Web-Based Cognitive Behavior Therapy for Depression in People With Diabetes Mellitus: A Randomized Controlled Trial

Economic Evaluation of a Web Application Implemented in Primary Care for the Treatment of Depression in Patients With Type 2 Diabetes Mellitus: Multicenter Randomized Controlled Trial

BACKGROUND

Depressive disorder and type 2 diabetes mellitus (T2DM) are prevalent in primary care (PC). Pharmacological treatment, despite controversy, is commonly chosen due to resource limitations and difficulties in accessing face-to-face interventions. Depression significantly impacts various aspects of a person's life, affecting adherence to medical prescriptions and glycemic control and leading to future complications and increased health care costs. To address these challenges, information and communication technologies (eg, eHealth) have been introduced, showing promise in improving treatment continuity and accessibility. However, while eHealth programs have demonstrated effectiveness in alleviating depressive symptoms, evidence regarding glycemic control remains inconclusive. This randomized controlled trial aimed to test the efficacy of a low-intensity psychological intervention via a web app for mild-moderate depressive symptoms in individuals with T2DM compared with treatment as usual (TAU) in PC.

OBJECTIVE

This study aimed to analyze the cost-effectiveness and cost-utility of a web-based psychological intervention to treat depressive symptomatology in people with T2DM compared with TAU in a PC setting.

METHODS

A multicenter randomized controlled trial was conducted with 49 patients with T2DM, depressive symptoms of moderate severity, and glycosylated hemoglobin (HbA1c) of 7.47% in PC settings. Patients were randomized to TAU (n=27) or a web-based psychological treatment group (n=22). This web-based treatment consisted of cognitive behavioral therapy, improvement of diabetes self-care behaviors, and mindfulness. Cost-effectiveness analysis for the improvement of depressive symptomatology was conducted based on reductions in 3, 5, or 50 points on the Patient Health Questionnaire-9 (PHQ-9). The efficacy of diabetes control was estimated based on a 0.5% reduction in HbA1c levels. Follow-up was performed at 3 and 6 months. The cost-utility analysis was performed based on quality-adjusted life years.

RESULTS

Efficacy analysis showed that the web-based treatment program was more effective in improving depressive symptoms than TAU but showed only a slight improvement in HbA1c. Incremental cost-effectiveness ratios of 186.76 for a 3-point reduction in PHQ-9 and 206.31 for reductions of 5 and 50 percentage points were obtained. In contrast, the incremental cost-effectiveness ratio for improving HbA1c levels amounted to €1510.90 (€1=US $1.18 in 2018) per participant. The incremental cost-utility ratio resulted in €4119.33 per quality-adjusted life year gained.

CONCLUSIONS

The intervention, using web-based modules incorporating cognitive behavioral therapy tools, diabetes self-care promotion, and mindfulness, effectively reduced depressive symptoms and enhanced glycemic control in patients with T2DM. Notably, it demonstrated clinical efficacy and economic efficiency. This supports the idea that eHealth interventions not only benefit patients clinically but also offer cost-effectiveness for health care systems. The study emphasizes the importance of including specific modules to enhance diabetes self-care behaviors in future web-based psychological interventions, emphasizing personalization and adaptation for this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03426709; https://clinicaltrials.gov/study/NCT03426709.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/S12888-019-2037-3.

Efficacy of a Digital Diabetes Logbook for People With Type 1, Type 2, and Gestational Diabetes: Results From a Multicenter, Open-Label, Parallel-Group, Randomized Controlled Trial

BACKGROUND

In a randomized controlled trial, the efficacy of a digital diabetes diary regarding a reduction of diabetes distress was evaluated.

METHODS

A randomized controlled trial with a 12-week follow-up was conducted in 41 study sites across Germany. Key eligibility criteria were a diagnosis of type 1, type 2, or gestational diabetes and regular self-monitoring of blood glucose. Participants were randomly assigned (2:1 ratio) to either use the digital diabetes logbook (mySugr PRO), or to the control group without app use. The primary outcome was the reduction in diabetes distress at the 12-week follow-up. All analyses were based on the intention-to-treat population with all randomized participants. The trial was registered at the German Register for Clinical Studies (DRKS00022923).

RESULTS

Between February 11, 2021, and June 24, 2022, 424 participants (50% female, 50% male) were included, with 282 being randomized to the intervention group (66.5%) and 142 to the control group (33.5%). A total of 397 participants completed the trial (drop-out rate: 6.4%). The median reduction in diabetes distress was 2.41 (interquartile range [IQR]: -2.50 to 8.11) in the intervention group and 1.25 (IQR: -5.00 to 7.50) in the control group. The model-based adjusted between-group difference was significant (-2.20, IQR: -4.02 to -0.38, P = .0182) favoring the intervention group. There were 27 adverse events, 17 (6.0%) in the intervention group, and 10 (7.0%) in the control group.

CONCLUSIONS

The efficacy of the digital diabetes logbook was demonstrated regarding improvements in mental health in people with type 1, type 2, and gestational diabetes.

Mind-body internet and mobile-based interventions for depression and anxiety in adults with chronic physical conditions: A systematic review of RCTs

This review summarizes the effectiveness of scalable mind-body internet and mobile-based interventions (IMIs) on depression and anxiety symptoms in adults living with chronic physical conditions. Six databases (MEDLINE, PsycINFO, SCOPUS, EMBASE, CINAHL, and CENTRAL) were searched for randomized controlled trials published from database inception to March 2023. Mind-body IMIs included cognitive behavioral therapy, breathwork, meditation, mindfulness, yoga or Tai-chi. To focus on interventions with a greater potential for scale, the intervention delivery needed to be online with no or limited facilitation by study personnel. The primary outcome was mean change scores for anxiety and depression (Hedges' g). In subgroup analyses, random-effects models were used to calculate pooled effect size estimates based on personnel support level, intervention techniques, chronic physical condition, and survey type. Meta-regression was conducted on age and intervention length. Fifty-six studies met inclusion criteria (sample size 7691, mean age of participants 43 years, 58% female): 30% (n = 17) neurological conditions, 12% (n = 7) cardiovascular conditions, 11% cancer (n = 6), 43% other chronic physical conditions (n = 24), and 4% (n = 2) multiple chronic conditions. Mind-body IMIs demonstrated statistically significant pooled reductions in depression (SMD = -0.33 [-0.40, -0.26], p<0.001) and anxiety (SMD = -0.26 [-0.36, -0.17], p<0.001). Heterogeneity was moderate. Scalable mind-body IMIs hold promise as interventions for managing anxiety and depression symptoms in adults with chronic physical conditions without differences seen with age or intervention length. While modest, the effect sizes are comparable to those seen with pharmacological therapy. The field would benefit from detailed reporting of participant demographics including those related to technological proficiency, as well as further evaluation of non-CBT interventions. Registration: The study is registered with PROSPERO ID #CRD42022375606.

Effect of self-help interventions on psychological, glycemic, and behavioral outcomes in patients with diabetes: A meta-analysis of randomized controlled trials

BACKGROUND

Self-help interventions are beneficial for patients with diabetes; however, related studies have reported conflicting results. To date, no review has examined the effect of self-help interventions on diabetes outcomes.

OBJECTIVES

To systematically evaluate the effects of self-help interventions on psychological, glycemic, and behavioral outcomes in patients with diabetes.

DESIGN

A systematic review and meta-analysis of randomized controlled trials.

METHODS

Five databases-PubMed, CINAHL, Embase, PsycINFO, and ClinicalTrials.gov-were searched from 1996, 1937, 1947, 1887, and 2000, respectively, to 2 June 2023. Studies that employed a randomized controlled trial design, enrolled adults with diabetes, implemented a self-help intervention as the main or an additional intervention, and reported the outcomes of interest were included. Studies providing self-help interventions to patients with gestational diabetes or pregnant women were excluded. The primary outcomes were diabetes distress, depression, and anxiety, and the secondary outcomes were glycemic and behavioral outcomes (self-management behavior, self-efficacy, and quality of life). Hedges' g and the associated 95 % confidence interval (CI) were calculated using a random-effects model to obtain the pooled estimates of short-, mid-, and long-term effects of self-help interventions. Heterogeneity was explored using I2 and Q statistics, and moderator analysis was performed to identify the sources of heterogeneity.

RESULTS

Of 17 eligible studies, 16 provided data for meta-analysis. We included 3083 patients with diabetes; the majority were women (61.95 %), and their average age was 55.13 years. Self-help interventions exerted significant short-term effects on diabetes distress (g = -0.363; 95 % CI = -0.554, -0.173), depression (g = -0.465; 95 % CI = -0.773, -0.156), anxiety (g = -0.295; 95 % CI = -0.523, -0.068), glycosylated hemoglobin level (g = -0.497; 95 % CI = -0.791, -0.167), self-efficacy (g = 0.629; 95 % CI = 0.060, 1.197), and quality of life (g = 0.413; 95 % CI = 0.104, 0.721; g = 0.182; 95 % CI = 0.031, 0.333; and g = 0.469; 95 % CI = 0.156, 0.783 for overall, physical, and mental domains, respectively). We also noted significant mid-term effects of self-help interventions on diabetes distress (g = -0.195; 95 % CI = -0.374, -0.016), self-management behavior (g = 0.305; 95 % CI = 0.155, 0.454), and overall quality of life (g = 0.562; 95 % CI = 0.315, 0.810). The certainty of evidence ranged from high to very low certainty for the measured outcomes.

CONCLUSIONS

Self-help interventions may have some positive effects on diabetes distress, anxiety, self-management behavior, and quality of life.

REGISTRATION

This review was registered in PROSPERO (CRD42022329905).

TWEETABLE ABSTRACT

This meta-analysis demonstrated that self-help interventions might improve psychological and behavioral outcomes in patients with diabetes.

The effects of treatment via telemedicine interventions for patients with depression on depressive symptoms and quality of life: a systematic review and meta-ranalysis

Aim: The aim of this systematic review and meta-analysis was to identify, evaluate, and synthesize the evidence from studies that have investigated the treatment effect via telemedicine interventions on depressive symptoms, quality of life, and work and social functioning in patients with depression.Methods: Six electronic databases (MEDLINE [1916-2021], PubMED [1950-2021], PsycINFO [1971-2021], Scopus [2004-2021], Embase [1972-2021], and CINAHL [1937-2021]) were systematically searched in March 2021. Reference lists of identified articles were hand searched. Randomized controlled trials were included if they investigated the treatment effects via telemedicine interventions in patients who had a depression diagnosis. Quality assessment was evaluated using the critical appraisal checklists developed by the Joanna Briggs Institute.Results: Seventeen (17) trials (n = 2,394) met eligibility criteria and were included in the analysis. Eleven (11) randomized controlled trials shared common outcome measures, allowing meta-analysis. The results provided evidence that treatment via telemedicine interventions were beneficial for depressive symptoms (standardized mean difference= -0.44; 95% CI= -0.64 to -0.25; p < .001) and quality of life (standardized mean difference= 0.25, 95% CI -0.01 to 0.49, p = .04) in patients of depression. There were insufficient data for meta-analysis of work and social functioning.Conclusion: This study showed the positive effects of treatment via telemedicine interventions on depressive symptoms and quality of life in patients with depression and supported the idea for clinical practice to establish a well-organized telepsychiatry system.KEY MESSAGESTelemedicine is effective at reducing symptoms of depression.Telemedicine can improve quality of life in persons with depression.

