A mobile phone and web-based intervention for improving mental well-being in young people with type 1 diabetes: design of a randomized controlled trial

Self-management, self-care, and self-help in adolescents with emotional problems: a scoping review

This study aimed to review the existing published and grey literature describing the concepts of self-management, self-care, and self-help, and to capture strategies or techniques related to these concepts, for adolescents with emotional problems. Emotional problems are rising amongst adolescents, yet timely access to specialist mental health treatment is limited to those with greater severity of mental health difficulties. Self-management, self-care, and self-help strategies may be used by adolescents with emotional problems both in terms of those waiting for treatment and to prevent relapse. Given the overlap in existing definitions and the lack of clarity around these concepts in an adolescent mental health context, a scoping review of the literature is warranted to provide clarity. Eligible studies were those involving adolescents aged 10 to 19 years with symptoms of emotional problems. Studies referenced self-management, self-care, or self-help, not involving a professional, in this population. Quantitative, qualitative, economic, and mixed methods studies, as well as systematic, scoping, and literature reviews, from 2000 onwards and in the English language, were eligible for inclusion. A systematic search was conducted of both published and grey literature. Databases searched included PsycINFO, Medline, Embase, Web of Science, and CINAHL Plus. Mednar was also searched for unpublished studies and grey literature. Tables  of themes, terms, and associated strategies are presented alongside a thematic analysis of the results. 62 articles were included. These were 20 quantitative studies, 14 systematic reviews, 10 qualitative studies, five review papers, four book chapters, four mixed methods studies, two dissertations, two meta-analyses and one scoping review and systematic review. Most of the included articles referenced self-help (n = 51), followed by self-management (n = 17) and self-care (n = 6). A total of 12 themes were identified from a reflexive thematic analysis of descriptions (and associated strategies) of self-management, self-help, or self-care in included texts. This scoping review provides clarity on the similarities and differences between how these concepts are discussed, and the strategies which are associated with each of these concepts in the relevant literature. Implications for policy and intervention development for adolescents' self-management, self-help, and self-care of their mental health are discussed. There is considerable overlap in both the ways in which these concepts are described, and the strategies or approaches proposed in relation to them, supporting previous research suggesting these strategies should be grouped under a single term, such as "self or community approaches." More research is needed for self-management, self-help, and self-care amongst marginalized groups as these adolescents may have the highest unmet need for mental health support.

Internet-based cognitive-behavioral therapy is effective in reducing depressive symptomatology in type 1 diabetes: results of a randomized controlled trial

Objective

Depression in people with diabetes is associated with poorer health outcomes. Although web programs integrating cognitive-behavioral therapy with diabetes education have shown good results, no similar approach has been implemented in Spain. This aim of this study was to administer an Internet-based cognitive-behavioral therapy program (CBT) for the treatment of mild-moderate depressive symptomatology in individuals with type 1 diabetes (WEB_TDDI1 study) and evaluate the efficacy of this program.

Research design and methods

A pre-post randomized controlled study was conducted. The sample comprised 65 people with type 1 diabetes and mild-moderate depressive symptoms: 35 treatment group (TG) and 30 control group (CG). The following effects of the nine-session program were analyzed: depression (Beck Depression Inventory Fast Screen, BDI-FS), metabolic variables (glycosilated hemoglobin, HbA1c), and other psychological variables including anxiety (State Trait Anxiety Inventory, STAI), fear of hypoglycemia (Fear of Hypoglycemia Questionnaire, FH-15), distress (Diabetes Distress Questionnaire (DDS), quality of life (Diabetes Quality of Life Questionnaire, DQOL),and treatment adherence (Diabetes Self-Care Inventory-Revised questionnaire, SCI-R).

Results

At the end of the treatment program, only 28 people were evaluated (TG=8; CG=20). However, a significant reduction was found in both groups in BDI-FS and STAI-T scores, which was significantly greater in the TG. Significant improvements were also found in the TG in DQOL, FH-15, DDS and SCI-R scores. The percentage change in these variables was also statistically significant in the TG versus the CG. However, no significant results were found in HbA1c.

