Cognitive-Behavioral Therapy for Adherence and Depression (CBT-AD) in Type 2 Diabetes
Gonzalez, Jeffrey S., McCarl, Lauren A., Wexler, Deborah J., Cagliero, Enrico, Delahanty, Linda, Soper, Tiffany D., Goldman, Valerie, Knauz, Robert, Safren, Steven A., Journal of Cognitive Psychotherapy
Depression is one of the most common psychological problems among individuals with diabetes, and is associated with worse treatment adherence and clinical outcomes. As part of a program of treatment research aimed at integrating interventions for depression and treatment nonadherence, five depressed patients with suboptimally controlled type 2 diabetes were treated with 10-12 sessions of individual cognitive-behavioral therapy for adherence and depression (CBT-AD) in a case-series design. The intervention was delivered in a hospital setting by a collaborative team consisting of a psychologist, a nurse educator, and a dietitian. Post-treatment, all participants demonstrated a decrease in depression severity and demonstrated improvements in diabetes self-care. Four of the five demonstrated improved glycemic control. These preliminary results provide evidence for the acceptability, feasibility, and potential utility of CBT-AD for patients with type 2 diabetes and depression.
Keywords: CBT; depression; diabetes; adherence; compliance
Depression is a common condition facing individuals with a medical illness in general and diabetes in particular. Patients with diabetes are estimated to be 160%-200% more likely to experience depression as the general population (Adriaanse et al., 2008; Ali, Stone, Peters, Davies, & Khunti, 2006; Anderson, Freedland, Clouse, & Lustman, 2001; Egede, 2005; Fisher et al., 2008). When depression is present in these patients, even at subclinical levels, it is consistently associated with worse diabetes control and increased risk of complications of diabetes (de Groot, Anderson, Freedland, Clouse, & Lustman, 2001; Lustman et al., 2000). Most strikingly, depressed diabetes patients have been shown to face 2.3 times the risk of mortality as patients with type 2 diabetes who are not depressed (Katon et al., 2005). This is of concern because type 2 diabetes is one of the largest public health problems facing the United States today, affecting approximately 8% of the US population (Centers for Disease Control and Prevention, 2008).
Nonadherence to the diabetes treatment regimen may be one pathway through which depression is associated with worse diabetes outcomes. A recent meta-analysis of depression and treatment nonadherence in 47 independent samples of patients with diabetes documented a consistent association between depression and nonadherence, with effect sizes near the medium range for the relationship between symptoms of depression and most diabetes self-care behaviors (Gonzalez et al., 2008). The relationship between depression and diabetes treatment adherence is important because the ability to treat and manage type 2 diabetes is largely dependent upon patient adherence to a set of complex self-care behaviors (Anderson, 1995). These adherence behaviors include 1) adherence to medications that control hyperglycemia and the metabolic conditions associated with type 2 diabetes, such as hypertension and hyperlipidemia, 2) adherence to dietary recommendations aimed at lowering blood glucose by reducing body weight and improving diet composition, 3) increasing physical activity to improve insulin sensitivity and facilitate weight loss, 4) self-monitoring of blood glucose levels to measure fluctuations in glucose and the impact of behavioral factors on glucose levels (e.g., medication, exercise, diet), and 5) proper preventive foot care to reduce the risk of podiatric complications.
Generally speaking, individuals with diabetes, like individuals with other chronic illnesses in general, exhibit suboptimal adherence to medical recommendations, with patients with diabetes exhibiting the second lowest adherence rate of the 17 chronic illnesses (see meta-analysis by DiMatteo, 2004; Hernandez-Ronquillo, Tellez-Zenteno, Garduno-Espinosa, & Gonzalez-Acevez, 2003; Kirk, Mutrie, Macintyre, & Fisher, 2003; Rubin, 2005). Misconceptions about diabetes and its treatment are prevalent and associated with worse diabetes control (Mann, Ponieman, Leventhal, & Halm, 2009), and concerns about negative effects of treatment, which are often unfounded, are associated with nonadherence to antihyperglycemic and antihypertensive treatments and worse diabetes and hypertension control in patients with diabetes (Aikens & Piette, 2009). …