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.

Effects of digital psychotherapy for depression and anxiety: A systematic review and bayesian network meta-analysis

OBJECTIVE

To evaluate the effectiveness of digital psychotherapies for depression and anxiety. We conducted a systematic review and network meta-analyses (NMA) to make comparisons of digital psychotherapies.

METHODS

A bayesian NMA was conducted in this study. The databases including PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials and CINAL were searched for all eligible randomized controlled trials (RCTs) published from Jan 1, 2012 to Oct 1, 2022. We used the Cochrane Collaboration's Risk of bias tool for quality assessment. The primary outcomes were set as a standardized mean difference model in efficacy to describe continuous outcomes. We used STATA and WinBUGS to conduct a bayesian network meta-analysis of all interventions based on a random-effects model. This study was registered with PROSPERO, number CRD42022374558.

RESULTS

From the retrieved 16,750 publications, we included 72 RCTs (13,096 participants) with the overall medium quality and above. In terms of depression scale, cognitive behavioral therapy (CBT) was more effective than TAU (SMDs 0.53) and NT (SMDs 0.98). In terms of anxiety scale, CBT (SMDs 0.68; SMDs 0.72) and exercise therapy (ERT) (SMDs 1.01; SMDs 1.05) were more effective than TAU and NT.

LIMITATIONS

Uneven quality of literature, simple network, and subjective judgment.

CONCLUSION

Based on NMA results, we suggest that CBT, which is the most commonly used digital technology, should be preferred among digital psychotherapy for relieving depression and anxiety symptoms. Digital exercise therapy is an effective strategy to relieve some anxiety problems in the context of COVID-19.

E-Health technologies for treatment of depression, anxiety and emotional distress in person with diabetes mellitus: A systematic review and meta-analysis

OBJECTIVE

This systematic review of randomized clinical trials (RCT) summarized the available evidence regarding the use of e-Health technologies for the treatment of depression, anxiety, and emotional distress in person with diabetes mellitus.

METHODS

The Cochrane CENTRAL, MEDLINE, EMBASE, Web of Science and LILACS databases searched were up to January 11th, 2023. The primary outcomes were improvement of depression, anxiety, diabetes-related emotional distress and quality of life. Reviewers, in pairs and independently, selected the studies and extracted their data.

RESULTS

A total of 10 RCT involving 2,209 participants were analyzed. The methodological quality of the studies reviewed was high. Results showed improvements in depression with the use of Internet-Guided Self-Help (SMD = -0.74, 95%CI = -1.04 to -0.43) or Telephone-Delivered Cognitive Behavioral Therapy (CBT) (SMD = -0.42, 95%CI = -0.65 to -0.19); in anxiety with Internet-Guided Self-Help (SMD = -0.72, 95%CI = -1.02 to -0.42) or Diabetes-specific-CBT (SMD = -0.60, 95%CI = -1.18 to -0.02); and in emotional distress with Internet-Guided Self-Help (SMD = -0.72, 95%CI = -1.02 to -0.41) or Healthy Outcomes through Patient Empowerment (SMD = -0.26, 95%CI = -0.53 to 0.01) compared to usual care.

CONCLUSION

Due to heterogeneity in interventions, populations, follow-up time and outcomes, future RCT should be conducted to confirm these findings.

Long-Term Efficacy of Internet-Based Cognitive Behavioral Therapy Self-Help Programs for Adults With Depression: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Depression is a worldwide mental disorder and a leading cause of disability. Many people with depression do not want to take medication or have the motivation to seek psychotherapy treatment for many reasons. Guided internet-based self-help programs may be a promising solution for addressing these issues. This kind of intervention has proven to be effective in reducing depression symptoms on a short-term scale. However, as treatment often is a long-term rehabilitation process, it is important to examine not only the short-term effects of internet-based cognitive behavioral therapy (iCBT) self-help treatment but also the follow-up or long-term efficacy of this kind of intervention.

OBJECTIVE

This systematic review and meta-analysis aimed to identify studies that examined follow-up data ≥8 weeks after posttreatment measurements and thereby examined the long-term efficacy of iCBT self-help programs with minimal weekly guidance for people with depression. It aimed to analyze the long-term efficacy of iCBT treatments compared to control conditions as well as long-term efficacy within the iCBT treatment conditions. Additionally, it aimed to conduct subgroup analyses according to the follow-up time points for each outcome. Finally, it examined long-term improvements in quality of life.

METHODS

The Cochrane Collaboration Depression, Anxiety, and Neurosis Controlled Trials Register (CCDANCTR), grey literature, reference lists, and correspondence were used to search for published and unpublished randomized controlled trials (RCTs) that reported the long-term or follow-up efficacy of computer-based or iCBT self-help treatments for depression with minimal guidance of up to 10 min/wk. The search took place between 2015 and 2022 (October).

RESULTS

The search resulted in a total of 2809 study abstracts, of which 15 studies (with 17 samples) met all inclusion criteria and were included in the long-term analysis. The results showed that the depression outcomes of all follow-up time points together in the treatment conditions were favored over the control conditions with a medium effect size of 0.43 (n=1689 participants; 9 RCTs; standardized mean difference [SMD] -0.43, 95% CI -0.67 to -0.20; P<.001). The analysis of long-term efficacy within the iCBT treatment conditions showed that the follow-up outcomes of the treatment groups were favored over the posttreatment outcomes with a small effect size of 0.20 (n=2196 participants; 17 RCTs; SMD 0.20, 95% CI 0.07-0.49; P=.003). Findings for improving quality of life also showed that the iCBT conditions were favored over the control conditions with a small effect size of 0.19 (n=1345 participants; 3 RCTs; SMD 0.19, 95% CI 0.08-0.30; P<.001).

CONCLUSIONS

This systematic review and meta-analysis found that iCBT self-help interventions had a superior long-term efficacy for individuals with depressive symptoms compared to control groups. The within-group analysis of iCBT treatment conditions also showed statistically significant improvements in reducing depressive symptoms at follow-up compared to posttreatment measurements.

The evaluation of cognitive-behavioral therapy-based intervention on type 2 diabetes patients with comorbid metabolic syndrome: a randomized controlled trial

BACKGROUND

Cognitive behavior therapy (CBT) has been applied in intervention research in diabetes patients with satisfying results. However, there was no research on type 2 diabetes (T2DM) patients with comorbidities. This study aimed to investigate the effectiveness of CBT on psychological variables, behavior variables, quality of life, sleep quality, and physical variables among adult T2DM patients with comorbid metabolic syndrome (MS).

METHODS

281 patients aged 18-75 years were recruited from Ningbo First Hospital in China from October 2021 to March 2022. Patients were randomized to the intervention group (IG, N = 148) or control group (CG, N = 133). Patients in the IG received 12 CBT-based sessions during a six-month intervention time. Patients in the CG received the usual care only. Univariate General Linear Model was used to analyze the effect of CBT-based interventions. The analysis was conducted by SPSS Version 28.

RESULTS

Results indicated that CBT-based intervention was superior in the following aspects: relieving depression symptoms: IG (4.11 ± 4.35 vs. 1.99 ± 2.12), CG (3.40 ± 3.26 vs. 2.32 ± 1.88), interaction effect (F = 4.074, P = 0.044); enhancing diabetes self-care behaviors: IG (26.79 ± 12.18 vs. 37.49 ± 10.83), CG (25.82 ± 13.71 vs. 31.96 ± 11.72), interaction effect (F = 5.242, P = 0.022); promoting the efficacy of CBT: IG (47.45 ± 6.83 vs. 50.76 ± 4.98), CG (46.74 ± 6.94 vs. 47.87 ± 5.11), interaction effect (F = 5.198, P = 0.023); improving subjective sleep quality: IG (0.93 ± 0.68 vs. 0.69 ± 0.63), CG (1.03 ± 0.72 vs. 1.01 ± 0.68), interaction effect (F = 3.927, P = 0.048).

CONCLUSIONS

The CBT-based intervention was beneficial in improving depression symptoms, diabetes self-care behaviors, the efficacy of CBT, and sleep quality in T2DM patients with comorbid MS. The downtrend of body mass index, systolic blood pressure, diastolic pressure, and glycated hemoglobin was larger in the intervention group but not to a significant level.

TRIAL REGISTRATION

This study has been prospectively registered at Australia New Zealand Clinical Trials Registry (Registration ID: ACTRN12621001348842 website: https://www.anzctr.org.au/trial/MyTrial.aspx ).

Assessing the Smallest Detectable Change of the Kessler Psychological Distress Scale Score in an Adult Population in Japan

Background

Psychological distress is prevalent worldwide and can lead to the development of mental conditions such as major depression and anxiety disorders. It is essential to assess the severity of patient-reported outcomes to provide effective treatment for psychological distress. The Kessler Psychological Distress Scale (K6) is one of the most widely used psychological distress scales. However, the smallest detectable change (SDC) of the K6 score has not been elucidated. Therefore, the current study aimed to determine the SDC of the K6 score in a Japanese adult population.

Methods

Participants aged 20-59 years who are native Japanese speakers were recruited from the panel list of a web research firm. The K6 score was assessed at baseline (T1) and at 2-week follow-up (T2). SDCs were calculated at the individual (SDC_ind) and group (SDC_group) levels. Intraclass correlation coefficient agreement (ICC_agreement) was calculated to assess test-retest reliability and Cronbach's alpha to evaluate internal consistency.

Results

A total of 3254 (1627 [50%] female) responded at T1 and T2. The mean (standard deviation) K6 scores were 5.71 (5.84) at T1 and 5.65 (5.83) at T2. The SDC_ind and SDC_group of the K6 score were 8.47 (35.31%) and 0.15 (0.63%), respectively. The ICC_agreement was 0.73, and the Cronbach's alpha was 0.94.

Conclusion

Our study provided evidence on the reliability and interpretation of the K6 score. Calculating the SDC of the K6 score can help identify the significance of changes in psychological distress over time and can determine the efficacy of interventions for psychological distress.

Efficacy of Neck-Specific Exercise With Internet Support Versus Neck-Specific Exercise at a Physiotherapy Clinic in Chronic Whiplash-Associated Disorders: Multicenter Randomized Controlled Noninferiority Trial

BACKGROUND

Neck-specific exercises (NSE) supervised by a physiotherapist twice a week for 12 weeks have shown good results in chronic whiplash-associated disorders (WADs), but the effect of exercise delivered via the internet is unknown.