Conclusions

The Internet-based cognitive-behavioral therapy program for the treatment of mild-moderate depressive symptomatology in people with type 1 diabetes (WEB_TDDI1 study) is effective in reducing depressive symptomatology in the sample that completed the study. Positive results are also produced in other variables associated with depression in this population such as diabetes-related distress, trait anxiety, fear of hypoglycemia, quality of life, and adherence to diabetes treatment. Although new studies would be necessary to support the results of this platform, the results obtained are positive and support the use of this platform as an appropriate treatment for this population.

Clinical trial registration

ClinicalTrials.gov; identifier NCT03473704.

Internet-based Cognitive-behavioral therapy (CBT) for depressive symptomatology in individuals with type 1 diabetes (WEB_TDDI1 study): A randomized controlled trial protocol

Background

Professionals need adequate tools to help patients with diabetes and depression. Although web programs integrating cognitive-behavioral therapy with diabetes education have shown good results, no similar approach has been performed as yet in Spain. The objective is to develop an Internet-based program for the treatment of mild-moderate depressive symptomatology in individuals with type 1 diabetes (WEB_TDDI1 study) based on Cognitive-behavioral therapy (CBT) and assess its results.

Methods

A 2-arm randomized controlled trial will be conducted. Adults with type 1 diabetes and mild-moderate depressive symptoms will be screened to participate in the study and randomly assigned to either the treatment group (TG) that will use a Web-based application for a specific 9-week intervention in depression and type 1 diabetes or the control group (CG) that will be on the waiting list during that time.

Results

Data on the primary variable (depressive symptoms) and secondary variables (treatment-related distress, anxiety, fear of hypoglycemia, quality of life, treatment adherence, coping strategies and glycemic control) will be collected from the TG at the beginning/baseline, at the end of treatment and at 3, 6 and 12 months after treatment. The CG will be assessed at the beginning and at the end of the TG intervention. On completion of the program by the TG, the treatment will then be carried out in the CG.

Conclusions

The new web application developed is expected to be effective for the treatment of mild-moderate depressive symptoms in adults with type 1 diabetes, reducing depressive symptoms and improving the rest of the analyzed variables.

Trial registration

Registry: NCT03473704 (March 21, 2018); ClinicalTrials.gov.

Diabetes-Related Stigma among Adolescents: Emotional Self-Efficacy, Aggressiveness, Self-Care, and Barriers to Treatment Compliance

Recent studies indicate that over 60% of adolescents with type 1 diabetes (T1D) experience diabetes-related stigma (DRS). DRS may affect their emotional self-efficacy (ESE), behavior, and self-care while increasing barriers to comply with physical and mental health treatment. We examined differences in ESE, aggressiveness, self-care, and barriers to comply with treatment among 51 T1D youths (aged 12-17 years) with (G1; n = 35) and without (G2; n = 16) any history of DRS enrolled in a depression treatment study. Using a MANOVA followed by individual univariate analyses, we compared groups in continuous variables, and to conduct comparisons in categorical variables, we used Chi-square tests. MANOVA results were significant, F(5, 45) = 3.20, p = .015. G1 reported lower scores than G2 on ESE, perception of the potential therapeutic impact of group sessions, and family support to comply with insulin treatment. G1 caregivers perceived their offspring as more aggressive and affected by barriers to treatment adherence than their counterparts. G1 members showed a higher proportion of cases with body mass index problems, non-compliance with their meal plan, and multiple episodes of hypoglycemia. Compared to G2, a lower percentage of adolescents in G1 met the recommended glycemic control levels. Our findings support the relationship of DRS with a lower ESE, more behavioral problems, difficulties in food-related self-care, and more barriers to comply with the treatment of diabetes and emotional problems in adolescents. They suggest the need for large-scale education to prevent DRS and psychosocial interventions to combat its impact in adolescents.

E-Health interventions for anxiety and depression in children and adolescents with long-term physical conditions

BACKGROUND

Long-term physical conditions affect 10% to 12% of children and adolescents worldwide; these individuals are at greater risk of developing psychological problems, particularly anxiety and depression. Access to face-to-face treatment for such problems is often limited, and available interventions usually have not been tested with this population. As technology improves, e-health interventions (delivered via digital means, such as computers and smart phones and ranging from simple text-based programmes through to multimedia and interactive programmes, serious games, virtual reality and biofeedback programmes) offer a potential solution to address the psychological needs of this group of young people.

