Depressive Symptoms in a Trial Behavioral Family Systems Therapy for Diabetes: A Post Hoc Analysis of Change

Rethinking family-based obesity treatment

Emerging research in paediatric obesity has demonstrated that parental involvement in the weight management process can improve weight outcomes in children. Recent guidelines by the American Academy of Pediatrics note the importance of parent and family involvement in treatment. However, it is currently unknown if including the entire family in obesity treatment can supersede outcomes associated with participation of only one parent. Family Systems Theory (FST) provides the theoretical foundation for examining one's healthy behaviours as they exist within the context of their family, defined by family dynamics. This narrative review aims to reconsider prior definitions of paediatric family-based management using the FST framework to be inclusive of family and household diversity and in doing so, inform research not only within weight management but also other domains of clinical care requiring family support or change. Applying FST to paediatric weight management highlights the link between family dynamics and paediatric obesity, demonstrating the association of dysfunctional family dynamics with more severe obesity. While family-based weight management remains the gold standard for treatment of paediatric obesity, more investigation is needed in expanding family-based interventions to impact entire families and potentially improve outcomes more broadly for overall family health and wellbeing.

Narrowing the Divide: The Role of Telehealth in Type 1 Diabetes Care for Marginalized Communities

Widespread uptake of telehealth in response to the COVID-19 pandemic has highlighted geographic, demographic, and economic disparities in access to virtual care. However, research studies and clinical programs that predate the pandemic demonstrate the potential for telehealth-based interventions to improve access to and outcomes of type 1 diabetes (T1D) care for individuals in geographically or socially marginalized communities. In this expert commentary, we discuss telehealth-based care models that have been successful in improving care for marginalized T1D populations. We also outline the policy changes needed to expand access to such interventions to reduce established disparities in T1D care and promote better health equity among people living with T1D.

Telehealth v. face-to-face provision of care to patients with depression: a systematic review and meta-analysis

Ensuring continuity of care for patients with major depressive disorders poses multiple challenges. We conducted a systematic review and meta-analysis of randomised controlled trials comparing real-time telehealth to face-to-face therapy for individuals with depression. We searched Medline, Embase, and Cochrane Central (to November 2020), conducted a citation analysis (January 2021), and searched clinical trial registries (March 2021). We included randomised controlled trials comparing similar or identical care, delivered via real-time telehealth (phone, video) to face-to-face. Outcomes included: depression severity, quality of life, therapeutic alliance, and care satisfaction. Where data were sufficient, mean differences were calculated. Nine trials (1268 patients) were included. There were no differences between telehealth and face-to-face care for depression severity at post-treatment (SMD -0.04, 95% CI -0.21 to 0.13, p = 0.67) or at other time points, except at 9 months post-treatment (SMD -0.39, 95% CI -0.75 to -0.02, p = 0.04). One trial reported no differences in quality-of-life scores at 3- or 12-months post-treatment. One trial found no differences in therapeutic alliance at weeks 4 and 14 of treatment. There were no differences in treatment satisfaction between telehealth and face-to-face immediately post-treatment (SMD -0.14, 95% CI -0.56 to 0.28, p = 0.51) or at 3 or 12-months. Evidence suggests that for patients with depression or depression symptoms, the provision of care via telehealth may be a viable alternative to the provision of care face-to-face. However, additional trials are needed with longer follow-up, conducted in a wider range of settings, and with younger patients.

Mechanisms of Change in Digital Health Interventions for Mental Disorders in Youth: Systematic Review

Background

Digital health interventions (DHIs) are efficacious for several mental disorders in youth; however, integrated, evidence-based knowledge about the mechanisms of change in these interventions is lacking.

Objective

This systematic review aims to comprehensively evaluate studies on mediators and mechanisms of change in different DHIs for common mental disorders in children and adolescents.

Methods

A systematic literature search of the electronic databases Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and PsycINFO was conducted, complemented by backward and forward searches. Two independent reviewers selected studies for inclusion, extracted the data, and rated the methodological quality of eligible studies (ie, risk of bias and 8 quality criteria for process research).

Results

A total of 25 studies that have evaluated 39 potential mediators were included in this review. Cognitive mediators were the largest group of examined intervening variables, followed by a broad range of emotional and affective, interpersonal, parenting behavior, and other mediators. The mediator categories with the highest percentages of significant intervening variables were the groups of affective mediators (4/4, 100%) and combined cognitive mediators (13/19, 68%). Although more than three-quarters of the eligible studies met 5 or more quality criteria, causal conclusions have been widely precluded.

Conclusions

The findings of this review might guide the empirically informed advancement of DHIs, contributing to improved intervention outcomes, and the discussion of methodological recommendations for process research might facilitate mediation studies with more pertinent designs, allowing for conclusions with higher causal certainty in the future.

