Psychological therapy in youth with diabetes

The prevalence of psychological issues in young people with diabetes is significantly higher than in those without, yet the aetiology for the increased risk remains largely unclear. Depression prevalence has been reported as 12% in children and 18-22% in adolescents with diabetes, anxiety ranges between 9-19% and eating disorders, particularly in girls, range between 8-30%. In addition, adjustment disorder is also high in children as they adapt to the diagnosis of diabetes with around 30% of children developing some form of withdrawal and anxiety in the 3 months following diagnosis. The incidence of psychological issues is associated with decreased self-care, poor diabetes outcomes, higher HbA1c and increased health costs.

In adolescence, those with diabetes not only have to deal with the physiological and hormonal changes of puberty but also cope with how this impacts on their metabolic control and family relationships. Although adolescents want to establish autonomy, this is a difficult stage when they make the transition from child to adult care services -a process that is not always smooth - and when families typically become less involved in their diabetes management. Previous studies have found that 25% of adolescents do not adhere to medication, often failing to see its importance, and almost half of adolescents have a HbA1c greater than 9.0% thus increasing their risk of complications if they have not already started to develop [1]. Furthermore, children with DKA are more likely to have psychiatric disorders than children with good metabolic control [2]. Psychological treatment and support are particularly important for youth who are more vulnerable to problems and who are at risk of life-long diabetes complications.

Psychological treatments for youth are effective

Based on evidence from numerous reviews we can conclude that psychological treatment is effective for children and adolescents with type 1 diabetes. Four of these were systematic reviews and meta-analyses demonstrating a significant moderate effect of psychological treatment on glycaemic control, a reduction of HbA1c in the region of 0.3-0.5% [3][4] or effect size of -0.3- -0.6 [3][4][5], and improvement in psychosocial outcomes (effect size, -0.33 - -0.46 [3][4][6]). Whilst each of the meta-analyses had different aims, 3 focussed on psycho-educational/psychological interventions for children and/or adolescents and the other focussed on family interventions for children, most drew similar conclusions. Most found, that the quality of intervention studies is improving and successful intervention is dependent on using a psychological or behavioural intervention in addition to education. Most studies demonstrating a good outcome were delivered to the family, groups of families or parents.

The most commonly identified modes of therapy were cognitive behavioural therapy (CBT), supportive or counselling approaches and family systems therapy. Since the Winkley review [4] there have been a further 7 randomised controlled trials published targeting a population with sub-optimal glycaemic control. Two of these used family CBT [7][8], 1 study used family systemic therapy [9], 1 study used behavioural family systems therapy specific to diabetes [10], 1 study used individual counselling [11] and 1 used motivational interviewing [12]. There were significant improvements in family functioning [7][8], blood glucose testing and inpatient admissions [9] in addition to improved glycaemic control and quality of life compared with the control group[10][11][12].

Target of treatment and mode of delivery

Many interventions in children and adolescence now include the family as the target of treatment and especially in the months immediately after diagnosis. Studies in adolescence that have addressed communication within families and encouraged families to take a more supportive, less intrusive role have also found a significant improvement in metabolic control and in family life [2]. Other studies that have focussed on coping skills interventions for families have found positive results using a behavioural family systems group therapy approach[10].

The majority of psychological interventions in diabetes that are delivered in groups primarily target glycaemic control [3][4] but improvements have been found in stress management and coping skills [2]. This has clear advantages over individual treatment in terms of logistics and costs especially in family therapy but also adolescents and their carers found the peer-to-peer contact in group sessions rewarding and supportive. There have been a number of studies demonstrating a significant effect of peer-support on psychological outcomes, including a mentoring program and a residential camp delivering peer-support and education. However, not all group interventions or those using peer support demonstrate significant results. Moreover, one study found significant results in a one to one setting using a motivational interviewing approach [12], which may be more appropriate depending on the outcome that the patient and care provider wish to improve.

In recent years, there have been developments in telehealth behaviour therapy that have aimed to improve the accessibility and engagement with trained professionals by administrating problem solving and communication skills over the phone or by web-based interventions [13]. Evidence so far has indicated that although cost-effective, reduction in HbA1c has been non-significant with increased unsupportive parental behaviour in the intervention group [13]. However, this is likely to become an avenue for future research owing to the relative lack of age-specific interventions for adolescents living with diabetes.

