I arrived at my friend’s house in Fort Worth last night after 13 hours in the car and only two pit-stops. I had planned on being a little more leisurely about it, but once I was going, I just wanted to get here, thus there was no stopping to soak up a little wi-fi time. Starting tomorrow, I have a couple of guest blogs queued up so far, and some offers to guest blog so hopefully there will be more to follow.

Today is Thesis Thursday though, a weekly series of consecutive sections from my master’s thesis, Art Therapy with Type 1 Diabetic Adolescents, Non-Adherent to Treatment: A Literature Based Study. Last week, you read the first part of my review of some research on psychosocial intervention research, specifically research focusing on medical office-based treatment. Today I offer a discussion of a research study on the application of cognitive-behavior treatment.

Psychosocial Interventions for Diabetes (continued)

Cognitive-Behavioural group training (CBGT) was examined by van der Ven, Chatrou, and Snoek (2000).

Central to cognitive therapy is the assumption that behaviour and emotions are in constant interaction with cognitions. These cognitions or beliefs may be inaccurate, leading to excessive emotional reactions and a failure to cope effectively. The aim of cognitive therapy is to help make patients identify their dysfunctionsl cognitions, test them against reality and alter them, thereby modifying emotional disturbances and improving coping behaviour. (van der Ven, Chatrou & Snoek, 2000, p. 209)

In CBGT, cognitive and behavioral techniques such as cognitive restructuring, stress-management, and cueing are implemented “to help patients to diminish diabetes-related distress, to reduce perceived barriers to various aspects of self-management and to enhance coping skills” (van der Ven, Chatrou & Snoek, 2000, p. 213). The goal of Cognitive-Behavioural group training “is to help patients cope more effectively with their diabetes regimen, in order to improve glycaemic control, without compromising, and possibly enhancing, psychological well-being” (van der Ven, Chatrou & Snoek, 2000, p. 213).

A psychologist and diabetes educator facilitated the CBGT in four consecutive two hour weekly meetings to groups of five to eight participants. A different theme was addressed each week. These themes were:

(a) the way cognitions affect emotions and behavior—developing a different view on diabetes and self-care; (b) stress and metabolic control—ways to cope with stressful situations; (c) diabetes, complications and the future—ways to cope with worries and insecurity; and (d) diabetes and social relationships—ways to obtain support from your environment. (van der Ven, Chatrou & Snoek, 2000, p. 214)

The 24 participants in this study were not adolescent, but all had type 1 diabetes for a mean duration of 17.62 (±9.35) years. The mean age of the participants was 35.17 (±11.13); two were on conventional (two injection) insulin therapy, seventeen were on intensive (> three injections) insulin therapy, and five were on insulin pump therapy; and the mean HbA1c was 9.22 (±1.19) at baseline (van der Ven, Chatrou & Snoek, 2000, p. 219).

Van der Ven, Chatrou and Snoek (2000) concluded that after the course of CBGT, there were improvements in diabetes-related distress, measured with the Dutch version of the Problem Areas In Diabetes (PAID) questionnaire (p. 222). Using the Perceived Barriers in Diabetes Self-care scale (BDQ), they saw a slight decrease compared to baseline (p. 223). The barriers considered most serious by the participants were items concerning SMBG, difficulties maintaining normal blood-glucose levels in special situations (i.e. weekends, when under increased stress), and items relating to hypoglycemia (p. 222).

The Hypoglycaemia Fear Survey (HFS) measured changes in fear of hypoglycemia as a barrier to good diabetes control. Van der Ven, Chatrou and Snoek (2000) found that fear of hypoglycemia was not a problem to the group as a whole at baseline. Two of the twenty-four participants scored high at baseline however, indicating that this was a significant barrier for them. Again, at three months follow-up, fear of hypoglycemia was not a problem for the group as a whole.

However, one participant had an increased worry score (29-42), without an increase in hypoglycaemic episodes, while two others had considerably lower scores (drops from 26 to 17 and from 61 to 54). Although this last change may be an important improvement clinically, it still indicates a high level of fear. (van der Ven, Chatrou & Snoek, 2000, p. 223)

Emotional well-being was measured using the short form of the Well-Being Questionnaire (WBQ-12). Following treatment, mean total score increased slightly, indicating some overall improvement and positive well-being increased significantly, “indicating that improvement of HbA1c did not occur at the cost of well-being” (van der Ven, Chatrou & Snoek, 2000, p. 223).

A short form of the Diabetes Self-Care Inventory-1 (DSC-1) was used to assess self-care behaviors.

Self-reported self-care behaviour varied greatly among participants … The degree of non-adherence varied from participants not inspecting their feet to not performing SMBG at all. Given this large inter-individual variation, the effects of CBGT are likely to be differential: every participant has his/her own areas of potential improvement. (van der Ven, Chatrou & Snoek, 2000, pp. 223-224)

The researchers found that for SMBG, only one of seven non-adherers improved; they had expected greater improvement at follow-up (p. 224). When taking diabetes into account when eating or drinking, seven reported this to be the case some of the time, while five never or rarely did this; at follow-up only one of these participants had improved (p. 224).

In analyzing glycemic control of the participants, nine were in moderately poor control (HbA1c 8-9%), nine were in poor control (HbA1c 9-10%), and four were in very poor control (HbA1c > 10%) at baseline. At three months follow-up, mean HbA1c improved from 9.57 (±1.22) to 8.86 (±1.38), with all participants in very poor control at baseline showing improvement, some significant, and participants in the poor control and moderately poor control groups showing varied results. At six months follow-up, some participants in poor control at baseline who did not show improvement at three months follow-up, did eventually show improvement in HbA1c levels (van der Ven, Chatrou & Snoek, 2000, p. 225).

Hypoglycemic episodes, noted as an item of concern for the participants using the Perceived Barriers in Diabetes Self-care scale, were measured at baseline and at follow-up. The mean number of hypoglycemic episodes per week doubled from 2.07 (±1.32) to 4.17 (±3.47). According to the researchers, “the increase of hypos may be directly related to the observed improvement in glycaemic control. Also, it is likely that participants have become more aware of hypoglycaemia” (van der Ven, Chatrou & Snoek, 2000, p. 226).

The authors conclude that “CBGT appears to be successful in improving HbA1c while reducing diabetes-related distress and preserving well-being” (van der Ven, Chatrou & Snoek, 2000, p. 227). However, they point out that there was not consistent improvement in diabetes-related self-care behavior, although some participants showed significant improvement. Patients in poor control who do not experience correlating distress might not benefit from CBGT due to decreased levels of “readiness to change” (van der Ven, Chatrou & Snoek, 2000, p. 227).

At the conclusion of the study, the researchers decided to add two classes, going from four to six sessions. The first additional session will be based on the theme of goal setting in order to increase focus on self-management behavior and assist patients in setting individual and realistic self-care goals. The theme of the second additional setting will be how to be a patient, focusing on “adopting an assertive, active attitude, to get the most out of contacts with health care providers” (van der Ven, Chatrou & Snoek, 2000, p. 227). While an increased number of sessions will likely impact attendance levels negatively, van der Ven, Chatrou and Snoek (2000) believe that the longer course will ultimately have a positive impact on glycemic levels and emotional well-being (p. 228).

Check back next Thursday for continued discussion of Psychosocial Interventions for Diabetes.