OBJECTIVE

This study examined whether NSE with internet support (NSEIT) and 4 physiotherapy sessions for 12 weeks were noninferior to the same exercises supervised by a physiotherapist twice a week for 12 weeks (NSE).

METHODS

In this multicenter randomized controlled noninferiority trial with masked assessors, we recruited adults aged 18-63 years with chronic WAD grade II (ie, neck pain and clinical musculoskeletal signs) or III (ie, grade II plus neurological signs). Outcomes were measured at baseline and at 3- and 15-month follow-ups. The primary outcome was change in neck-related disability, measured with the Neck Disability Index (NDI; 0%-100%), with higher percentages indicating greater disability. Secondary outcomes were neck and arm pain intensity (Visual Analog Scale [VAS]), physical function (Whiplash Disability Questionnaire [WDQ] and Patient-Specific Functional Scale [PSFS]), health-related quality of life (EQ-5D-3L and EQ VAS), and self-rated recovery (Global Rating Scale [GRS]). The analyses were conducted on an intention-to-treat basis and with the per-protocol approach as sensitivity analyses.

RESULTS

Between April 6, 2017, and September 15, 2020, 140 participants were randomly assigned to the NSEIT group (n=70) or the NSE group (n=70); 63 (90%) and 64 (91%), respectively, were followed up at 3 months, and 56 (80%) and 58 (83%), respectively, at 15 months. NSEIT demonstrated noninferiority to NSE in the primary outcome NDI, as the 1-sided 95% CI of the mean difference in change did not cross the specified noninferiority margin (7 percentage units). There were no significant between-group differences in change in NDI at the 3- or 15-month follow-up, with a mean difference of 1.4 (95% CI -2.5 to 5.3) and 0.9 (95% CI -3.6 to 5.3), respectively. In both groups, the NDI significantly decreased over time (NSEIT: mean change -10.1, 95% CI -13.7 to -6.5, effect size=1.33; NSE: mean change -9.3, 95% CI -12.8 to -5.7, effect size=1.19 at 15 months; P<.001). NSEIT was noninferior to NSE for most of the secondary outcomes except for neck pain intensity and EQ VAS, but post hoc analyses showed no differences between the groups. Similar results were seen in the per-protocol population. No serious adverse events were reported.

CONCLUSIONS

NSEIT was noninferior to NSE in chronic WAD and required less physiotherapist time. NSEIT could be used as a treatment for patients with chronic WAD grades II and III.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03022812; https://clinicaltrials.gov/ct2/show/NCT03022812.

Reducing social diabetes distress with a conversational agent support system: a three-week technology feasibility evaluation

Background

People with diabetes mellitus not only have to deal with physical health problems, but also with the psycho-social challenges their chronic disease brings. Currently, technological tools that support the psycho-social context of a patient have received little attention.

Objective

The objective of this work is to determine the feasibility and preliminary efficacy of an automated conversational agent to deliver, to people with diabetes, personalised psycho-education on dealing with (psycho-)social distress related to their chronic illness.

Methods

In a double-blinded between-subject study, 156 crowd-workers with diabetes received a social help program intervention in three sessions over three weeks. They were randomly assigned to receive support from either an interactive conversational support agent (n=79) or a self-help text from the book "Diabetes burnout" as a control condition (n=77). Participants completed the Diabetes Distress Scale (DDS) before and after the intervention, and after the intervention, the Client Satisfaction Questionnaire (CSQ-8), Feeling of Being Heard (FBH), and System Usability Scale (SUS).

Results

Results indicate that people using the conversational agent have a larger reduction in diabetes distress (M=-0.305, SD=0.865) than the control group (M=0.002, SD=0.743) and this difference is statistically significant (t(154)=2.377, p=0.019). A hypothesised mediation effect of "attitude to the social help program" was not observed.

Conclusions

An automated conversational agent can deliver personalised psycho-education on dealing with (psycho-)social distress to people with diabetes and reduce diabetes distress more than a self-help book.

Ethics Study Registration and Open Science

This study has been preregistered with the Open Science Foundation (osf.io/yb6vg) and has been accepted by the Human Research Ethics Committee - Delft University of Technology under application number 1130. The data and analysis script are available: https://surfdrive.surf.nl/files/index.php/s/4xSEHCrAu0HsJ4P.

Technology-Supported Integrated Care Innovations to Support Diabetes and Mental Health Care: Scoping Review

BACKGROUND

For individuals living with diabetes and its psychosocial comorbidities (eg, depression, anxiety, and distress), there remains limited access to interprofessional, integrated care that includes mental health support, education, and follow-up. Health technology, broadly defined as the application of organized knowledge or skill as software, devices, and systems to solve health problems and improve quality of life, is emerging as a means of addressing these gaps. There is thus a need to understand how such technologies are being used to support, educate, and help individuals living with co-occurring diabetes and mental health distress or disorder.

OBJECTIVE

The purpose of this scoping review was to (1) describe the literature on technology-enabled integrated interventions for diabetes and mental health; (2) apply frameworks from the Mental Health Commission of Canada and World Health Organization to elucidate the components, type, processes, and users of technology-enabled integrated interventions for diabetes and mental health; and (3) map the level of integration of interventions for diabetes and mental health.

METHODS

We searched 6 databases from inception to February 2022 for English-language, peer-reviewed studies of any design or type that used technology to actively support both diabetes and any mental health distress or disorder in succession or concurrently among people with diabetes (type 1 diabetes, type 2 diabetes, and gestational diabetes). Reviewers screened citations and extracted data including study characteristics and details about the technology and integration used.

RESULTS

We included 24 studies described in 38 publications. These studies were conducted in a range of settings and sites of care including both web-based and in-person settings. Studies were mostly website-based (n=13) and used technology for wellness and prevention (n=16) and intervention and treatment (n=15). The primary users of these technologies were clients and health care providers. All the included intervention studies (n=20) used technology for clinical integration, but only 7 studies also used the technology for professional integration.

CONCLUSIONS

The findings of this scoping review suggest that there is a growing body of literature on integrated care for diabetes and mental health enabled by technology. However, gaps still exist with how to best equip health care professionals with the knowledge and skills to offer integrated care. Future research is needed to continue to explore the purpose, level, and breadth of technology-enabled integration to facilitate an approach to overcome or address care fragmentation for diabetes and mental health and to understand how health technology can further drive the scale-up of innovative integrated interventions.

The short- and long-term effects of cognitive behavioral therapy on the glycemic control of diabetic patients: a systematic review and meta-analysis

BACKGROUND

Glycemic control is an important issue in the treatment of diabetic patients. However, traditional methods, such as medication (the usual treatment), have limitations. Cognitive behavioral therapy (CBT) might be a useful option to help control the glycemic condition. The effects can be revealed by systemic review or meta-analysis of randomized clinical trials (RCT).

METHODS

A systematic search and a meta-analysis for the RCT were done of the short- and long-term effects of CBT on the glycemic control of diabetic patients in a comparison with the usual treatment. Nineteen RCT studies and 3,885 diabetic patients were enrolled in this meta-analysis. Subgroup analyses of types 1 and 2 diabetes and individual and group CBT were also performed.

RESULTS

Patients treated with CBT showed no significant difference in HbA1c when compared to the usual treatment within six months. However, CBT was more effective in reducing HbA1c when compared to usual treatment with at least six months of treatment duration [standardized mean difference: -0.44 (95% confidence interval (CI): -0.63 ~ -0.25), Z = 4.49]. Subgroup analysis of type 1 and 2 diabetic patients supported a long-term effect of CBT on glycemic control [standardized mean difference: -0.85 (95% CI: -1.19 ~ -0.10), Z = 2.23, standardized mean difference: -0.33 (95% CI:-0.47 ~ -0.19), Z = 4.52, respectively].

CONCLUSIONS

CBT would be a useful option for improving the glycemic control of diabetic patients undergoing long-term treatment. The advantages of the long-term effects of CBT should be considered by clinicians and staff.

The impact of technology systems and level of support in digital mental health interventions: a secondary meta-analysis

BACKGROUND

The majority of people with a chronic disease (e.g., diabetes, hypertension, COPD) have more than one concurrent condition and are also at higher risk for developing comorbidities in mental health, including anxiety and depression. There is an urgent need for more relevant and accurate data on digital interventions in this area to prepare for an increase demand for mental health services. The aim of this study was to conduct a meta-analysis of the digital mental health interventions for people with comorbid physical and mental chronic diseases to compare the effect of technology systems and level of support.

METHODS

This secondary meta-analysis follows a rapid review of systematic reviews, a virtual workshop with knowledge users to identify research questions and a modified Delphi study to guide research methods: What types of digital health interventions (according to a recognized categorization) are the most effective for the management of concomitant mental health and chronic disease conditions in adults? We conducted a secondary analysis of the primary studies identified in the rapid review. Two reviewers independently screened the titles and abstracts and applied inclusion criteria: RCT design using a digital mental health intervention in a population of adults with another chronic condition, published after 2010 in French or English, and including an outcome measurement of anxiety or depression.

RESULTS

Seven hundred eight primary studies were extracted from the systematic reviews and 84 primary studies met the inclusion criteria Digital mental health interventions were significantly more effective than in-person care for both anxiety and depression outcomes. Online messaging was the most effective technology to improve anxiety and depression scores; however, all technology types were effective. Interventions partially supported by healthcare professionals were more effective than self-administered.

CONCLUSIONS

While our meta-analysis identifies digital intervention's characteristics are associated with better effectiveness, all technologies and levels of support could be used considering implementation context and population.

TRIAL REGISTRATION

The protocol for this review is registered in the National Collaborating Centre for Methods and Tools (NCCMT) COVID-19 Rapid Evidence Service (ID 75).

Internet-based and mobile-based cognitive behavioral therapy for chronic diseases: a systematic review and meta-analysis

Positive adjustment to chronic diseases reduces psychiatric comorbidity and enhances quality of life. Very little is known about the benefit of internet-based and mobile-based Cognitive Behavioral Therapy (IM-CBT) on physical outcomes and its reciprocal interactions with psychiatric outcomes, the active therapeutic elements, and effect moderators among people with major chronic medical conditions. In this systematic review and meta-analysis (PROSPERO: CRD42022265738), CINAHL of Systematic Reviews, MEDLINE, PsycINFO, PubMed, Web of Science are systematically searched up to 1 June 2022, for randomized controlled trials (RCTs) comparing IM-CBT against non-CBT control condition(s) among people with chronic disease(s). Primary outcomes include improvements in psychiatric symptoms (depressive, anxiety, PTSD symptoms, general psychological distress) from baseline to post-intervention and follow-ups. Secondary outcomes include improvements in physical distress (physical symptoms, functional impairment, self-rated ill health, objective physiological dysfunction). Among 44 RCTs (5077 patients with seven different chronic diseases), IM-CBT improves depressive symptoms, anxiety symptoms, and general psychological distress at post-intervention and across follow-ups, and improves physical distress and functional impairment at post-intervention. Preliminary evidence suggests that behavioral modification and problem-solving could be necessary components to reduce psychiatric symptoms in IM-CBT, whereas cognitive restructuring, psychoeducation, and mindfulness elements relate to reduced physical distress. IM-CBT shows stronger benefits in chronic pain, cancer, arthritis, and cardiovascular disease, relative to other conditions. Changes in psychiatric symptoms and physical distress prospectively predict each other over time. IM-CBT is an effective intervention for comprehensive symptom management among people with chronic diseases.

