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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Evaluating the effectiveness of psychosocial interventions for individuals with visible differences: a systematic review of the empirical literature

A Bessell and TP Moss.

Review published: 2007.

CRD summary

The authors concluded that there was insufficient data to adequately assess the effectiveness of psychosocial interventions for adults with visible differences and that further research was required. There were limitations to this review, but overall the authors' conclusions reflect the limited evidence presented in the review.

Authors' objectives

To evaluate the effectiveness of psychosocial interventions for adults with visible differences.


MEDLINE, EMBASE, PsychINFO, Social Care Online, Social Sciences Citation Index, Allied and Alternative Medicine, Applied Social Sciences Index and Abstracts, British Nursing Index, Campbell Collaboration, CINAHL, The Cochrane Library, EMB Reviews, Health Management Information Consortium, International Bibliography of Social Sciences, ISI Web of Science conference proceedings, LILACS, National Research Register (UK), OTseeker and the British Library Grey Literature databases were searched to July 2006. References lists of noted papers were scanned for additional publications. Search terms were reported.

Study selection

Studies evaluating the effectiveness of psychosocial interventions for improving psychological symptoms, interpersonal and social functioning, preference, satisfaction and acceptability of treatment in adults with visible differences aged 17 years or older were eligible for inclusion.

Studies of group and individual cognitive behavioural therapy (CBT), group-based person centred therapy, group-based social skills training and support, and self-help materials were included in the review. Duration of intervention varied between studies. Studies of adults with congenital skin conditions, abnormalities due to cancer or scars resulting from injury were included. Outcomes in the included studies were measured using a variety of published scales.

Titles and abstracts were initially screened by one reviewer. Relevant articles were then assessed for inclusion by two reviewers. A team of experts (including academics and experts in the field) verified the final studies selected for inclusion.

Assessment of study quality

Validity was assessed using 24 criteria covering inclusion criteria, randomisation method, concealment of allocation, blinding, comparability at baseline, sample size, attrition, comparability, intention to treat analysis, statistical analysis, outcomes, acceptability of intervention and follow-up. Study designs were categorised into a hierarchy of evidence according to criteria from CRD (2001). Each study type (randomised controlled trials, quasi-experimental, before-and-after, case-series) was assessed using different criteria and rated as no evidence, poor evidence, limited evidence, good evidence and excellent evidence. The authors did not state how many reviewers performed the validity assessment.

Data extraction

Data on effect sizes and changes in outcomes of interest were extracted by one reviewer and checked for accuracy by a second reviewer. A third reviewer made a final check. Disagreements were resolved by discussion.

Methods of synthesis

The studies were combined in a narrative synthesis grouped by type of intervention. Each study was described in the text and additional descriptive information was presented in tables.

Results of the review

Eleven studies (n=535) in 12 papers were included in the review (one randomised controlled trial, five described as experimental design, two described as before-and-after studies and three case series). Methodological validity was reported to be poor or limited for all included studies.

For individuals with visible differences: limited evidence of effectiveness was found to support the use of self-help interventions (one study, n=108) and individual CBT-based interventions (two studies, n=52) and poor evidence was found to support the use of person-centred group counselling interventions (one study, n=47). Poor to no evidence of effectiveness was also found for the use of support group interventions (four studies, n=109). Poor to limited evidence was found to support the use of group social skills training interventions (two studies, n=123) and for group CBT-based interventions (two studies, n=140).

Authors' conclusions

There was insufficient evidence to adequately assess the effectiveness of psychosocial interventions for adults with visible differences. Further research was required.

CRD commentary

Inclusion criteria were defined in terms of interventions, participants and outcomes, but not in terms of study design. Many relevant sources were searched. Search terms were reported, but it is unclear if language restrictions were applied. Some attempts were made to reduce publication bias. More than one reviewer independently selected studies and extracted data, thus reducing the potential for reviewer bias and errors, although it is unclear whether similar steps were taken in the validity assessment. Validity was assessed using specified criteria and results of the assessment were reported for each study in the text. In view of the differences between studies, a narrative synthesis with studies grouped by intervention was appropriate. Characteristics of the included studies were reported in the text and presented in tables. However, results for individual studies were reported without supporting data or levels of statistical significance. This meant it was not possible to verify the findings reported in the review. The authors appropriately considered the limitations and differences across studies. There were limitations to the review, but overall the authors' conclusions reflected the limitations of the evidence presented in the review.

Implications of the review for practice and research

Practice: The authors stated no implications for practice.

Research: The authors stated that further randomised controlled trials and experimental studies of rigorous methodological quality were needed to evaluate the effectiveness of interventions for people with visible differences. Future studies should include intention to treat analyses, report detailed information on attrition, evaluate interventions against control groups as standard, include comprehensive inclusion and exclusion criteria and systematically use standardised outcome measures to analyse effects. Larger sample sizes were required to obtain more robust data. Patient acceptability should be measured and interventions should be compared to assess patient preference. There was also a need for research to evaluate interventions for people in more remote areas.


Not stated.

Bibliographic details

Bessell, A, Moss T P. Evaluating the effectiveness of psychosocial interventions for individuals with visible differences: a systematic review of the empirical literature. Body Image 2007; 4(3): 227-238. [PubMed: 18089269]

Indexing Status

Subject indexing assigned by NLM


Adaptation, Psychological; Adolescent; Adult; Body Image; Burns /psychology; Cicatrix /psychology; Cognitive Therapy; Face; Facial Injuries /psychology; Head and Neck Neoplasms /psychology; Humans; Phobic Disorders /psychology /therapy; Prejudice; Psoriasis /psychology; Psychotherapy, Group; Randomized Controlled Trials as Topic; Self-Help Groups; Skin /injuries; Skin Abnormalities /psychology; Skin Diseases /psychology; Social Desirability; Treatment Outcome; Vitiligo /psychology



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 18089269

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