OBJECTIVES

To assess the effectiveness of e-health interventions in comparison with attention placebos, psychological placebos, treatment as usual, waiting-list controls, or non-psychological treatments for treating anxiety and depression in children and adolescents with long-term physical conditions.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Group's Controlled Trials Register (CCMDTR to May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 8, 2017), Web of Science (1900 - 18 August 2016, updated 31 August 2017) and Ovid MEDLINE, Embase, PsycINFO (cross-search 2016 to 18 Aug 2017). We hand-searched relevant conference proceedings, reference lists of included articles, and the grey literature to May 2016. We also searched international trial registries to identify unpublished or ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-randomised trials, and cross-over trials of e-health interventions for treating any type of long-term physical condition in children and adolescents (aged 0 to 18 years), and that measured changes in symptoms or diagnoses of anxiety, depression, or subthreshold depression. We defined long-term physical conditions as those that were more than three-months' duration. We assessed symptoms of anxiety and depression using patient- or clinician-administered validated rating scales based on DSM III, IV or 5 (American Psychological Association 2013), or ICD 9 or 10 criteria (World Health Organization 1992). Formal depressive and anxiety disorders were diagnosed using structured clinical interviews. Attention placebo, treatment as usual, waiting list, psychological placebo, and other non-psychological therapies were eligible comparators.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed titles, abstracts, and full-text articles; discrepancies were resolved through discussion or addressed by a third author. When available, we used odds ratio (OR) to compare dichotomous data and standardised mean differences (SMD) to analyse continuous data, both with 95% confidence intervals (CI). We undertook meta-analysis when treatments, participants, and the underlying clinical question were adequately similar. Otherwise, we undertook a narrative analysis.

MAIN RESULTS

We included five trials of three interventions (Breathe Easier Online, Web-MAP, and multimodal cognitive behavioural therapy (CBT)), which included 463 participants aged 10 to 18 years. Each trial contributed to at least one meta-analysis. Trials involved children and adolescents with long-term physical conditions, such as chronic headache (migraine, tension headache, and others), chronic pain conditions (abdominal, musculoskeletal, and others), chronic respiratory illness (asthma, cystic fibrosis, and others), and symptoms of anxiety or depression. Participants were recruited from community settings and hospital clinics in high income countries.For the primary outcome of change in depression symptoms versus any control, there was very low-quality evidence meaning that it could not be determined whether e-health interventions were clearly better than any comparator (SMD -0.06, 95% CI -0.35 to 0.23; five RCTs, 441 participants). For the primary outcome of change in anxiety symptoms versus any comparator, there was very low-quality evidence meaning that it could not be determined whether e-health interventions were clearly better than any comparator (SMD -0.07, 95% CI -0.29 to 0.14; two RCTs, 324 participants). For the primary outcome of treatment acceptability, there was very low-quality evidence that e-health interventions were less acceptable than any comparator (SMD 0.46, 95% CI 0.23 to 0.69; two RCTs, 304 participants).For the secondary outcome of quality of life, there was very low-quality evidence meaning that it could not be determined whether e-health interventions were clearly better than any comparator (SMD -0.83, 95% CI -1.53 to -0.12; one RCT, 34 participants). For the secondary outcome of functioning, there was very low-quality evidence meaning that it could not be determined whether e-health interventions were clearly better than any comparator (SMD -0.08, 95% CI -0.33 to 0.18; three RCTs, 368 participants). For the secondary outcome of status of long-term physical condition, there was very low-quality evidence meaning that it could not be determined whether e-health interventions were clearly better than any comparator (SMD 0.06, 95% CI -0.12 to 0.24; five RCTs, 463 participants).The risk of selection bias was considered low in most trials. However, the risk of bias due to inadequate blinding of participants or outcome assessors was considered unclear or high in all trials. Only one study had a published protocol; two trials had incomplete outcome data. All trials were conducted by the intervention developers, introducing another possible bias. No adverse effects were reported by any authors.