Supporting Teen Problem-Solving (STEPS) 3 year outcomes: Preventing diabetes-specific emotional distress and depressive symptoms in adolescents with type 1 diabetes

OBJECTIVE

This article reports the 3-year outcomes for the Supporting Teen Problem-Solving (STePS) multisite Randomized Control Trial (RCT); reporting the overall impact of the STePS trial, and the differential impact of each arm of the trial (a resilience promoting intervention [PRP T1D] vs. a diabetes education intervention [EI]) on diabetes-specific emotional distress and depressive symptoms.

METHOD

Participants included 264 adolescents with Type 1 diabetes (T1D), ages 14-18, in Chicago and San Francisco. Both intervention arms lasted 4.5 months and assessments were conducted at baseline, postintervention (4.5 months), and 5 follow-up visits (8, 12, 16, 28, and 40 months from baseline). Intervention efficacy was investigated using latent growth curve modeling (LGCM) to analyze the rate and shape of change of outcomes from preintervention across postintervention and follow-up time points.

RESULTS

Mean age of participants was 15.7 years, mean T1D duration was 6.9 years, mean HbA1c at baseline was 9.1%. The sample was diverse with nearly 35% identifying as racial or ethnic minorities, and 60% were female. PRP T1D participants reported significantly lower diabetes distress compared with EI participants, and the effect size increased over time. For the pooled sample, while 40% of youth reported elevated distress at baseline, only 23% reported elevated distress 3 years postintervention. Moreover, PRP T1D participants experienced a significant decline in depressive symptoms from 16 to 40 months postbaseline, while participants in the education arm did not.

CONCLUSIONS

Results from the 3-year outcomes assessment demonstrate the robust effects of PRP T1D in adolescents with declines in distress and depressive symptoms. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Mediators and mechanisms of change in internet- and mobile-based interventions for depression: A systematic review

The efficacy of Internet- and mobile-based interventions (IMIs) for depression in adults is well established. Yet, comprehensive knowledge on the mediators responsible for therapeutic change in these interventions is pending. Therefore, we conducted the first systematic review on mediators in IMIs for depression, investigating mechanisms of change in interventions with different theoretical backgrounds and delivery modes (PROSPERO CRD42019130301). Two independent reviewers screened references from five databases (i.e., Cochrane Library, Embase, MEDLINE/PubMed, PsycINFO and ICTRP), selected studies for inclusion and extracted data from eligible studies. We included 26 RCTs on mediators in IMIs for depression (6820 participants), rated their risk of bias and adherence to methodological quality criteria for psychotherapy process research. Primary studies examined 64 mediators, with cognitive variables (e.g., perceived control, rumination or interpretation bias) being the largest group of both examined (m = 28) and significant mediators (m = 22); followed by a range of other mediators, including mindfulness, acceptance and behavioral activation. Our findings might contribute to the empirically-informed advancement of interventions and mental health care practices, enabling optimized treatment outcomes for patients with depression. Furthermore, we discuss implications for future research and provide methodological recommendations for forthcoming mediation studies with more pertinent designs, allowing for inferences with higher causal specificity.

Impact and Cost-Effectiveness of Integrated Psychology Services in a Pediatric Endocrinology Clinic

Including psychology services in pediatric endocrinology clinics may improve patients' adherence to diabetes management behaviors, and, subsequently, glycemic control; however, an evaluation of the impact and cost-effectiveness of this integration is needed. The change in HbA1c and cost-effectiveness of integrated psychology services, from the hospital and insurance provider perspectives, were evaluated using a linear effects model and Incremental Cost-Effectiveness Ratios (ICERs). Data from 378 patients with T1D (50% female; 65% Caucasian; M age = 12.0 years) were obtained via medical chart review (2241 appointments). Patients demonstrated significant improvements in HbA1c following clinic visits in which they met with psychology (b = - 0.16, p = 0.006). A larger proportion of the distribution of ICER values fall below the $1000/1% HbA1c threshold from both the insurance (89%) and hospital (94%) perspectives. These results indicate that providing integrated psychology services in the endocrinology clinic is highly beneficial from the patient, hospital, and insurance provider perspectives.

Psychological therapies 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, sometimes directly related to their illness or medical care (e.g. health-related anxiety). There is limited evidence regarding the effectiveness of psychological therapies for treating anxiety and depression in this population. Therapies designed for children and adolescents without medical issues may or may not be appropriate for use with those who have long-term physical conditions.

OBJECTIVES

This review was undertaken to assess the effectiveness and acceptability of psychological therapies in comparison with controls (treatment-as-usual, waiting list, attention placebo, psychological placebo, or non-psychological treatment) for treating anxiety and depression in children and adolescents with long-term physical conditions.