Mediating effect of anxiety and depression between family function and hope in patients receiving maintenance hemodialysis: a cross-sectional study

OBJECTIVES

This study aimed to explore the levels of hope in patients receiving maintenance hemodialysis (MHD), and whether anxiety and depression mediate the relationship between family function and hope.

METHODS

The family APGAR index, hospital anxiety and depression scale, and Herth hope index were recorded using the self-reported questionnaires completed by 227 MHD patients.

RESULTS

The family function can directly predict hope, positively predict hope through depression (β = 0.052, p = 0.001), and positively predict hope through the chain mediating of anxiety and depression (β = 0.087, p = 0.001), according to chain mediation analysis. The total effect size was 28.31%. The total indirect effect value was 0.139, and the total effect value was 0.491.

CONCLUSIONS

Our findings suggest that family function had a direct impact on MHD patients' hope, and that lowering anxiety and depression can help to feel more hopeful.

Internet-Based Cognitive Behavioural Therapy for Individuals With Depression and Chronic Health Conditions: A Systematic Review

Cognitive behavioural therapy (CBT) has heightened the need for internet-delivered intervention for depression with chronic diseases than a traditionally-based treatment procedure, and the need for CBT as an internet-delivered intervention has increased because it scales down the stigma of proceeding to a therapist, saves travel time from different geographical areas, and increases access to the service. This study aimed to evaluate the contemporary evidence for the effectiveness of internet-delivered cognitive behavioural therapy (CBT) as a treatment option for depression with chronic illness (CVD, diabetes, chronic pain, cancer, and chronic obstructive pulmonary disease (COPD)) among adult populations in high-income countries. A systematic search strategy was devised based on selecting search terms, inclusion and exclusion criteria, and refinement processes. Electronic searches were conducted using databases related to healthcare and containing peer-reviewed literature: the Cumulated Index to Nursing and Allied Health Literature (CINAHL), the Excerpta Medica Database (Embase), the Medical Literature Analysis and Retrieval System Online (Medline), and PsycINFO. Key search terms were applied to all databases and combined using Boolean operators to maximise the efficiency of the search. This review included randomised controlled trials (RCTs) evaluating the adult population aged ≥18 years published from 2006-2021. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was employed to guide the review process. The initial search yielded 134 studies across all databases, which were refined, leading to 18 studies in the final review data set. This review suggests that internet-based CBT is an effective strategy for reducing depressive symptoms in patients with comorbid depression and chronic diseases.

Efficacy of computer- and/or internet-based cognitive-behavioral guided self-management for depression in adults: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Depression is a worldwide disease. CBT-based self-help treatment allows patients with mild to moderate depression symptoms to improve their depression or to bridge the waiting- or pandemic period until they receive further clinical treatment.

OBJECTIVE

This systematic review and meta-analysis aims to explore the efficacy, acceptability and improvement in quality of life of computer-delivered and/or internet-based CBT self-help interventions with minimal guidance (up to 10 min) for depression. The second aim was to compare the effectiveness of reducing depression symptoms at post-treatment of treatment by the type of minimal guidance: (1) e-mail, (2) telephone calls, (3) e-mail and telephone together, or (4) face-to-face.

METHODS

The Cochrane depression, anxiety, and neurosis review group's specialized register electronic searches, grey literature, reference lists and correspondence were used to search for published and unpublished RCTs that reported efficacy of computer- and/or internet-based CBT self-help treatments for depression with minimal guidance up to 10 min per week. Methodological quality of included studies was evaluated with Cochrane Collaboration tools for assessing risk of bias. The meta-analysis was accomplished using the RevMen software.

RESULTS

In total, 2809 study abstracts were checked for eligibility. Out of these, 19 studies (21 samples) with a total of 3226 participants were included. The results showed that concerning efficacy, the treatment group is superior to the control group with a medium to large effect size of 0.65. Also, treatment groups with combined guidance by e-mail and telephone calls together had greater effects (SMD -0.76) than groups with other types of minimal guidance (guided by e-mail SMD -0.63; guided face to-face SMD - 0.66; guided by telephone calls SMD -0.49). Findings showed also, that iCBT with minimal guidance had small but statistically significant effect size of 0.28 in improving quality of life. Moreover, there were higher drop-out rates in the treatment condition (RR 1.36) than in the control groups.

CONCLUSIONS

The results of this meta-analysis support the efficacy of computer- and/or internet-based CBT self-help programs with minimal weekly guidance up to only 10 min for improving depression symptoms at post-treatment for adults. In addition, the results are pointing towards two practical implications. Firstly, depressed persons can use self-help treatment with minimal guidance at home to improve their symptoms or to bridge the waiting time - or pandemic period - before they receive professional face-to-face treatment. Secondly, it can help clinicians to make the decision about using CBT-based self-help treatments for patients that do not need urgent professional treatment, or to combine it with face-to-face therapy.

Guided Internet-Delivered Treatment for Depression: Scoping Review

BACKGROUND

Studies on guided internet-delivered treatment have demonstrated promising results for patients with depressive disorder.

OBJECTIVE

The aim of this study was to provide an overview of this research area and identify potential gaps in the research.

METHODS

In this scoping review, web-based databases were used to identify research papers published between 2010 and 2022 where guided internet-delivered treatment was administered to participants with depressive disorders, a standardized rating scale of depressive symptoms was used as the primary outcome measure, and the treatment was compared with a control condition.

RESULTS

A total of 111 studies were included, and an overview of the studies was provided. Several gaps in the research were identified regarding the design of the studies, treatments delivered, participant representation, and treatment completion.

CONCLUSIONS

This review provides a comprehensive overview of the research area, and several research gaps were identified. The use of other designs and active control conditions is recommended. Future studies should provide access to treatment manuals, and more replications should be conducted. Researchers should aim to include underrepresented populations and provide reports of comorbidities. Definitions of adequate dosage, reports of completion rates, and reasons for treatment dropout are recommended for future studies.

Reduktion von diabetesbezogenem Distress bei Typ-1- und Typ-2-Diabetes durch eine kognitiv-verhaltenstherapeutische Gruppenintervention

Das Stresserleben durch die Erkrankung Diabetes mellitus stellt für einen Großteil der betroffenen Personen oft eine deutliche Belastung dar, die sich negativ auf das Diabetes-Selbstmanagement und damit auf die Gesundheit der Betroffenen auswirken kann. Das Ziel der vorliegenden Studie war die Evaluation einer diabetesspezifischen kognitiv-verhaltenstherapeutischen Gruppentherapie zur Reduktion des Stresserlebens, bestehend aus sechs Sitzungen für Personen mit Typ-1- oder Typ-2-Diabetes. Vermittelt wurden Techniken zur Stressbewältigung, wie Achtsamkeit und Entspannungsübungen, sowie kognitive Techniken, die auf den Alltag mit der Diabeteserkrankung und damit verbundene Gedanken und Emotionen der Teilnehmenden bezogen waren. Von 52 Personen (51,9% mit Typ-1-Diabetes, 61,5% weiblich, Alter MW= 50,4 Jahre) lagen nach Studienteilnahme Fragebögen vor. Eine signifikante Verbesserung konnte im Problem Areas In Diabetes Questionnaire (Δ6.24 [95%-KI: 1.85–10.62], p=.006), dem Perceived Stress Survey (Δ2.93 [95%-KI: 1.59–4.26], p=.000) und der Diabetes Acceptance Scale (Δ5.5 [95%-KI: 9.07–1.93], p=.003) erreicht werden. Diese erwies sich auch im Follow-Up nach sechs Monaten als stabil. Der selbstberichtete HbA1c-Wert reduzierte sich im Befragungszeitraum bei der Teilstichprobe von N= 40, von der die Daten verfügbar waren, ebenfalls signifikant (Δ0.73 [95%-KI: 0.015–1.452], p=.046). Das Gruppentherapieprogramm zur Stressreduktion kann als eine niedrigschwellige, psychotherapeutische Interventionen zur Reduktion diabetesbezogener Belastungen angesehen werden. Es könnte ein hilfreiches primär- und sekundärpräventives Angebot für stressbelastete Menschen mit Diabetes in der Standardversorgung darstellen.

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.

The efficacy of cognitive behavioral therapy-based intervention on patients with diabetes: A meta-analysis

AIMS

This meta-analysis aims to update former meta-analyses from randomized controlled trials (RCT) focused on the efficacy of CBT for diabetes.

METHODS

Five databases were searched for RCTs. Primary outcomes were glycated hemoglobin (HbA_1c), fasting blood glucose (FBS), systolic blood pressure (SBP), diastolic blood pressure (DBP), and body mass index (BMI). Secondary outcomes were depression, anxiety and distress symptoms, quality of life, sleep quality.

RESULTS

32 RCTs were included. Results revealed that CBT could reduce HbA_1c: -0.14% (95% CI: -0.25 to -0.02%, P = 0.020); FBS: -15.48 mg/dl (95% CI: -30.16 to -0.81 mg/dl, P = 0.040); DBP: -2.88 mmHg (95% CI: -4.08 to -1.69 mmHg, P < 0.001); depression symptoms: -0.90 (95% CI: -1.22 to -0.57, P < 0.001); anxiety symptoms: -0.28 (95% CI: -0.50 to -0.07, P = 0.009); improve sleep quality: -0.92 (95% CI: -1.77 to -0.07, P = 0.030). Subgroup analysis indicated that CBT has siginificantly reduced HbA_1c when delivered as a group-based and face-to-face method, and psycho-education, behavioral, cognitive, goal-setting, homework assignment strategies were applied as central strategies.

CONCLUSION

CBT was an effective treatment for diabetes patients, significantly reduced their HbA_1c, FBS, DBP, depression and anxiety symptoms, and improved sleep quality.

A mixed-methods approach to understanding the perspectives, experiences, and attitudes of a culturally tailored cognitive behavioral therapy/motivational interviewing intervention for African American patients with type 2 diabetes: a randomized parallel design pilot study

Background

African American (AA) adults are 60% more likely to be diagnosed with diabetes mellitus (DM) and experience more complications than non-Hispanic White adults. Cognitive behavioral therapy (CBT) has shown to be an effective modality for helping patients improve health behaviors and regulate emotional states. Motivational interviewing (MI) addresses participant engagement and motivation. Therefore, MI was combined with CBT as an approach to the process of learning using CBT skills to promote healthy lifestyle choices. We aimed to assess the effects of a culturally tailored CBT/MI intervention on glycemic control in AA participants and understand their perspectives, attitudes, and experiences while participating in this intervention.

