Depression: psychological therapies
Psychotherapy has been used to treat depression in adults with type 1 and type 2 diabetes. A variety of treatment approaches have been found to be effective in reducing depressive symptoms and, in some cases, improving glycemic control. The predominant therapeutic orientation has been cognitive-based therapies, such as cognitive behavioral therapy (CBT) and problem-solving therapy (PST), with emerging evidence found using alternative therapies, such as mindfulness-based therapy and exercise. The evidence for the effectiveness of these psychological treatment approaches is provided below.
Cognitive Behavioral Therapy
Drawn from clinical theory and research in the areas of cognitive and behavioral psychology, cognitive behavioral therapy (CBT) posits that cognitions, emotions and behaviors are interwoven and mutually reinforcing in people with depression. These three elements are also influenced by environmental and physical cues that are interpreted by the individual. Treatment involves the identification of “automatic thoughts” (i.e., cognitive biases) that work in the service of negative core cognitive beliefs which can be restructured to enable the patient to make different interpretations of emotional or interpersonal events. CBT may be used in individual face-to-face, web-based or group formats.
In a systematic literature review in 2012, van der Feltz-Cornelius reported that a total of 8 randomized controlled trials (RCT) had been published evaluating the efficacy of psychotherapeutic interventions on depression in adults with type 1 or type 2 diabetes. Studies varied considerably in sample size, type of diabetes treated (type 2 only vs. mixed type 1 and type 2 diabetes), method of depression assessment (e.g. psychiatric evaluation vs. self-reported depressive symptoms) and duration of treatment. Across studies, these approaches showed similar beneficial effects on depressive symptoms or depressive disorders. For example, Lustman and colleagues conducted a randomized controlled trial to compare the efficacy of CBT treatment compared to diabetes education in a cohort of 51 patients with type 2 diabetes and MDD. Lustman found that participants randomized to the CBT arm had an 85% (v. 27% in diabetes education) remission rate of major depression disorder following the 10 session CBT treatment with 70% of the sample remaining depression-free at the 6-month follow-up assessment compared with 36% in the education arm.
More recently, Safren and colleagues conducted a randomized controlled trial of adults with type 2 diabetes and depression in which participants were randomized to either CBT and adherence support (9-11 sessions) or enhanced treatment as usual. Participants receiving CBT showed significant improvements in depression symptoms following treatment (6.4 point decrease on the Montgomery-Asberg Depression Rating Scale) compared to participants receiving enhanced usual care. No group differences were found 4-12 months following the completion of treatment although improvements in depression symptoms were observed across both groups.
Electronic and Telephone-Based CBT
Two trials have been completed to evaluate the effects of either web-based or telephone-based CBT for the treatment of depression in diabetes among adults. Both studies showed improvements in depression following treatment. However, the magnitude of effect for these improvements using these treatment modalities was significantly lower than studies in which participants received face-to-face treatment.
Problem Solving Therapy (PST) identifies problems, selects approaches to address the problems, implements and evaluates these approaches which may be applied to mental health and health conditions. It has been adapted from the fields of cognitive psychology and learning theory. PST posits that depression develops from unsuccessful attempts to solve problems that result in feelings of failure or learned helplessness. In PST, seven core skills are presented and reinforced over the course of brief treatment:
- selecting and defining problem areas;
- identifying realistic and achievable goals;
- identifying possible solutions;
- evaluating the advantages (pros) and disadvantages (cons) of each possible solution;
- choosing a solution;
- creating a plan of action; and
- evaluating outcomes.
Target problems are those within the control of the patient and represent realistic, attainable goals.
PST has been applied to diabetes self-management skills generally as well as depression and diabetes specifically. In the Pathways study, participants were randomized to PST, an antidepressant medication or usual care. Participants were re-evaluated after 12 weeks. In patients who did not show improvement in depressive symptoms, they were offered either a second course of their original treatment choice or were offered another treatment option. At the end of the trial, participants receiving PST showed greater improvements in depressive symptoms, received more treatment, and had greater satisfaction with their treatment experience.
Mindfulness-Based Psychological Therapy
An emerging literature has examined the effectiveness of ‘third wave’ therapies which focus on processes of thinking rather than the content of thoughts. Mindfulness-based therapy has demonstrated an impact on depressive symptoms in adults with type 1 and type 2 diabetes. It is important to note that no trials have been conducted to date in which patients with clinical depression or depressive symptoms have been treated with mindfulness-based therapy. Hartmann and colleagues conducted an RCT for 110 patients with type 2 diabetes and microalbuminuria. Participants randomized to mindfulness-based stress reduction (N=53) received one group (6-10 participants) meeting and a 6-month booster session. At 12-month follow-up, the mindfulness-based stress reduction group showed improved depressive symptoms compared to controls. No differences were observed in levels of microalbuminuria.
