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Psychotherapy
For those in the diabetic and depressed population, the treatment options without pharmacological intervention usually lean towards the use of cognitive behavioural therapy (CBT) in an effort to decrease the depressive symptoms and improve glycaemic control. Many studies have been conducted in order to determine the effectiveness of CBT in the treatment of DM related depression, and to ascertain whether the solution is cost effective.
CBT is the name given to a series of discussions with a patient that explore the thoughts they are experiencing, with specific emphasis on the negative and positive thoughts they have regarding their condition (74). CBT does not, however, focus only on thoughts; it also explores the patient’s physical reactions to thoughts, and the environment that the patient is in. The idea of CBT is to manage the patient’s emotional response to their condition in order to reduce depressive symptoms (74).
Trials investigating the effects of CBT on glycaemic control and depressive symptoms in depressed diabetic patients have had fairly mixed results. An early prominent study by Lustman et al. was conducted in this area, and found that at follow-up 70% of depressed diabetic patients in the CBT group achieved remission compared to only 33.3% in the control (75). Glycaemic control was also better in the CBT group; glycated haemoglobin (GHb) levels decreased by 0.7% in the CBT group, whereas they increased by 0.9% in the control. A possible association was also found between depression and glycaemic control. The experiment was well-planned, with confounding factors accounted for, and only included patients who were diagnosed with depression. However, the sample size for the Lustman study was quite small (with 51 participants) and the follow-up period was only 6 months, raising the question of whether the positive results would have been sustained (especially as the percentage of patients with depression in remission decreased from post-treatment to follow-up).
The results from other studies have been varied. A randomized controlled trial by Penckofer et al. tested the efficacy of group CBT and found that within a group of 74 women, there was a lasting change in depression for the CBT group (76). Conversely, there was no indication that CBT was more effective in decreasing HbA1c over time than the control. On the other hand, a study by Snoek et al. (77) comparing CBT to blood glucose awareness training (BGAT) found a significant decrease in HbA1c in the CBT group, and a non-significant reduction of depression in both groups, raising the question of why glycaemic control was superior in the intervention group, despite no difference between the two in psychological outcome.
An interesting point made in Lustman et al’s study, however, was that adherence to self-monitoring of glucose actually declined in the CBT group (75). In response to the inconsistent findings of other trials in the improvement of glycaemic control, a study was conducted by Safren et al. (78) which tested an integrative treatment of CBT for adherence and depression (CBT-AD) in type 2 DM. Unsurprisingly, this proved much more successful in improving adherence to glucose monitoring, with the CBT-AD achieving 30.2% points higher than the control group, even though this declined to 16.9% points after a 4 month follow-up.
A randomised controlled trial by N C W Van der Ven et al (79) looked at adult type 1 DM patients with prolonged poor glycaemic control. They found results similar to Lustman et al, which showed that CBT was of some benefit when measuring glycaemic control using HbAC1 as an indicator (75). Additionally, it found that along with depressive symptoms being reduced in patients receiving CBT, there was an increase in DM management self-efficacy from 71.6 to 74.3 using the confidence in DM self-care scale.
Unlike the other studies, in which the education level of the intervention and control groups were relatively equal, a study by Bosma et al. (80) examined patients with either type 2 DM or COPD to see whether the benefits of self-management intervention (including CBT) would differ across education levels. Contrary to their hypothesis, it was found that the only group who showed a significant improvement (a 50% or greater reduction in depression compared to baseline) was the intervention group for those with the highest level of education. Despite having a mix of COPD and DM patients, stratification (dividing COPD and DM patients and choosing equal numbers of each strata at random) was utilised to ensure an equal spread of patients with both underlying diseases in all groups. Analysis showed that findings did not differ significantly by disease or severity of disease.
A study by Lamers et al (81) also found that those of a higher education level are more likely to benefit from CBT; over 9 months, only those of a high education level showed a statistically significant (P=0.03) reduction in both emotional distress and symptom distress. However, the study concluded that nurse administered CBT had limited effects on diabetic specific quality of life, despite the fact that it is potentially beneficial in glycaemic control.
From reviewing the literature on the subject there is little evidence to prove that CBT affects diabetic control in all patients with DM. However there is potential for CBT to be used as a first line prophylactic intervention by GPs or mental health professionals, in order to prevent deterioration in glycaemic control in diabetic patients with depression. The use of CBT to decrease depressive symptoms in diabetic patients and increase their quality of life is a topic that may require more research. Using CBT as a prophylactic measure in diabetic patients with depression may be appropriate and cost effective, as it could reduce admissions for depression and events from these co-morbidities.
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