Methods

Using a randomized, parallel design pilot study (web-based group vs in-person group), 20 participants aged ≥ 18 years, identifying as AA and having a glycosylated hemoglobin (HbA1c) > 8%, were recruited. A CBT/MI intervention was administered in six sessions over 3 months. Participants completed baseline and follow-up assessments on measures for diabetes control (HbA1c), self-efficacy, generalized anxiety, depression, perceived stress, health-related quality of life, and cognitive ability. Post-CBT/MI intervention focus groups were conducted to determine patient perspectives regarding the intervention.

Results

Fourteen participants completed the study, their mean HbA1c improved from 10.0 to 8.9% (t(26) = 0.5, p-value = 0.06). The Diabetes Distress Scale demonstrated decreased distress overall (t(26) = 2.6; p-value = 0.02). The Generalized Anxiety Disorder Scale demonstrated decreased generalized anxiety for all participants (t(26) = 2.2; p = 0.04). Themes identified in focus groups included (1) intervention group social support through information sharing, (2) mental health and personal identities in diabetes understanding and management, and (3) receptivity to CBT/MI intervention positively impacts self-efficacy through improved health literacy.

Conclusion

This group-based, culturally tailored CBT/MI intervention for type 2 DM care was positively received by AA participants and helped improve diabetes control, as demonstrated by the change in HbA1c. There were additional benefits of social support through group interactions and a stronger sense of self-efficacy due to health education. A comprehensive treatment plan using a CBT/MI intervention may be useful in promoting healthy diabetes self-management.

Trial registration

ClinicalTrials.gov, NCT03562767. Registered on 19 June 2018

Type 1 diabetes and the challenges of emotional support in crisis situations: results from a feasibility study of a multidisciplinary teleintervention

The association between type 1 diabetes and mental health disorders could be exacerbated in a stressful environment. This study aimed to evaluate the feasibility of a teleguided intervention on emotional disorders in patients with type 1 diabetes during the COVID-19 outbreak. This study was performed during the social distancing period in the COVID-19 outbreak in Brazil. Individuals with type 1 diabetes aged ≥ 18 years were selected to receive a teleguided multidisciplinary intervention or the usual care plus an educational website access. The proposed intervention aimed addressing aspects of mental health, diabetes care and lifestyle habits during the pandemic. The feasibility outcome included the assessment of recruitment capability and adherence to the proposed intervention. Moreover, we evaluated the presence of positive screening for emotional disorders (Self Report Questionnaire 20) after a 16-week intervention, patients' perceptions of pandemic-related changes, diabetes-related emotional distress, eating disorders, and sleep disorders. Data were analyzed with the intent-to-treat principle. Fifty-eight individuals (mean age, 43.8 ± 13.6 years) were included (intervention group, n = 29; control group, n = 29). At the end of the study, a total of 5 participants withdrew from the study in the intervention group compared to only 1 in the control group. Participants who dropout from the study had similar mean age, sex and income to those who remained in the study. The analysis of mental health disorders was not different between the groups at the follow up: a positive screening result was found in 48.3% and 34.5% of participants in the intervention and control groups, respectively (P = 0.29). The intervention group felt more supported in their diabetes care during the social distancing period (82.8% vs. 48.3% in the control group, P < 0.01). Our study identified a disproportionate higher number of withdrawals in the intervention group when compared to the control group. This difference may have compromised the power of the study for the proposed assessments and should be reevaluated in future studies.Trial registration: ClinicalTrials.gov (NCT04344210). Date of registration: 14/04/2020.

Digital Health Interventions for Depression and Anxiety Among People with Chronic Conditions: Scoping Review (Preprint)

Background

Chronic conditions are characterized by their long duration (≥1 year), need for ongoing medical attention, and limitations in activities of daily living. These can often co-occur with depression and anxiety as common and detrimental comorbidities among the growing population living with chronic conditions. Digital health interventions (DHIs) hold promise in overcoming barriers to accessing mental health support for these individuals; however, the design and implementation of DHIs for depression and anxiety in people with chronic conditions are yet to be explored.

Objective

This study aimed to explore what is known in the literature regarding DHIs for the prevention, detection, or treatment of depression and anxiety among people with chronic conditions.

Methods

A scoping review of the literature was conducted using the Arksey and O’Malley framework. Searches of the literature published in 5 databases between 1990 and 2019 were conducted in April 2019 and updated in March 2021. To be included, studies must have described a DHI tested with, or designed for, the prevention, detection, or treatment of depression or anxiety in people with common chronic conditions (arthritis, asthma, diabetes mellitus, heart disease, chronic obstructive pulmonary disease, cancer, stroke, and Alzheimer disease or dementia). Studies were independently screened by 2 reviewers against the inclusion and exclusion criteria. Both quantitative and qualitative data were extracted, charted, and synthesized to provide a descriptive summary of the trends and considerations for future research.

Results

Database searches yielded 11,422 articles across the initial and updated searches, 53 (0.46%) of which were included in this review. DHIs predominantly sought to provide treatment (44/53, 83%), followed by detection (5/53, 9%) and prevention (4/53, 8%). Most DHIs were focused on depression (36/53, 68%), guided (32/53, 60%), tailored to chronic physical conditions (19/53, 36%), and delivered through web-based platforms (20/53, 38%). Only 2 studies described the implementation of a DHI.

Conclusions

As a growing research area, DHIs offer the potential to address the gap in care for depression and anxiety among people with chronic conditions; however, their implementation in standard care is scarce. Although stepped care has been identified as a promising model to implement efficacious DHIs, few studies have investigated the use of DHIs for depression and anxiety among chronic conditions using such models. In developing stepped care, we outlined DHI tailoring, guidance, and intensity as key considerations that require further research.

Type 1 diabetes and the challenges of emotional support in crisis situations: results from a randomized clinical trial of a multidisciplinary teleintervention

The association between type 1 diabetes and mental health disorders could be exacerbated in a stressful environment. This study aimed to evaluate the effectiveness of a teleguided intervention on emotional disorders in patients with type 1 diabetes during the COVID-19 outbreak. An open-label clinical trial was performed during the social distancing period in the COVID-19 outbreak in Brazil. Individuals with type 1 diabetes aged ≥ 18 years were randomized to receive a teleguided multidisciplinary intervention or the usual care plus an educational website access. The primary outcome was a positive screening for emotional disorders (Self Report Questionnaire 20) after a 16-week intervention. Secondary outcomes included evaluation of patients’ perceptions of pandemic-related changes, diabetes-related emotional distress, eating disorders, and sleep disorders. Data were analyzed with the intent‐to‐treat principle. Fifty-eight individuals (mean age, 43.8 ± 13.6 years) were included (intervention group, n = 29; control group, n = 29). The primary outcome was not different between the groups. The intervention group felt more supported in their diabetes care during the social distancing period (82.8% vs. 48.3% in the control group, P < 0.01). Both groups reported a similar self-perceived worsening of physical activity habits and mental health during the outbreak. There was no benefit to using the telehealth strategy proposed for emotional disorders in patients with type 1 diabetes during the COVID-19 outbreak. Further studies are needed to determine the impact on metabolic parameters and to understand why it is so difficult to emotionally support these patients.

Trail Registration: ClinicalTrials.gov (NCT04344210), 14/04/2020.

Effectiveness of eHealth-Based Psychological Interventions for Depression Treatment in Patients With Type 1 or Type 2 Diabetes Mellitus: A Systematic Review

BACKGROUND

Comorbidity between diabetes mellitus and depression is highly prevalent. The risk of depression in a person with diabetes is approximately twice that of a person without this disease. Depression has a major impact on patient well-being and control of diabetes. However, despite the availability of effective and specific therapeutic interventions for the treatment of depression in people with diabetes, 50% of patients do not receive psychological treatment due to insufficient and difficult accessibility to psychological therapies in health systems. The use of information and communication technologies (ICTs) has therefore been proposed as a useful tool for the delivery of psychological interventions, but it continues to be a field in which scientific evidence is recent and controversial. This systematic review aims to update the available information on the efficacy of psychological interventions delivered through ICTs to improve depressive symptomatology in patients with diabetes.

METHODS

A systematic review of the literature was performed following the PRISMA guidelines and using MEDLINE, Embase, PubMed, Web of Science, PsycINFO, Scopus, and Cochrane Library databases to search for randomized clinical trials of eHealth treatments for patients with diabetes and comorbid depression from 1995 through 2020. In addition, studies related to follow-up appointments were identified. Inclusion criteria were as follows: (a) randomized clinical trials (RCTs); (b) patients with type 1 and type 2 diabetes; (c) adult population over 18 years of age; (d) presence of depressive symptomatology assessed with standardized instruments; (e) treatments for depression based on established psychotherapeutic techniques and principles; (f) delivered through eHealth technologies. We did not limit severity of depressive symptomatology, delivery setting or comparison group (treatment as usual or other treatment). Two coauthors independently reviewed the publications identified for inclusion and extracted data from the included studies. A third reviewer was involved to discuss discrepancies found. The PEDro scale was used to assess the quality of the RCTs. No meta-analysis of the results was performed. The protocol used for this review is available in PROSPERO (Reg; CRD42020180405).

RESULTS

The initial search identified 427 relevant scientific publications. After removing duplicates and ineligible citations, a total of 201 articles were analyzed in full text. Ten articles met the criteria of this review and were included, obtaining very good scientific quality after evaluation with the PEDro scale. The main results show that the eHealth psychological intervention for depression in patients with diabetes showed beneficial effects both at the end of treatment and in the short (3 months) and long term (6 and 12 months) for the improvement of depressive symptomatology. The methodology used (type of diabetes, eHealth technology used, recruitment context, implementation and follow-up) was very heterogeneous. However, all studies were based on cognitive-behavioral tools and used standardized assessment instruments to evaluate depressive symptomatology or diagnosis of MDD. Glycemic control was assessed by glycosylated hemoglobin, but no benefits were found in improving glycemic control. Only four studies included psychoeducational content on diabetes and depression, but none used tools to improve or enhance adherence to medical prescriptions or diabetes self-care.

CONCLUSIONS

ICT-based psychological interventions for the treatment of depression in people with diabetes appear to be effective in reducing depressive symptomatology but do not appear to provide significant results with regard to glycemic control. Nonetheless, the scientific evidence reported to date is still very limited and the methodology very diverse. In addition, no studies have implemented these systems in routine clinical practice, and no studies are available on the economic analysis of these interventions. Future research should focus on studying and including new tools to ensure improvements in diabetes outcomes and not only on psychological well-being in order to advance knowledge about these treatments. Economic evaluations should also be undertaken to analyze whether these treatment programs implemented using eHealth technologies are cost-effective.

Online psychological interventions to reduce symptoms of depression, anxiety, and general distress in those with chronic health conditions: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Over the past 15 years, there has been substantial growth in web-based psychological interventions. We summarize evidence regarding the efficacy of web-based self-directed psychological interventions on depressive, anxiety and distress symptoms in people living with a chronic health condition.

