ReviewAn updated meta-analysis to assess the effectiveness of psychological interventions delivered by psychological specialists and generalist clinicians on glycaemic control and on psychological status
Introduction
Diabetes is a complex metabolic condition in which the patient has a life-long responsibility for managing their condition. The first aim of diabetes management is the control of blood glucose levels, usually termed glycaemic control, which is measured by an HbA1c blood test. HbA1c measures the amount of circulating glucose in the blood over a 120-day period. The aim of treatment and patient management is to achieve HbA1c levels ≤6.5% and the UKPDS [1] established that every 1% reduction in HbA1c towards this goal carries a 14–37% reduction in serious diabetes-related complications such as heart disease, blindness and kidney disease [1]. In order to achieve optimum glycaemic control people living with diabetes have to regulate their behaviour on a daily basis. The behavioural challenges imposed by close attention to diet, medication regimens including subcutaneous insulin injections, exercise, weight management, self-monitoring of daily blood glucose levels and foot care are burdensome and have social and emotional consequences [2]. In addition to this, specific psychological problems including depressive disorders [3], [4] and eating disorders [5] can manifest themselves through poor glycaemic control thus giving rise to further complications.
Ismail et al. [2] published a systematic review and meta-analysis in 2004 which identified the potential clinical and psychological benefits of offering psychological interventions to patients with type 2 diabetes. The review [2] incorporated interventions comprising the most commonly used psychotherapeutic models used in health-care settings. They included supportive or counselling therapy (including motivational interviewing and non-directive counselling), brief psychodynamic therapy, interpersonal psychotherapy and cognitive behaviour therapy and its associated techniques including contract setting, goal setting, problem solving, activity scheduling, stress management and relaxation.
Ismail et al. [2] identified 25 trials and observed significant reductions in HbA1c of 1%, similar to that of the UKPDS [1] but notably and unlike the UKPDS, these were achieved by non-pharmacological means. Psychological distress was also reduced. The findings suggest that psychological therapies may be a useful adjunct to current routine diabetes care.
However, despite the apparent benefits of psychological care in diabetes [6], [7], [8], there remains a severe shortage of psychological specialists within mainstream health care preventing access for the majority of patients [9]. Ismail et al.’s [2] review included a number of trials in which the psychological intervention had been delivered by a physician or nurse (generalist clinicians) compared to delivery by a professional with specialist training in psychology (specialist). It is not clear whether the discipline and training of the therapist makes a difference to outcome. If psychological interventions can be effectively delivered by generalist clinicians, access to this care becomes more possible for patients.
This paper reports an update to the Ismail et al. [2] review and meta-analysis to establish whether the 1% reduction in HbA1c has been maintained and to compare the impact of the intervention on glycaemic control and psychological status if the intervention is delivered by generalist clinicians compared to psychological specialists. Additionally, the previous review was subjected to some criticism upon publication and there was concern that the small sample sizes of included trials and poor trial quality had resulted in an overestimation of treatment effect [10], [11]. We will report on whether the quality of psychological intervention trials has improved subsequent to the more recent common acceptance of the CONSORT trial quality criteria [12].
Section snippets
Selection criteria
The review follows the original protocol [13] and eligible studies were randomised control trials (RCT's) utilising a psychological intervention in adults with type 2 diabetes. Studies describing psychological therapies were included as were psycho-educational studies with a detailed psychological component and where the intervention balance was more towards the psychological component. We classified the interventions based on the psychological techniques used, mode of delivery and type of
Description of new trials
The 2003–2007 searches identified 3218 new studies from which 48 full texts were selected for further extraction with a substantial level of agreement between the reviewers (κ = 0.67) [14]. Fig. 1 shows the flow of original and newly identified studies considered for the review. Ten new trials which were published after the CONSORT statement [12] were identified for inclusion in the systematic review.
Discussion
The current review identified 10 additional trials to add to the original review and in total 35 RCTs were included in the review. Meta-analysis of 19 trials of psychological interventions demonstrated a 0.54% reduction in HbA1c. The psychological specialists delivered a 0.57% reduction in HbA1c and the generalist clinicians a 0.51% reduction. The positive trend in increasing sample size was not concomitant with improvements in the reporting of potential biases and hence trial quality, which
Acknowledgements
We would like to thank the following colleagues for their help in undertaking this review and preparing this manuscript, Chris Bridle, Khalida Ismail, Hilary Hearnshaw, Hugh McGuire and Chiu Wong.
Contributors: KI and KW developed the protocol and search strategy, JS devised and designed the study. JS, RA and KW undertook data-extraction. RL & RA undertook the analysis. RA, RL & JS co-wrote the initial drafts. All authors contributed to the final manuscript.
