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Randomised controlled trial
CBT improves glucose control and psychosocial factors in type 1 diabetes
  1. Marcel C Adriaanse
  1. Correspondence to Marcel C Adriaanse
    Section of Prevention and Public Health, Department of Health Sciences and EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands; marcel.adriaanse{at}

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Type 1 diabetes is a chronic disease that requires continuing medical care, education and diligent patient self-management. Tight blood glucose control is essential in preventing acute and long-term complications, as demonstrated by the landmark diabetes control and complications trials.1 2 Yet many patient have persistently poor glycaemic control – that is, high HbA1c levels. This is mainly a result of difficulties coping with the daily demands of diabetes self-care. Cognitive behavioural therapy (CBT) is an innovative psychotherapeutic approach to enhancing patients' self-management and well-being that may lead to better glycaemic control.

Amsberg and colleagues report results from a 48-week randomised trial that examined the impact of a CBT-based intervention on HbA1c, self-care behaviours and psychosocial factors among adult patients with poorly controlled type 1 diabetes. This study showed greater improvements in all outcomes in the intervention group than in the control group. The authors conclude that CBT-based intervention appears to be a promising approach to diabetes self-management.

Although this was a well-designed study, the data need to be interpreted with caution. Major limitations were the relatively small sample sizes, the attrition, the lack of blinding and the unsatisfactory blood glucose levels. Moreover, the primary outcome of interest (HbA1c levels) did not change in the intervention and control group at 8–48 weeks. Nonetheless, it should be noted that the authors included relevant patient-reported outcomes in addition to HbA1c, including diabetes-related distress, depression and frequency of blood glucose monitoring. Continuous blood glucose monitoring has been shown to be associated with improved glycaemic control in adults with type 1 diabetes.3

Previously only two randomised studies of CBT among patients with poorly controlled type 1 diabetes have been conducted. The first study showed improvements in self-efficacy, diabetes-related distress and mood at 3-month follow-up but not in glycaemic control.4 The second study compared CBT with blood glucose awareness training, with special interest in the long-term effects on HbA1c moderated by depression.5 It was concluded that CBT can effectively help patients with type 1 diabetes with co-morbid depression achieve and maintain better glycaemic outcomes. Yet no significant impact on HbA1c at 6-month and 12-month follow-up was found. Unlike in the study by Amsberg and colleagues, the overall effect of CBT on glycaemic control is not shown in other studies.

Research in this area is in its infancy. At present the implications for clinical and nursing practice are limited. New interactive media such as mobile phones and the Internet are part of today's approach to diabetes research, and the results of trials of these media are awaited. More rigorous research is needed to show the effectiveness of CBT in patients with poorly controlled type 1 diabetes. In particular, there is a great need for larger-scale blinded randomised controlled trials with long-term follow-up. Future systematic reviews including meta-analysis should establish the direction and magnitude of effect. Special efforts are needed to overcome attrition in randomised controlled trials. It is hoped that future initiatives will lead to better glycaemic control and psychosocial outcomes and fewer long-term clinical complications, ultimately improving the quality of life of patients with type 1 diabetes and their families.


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  • Competing interests None.

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