METHOD

We searched Medline, PsycINFO, CINAHL, EMBASE databases and Cochrane Database from 1990 to 1 May 2019. English language papers of randomized controlled trials (usual care or waitlist control) of web-based psychological interventions with a primary or secondary aim to reduce anxiety, depression or distress in adults with a chronic health condition were eligible. Results were assessed using narrative synthases and random-effects meta-analyses.

RESULTS

In total 70 eligible studies across 17 health conditions [most commonly: cancer (k = 20), chronic pain (k = 9), arthritis (k = 6) and multiple sclerosis (k = 5), diabetes (k = 4), fibromyalgia (k = 4)] were identified. Interventions were based on CBT principles in 46 (66%) studies and 42 (60%) included a facilitator. When combining all chronic health conditions, web-based interventions were more efficacious than control conditions in reducing symptoms of depression g = 0.30 (95% CI 0.22-0.39), anxiety g = 0.19 (95% CI 0.12-0.27), and distress g = 0.36 (95% CI 0.23-0.49).

CONCLUSION

Evidence regarding effectiveness for specific chronic health conditions was inconsistent. While self-guided online psychological interventions may help to reduce symptoms of anxiety, depression and distress in people with chronic health conditions in general, it is unclear if these interventions are effective for specific health conditions. More high-quality evidence is needed before definite conclusions can be made.

Brief Cognitive Behavioral Therapy for Patients with Comorbid Depression and Type 2 Diabetes in an Urban Primary Care Facility: Randomized Controlled Trial

Background: The relation between depression and diabetes is bidirectional and both can lead to morbidity and mortality. Despite the success of Cognitive Behavioral Therapy (CBT) in managing psychiatric comorbidities, research on its use in the treatment of comorbid diabetes and depression is limited and with varying results. The aim of the study is to assess the efficacy of CBT on depressed patients with type 2 diabetes. Methods: This randomized controlled trial was conducted at an urban primary healthcare center in Egypt from February 2019 to March 2020 and included 80 participants. Key inclusion criteria were uncontrolled type 2 diabetes (T2D) (HbA1c >7.5%) and depression symptoms diagnosed by Beck’s Depression Index. Participants were assessed for all battery of instruments. Subsequently, participants were randomized to control and treatment groups. The treatment group received four CBT sessions. Both groups received a thirty-minute structured diabetes education and their usual diabetes treatment. Three months later, all participants were reassessed for depression and diabetes compliance and all labs were performed post intervention. Both the primary (the difference in HbA1c pre-post intervention) and secondary outcomes (the change in depressive symptoms assessed) were analyzed using ANCOVA.  Results: Both groups were matching at baseline. Post intervention, the CBT group revealed a significant reduction in depressive symptoms while adjusting for Beck Depression Index (BDI) pre-intervention [F (1, 74) = 7.074, p = 0.010]. Moreover, HBA1c was improved significantly when controlling for pre-intervention BDI scores and BMI [F (1,73) = 4.27, p = 0.042] compared to the control group. Conclusions: The CBT program was both inexpensive and easily accessible. It could fit very well in primary care settings. The results indicated CBT intervention was effective in improving diabetes control and depression. However, a larger-scale study to test its effect on a larger scale population and its long-term impact is recommended.

Nocturnal dexmedetomidine alleviates post-intensive care syndrome following cardiac surgery: a prospective randomized controlled clinical trial

BACKGROUND

Dexmedetomidine is a sedative agent that may have the potential to reduce the risk of post-intensive care syndrome (PICS). This study aimed to establish whether prophylactic nocturnal dexmedetomidine safely reduces postoperative PICS incidence and to develop an easy-to-use model for predicting the risk of PICS following cardiac surgery.

METHODS

This was a single-center, double-blind, randomized, prospective, placebo-controlled trial. Patients undergoing cardiac surgery were randomly assigned (1:1) to dexmedetomidine or placebo (normal saline) groups between January 2019 and July 2020. Dexmedetomidine or a similar volume of saline was administered, with an infusion rate up to 1.2 μg/kg/h until the RASS remained between - 1 and 0. The primary study endpoint was PICS incidence at 6 months follow-up, as defined by cognitive, physical, or psychological impairments.

RESULTS

We assessed 703 individuals for eligibility, of whom 508 were enrolled. Of these, there were 251 in the dexmedetomidine group and 257 in the placebo group that received the trial agent, forming a modified intention-to-treat population. PICS incidence at 6-month follow-up was significantly decreased in the dexmedetomidine group (54/251, 21.5%) relative to the placebo group (80/257, 31.1%) (odds ratio [OR] 0.793, 95% CI 0.665-0.945; p = 0.014). Psychological impairment was significantly reduced in the dexmedetomidine group relative to the placebo group (18.7% vs. 26.8%, OR 0.806, CI 0.672-0.967, p = 0.029). However, dexmedetomidine treatment was associated with a higher rate of hypotension. A nomogram revealed that age, education, a medical history of diabetes and smoking, dexmedetomidine treatment, postoperative atrial fibrillation, and sequential organ failure assessment scores at 8 h post-surgery were independent predictors of PICS.

CONCLUSIONS

Prophylactic nocturnal dexmedetomidine administration significantly reduced PICS incidence by a marked reduction in psychological impairment within a 6-month follow-up period.

TRIAL REGISTRATION

ChiCTR, ChiCTR1800014314 . Registered 5 January 2018, http://www.chictr.org.cn/index.aspx.

Clinical Effectiveness and Cost-effectiveness of Videoconference-Based Integrated Cognitive Behavioral Therapy for Chronic Pain: Randomized Controlled Trial

BACKGROUND

Cognitive behavioral therapy is known to improve the management of chronic pain. However, the components of this therapy are still being investigated and debated.

OBJECTIVE

This study aimed to examine the effectiveness of an integrated cognitive behavioral therapy program with new components (attention-shift, memory work, video feedback, and image training) delivered via videoconferencing.

METHODS

This study was unblinded and participants were recruited and assessed face-to-face in the outpatient department. We conducted a randomized controlled trial for chronic pain to compare 16 weekly videoconference-based cognitive behavioral therapy (vCBT) sessions provided by a therapist with treatment as usual (TAU). Thirty patients (age range, 22-75 years) with chronic pain were randomly assigned to either vCBT (n=15) or TAU (n=15). Patients were evaluated at week 1 (baseline), week 8 (midintervention), and week 16 (postintervention). The primary outcome was the change in pain intensity, which was recorded using the numerical rating scale at 16 weeks from the baseline. Secondary outcomes were pain severity and pain interference, which were assessed using the Brief Pain Inventory. Additionally, we evaluated disability, pain catastrophizing cognition, depression, anxiety, quality of life, and cost utility.

RESULTS

In the eligibility assessment, 30 patients were eventually randomized and enrolled; finally, 15 patients in the vCBT and 14 patients in the TAU group were analyzed. Although no significant difference was found between the 2 groups in terms of changes in pain intensity by the numerical rating scale scores at week 16 from baseline (P=.36), there was a significant improvement in the comprehensive evaluation of pain by total score of Brief Pain Inventory (-1.43, 95% CI -2.49 to -0.37, df=24; P=.01). Further, significant improvement was seen in pain interference by using the Brief Pain Inventory (-9.42, 95% CI -14.47 to -4.36, df=25; P=.001) and in disability by using the Pain Disability Assessment Scale (-1.95, 95% CI -3.33 to -0.56, df=24; P=.008) compared with TAU. As for the Medical Economic Evaluation, the incremental cost-effectiveness ratio for 1 year was estimated at 2.9 million yen (about US $25,000) per quality-adjusted life year gained.

CONCLUSIONS

The findings of our study suggest that integrated cognitive behavioral therapy delivered by videoconferencing in regular medical care may reduce pain interference but not pain intensity. Further, this treatment method may be cost-effective, although this needs to be further verified using a larger sample size.

TRIAL REGISTRATION

University Hospital Medical Information Network UMIN000031124; https://tinyurl.com/2pr3xszb.

Support for a non-therapist assisted, Internet-based cognitive-behavioral therapy (iCBT) intervention for mental health in rheumatoid arthritis patients

BACKGROUND

Anxiety is common in patients with rheumatoid arthritis (RA) and associated with worse RA outcomes. This study assessed the feasibility and preliminary health impacts (mental and physical) of a non-therapist assisted, online mental health intervention targeting anxiety in this population.

METHODS

Participants with confirmed RA and elevated anxiety symptoms were enrolled into the Worry and Sadness program, an Internet-based cognitive-behavioral therapy (iCBT) intervention for anxiety and depression shown to be effective in the general population. Validated self-report measures of anxiety, depression, pain interference, fatigue, physical health-related quality of life, functional status, and patient-reported disease severity were collected at baseline, post-intervention, and at three-month follow-up. Emotional distress scores were tracked between lessons. Participants provided qualitative feedback in writing post-intervention.

RESULTS

We analyzed the responses of 34 participants; the majority was female (86%) and the mean age was 57 (SD = 13). Of these, 80% (n = 28) completed the study in its entirety. Among these completers, 94.1% described the program as worthwhile. We found statistically significant improvements in anxiety, depression and fatigue from baseline to three-month follow-up, with small to large effect sizes (d = 0.39-0.81). Post-hoc analyses revealed that statistically significant change occurred between baseline and post-intervention for anxiety and depression and was maintained at three-month follow-up, whereas statistically significant change occurred between baseline and three-month follow-up for fatigue. Statistically significant reductions in emotional distress occurred across the program, with a large effect size (d = 1.16) between the first and last lesson.

CONCLUSION

The Worry and Sadness program shows promise as a feasible resource for improving mental health in RA.

Effectiveness of a Psychoeducational Group Intervention Carried Out by Nurses for Patients with Depression and Physical Comorbidity in Primary Care: Randomized Clinical Trial

The association between physical illness and depression implies a poorer management of chronic disease and a lower response to antidepressant treatments. Our study evaluates the effectiveness of a psychoeducational group intervention led by Primary Care (PC) nurses, aimed at patients of this kind. It is a randomized, multicenter clinical trial with intervention (IG) and control groups (CG), blind response variables, and a one year follow-up. The study included 380 patients ≥50 years of age from 18 PC teams. The participants presented depression (BDI-II > 12) and a physical comorbidity: diabetes mellitus type 2, ischemic heart disease, chronic obstructive pulmonary disease, and/or asthma. The IG (n = 204) received the psychoeducational intervention (12 weekly sessions of 90 min), and the CG (n = 176) had standard care. The patients were evaluated at baseline, and at 4 and 12 months. The main outcome measures were clinical remission of depressive symptoms (BDI-II ≤ 13) and therapeutic response (reduction of depressive symptoms by 50%). Remission was not significant at four months. At 12 months it was 53.9% in the IG and 41.5% in the CG. (OR = 0.61, 95% CI, 0.49–0.76). At 4 months the response in the IG (OR = 0.59, 95% CI, 0.44–0.78) was significant, but not at 12 months. The psychoeducational group intervention led by PC nurses for individuals with depression and physical comorbidity has been shown to be effective for remission at long-term and for therapeutic response at short-term.

