A systematic review of psychosocial outcomes following education, self-management and psychological interventions in diabetes mellitus

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Abstract

Self-management and psychological interventions for diabetes have become increasingly common and have shown some positive impact on glycemic control. The association of such interventions with psychosocial outcomes is however, less clear. The current review examines the impact of these interventions on psychosocial outcomes including depression, anxiety, adjustment and quality of life. A systematic search of the literature was performed on Medline, Embase and Psychlit. Reference lists were screened for studies that met inclusion/exclusion criteria. Studies were coded on outcomes both over time and relative to control groups. In addition studies were classified as being principally educational, self-management or psychological in type, and the different components in the intervention were determined. Thirty-six studies were identified. Detrimental effects were not generally seen following any type of intervention. Depression seemed to be particularly improved following psychological interventions, whilst quality of life improved more following self-management interventions. A number of methodological issues, such as the specificity of measure used, characteristics of the population and type of intervention were however, influential in the impact of interventions on outcomes. It is recommended that future studies would benefit from being larger with controlled designs, using diabetes specific measures and providing clearer descriptions of intervention components. This will allow greater understanding of what contexts different interventions are most suited to, and which components are key to, improving psychological well-being and quality of life.

Introduction

Management of diabetes requires a complex and demanding behavioral regimen, commonly including diet, exercise, medication and blood sugar testing as key components of care. Over the past two decades, an appreciation of the difficulties associated with following such a regimen, such as poor adherence and low mood, has been reflected in the number of interventions developed to address these issues. These may be classified into three basic types. Two focus principally on issues to do with adherence to the regimen. Early interventions with this aim were basic education programs developed on the premise that increased knowledge would lead to improved adherence and hence outcomes. It is now apparent, however, that while knowledge is necessary it is often insufficient for behavior change and improved clinical outcomes in diabetes [1]. Consequently, more recent interventions, referred to as self-management interventions, tend to go further than just providing information and include a variety of techniques including technical skills training, behavioral and problem solving approaches, and may address how an individuals diabetes specific beliefs and attitudes impact on behavior [2], [3], [4]. A third set of interventions work directly on certain mood states such as depression, anxiety or high levels of stress. These psychological interventions aim to reduce the negative mood states, through mainly cognitive approaches [5], [6].

Evaluation of psychological interventions is often by psychosocial outcomes and, traditionally, evaluation of education and self-management interventions has been by glycemic control. A number of systematic reviews and meta-analysis have indicated the overall benefits of such interventions on this outcome [7], [8], [9], [10]. Glasgow and Osteen [11] however highlighted that other important variables were often not measured in these intervention studies. They and others have argued that it is important to consider psychosocial outcomes such as quality of life and depression or diabetes distress [11], [12], [13]. The evaluation of these outcomes in relation to education and self-management interventions is important for a number of reasons.

Firstly, it is possible that more intensive management of diabetes, including self-management, could lead to increased feelings of burden and subsequent negative effects on psychological well-being and quality of life. If this is the case, the benefits of improved glycemic control from self-management interventions would have to be weighed against their negative impact on psychological well-being and quality of life. In contrast no change on psychosocial outcomes could be viewed as a positive outcome.

Secondly, it is possible that psychological well-being and quality of life may improve following self-management or educational interventions. This would be important given that the incidence of factors such as depression and anxiety are reportedly higher for individuals with diabetes than the general population. Studies have reported that the incidence of depression and anxiety for individuals with diabetes is 41 and 49%, respectively, while it is less than 10% in the general population [14]. Similarly, quality of life is reported to be lower for individuals with either type 1 or 2 diabetes than in the general population [13]. Any improvement in these figures would clearly be beneficial.

For all three types of intervention improvements in psychological well-being and quality of life might also lead to clinical benefits in terms of metabolic control. A review by Lustman et al. [15] reported evidence to suggest that especially within the type 2 population, reductions in depression are associated with better glycemic control. A similar pattern has been indicated for quality of life where better ratings are associated with lower HbA1c levels [13]. Whilst the direction of causality in these studies is unclear it reinforces the importance of assessing psychological well-being and quality of life in all three types of interventions.

It is likely, however, that the populations that each type of intervention targets will differ. For example self-management and education interventions may target individuals either with low adherence or poor levels of glycemic control, whilst psychological interventions would be more likely to target individuals with high levels of depression, anxiety or stress. These differences mean that it is important to consider the impact of different types of intervention separately, and examine whether they vary in their impact on psychological well-being and quality of life.

The current review also aims to go further by considering which of the elements or components of interventions are associated with greatest efficacy. Components are for example discussion, skills training, problem solving, cognitive techniques, etc. An examination of the components of interventions is necessary because of the diverse nature of interventions. Such an approach seeks to give a more informed view as to what elements of interventions work, for what outcomes, in what context. This approach has been used in other chronic conditions [16]. Although previous reviews of diabetes interventions have considered which general methods and theoretical basis have been used in interventions [7], [8], [10] they have not examined the components of interventions in relation to different psychosocial outcomes.

Section snippets

Method

Studies to be included in the review were identified using the following search terms in Embase, Medline and Psychlit: (diabetes) plus (intervention, program/programme or trial) plus (quality of life, adjustment, depression or anxiety). The search covered years 1980–2001 inclusive. In addition studies were identified by manually searching reference lists of reviews and retrieved papers.

Inclusion criteria were studies which (i) investigated an adult (>21 years of age) population with type 1 or 2

Study characteristics

Thirty-six studies evaluated either psychological well-being or quality of life as an outcome. Fifty-four percent of studies were conducted with patients with type 2 diabetes, 11% type 1 and 35% used a combined sample. The range of mean ages for participants in the studies was 24–70 years with the majority (68%) of studies having a mean population age in the 50s or 60s. Three studies used single sex samples while the rest tended to have a higher percentage of women compared to men (70%). In

Discussion and conclusions

The identification of 36 studies which examined the impact of a self-management program on psychological well-being or quality of life was encouraging given that previous papers have reported that the measurement of such outcomes is infrequent [11], [54]. Seventy-five percent of studies in this review were reported after 1992, which suggests that the call from Glasgow and Osteen [11] to measure more than the traditional outcomes of glycemic control and knowledge has been followed.

It is clear

Practice implications

The findings of this review support the use of both self-management and psychological interventions in diabetes care, although, the choice between these two types of intervention may be dependent on the population of interest. There is not, however, convincing evidence to further support the use of didactic education programs alone given their relative lack of efficacy for improving glycemic control [7], [8], [9] and their relative lack of benefits compared to self-management or psychological

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