Von Son and colleagues reported significant improvements in depressive symptoms in an RCT of 139 outpatients with type 1 or type 2 diabetes randomized to either 8 weekly sessions of mindfulness-based cognitive therapy or wait list control. These data are comparable to two prior studies which also observed improvements in mood symptoms in adults with type 2 diabetes treated with mindfulness-based therapy.
Acceptance and Commitment Therapy (ACT), another emerging ‘third wave’ therapy has been applied in one trial of diabetes self-management. In this trial, Gregg and colleagues randomized 81 patients with type 2 diabetes to either diabetes education, or diabetes education plus 4 hours of group-based ACT. At 3 months, compared with controls, those in the ACT group showed improved glycated haemoglobin (HbA1c), improved coping, and higher diabetes self-care behaviors. Several small, non-randomized mindfulness programs also suggest potential benefits for patients with diabetes. This therapeutic approach has not been applied to the treatment of depression in adults with type 1 or type 2 diabetes to date although there is reason to believe it could be effective.
There has been increased interest in the benefits of ‘exercise as medicine’and in the treatment for depression in adults with diabetes. Exercise has been shown to be an efficacious treatment for clinical depression among adults without type 2 diabetes. In a meta-analysis of 37 exercise intervention trials in clinically depressed samples, Craft & Landers found a large effect size (-0.72) for the impact of exercise on depression regardless of type of aerobic exercise (for example running, walking, other aerobic activity) and depression status (mild to moderate vs. severe) with the greatest impact found in samples with moderate-to-severe levels of depression. Exercise interventions of 9 to12 weeks showed significantly greater impact on depression outcomes with no observed differences between types of exercise used in treatment protocols.
Two studies have examined the effects of exercise on depression in adults with type 2 diabetes. Piette and colleagues conducted a randomized controlled trial of 291 adults with type 2diabetes and significant depressive symptoms in which participants were randomized to telephone-based CBT and walking or usual care. At 12-month follow-up assessment, participants receiving CBT and walking showed significant improvements in depressive symptom scores compared to those in usual care (4.5 point decrease in total scores on the Beck Depression Inventory).
In a pilot study of 50 adults with type 2 diabetes and major depressive disorder, de Groot and colleagues evaluated the effects on depression in participants receiving 10 sessions of individual CBT combined with 12-weeks of community-based exercise. They found that 66% of participants no longer met criteria for major depressive disorder post-intervention and 3-month follow-up assessments in this single-arm effectiveness treatment trial.
Effects of Psychotherapy for Depression on Glycemic Control
A related issue to the efficacy and effectiveness of psychotherapy treatment on depression outcomes among people with diabetes is the extent to which this treatment has an impact on diabetes outcomes. To date, the evidence is mixed for psychological interventions. Lustman and colleagues observed a 0.7% (7 mmol/mol) decline in HbA1c at the 6-month follow-up period while Katon and colleagues did not observe changes in HbA1c using PST. In a systematic review, van der Feltz and colleagues noted mixed results in change in HbA1c across 8 studies using CBT with greater change observed in face-to-face treatment modalities compared to electronic or telephone interventions. Among studies of mindfulness-based therapy, only one pilot study has observed improvements in HbA1c following the use mindfulness-based therapy. In studies using exercise as a treatment modality in participants with diabetes and depression, one study observed improvements in HbA1c following 12 weeks of community-based exercise while the telephone-based CBT and walking protocol did not.
Alleviation of depressive symptoms could be expected to translate to improvements in diabetes self-management behaviors and thereby overall glycemic control, however, these pathways have not been rigorously examined in depression treatment trials. Recent interventions that combine adherence or medication interventions in conjunction with depression treatment have shown the greatest improvements in diabetes outcomes to date for patients with depression and diabetes.
Psychological therapies have been found to be effective in treating depression in mixed samples of adults with type 1 and type 2 diabetes. There is less evidence for additional impacts of these therapies alone on diabetes outcomes such as improved HbA1c. Much work remains to establish the effectiveness of a broader the range of therapeutic approaches, examine the effectiveness of newer psychological treatment modalities that make use of technology, and conduct more research on the treatment of depression in adults with type 1 diabetes separate from type 2 diabetes samples.
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