SEARCH METHODS

We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 27 September 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to May 2016). In addition we searched the Web of Science (Core Collection) (12 October 2018) and conducted a cited reference search for reports of all included trials. We handsearched relevant conference proceedings, reference lists of included articles, and grey literature.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-randomised trials and cross-over trials of psychological therapies for treating anxiety or depression in children with long-term physical conditions were included.

DATA COLLECTION AND ANALYSIS

Abstracts and complete articles were independently reviewed by two authors. Discrepancies were addressed by a third author. Odds ratio (OR) was used for comparing dichotomous data and standardised mean differences (SMD) for comparing continuous data. Meta-analysis was undertaken when treatments, participants, and the underlying clinical question were similar. Otherwise, narrative analysis of data was undertaken.

MAIN RESULTS

Twenty-eight RCTs and one cross-over trial with 1349 participants were included in the review. Most participants were recruited from community settings and hospital clinics in high-income countries. For the primary outcome of treatment efficacy, short-term depression (versus any control), there was low-quality evidence from 16 trials involving 1121 participants suggesting that psychological therapies may be more effective than control therapies (SMD -0.31, 95% CI -0.59 to -0.03; I² = 79%). For the primary outcome of treatment efficacy, short-term anxiety (versus any control), there was inadequate evidence of moderate-quality from 13 studies involving 578 participants to determine whether psychological therapies were more effective than control conditions (SMD -0.26, CI -0.59 to 0.07, I² = 72%). Planned sensitivity analyses could not be undertaken for risk of bias due to the small number of trials that rated high for each domain. Additional sensitivity analysis demonstrated that psychological interventions specifically designed to reduce anxiety or depression were more effective than psychological therapies designed to improve other symptoms or general coping. There was some suggestion from subgroup analyses that they type of intervention (Chi² = 14.75, df = 5 (P = 0.01), I² = 66.1%), the severity of depression (Chi² = 23.29, df = 4 (P = 0.0001), I² = 82.8%) and the type of long-term physical condition (Chi² = 10.55, df = 4 (P = 0.03), I² = 62.1%) may have an impact on the overall treatment effect.There was qualitative (reported), but not quantitative evidence confirming the acceptability of selected psychological therapies for anxiety and depression. There was low-quality evidence that psychological therapies were more effective than control conditions in improving quality of life (SMD 1.13, CI 0.44 to 1.82, I² = 89%) and symptoms of long-term physical conditions (SMD -0.34, CI -0.6 to -0.06, I² = 70%), but only in the short term. There was inadequate low-quality evidence to determine whether psychological therapies were more effective than control conditions at improving functioning in either the short term or long term. No trials of therapies for addressing health-related anxiety were identified and only two trials reported adverse effects; these were unrelated to psychological therapies. Overall, the evidence was of low to moderate quality, results were heterogeneous, and only one trial had an available protocol.

AUTHORS' CONCLUSIONS

A limited number of trials of variable quality have been undertaken to assess whether psychological therapies are effective for treating anxiety and depression in children and adolescents with long-term physical conditions. According to the available evidence, therapies specifically designed to treat anxiety or depression (especially those based on principles of cognitive behaviour therapy (CBT)) may be more likely to work in children and adolescents who have mild to moderate levels of symptoms of these disorders, at least in the short term. There is a dearth of therapies specifically designed to treat health-related anxiety in this age group.

Family Functioning and Childhood Obesity Treatment: A Family Systems Theory-Informed Approach

Childhood obesity recommendations advise providers to use family-based care for the treatment of youth and adolescent obesity. Family-based care, defined as the inclusion of a caregiver and a youth, is commonly conducted through behavioral interventions that target the dietary and physical activity behaviors of the attending parent-youth dyads. However, focusing on behaviors isolated to the parent and youth neglects the rest of the family members, and the larger rules, routines, communication, and dynamics in the family. Family-based interventions grounded in family systems theory (FST) target family dynamics to influence weight-related behaviors through higher-level changes in the family. The utility of using FST in childhood obesity treatment has not been extensively conceptualized or applied. Few outcome studies have reported on variables representative of FST, and even fewer FST interventions have been conducted. Because of the lack of detail on the application of FST to childhood obesity treatment, providers are left with little clarity on how to use FST in clinical encounters. We provide the background and evidence for use of FST, detail how families organize around weight-related behaviors that contribute to obesity, and on the basis of their organization, what type of treatment might be beneficial, FST-informed or family-based behavioral interventions. Finally, a suggested family-based clinical algorithm is provided detailing the use of FST through assessment, intervention, and follow-up that can be refined over time by providers and researchers committed to viewing obesity in the context of the family and family dynamics.