AUTHORS' CONCLUSIONS

At present, the field of e-health interventions for the treatment of anxiety or depression in children and adolescents with long-term physical conditions is limited to five low quality trials. The very low-quality of the evidence means the effects of e-health interventions are uncertain at this time, especially in children aged under 10 years.Although it is too early to recommend e-health interventions for this clinical population, given their growing number, and the global improvement in access to technology, there appears to be room for the development and evaluation of acceptable and effective technologically-based treatments to suit children and adolescents with long-term physical conditions.

Contribution of mobile health applications to self-management by consumers: review of published evidence

Objective The aim of the present study was to review the contribution of mobile health applications ('apps') to consumers' self-management of chronic health conditions, and the potential for this practice to inform health policy, procedures and guidelines. Methods A search was performed on the MEDLINE, Cochrane Library, ProQuest and Global Health (Ovid) databases using the search terms 'mobile app*', 'self-care', 'self-monitoring', 'trial', 'intervention*' and various medical conditions. The search was supplemented with manual location of emerging literature and government reports. Mapping review methods identified relevant titles and abstracts, followed by review of content to determine extant research, reports addressing the key questions, and gaps suggesting areas for future research. Available studies were organised by disease state, and presented in a narrative analysis. Results Four studies describing the results of clinical trials were identified from Canada, England, Taiwan and Australia; all but the Australian study used custom-made apps. The available studies examined the effect of apps in health monitoring, reporting positive but not robust findings. Australian public policy and government reports acknowledge and support self-management, but do not address the potential contribution of mobile interventions. Conclusions There are limited controlled trials testing the contribution of health apps to consumers' self-management. Further evidence in this field is required to inform health policy and practice relating to self-management. What is known about the topic? Australian health policy encourages self-care by health consumers to reduce expenditure in health services. A fundamental component of self-care in chronic health conditions is self-monitoring, which can be used to assess progress towards treatment goals, as well as signs and symptoms of disease exacerbation. An abundance of mobile health apps is available for self-monitoring. What does this study add? A limited number of randomised control trials have assessed the clinical impact of health apps for self-monitoring. The body of evidence relating to current and long-term clinical impact is developing. Despite endorsing self-care, Australian health policy does not address the use and potential contribution of mobile health apps to health care. What are the implications? Widespread and sustained use of validated mobile health apps for chronic health conditions should have potential to improve consumer independence, confidence and burden on health services in the longer term. However, a significant body of scientific evidence has not yet been established; this is mirrored in the lack of acknowledgement of health apps in Australian health policy referring to consumers' self-management.

"They called me a terrorist": Social and Internalized Stigma in Latino Youth with Type 1 Diabetes

Background

Diabetes-related stigma (DRS) globally affects patients' lives. Over a third of adolescents with type 1 diabetes (T1D) in Puerto Rico reported concerns of others knowing about their diabetes and about being different.

Participants and Procedures

We examined DRS among 65 T1D Latino youth (aged 12-17). During a depression-treatment study screening, they answered open-ended questions about diabetes-related concerns/difficulties and issues bothering them while interacting with peers, family, and healthcare professionals because of T1D. Using content analysis, we classified responses into Social Stigma (SS), Internalized Stigma (IS), and No Stigma. Four SS and IS sub-categories were developed.

Results

After coding, inter-rater reliability (Cohen's kappa) ranged from .73 to .1.00 (p≤.001). Forty-four youth (67.69%) reported at least one DRS verbalization, and 25 reported more than one. Both SS and IS were identified in 32 (49.23%) adolescents. Among SS experiences were: "they call me a junkie [because of insulin shots]"; "they call me a terrorist [because of insulin pump]". IS verbalizations included: "I've never wanted to accept that I have T1D, so I don't practice good self-care"; "at times I do not feel the same as others". We found more stigma-related verbalizations among those from urban zones or larger families. DRS was related to increased depressive symptoms and risk of a depressive disorder. Peers were the main source of SS.

Conclusion

DRS was common, pervasive, and linked to depression. This study innovatively examines DRS in an exclusively T1D Latino and adolescent sample. Understanding its extent and nature is essential for developing interventions to address DRS.

