Response to Comment on Young-Hyman et al. Psychosocial Care for People With Diabetes: A Position Statement of the American Diabetes Association. Diabetes Care 2016;39:2126-2140

Online Guided Self-help Cognitive Behavioral Therapy With Exposure to Anxiety and Problem Solving in Type 1 Diabetes Mellitus: Case Study

Background

Type 1 diabetes mellitus (T1DM) is dependent on self-care to avoid short- and long-term complications. There are several problem areas in diabetes that could be addressed by psychological interventions, such as suboptimal problem-solving strategies and fear of hypoglycemia. There is empirical support for a few psychological interventions, most often cognitive behavioral therapy, with various treatment aims. However, these interventions are largely unavailable in regular diabetes health care. Online guided self-help cognitive behavioral therapy could help achieve greater outreach.

Objective

We tested a manualized treatment in the early stage for further development, with the long-term aim to increase access to care. The purpose of this report was to show the potential of this newly developed online intervention by describing 2 illustrative cases.

Methods

An online guided self-help cognitive behavioral therapy protocol featuring problem solving and exposure was developed. The treatment was administered from a secure online platform and lasted for 8 weeks. Case 1 was a male participant. He had a number of diabetes-related complications and was worried about his future. He reported that he had a general idea that he needed to change his lifestyle but found it difficult to get started. Case 2 was a female participant. She had fear of hypoglycemia and unhelpful avoidance behaviors. She kept her blood glucose levels unhealthily high in order to prevent hypoglycemic episodes. Furthermore, she avoided contact with diabetes health care.

Results

The 2 participants showed clinically significant improvements in their most relevant problem areas. In case 1, the participant’s blood glucose levels reduced, and he was able to establish healthy routines, such as increase physical exercise and decrease overeating. In case 2, the participant’s fear of hypoglycemia greatly decreased, and she was able to confront many of her avoided situations and increase necessary visits to her diabetes clinic. Treatment satisfaction was high, and no adverse events were reported.

Conclusions

It is possible to deliver a cognitive behavioral therapy intervention aimed at problem areas in diabetes online. Problem solving appears to help with problems in everyday routines and lifestyle choices. Exposure to aversive stimuli appears to be a plausible intervention specifically aimed at the fear of hypoglycemia. Larger and controlled studies are needed.

Systematic review and meta-analysis of randomized controlled trials of psychological interventions to improve glycaemic control in children and adults with type 1 diabetes

AIM

We conducted a systematic review aggregate and network meta-analysis of psychological interventions for people with type 1 diabetes to assess their effectiveness in improving glycaemic levels.

METHODS

We searched the following databases from 1 January 2003 to 1 July 2018: MEDLINE, CINAHL, PsycINFO, Embase, Cochrane Controlled Trials, Web of Science, clinicaltrials.gov, Dissertation Abstract International. We included randomized controlled trials (RCT) of psychological interventions for children and adults with type 1 diabetes reported in any language. We extracted data on publications, participant characteristics at baseline, intervention and control group, and data for the primary outcome, change in glycaemic control [HbA1c (mmol/mol/%)]. Study authors were contacted for missing data. The review was registered with international prospective register of systematic reviews registration (PROSPERO) CRD42016033619.

RESULTS

Twenty-four adult RCTs and 23 of children with type 1 diabetes were included in the systematic review. In aggregate meta-analysis there was no overall effect of psychological intervention compared with control on HbA1c [adults, nine RCTs, n = 1102, pooled mean difference -0.12, 95% confidence intervals (CI) -0.27 to 0.03, I2 = 29.0%, P = 0.19; children, 20 RCTs, n = 2567, -0.09, 95% CI -0.22 to 0.04, I2 =54.0% P=0.002]. Network meta-analysis suggested that probability and rank-ordering of effectiveness is highest for attention control groups (b = -0.47, 95% CI -0.80 to -0.12) followed by cognitive behavioural therapy (CBT) (-0.26, 95% CI -0.45 to -0.06) compared with usual care for adults.

CONCLUSIONS

Overall psychological interventions for children and adults with type 1 diabetes do not improve glycaemic control. For adults, CBT-based interventions have the potential to be effective.