Does written emotional disclosure improve the psychological and physical health of caregivers? A systematic review and meta-analysis

Rationale: 5.8 million caregivers provide support for the infirm, disabled or elderly in the UK; 1 in 10 adults are caregivers. Caregiving can result in increased depression, anxiety and post traumatic stress. Caregivers suffer worse physical health and premature mortality than non caregivers. Caregivers would benefit from an accessible intervention to improve their health such as written emotional disclosure (WED). This writing therapy involves the disclosure of traumatic experiences. It is thought to facilitate cognitive and emotional processing, reducing physiological stress associated with inhibiting emotions. Previous research shows that WED has beneficial effects on health in a range of populations. This systematic review and meta-analysis examined whether WED improves caregiver psychological and physical health. Methods: Keyword searches in Medline, PsycINFO, Embase, BNI, CINHAL, AMED and Cochrane Library between 1986 and 2015. Inclusion criteria – (1) RCTs or controlled trials (2) investigating the use of WED based on protocol developed by Pennebaker and Beall (3) reported numerical outcome measures (4) participants were caregivers. Outcome measures - depression, anxiety, trauma, burden, somatic symptoms/physical health, general psychological health, stress, health related quality of life (physical health), health related quality of life (mental health), mood, safety. Data was entered into Review Manager software. Summary tables detailing study characteristics were created. Assessments of risk of bias were made and tables compiled, using the Cochrane Collaboration’s tool for assessing risk of bias. Results: Ten trials investigating WED (625 participants) were eligible for inclusion; eight studies (401 participants) had data suitable for meta-analysis. Results from four studies indicated that WED reduces trauma (SMD=-0.46 95% CI -0.82, -0.09). Pooled data from three studies indicated that WED improves general psychological health (SMD= -0.46, 95% CI - 0.86, -0.06). There was no evidence from meta-analysis that WED improves other outcomes – depression, anxiety, somatic symptoms, burden, quality of life. None of the studies reported safety data. Systematic review showed mixed results for stress and mood. Studies were heterogeneous in regards to caregiver age, relationship to the care recipient, follow up period and outcome measures, with high or unclear bias often observed. Conclusions: WED alleviates trauma and improves general psychological health. There was no evidence of benefit for other outcomes. This was the first meta-analysis to examine WED in caregivers and it supported of the efficacy of WED. Previous research has failed to reach consensus regarding which psychological therapies will help improve caregiver wellbeing. A limitation was the poor methodological quality of some included studies. Future RCTs should publish study protocol to deter selective reporting and adopt standardised, validated outcome measures to improve reliability of results. There was some evidence that WED only helped participants with impaired psychological health, for example. This is supported by other literature. Further research should investigate this “ceiling effect” so that WED can be offered to those who are in need and would benefit.