Writing for Health: Rationale and Protocol for a Randomized Controlled Trial of Internet-Based Benefit-Finding Writing for Adults With Type 1 or Type 2 Diabetes

Background

Diabetes mellitus is Australia’s fastest growing chronic disease, and has high comorbidity with depression. Both subthreshold depression and diabetes distress are common amongst people with type 1 or type 2 diabetes, and are associated with poorer diabetes self-care. A need exists for low-intensity self-help interventions for large numbers of people with diabetes and diabetes distress or subthreshold depression, as part of a stepped-care approach to meeting the psychological needs of people with diabetes. Benefit-finding writing is a very brief intervention that involves writing about any positive thoughts and feelings about a stressful experience, such as an illness. Benefit-finding writing has been associated with increases in positive affect and positive growth, and has demonstrated promising results in trials amongst other clinical populations. However, benefit-finding writing has not yet been examined in people with diabetes.

Objective

The aim of this randomized controlled trial (RCT) is to evaluate the efficacy of an Internet-based benefit-finding writing (iBFW) intervention for adults with type 1 or type 2 diabetes (compared to a control writing condition) for reducing diabetes distress and increasing benefit-finding in diabetes, and also improving a range of secondary outcomes.

Methods

A two-arm RCT will be conducted, using the online program Writing for Health. Adults with type 1 or type 2 diabetes living in Australia will be recruited using diabetes-related publications and websites, and through advertisements in diabetes services and general practitioners’ offices. Potential participants will be referred to the study-specific website for participant information and screening. All data will be collected online. Participants will be randomized to either iBFW about diabetes, or a control writing condition of writing about use-of-time. Both conditions involve three daily sessions (once per day for three consecutive days) of 15-minute online writing exercises. Outcome measures will be administered online at baseline, one-month, and three-month follow-ups.

Results

This trial is currently underway. The primary outcomes will be diabetes distress and benefit-finding in diabetes. Secondary outcomes will be depression, anxiety, diabetes self-care, perceived health, and health care utilization. We aim to recruit 104 participants. All stages of the study will be conducted online using the Writing for Health program. Group differences will be analyzed on an intention-to-treat basis using mixed models repeated measures. Linguistic analyses of the writing exercise scripts, and examinations of the immediate emotional responses to the writing exercises, will also be undertaken.

Conclusions

This RCT will be the first study to examine iBFW for adults with type 1 or type 2 diabetes. If iBFW is found to be efficacious in reducing diabetes distress and improving diabetes self-care and other outcomes, iBFW may offer the potential to be a low-cost, easily accessible self-help intervention to improve the wellbeing of adults with diabetes.

Trial Registration

Australia and New Zealand Clinical Trials Registry (ACTRN12615000241538)

Mobile Phone and Web-based Cognitive Behavior Therapy for Depressive Symptoms and Mental Health Comorbidities in People Living With Diabetes: Results of a Feasibility Study

BACKGROUND

Depression is often comorbid with diabetes; however, undertreatment of depressive symptoms in people affected is common.

OBJECTIVE

We studied preliminary acceptability and effectiveness of a fully automated, mobile phone, and web-based public health intervention, myCompass, for reducing depressive symptoms and improving mental health comorbidities in people with diabetes.

METHODS

In this single-group feasibility study, 89 volunteers with type 1 (n=34) or type 2 (n=55) diabetes and at least mild depressive symptoms used myCompass for 7 weeks. Web-based measures of depressive and anxious symptoms, functional impairment, diabetes-specific variables, and user satisfaction were completed at baseline, postintervention, and 3-month follow-up.

RESULTS

Retention rates were 54% (n=48) at postintervention and 36% (n=32) at follow-up. Depressive symptoms were significantly improved at postintervention (P<.001; within-group effect size d=1.05), with gains persisting at follow-up. Mental health comorbidities, including anxiety (P<.001), functioning (P<.001), and diabetes-specific distress (P<.001), also showed significant and sustained improvement. Satisfaction with myCompass was high, with convenience and ease of program use, and relevance of program content rated positively by participants.

CONCLUSIONS

The myCompass program shows promise as an acceptable and effective treatment for depression and comorbid mental health problems in people with diabetes. The program is broadly available, free to use, and may benefit patients with diabetes who do not access services and/or wish to manage their mental health themselves. Replication of these findings in a controlled study is warranted.