Funding: This study was funded by a
References (60)
- et al.
Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes
Lancet
(2004) - et al.
The course of major depression in diabetes
Gen Hosp Psychiat
(1997) - et al.
A systematic review of psychosocial outcomes following education, self-management and psychological interventions in diabetes mellitus
Patient Educ Couns
(2003) Should we trust results of meta-analyses?
Lancet
(2004)- et al.
Should we trust results of meta-analyses?
Lancet
(2004) - et al.
The consort statement: revised recommendations for improving the quality of reports of parallel-group randomised trials
Lancet
(2001) - et al.
Assessing the quality of reports of randomized clinical trials: is blinding necessary?
Control Clin Trials
(1996) - et al.
Self-monitoring of blood glucose-psychological aspects relevant to changes in hba1c in type 2 diabetic patients treated with diet or diet plus oral antidiabetic medication
Patient Educ Couns
(2006) - et al.
Comparison of behavioral interventions for control of type ii diabetes mellitus
Behav Ther
(1986) - et al.
Smoking-cessation interventions by type of provider: a meta-analysis
Am J Prev Med
(2004)
Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (ukpds 35): prospective observational study
Brit Med J
Prevalence of depression in adults with diabetes: an epidemiological evaluation
Diabetes Care
Relationship of weight and eating disorders in type 2 diabetic patients: a multicenter study
Int J Eat Disorder
Effects of educational and psychosocial interventions for adolescents with diabetes mellitus: a systematic review
Health Technol Assess
Psychological interventions to improve glycaemic control in patients with type 1 diabetes: systematic review and meta-analysis of randomised controlled trials
Brit Med J
Psychological interventions for improving glycaemic control in patients with diabetes mellitus
(Protocol) Cochrane Database of Systematic Reviews
The measurement of observer agreement for categorical data
Biometrics
Meta-analysis: state-of-the-science
Epidemiol Rev
Measuring inconsistency in meta-analyses
Brit Med J
Empirical evidence of bias, dimensions of methodological quality associated with estimates of treatment effects in controlled trials
J Am Med Assoc
Bias in meta-analysis detected by a simple, graphical test
Brit Med J
Operating characteristics of a rank correlation test for publication bias
Biometrics
Effects of comprehensive psycho-intervention on life quality and carbohydrate metabolism in patients with type 2 diabetes mellitus
Zhongguo Linchuang Kangfu
Intervention effects of music relaxation therapy on the quality of life in patients with diabetic retinopathy
Zhongguo Linchuang Kangfu
Effects of diabetes education and psychological intervention on comprehensive treatment of type 2 diabetes
Chin J Clin Psychol
Comprehensive intervention on diabetes mellitus
Chin Ment Health J
Effects of a 12-month activity counselling intervention on glycaemic control and on the status of cardiovascular risk factors in people with type 2 diabetes
Diabetologia
A nurse-coaching intervention for women with type 2 diabetes
Diabetes Educator
Effect of mental intervention on type 2 diabetics: randomized controlled study
Zhongguo Linchuang Kangfu
Cited by (78)
Diabetes and Mental Health
2023, Canadian Journal of DiabetesFactors affecting self-management among adolescents and youths with type 2 diabetes mellitus: A meta-synthesis
2020, European Journal of Integrative MedicineBereavement, Grief and Adult Type 1 Diabetes: Living With Diabetes Today
2020, Canadian Journal of DiabetesCitation Excerpt :Some notable risk factors for MDD in those with diabetes, irrespective of type, include adolescent/young adult age, female sex, poor glycemic control (hypoglycemia), burden of illness and presence of complications (1,6). Common psychotherapies have been found to improve psychological outcomes and diabetes management (7,8), regardless of whether the therapies were conducted by general clinicians or specialists (9). Higher suicide risk (10) and increased risk of mortality from diabetes complications (11) highlight the urgency for comprehensive strategies to treat mental health concerns among those living with T1D.
2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines
2019, Journal of the American College of CardiologyDiabetes and Mental Health
2018, Canadian Journal of DiabetesCitation Excerpt :Psychological interventions with children and adolescents, as well as families, have been shown to improve mental health (136), including overall well-being and perceived quality of life (137), along with reducing depressive symptoms (138). In addition, there is evidence to show that psychosocial interventions can positively affect glycemic control (139,140). Most importantly, some studies have demonstrated that psychological interventions can increase both diabetes treatment adherence and glycemic control, as well as psychosocial functioning (141,142).