Effect of group cognitive behavioural therapy on psychological stress and blood glucose in people with type 2 diabetes mellitus: A community-based cluster randomized controlled trial in China

OBJECTIVE

To assess whether group cognitive behavioural therapy (GCBT) delivered by general practitioners reduces anxiety and depression and improves glycaemic levels in adults with type 2 diabetes mellitus.

METHODS

We conducted a community-based cluster randomized controlled trial in adults with type 2 diabetes mellitus from 48 communities in China. Participants received either GCBT plus usual care (UC) or UC only. General practitioners were trained in GCBT before intervention in the intervention group. The primary outcome was glycated haemoglobin (HbA_1c ) concentration. Outcome data were collected from all participants at baseline, 2 months, 6 months and 1 year. The secondary outcomes were depression (Patient Health Questionnaire-9; PHQ-9) and anxiety (General Anxiety Disorder questionnaire; GAD-7).

RESULTS

The GCBT group showed greater improvement in GAD-7 and PHQ-9 scores, respectively, than the UC group after 2 months post-baseline (T = -6.46, p < 0.0001; T = -5.29, p < 0.001), 6 months (T = -4.58, p < 0.001; T = -4.37, p < 0.001) and 1 year post-intervention (T = -3.91, p < 0.001; T = -3.57, p < 0.001). There was no difference in HbA_1c values between the GCBT and UC groups at 2 months while the values were lower in the GCBT group at 6 months and 1 year (T = -6.83, p < 0.001; T = -4.93, p < 0.001, respectively). Subgroup analysis indicated a long-term effect of GCBT only for mild and moderate anxiety and mild depression groups. Similarly, HbA_1c values reduced only in the mild and moderate anxiety and the mild depression groups.

CONCLUSIONS

General practitioners can deliver GCBT interventions. GCBT plus UC is superior to UC for reducing mild/moderate anxiety and depression, and improving glycaemic levels.

TRIAL REGISTRATION

Chinese clinical trials registration (ChiCTR-IOP-16008045).

Treatment for comorbid depressive disorder or subthreshold depression in diabetes mellitus: Systematic review and meta-analysis

OBJECTIVE

To provide an estimate of the effect of interventions on comorbid depressive disorder (MDD) or subthreshold depression in type 1 and type 2 diabetes.

METHODS

Systematic review and meta-analysis. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomized controlled trials evaluating the outcome of depression treatments in diabetes and comorbid MDD or subthreshold symptoms published before August 2019 compared to care as usual (CAU), placebo, waiting list (WL), or active comparator treatment as in a comparative effectiveness trial (CET). Primary outcomes were depressive symptom severity and glycemic control. Cohen's d is reported.

RESULTS

Forty-three randomized controlled trials (RCTs) were selected, and 32 RCTs comprising 3,543 patients were included in the meta-analysis. Our meta-analysis showed that, compared to CAU, placebo or WL, all interventions showed a significant effect on combined outcome 0,485 (95% CI 0.360; 0.609). All interventions showed a significant effect on depression. Pharmacological treatment, group therapy, psychotherapy, and collaborative care had a significant effect on glycemic control. High baseline depression score was associated with a greater reduction in HbA1 c and depressive outcome. High baseline HbA1 c was associated with a greater reduction in HbA1 c.

CONCLUSION

All treatments are effective for comorbid depression in type 1 diabetes and type 2 diabetes. Over the last decade, new interventions with large effect sizes have been introduced, such as group-based therapy, online treatment, and exercise. Although all interventions were effective for depression, not all treatments were effective for glycemic control. Effective interventions in comorbid depressive disorder may not be as effective in comorbid subthreshold depression. Baseline depression and HbA1 c scores modify the treatment effect. Based on the findings, we provide guidance for treatment depending on patient profile and desired outcome, and discuss possible avenues for further research.

Transforming Population-Based Depression Care: a Quality Improvement Initiative Using Remote, Centralized Care Management

INTRODUCTION

With the growing prevalence of value-based contracts, health systems are incentivized to consider population approaches to service delivery, particularly for chronic conditions like depression. To this end, UW Medicine implemented the Depression-Population Approach to Health (PATH) program in primary care (PC) as part of a system-wide Center for Medicare and Medicaid Innovation (CMMI) quality improvement (QI) initiative.

AIM

To examine the feasibility of a pilot PATH program and its impact on clinical and process-of-care outcomes.

SETTING

A large, diverse, geographically disparate academic health system in Western Washington State including 28 PC clinics across five networks.

PROGRAM DESCRIPTION

The PATH program was a population-level, centralized, measurement-based care intervention that utilized a clinician to provide remote monitoring of treatment progress via chart review and facilitate patient engagement when appropriate. The primary goals of the program were to improve care engagement and increase follow-up PHQ-9 assessments for patients with depression and elevated initial PHQ-9 scores.

PROGRAM EVALUATION

We employed a prospective, observational study design, including commercially insured adult patients with new depression diagnoses and elevated initial PHQ-9 scores. The pilot intervention group, consisting of accountable care network (ACN) self-enrollees (N = 262), was compared with a similar commercially insured cohort (N = 2527) using difference-in-differences analyses adjusted for patient comorbidities, initial PHQ-9 score, and time trends. The PATH program was associated with three times the odds of PHQ-9 follow-up (OR 3.28, 95% CI 1.79-5.99), twice the odds of a follow-up PC clinic visit (OR 1.74, 95% CI 0.99-3.08), and twice the odds of treatment response, defined as reduction in PHQ-9 score by ≥ 50% (OR 2.02, 95% CI 0.97-4.21).

DISCUSSION

Our results demonstrate that a centralized, remote care management initiative is both feasible and effective for large academic health systems aiming to improve depression outcome ascertainment, treatment engagement, and clinical care.

Feasibility study of real-time online text-based CBT to support self-management for people with type 1 diabetes: the Diabetes On-line Therapy (DOT) Study

INTRODUCTION

This study examines the feasibility of conducting diabetes-focused cognitive-behavioral therapy (CBT) via a secure online real-time instant messaging system intervention to support self-management and improve glycemic control in people with type 1 diabetes.

RESEARCH DESIGN AND METHODS

We used a pre-post uncontrolled intervention design over 12 months. We recruited adults with type 1 diabetes and suboptimal glycemic control (HbA1c ≥69 mmol/mol (DCCT 8.5%) for 12 months) across four hospitals in London. The intervention comprised 10 sessions of diabetes-focused CBT delivered by diabetes specialist nurses. The primary outcomes were number of eligible patients, rates of recruitment and follow-up, number of sessions completed and SD of the main outcome measure, change in HbA1c over 12 months. We measured the feasibility of collecting secondary outcomes, that is, depression measured using Patient Health Questionnaire-9 (PHQ-9), anxiety measured Generalised Anxiety Disorder (GAD) and the Diabetes Distress Scale (DDS).

RESULTS

We screened 3177 patients, of whom 638 were potentially eligible, from whom 71 (11.1%) were recruited. The mean age was 28.1 (13.1) years, and the mean HbA1c was 84.6 mmol/mol (17.8), DCCT 9.9%. Forty-six (65%) patients had at least 1 session and 29 (41%) completed all sessions. There was a significant reduction in HbA1c over 12 months (mean difference -6.2 (2.3) mmol/mol, DCCT 0.6%, p=0.038). The change scores in PHQ-9, GAD and DDS also improved.

CONCLUSIONS

It would be feasible to conduct a full-scale text-based synchronized real-time diabetes-focused CBT as an efficacy randomized controlled trial.

A Web-Based Mental Health Intervention to Improve Social and Occupational Functioning in Adults With Type 2 Diabetes (The Springboard Trial): 12-Month Outcomes of a Randomized Controlled Trial

BACKGROUND

People with type 2 diabetes mellitus (T2DM) often experience mental health symptoms that exacerbate illness and increase mortality risk. Access to psychological support is low in people with T2DM. Detection of depression is variable in primary care and can be further hampered by mental health stigma. Electronic mental health (eMH) programs may provide an accessible, private, nonstigmatizing mental health solution for this group.

OBJECTIVE

This study aims to evaluate the efficacy over 12 months of follow-up of an eMH program (myCompass) for improving social and occupational functioning in a community sample of people with T2DM and self-reported mild-to-moderate depressive symptoms. myCompass is a fully automated and self-guided web-based public health program for people with depression or anxiety. The effects of myCompass on depressive symptoms, diabetes-related distress, anxiety symptoms, and self-care behavior were also examined.

METHODS

Adults with T2DM and mild-to-moderate depressive symptoms (N=780) were recruited via online advertisements, community organizations, and general practices. Screening, consent, and self-report questionnaires were administered online. Eligible participants were randomized to receive either myCompass (n=391) or an attention control generic health literacy program (Healthy Lifestyles; n=379) for 8 weeks. At baseline and at 3, 6, and 12 months postintervention, participants completed the Work and Social Adjustment Scale, the Patient Health Questionnaire-9 item, the Diabetes Distress Scale, the Generalized Anxiety Disorder Questionnaire-7 item, and items from the Self-Management Profile for Type 2 Diabetes. Glycosylated hemoglobin measurements were obtained at baseline and 6 and 12 months postintervention.

RESULTS

A total of 38.9% (304/780) of the trial participants completed all postintervention assessments. myCompass users logged in on an average of 6 times and completed an average of 0.29 modules. Healthy Lifestyles users logged in on an average of 4 times and completed an average of 1.37 modules. At baseline, the mean scores on several outcome measures, including the primary outcome of work and social functioning, were close to the normal range, despite a varied and extensive recruitment process. Intention-to-treat analyses revealed slightly greater improvement at 12 months in work and social functioning for the Healthy Lifestyles group relative to the myCompass group. All participants reported equivalent improvements in depression anxiety, diabetes distress, diabetes self-management, and glycemic control across the trial.

CONCLUSIONS

The Healthy Lifestyles group reported higher ratings of social and occupational functioning than the myCompass group, but no differences were observed for any secondary outcome. Although these findings should be interpreted in light of the near-floor symptom scores at baseline, the trial yields important insights into how people with T2DM might be engaged in eMH programs and the challenges of focusing specifically on mental health. Several avenues emerge for continued investigation into how best to deal with the growing mental health burden in adults with T2DM.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Number (ACTRN) 12615000931572; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368109&isReview=true.

Comparing the Preferences of Patients and the General Public for Treatment Outcomes in Type 2 Diabetes Mellitus

BACKGROUND

Healthcare treatments and interventions are traditionally evaluated from the societal perspective, but a more patient-centric perspective has been proposed in recent years. We sought to compare preferences of patients and the general public for treatment outcomes of type 2 diabetes using both best-worst scaling (BWS) and rating approaches.