Preventing Diabetes Distress in Adolescents With Type 1 Diabetes: Results 1 Year After Participation in the STePS Program

OBJECTIVE

The aim is to report 1-year outcomes of the Supporting Teens Problem Solving (STePS) study, a randomized controlled trial comparing a distress and depression prevention program with a diabetes education program for adolescents with type 1 diabetes.

RESEARCH DESIGN AND METHODS

With 264 adolescents in two locations (Chicago and San Francisco Bay Area), a randomized controlled trial was conducted comparing the Penn Resilience Program for type 1 diabetes (PRP T1D) to Advanced Diabetes Education. Interventions lasted 4.5 months, and assessments were conducted at baseline, and 4.5, 8, 12, and 16 months. Outcomes of interest were diabetes distress (DD), depressive symptoms, resilience, diabetes self-management, and glycemic control. Latent growth curve modeling was used to test between-group differences over time.

RESULTS

Results indicate that there was acceptable randomization and exposure to interventions, and that exposure to PRP T1D was associated with substantial reductions in DD. In addition, stable glycemic control, resilience characteristics, and depressive symptoms were observed 1 year post-treatment. Diabetes management deteriorated in both groups.

CONCLUSIONS

Intervening before symptoms of psychological distress start can prevent the development of the DD commonly seen in adolescents with type 1 diabetes. The STePS program represents a promising prevention program, and future reports on 2- and 3-year outcomes will explore benefits over longer periods of time.

Family-Based Interventions Targeting Improvements in Health and Family Outcomes of Children and Adolescents with Type 1 Diabetes: a Systematic Review

PURPOSE OF REVIEW

A systematic review was conducted of family-based interventions to improve glycemic control, adherence, and psychosocial outcomes in children and adolescents with type 1 diabetes (T1D). Electronic databases were searched for randomized controlled trials (RCTs) published since the seminal Diabetes Control and Compliance Trial (DCCT). Interventions are summarized and findings reviewed to help guide clinical practice and future research.

RECENT FINDINGS

Twenty-five RCTs are reviewed. The majority of studies (n = 15) focused on interventions targeting both children and adolescents and their caregivers and were delivered in diabetes clinics, outpatient settings, mental health clinics, or participants' homes. Family-based interventions for youth with T1D appear effective at improving diabetes and family-centered outcomes. Additional research is needed to examine the pathways to improvement in glycemic control, as outcomes were mixed. Future research should also involve measures beyond HbA1c given new markers for sustained health improvement and outcomes are being explored.

Distal technologies and type 1 diabetes management

Type 1 diabetes requires intensive self-management to avoid acute and long-term health complications. In the past two decades, substantial advances in technology have enabled more effective and convenient self-management of type 1 diabetes. Although proximal technologies (eg, insulin pumps, continuous glucose monitors, closed-loop and artificial pancreas systems) have been the subject of frequent systematic and narrative reviews, distal technologies have received scant attention. Distal technologies refer to electronic systems designed to provide a service remotely and include heterogeneous systems such as telehealth, mobile health applications, game-based support, social platforms, and patient portals. In this Review, we summarise the empirical literature to provide current information about the effectiveness of available distal technologies to improve type 1 diabetes management. We also discuss privacy, ethics, and regulatory considerations, issues of global adoption, knowledge gaps in distal technology, and recommendations for future directions.

Videoconferencing for Teens With Diabetes: Family Matters

BACKGROUND

Adolescence is a developmental period associated with increased difficulty managing diabetes. During adolescence family functioning, including miscarried helping, family conflict, and acceptance of illness, is an important predictor of adherence to treatment recommendations. Multiple barriers exist to receiving behavioral health interventions to address suboptimal adherence. We hypothesized that behavioral family systems therapy-diabetes (BFST-D) delivered via telehealth would yield changes in family functioning that were not significantly different than changes in clinic-based treatment. Furthermore, that BFST-D would significantly improve overall family functioning.

METHODS

Ninety adolescent participants and their parents were randomized to receive BFST-D via telehealth or traditional (Clinic) treatment conditions. Repeated measures ANOVAs were used to assess changes in mean scores across pre, post, and follow-up assessments. Mediation analyses were conducted using methods outlined by Sobel and were confirmed by bootstrapping.

RESULTS

Changes in miscarried helping, family conflict and adjustment to illness were not significantly different across groups. Overall, clinically significant improvements were identified in youth- and parent-reported miscarried helping, family conflict, and acceptance of illness. Reductions in family conflict mediated the relationship between changes in miscarried helping and acceptance of illness. In addition, improvements in family functioning were associated with changes in adherence and glycemic control.

CONCLUSIONS

Results provide strong support for BFST-D (and similar interventions) delivered via telehealth as yielding outcomes no different than clinic-based treatment. In addition, further support was provided for the effectiveness of BFST-D.