Whilst some would recommend that psychological services are delivered by trained professionals such as a psychologist or counsellor, research from adult diabetes studies suggests that diabetes health professionals can be trained to deliver therapy. However, best practice would involve training the diabetes team to recognise, identify and discuss psychological problems with the family, and to have referral pathways for psychological services.

Discussion

Psychological interventions for youth are successful and are associated with improved glycaemic control, especially for adolescents, and improved psychological/family functioning when they involve the family. Most research has focussed on improving self-management and mild psychological distress rather than more severe forms of psychological and psychiatric problems. Higher intensity interventions with multiple sessions are more likely to be successful perhaps because the interventionists have had more time to develop, practice and apply the skills. Maintenance of treatment is necessary to avoid decline in improvement with regular and timely assessment of glycaemic control [3].

Effective interventions targeting youth with type 2 diabetes, eating disorders or diabetes related anxieties are rare or non-existent and more research is needed in these areas.

There is now almost universal recommendation that children and adolescents should have access to specific psychological care and that this should be integrated into their diabetes management with regular screening for psychosocial disorders and managing expectations at critical time points [2]. However, psychological services for youth are not widely available, may not meet the requirements of current guidelines and diabetes health professionals are less confident talking about psychosocial issues than medical ones. In summary, it is necessary to continue to raise the profile and importance of psychosocial diabetes care for young people.

References

  1. ^ Kovacs M, Brent D, Steinberg TF, Paulauskas S, Reid J (1986) Children's self-reports of psychological adjustment and coping strategies during the first year of insulin-dependent diabetes mellitus. Diabetes Care 9: 189-195

  2. ^ Delamater AM (2009) Psychological care of children and adolescents with diabetes. Pediatric Diabetes 10: 175-184

  3. ^ Hampson SE, Skinner TC, Hart J, et al. (2001) Effects of educational and psychosocial interventions for adolescents with diabetes mellitus: a systematic review. In. Health Technology Assessment, York, pp 1-77

  4. ^ Winkley K, Landau S, Ismail K (2006) Psychological interventions to improve glycaemic control in type 1 diabetes: systematic review and meta-analysis of randomised controlled trials. British Medical Journal 333: 65-68

  5. ^ Armour TA, Norris SL, Jack Jr L, Zhang X, Fisher L (2005) The effectiveness of family interventions in people with diabetes mellitus: a systematic review. Diabetic Medicine 22: 1295-1305

  6. ^ Murphy HR, Rayman G, Skinner TC (2006) Psycho-educational interventions for children and young people with Type 1 diabetes. Diabetic Medicine 23: 935-943

  7. ^ Ambrosino JM, Fennie K, Whittemore R, Jaser S, Dowd MF, Grey M (2008) Short-term effects of coping skills training in school-age children with type 1 diabetes. Pediatric Diabetes 9: 74-82

  8. ^ Nansel TR, Anderson BJ, Laffel LMB, et al. (2009) A multisite trial of a clinic-integrated intervention for promoting family management of pediatric type 1 diabetes: feasibility and design. Pediatric Diabetes 10: 105-115

  9. ^ Ellis DA, Yopp J, Templin T, et al. (2007) Family mediators and moderators of treatment outcomes among youths with poorly controlled type 1 diabetes: results from a randomized controlled trial. Journal of Pediatric Psychology 32: 194-205

  10. ^ Wysocki T, Harris MA, Buckloh LM, et al. (2007) Randomized trial of behavioral family systems therapy for diabetes. Diabetes care 30: 555-560

  11. ^ Nansel TR, Iannotti RJ, Simons-Morton BG, Pltonick LP, Clark LM, Zeitzoff L (2009) Long-term maintenance of treatment outcomes: diabetes personal trainer intervention for youth with type 1 diabetes. Diabetes care 32: 807-809

  12. ^ Channon SJ, Huws-Thomas MV, Rollnick S, et al. (2007) A Multicenter Randomized Controlled Trial of Motivational Interviewing in Teenagers With Diabetes. Diabetes care 30: 1390-1395

  13. ^ Lehmkuhl HD, Storch EA, Cammarata C, et al. (2010) Telehealth behavior therapy for the management of type 1 diabetes in adolescents. Journal of diabetes science and technology 4: 199-208

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