METHODS

A survey evaluating the treatment priorities for type 2 diabetes was conducted in the United States. Members of the general public and patients with type 2 diabetes were recruited from a nationally sampled panel. Participants indicated the importance of seven potential treatment outcomes (hypoglycemic events, glycated hemoglobin [A1c], weight loss, mental health, functioning, glycemic stability, and cardiovascular health) using (1) BWS case 1 and (2) a rating task. Preference differences from BWS prioritizations were explored using mixed logistic regression (BWS preference weights were probability re-scaled so that the weightings of the seven items collectively summed to 100). The consistency of scale between samples was explored using heteroskedastic conditional logistic regression of BWS data. Spearman rank correlation was used to compare standardized BWS preference weights and rating scores for each group. Both groups evaluated the BWS and rating activities using debriefing questions.

RESULTS

The public and patient samples included 314 and 313 respondents, respectively. The public was on average 16 years younger than patients (48 vs 64 years, P < 0.001). In BWS, patients and the public both ranked A1c, glycemic stability, and cardiovascular health within their top three outcomes. Patients valued the outcome A1c most highly and found it twice as important as did the public (41.0 vs 20.2, P < 0.001). The public valued cardiovascular health most highly, and found it to be twice as important than did patients (31.3 vs 17.4, P < 0.001). Patients were more consistent in their preferences than the public (λ = 1.66, P = 0.01). Preferences elicited using BWS and rating approaches were highly correlated for both patients (ρ = 0.96) and the public (ρ = 0.92). Patients were more likely than the public to endorse the BWS as easy to answer (P < 0.001), easy to understand (P < 0.001), consistent with preferences (P < 0.001), and relevant (P < 0.001). Both patients and the public found the rating activity easier to answer and understand, and more consistent with their preferences, than the BWS (P < 0.001).

CONCLUSIONS

We provide some of the first evidence demonstrating a difference in patient and public treatment priorities for diabetes. That patients were more consistent in their preferences than the public and found the BWS and Likert rating instruments more relevant suggests that patient priorities may be more appropriate than those of the general public in some medical decision-making contexts.

A randomized controlled trial of internet-delivered cognitive behaviour therapy to prevent the development of depressive disorders in older adults with multimorbidity

BACKGROUND

Multimorbidity, which commonly impacts older adults is associated with higher rates of depression. We aimed to investigate whether internet delivered cognitive-behaviour therapy (iCBT) could prevent depressive disorders in older adults with multimorbidity who were not currently depressed.

METHOD

302 primary care and community participants aged 65 years and over, who had multimorbidity but did not meet criteria for a depressive disorder were randomised to an intervention group who received an eight-week, five session iCBT (n = 150) or to a control group (n = 152) who received treatment as usual. Diagnostic interviews were conducted at baseline, and three and six months after the intervention period, where indicated, and the presence of depressive disorder was the primary outcome.

RESULTS

The intention to treat, chi-square analyses indicated there were significantly fewer cases of depressive disorder in the treatment group compared to the control group by six-month follow-up (χ²(1,302) = 5.21, p = .02).

LIMITATIONS

The main limitations of this RCT are a short follow up period and low proportion of participants who developed depressive disorders. Participants were relatively well educated, with a majority having English as their first language.

CONCLUSIONS

These results indicate that depressive disorder was prevented in the first six months following iCBT with three times the number of cases of depressive disorder in the control group compared to the treatment group. Further research is required to determine whether iCBT can be effective for preventing depressive disorder in this population over a longer time period.

Pharmacotherapeutic strategies for managing comorbid depression and diabetes

Introduction: The increasing prevalence of comorbid depression and diabetes exerts a heavy burden on global health. Co-occurrence of depression and diabetes is common, affecting 14% to 35.8% of patients with diabetes, leading to a higher mortality and morbidity rate, more micro- and macro-vascular diseases and more cognitive decline. Areas covered: In this paper, the authors address various areas from epidemiology, the association between depression and diabetes, treatment strategies and future directions based on the currently available literature to provide novel insight into the pharmacotherapeutic management of comorbid depression and diabetes. Expert opinion: Pharmacotherapy can help patients with comorbid depression and diabetes by relieving depressive symptoms and improving glycemic control. When combined with psychological therapy, as a collaborative care effort, pharmacological therapy based on selective serotonin reuptake inhibitors (SSRIs) is recommended for comorbid depression with diabetes. Furthermore, studies with larger sample sizes that can help to define different subtypes of diabetes and severity of depression are needed so that clinicians can draw up a precise and applicable management guidelines for the personalized therapy of these diseases.

A Web-Based Cognitive Behavior Therapy Intervention to Improve Social and Occupational Functioning in Adults With Type 2 Diabetes (The SpringboarD Trial): Randomized Controlled Trial

Background

Depressive symptoms are common in people with type 2 diabetes mellitus (T2DM). Effective depression treatments exist; however, access to psychological support is characteristically low. Web-based cognitive behavioral therapy (CBT) is accessible, nonstigmatizing, and may help address substantial personal and public health impact of comorbid T2DM and depression.

Objective

The aim of this study was to evaluate the Web-based CBT program, myCompass, for improving social and occupational functioning in adults with T2DM and mild-to-moderate depressive symptoms. myCompass is a fully automated, self-guided public health treatment program for common mental health problems. The impact of treatment on depressive symptoms, diabetes-related distress, anxiety symptoms, and self-care behavior was also examined.

Methods

Participants with T2DM and mild-to-moderate depressive symptoms (N=780) were recruited online via Google and Facebook advertisements targeting adults with T2DM and via community and general practice settings. Screening, consent, and self-report scales were all self-administered online. Participants were randomized using double-blind computerized block randomization to either myCompass (n=391) for 8 weeks plus a 4-week tailing-off period or an active placebo intervention (n=379). At baseline and postintervention (3 months), participants completed the Work and Social Adjustment Scale, the primary outcome measure. Secondary outcome measures included the Patient Health Questionnaire-9 item, Diabetes Distress Scale, Generalized Anxiety Disorder Questionnaire-7 item, and items from the Self-Management Profile for Type 2 Diabetes.

Results

myCompass users logged in an average of 6 times and completed an average of .29 modules. Healthy Lifestyles users logged in an average of 4 times and completed an average of 1.37 modules. At baseline, mean scores on several outcome measures, including the primary outcome of work and social functioning, were near to the normal range, despite an extensive recruitment process. Approximately 61.6% (473/780) of participants completed the postintervention assessment. Intention-to-treat analyses revealed improvement in functioning, depression, anxiety, diabetes distress, and healthy eating over time in both groups. Except for blood glucose monitoring and medication adherence, there were no specific between-group effects. Follow-up analyses suggested the outcomes did not depend on age, morbidity, or treatment engagement.

Conclusions

Improvement in social and occupational functioning and the secondary outcomes was generally no greater for myCompass users than for users of the control program at 3 months postintervention. These findings should be interpreted in light of near-normal mean baseline scores on several variables, the self-selected study sample, and sample attrition. Further attention to factors influencing uptake and engagement with mental health treatments by people with T2DM, and the impact of illness comorbidity on patient conceptualization and experience of mental health symptoms, is essential to reduce the burden of T2DM.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12615000931572; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368109&isReview=true (Archived by WebCite at http://www.webcitation.org/7850eg8pi)

Internet-delivered cognitive behaviour therapy for chronic health conditions: a systematic review and meta-analysis

This systematic review and meta-analysis aims to evaluate the effectiveness of internet-delivered cognitive behavioural therapy (ICBT) on anxiety and depression among persons with chronic health conditions. A systematic database search was conducted of MEDLINE, CINAHL, PsycInfo, EMBASE, and Cochrane for relevant studies published from 1990 to September 2018. A study was included if the following criteria were met: (1) randomized controlled trial involving an ICBT intervention; (2) participants experienced a chronic health condition; (3) participants ≥ 18 years of age; and (4) effects of ICBT on anxiety and/or depression were reported. The Cochrane Risk of Bias tool was used to assess the risk of bias on the included studies. Pooled analysis was conducted on the primary and condition specific secondary outcomes. Twenty-five studies met inclusion criteria and investigated the following chronic health conditions: tinnitus (n = 6), fibromyalgia (n = 3), pain (n = 7), rheumatoid arthritis (n = 3), cardiovascular disease (n = 2), diabetes (n = 1), cancer (n = 1), heterogeneous chronic disease population (n = 1), and spinal cord injury (n = 1). Pooled analysis demonstrated small effects of ICBT in improving anxiety and depression. Moderate effects of therapist-guided approach were seen for depression and anxiety outcomes; while, self-guided approaches resulted in small effects for depression and moderate effects in anxiety outcomes. ICBT shows promise as an alternative to traditional face-to-face interventions among persons with chronic health conditions. Future research on long-term effects of ICBT for individuals with chronic health conditions is needed.

Trial Registration PROSPERO registration number: CRD42018087292.

Web-Based Interventions for Depression in Individuals with Diabetes: Review and Discussion

Background

Depression is twice as common in people with diabetes, and this comorbidity worsens the course of both pathologies. In clinical practice guidelines, screening and treatment of depression in patients with diabetes are highly recommended. However, depression is still both underrecognized and undertreated. To find ways to enhance their reach, psychological treatments have taken advantage of benefits of internet and technological devices as delivery formats, providing interventions that require considerably less (or even no) interaction time with therapists. Web-based treatments hold promise for effective interventions at low cost with positive results.

Objective

The objectives of this review were to describe Web-based interventions for depression in individuals with diabetes and to discuss these studies’ procedures and findings in light of evidence from a wider range of interventions for depression and diabetes.

Methods

A comprehensive literature search was conducted in PsycINFO and MEDLINE electronic databases. Studies were included when they met the following selection criteria: the study was available in a peer-reviewed journal mainly publishing studies written in either English or Spanish; the studied sample comprised individuals with diabetes; the intervention targeted depression symptomatology; the intervention was accessible via the internet; and the intervention was accessible via the internet with little or no clinician support.

Results

Overall, 5 research studies were identified in the review. All studies were randomized controlled trials, and most used a wait list as a control; 4 studies reported treatment dropout, rates of which varied from 13% to 42%. Studies supported the notion that the Web-based format is a suitable psychology service delivery option for diabetic individuals with depression (effect size range for completers 0.7-0.89). Interventions varied in their characteristics but most were clinical-assisted, had a cognitive behavioral therapy approach, used diabetes-specific topics, had a weekly modular display, used homework assignments, and had some adherence management strategy. These characteristics are consistent with the intervention features associated with positive results in the literature.

Conclusions

The analyzed studies’ findings and procedures are discussed in light of evidence drawn from a wider range of reviews on Web-based interventions for depression and diabetes. Consistent with previous research on depression treatment, Web-based interventions for depression among individuals with diabetes have shown positive results. Future research should contribute new evidence as to why these interventions are effective, for whom, and which particular aspects can increase patients’ adherence.