evaluated in comparative studies? What are their defining characteristics? How are they delivered? What underlying theories have been proposed for their effect/s?2.What is the clinical effectiveness of the different types of therapeutic writing for long term health conditions compared to no writing or other suitable comparators? 3.How is heterogeneity in results of empirical studies accounted for in terms of patient and/or contextual factors and what are the mechanisms and moderators responsible for the success failure or partial success of interventions (i.e. what works for whom in what circumstances and why)?4.What is the cost effectiveness of one or more types of therapeutic writing in one or more representative chronic conditions where there is sufficient information on the intervention comparator and outcomes to conduct an economic evaluation.Design We will carry out two interlinked reviews simultaneously: a systematic review of the effectiveness of the different types of therapeutic writing and a realist review of therapeutic writing. The cost effectiveness objectives will be addressed by economic modelling. The effectiveness systematic review will establish if any of the different forms of therapeutic writing are shown to be effective and the realist synthesis by asking “what works for whom in what circumstances?” is well placed to explain heterogeneity in the findings of comparative effectiveness studies. Using the results of the systematic reviews we will estimate cost effectiveness of therapeutic writing if there are sufficient well-powered RCTs with homogenous outcomes in the same disease area or areas. Review strategyEffectiveness review: for some of the therapeutic writing interventions we will include controlled observational studies because of lack of randomised evidence. We will take care to evaluate risk of bias carefully. Studies’ findings will be extracted in duplicate using pre-designed and piloted data extraction forms Missing information will be obtained from investigators if it is crucial to subsequent analysis. The quality of the selected primary RCTs and observational studies will be assessed based on accepted contemporary standards using GRADE methodology. Meta-analyses will be conducted using standard software packages. Separate analyses will be performed on randomised and non-randomised data.Realist review: The realist review will cover the papers in effectiveness review along with any qualitative or mixed-method studies linked to these index papers but published separately. Realist review involves a process of interpretation and judgement: the central task is to identify the mechanisms ( i.e. ‘underlying entities processes or structures which operate in particular contexts to generate outcomes of interest’) by which an intervention might achieve its impact and consider how these mechanisms play out differently with different actors in different contexts. Some people with chronic illness might respond well to a particular therapeutic writing intervention while others might respond better to a different intervention or not respond at all. For the realist review we will begin with an initial ‘approximate’ theory of change and use each document as an opportunity to refine this using the following specific analytic techniques:•juxtaposing (e.g. when one study provides process data which help make sense of outcomes noted in another study)•reconciling (identifying differences which explain apparently contradictory sets of findings) •adjudicating between studies (e.g. in terms of quality of research)•consolidating (producing multi-faceted explanations of success failure and partial success)•situating (this mechanism in context A that one in context B) We will link the two reviews in an overarching narrative synthesis. Research outputThis work will put us into a position to make detailed recommendations for future research and will also be orientated towards directly influencing healthcare policy and practice. Our findings will be communicated to the public and the medical profession using established lines of communication such as peer reviewed journals the publications of the NIHR and patient interest groups such as the Pelvic Pain Support Network. We will also use our established connections with the lay media and work through the Queen Mary University of London and HTA press offices to ensure that the release of findings are accompanied by targeted press releases to all groups with a potential interest in them.


Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL
Health categories: GENERIC HEALTH RELEVANCE