Diabetes is an epidemic.
There is no cure for diabetes. It can only be treated by avoiding or delaying its consequences with diet, physical activity, medications, and regular screening and treatment for complications.
For this reason, it’s crucial that diabetes patients engage with their treatment programmes to manage their symptoms.
However, some struggle with this due to their mental health.
For a person with diabetes, the difficulties they experience with both their physical and mental health can compound – they’re more likely to develop conditions like anxiety and depression as a result of their diabetes, which then in turn make it harder for them to maintain the lifestyle they need to manage their condition.
To put this into perspective, it’s been reported that people with diabetes are twice as likely to have depression than people who do not. One of the challenges when experiencing depression is it makes it harder for people to remember, concentrate on and motivate themselves to do things they need to do. And if those things are as important as testing blood sugar, remembering to take regular medication, and keeping important doctor appointments, it’s easy to imagine how it can be difficult to manage all of the tasks required for diabetes management while depressed.
Given the severity of the consequences of poorly managed diabetes, the human cost of this can be devastating, but the financial cost is also significant - it is estimated that comorbid physical and mental health conditions increase physical healthcare costs by 45% to 75%.
For this reason, it’s long been recognised that mental health support such as cognitive behavioural therapy (CBT) could improve outcomes for people with diabetes.
But should it be prescribed as an integral part of their treatment? And what could that look like?
ieso has provided high-quality mental health treatment to over 100,000 patients across the last 10 years in partnership with NHS England. And as a pioneer in delivering therapy online, ieso is in a unique position to have reached a significant number of people living with diabetes.
The study
With support from Roche Diabetes Care Ltd, ieso set out to study the impact of ieso therapy on mental health and diabetes management.
In the study of 102 participants with type 2 diabetes, interventions were delivered by accredited therapists over the internet using text, during regularly scheduled synchronous live appointments, and following a diabetes-specific treatment protocol. The study consisted of up to 10 CBT sessions per person lasting up to 60 minutes each. Each course of online CBT was delivered over a period of approximately 12 weeks.
The online CBT therapy was delivered by therapists that were specially trained to understand the physical symptoms of diabetes and how to manage them. Therapists were also trained to use an innovative form of CBT, Acceptance and Commitment Therapy (ACT), that allowed for a more personalised approach than more protocol-driven forms of CBT.
The results
The study results showed that a course of personalised diabetes-specific online CBT helped patients adjust emotionally to their diagnosis and also supported the overall management of their diabetes. Participants who received the personalised diabetes-specific therapy reported reduced levels of distress about having diabetes, increased engagement in managing their condition, and improved quality of life when compared with individuals receiving care as standard. The results also showed that participants had much higher recovery rates in terms of their mood and anxiety symptoms, relative to patients who received traditional CBT that was not tailored to address diabetes-related issues.
- The Diabetes Distress Scale (DDS) is a 17-item self-report instrument where each item is rated on a 6-point scale from (1) “not a problem” to (6) “a very significant problem”. Participants in the study started at an average of 3.40, which is above the threshold of 3 for clinically significant diabetes distress, and decreased on average by 0.94 points with diabetes-tailored online CBT to 2.46 by the end of treatment.
- On the Audit of Diabetes Dependent Quality of Life (ADDQOL) score, which assesses an individual's perceptions of the impact of diabetes on their quality of life, participants who received ieso diabetes-tailored online CBT therapy decreased by 0.45 points, which represents a significant improvement in quality of life.
- Patient Activation Measure (PAM) measures a patient’s ability to manage their illness, classifying them into one of four levels, from 1 (disengaged and overwhelmed) to 4 (maintaining behaviours and pushing further). Participants who received diabetes-tailored online CBT showed a significant improvement in self-management of diabetes, with the proportion of participants at the lowest level of activation (Level 1) decreasing from 44.1% to 23.5%, pre- to post-treatment. The proportion of participants at the highest level of activation (Level 4) increased from 1.0% to 17.7% pre- to post-treatment.
- In terms of their mental health symptoms, participants who received diabetes-tailored online CBT showed recovery rates of 76%, compared with 56% for participants with diabetes who received standard online CBT.
Presenting the study
Shaun Mehew, Head of Clinical Behavioural Science at ieso, was one of the authors of the study and in June he discussed its findings in a symposium at the Association of Contextual Behavioral Science Conference in San Francisco. We spoke to him about the study:
“We have a unique opportunity here at ieso to conduct studies such as this one, and the results are very encouraging- not only does it show that diabetes-specific CBT can improve patient outcomes in Type 2 diabetes management and care, it also shows it can be delivered online. We have a way to go still, but this could pave the way for digital therapeutic products that will form an integral part of the overall treatment that diabetes patients receive.
As one of the authors of the study, alongside my ieso colleagues Dr Ana Catarino, Dr Anne Hayes, and Dr Andy Blackwell, I was pleased to be able to discuss its findings in San Francisco at the Association of Contextual Behavioral Science Conference with other behavioural scientists, researchers, and health professionals.
Scientific research is at the heart of what we do here at ieso, and an important part of that is sharing and discussing it with our peers at events such as this one. We are excited to take this work forward and continue exploring ways to improve the lives of individuals with long-term conditions"
Further to this, ieso also heard feedback on the paper at the American Diabetes Association 82nd Scientific Session, also in June, when our SVP for Clinical Innovation, Dr Jennifer Gentile, presented the results on behalf of the authors. This is the scientific poster she used at the event:
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She told us about some of the key topics that were discussed “It was my pleasure to present the results of this study at the 82nd Scientific Session by the American Diabetes Association, on behalf of my colleagues at ieso who authored it. The ADA Scientific Sessions attract leading physicians, scientists, and health care professionals from around the world to unveil cutting-edge research, treatment recommendations, and advances toward a cure for diabetes.
Accordingly, this is a great opportunity to showcase the study results and receive feedback from our peers in this field of study. Having interacted with many of them throughout the day, the key message I took away from the conference is that a lack of access to high-quality mental healthcare is causing people with diabetes to struggle unnecessarily with their condition, as they have poorer physical health outcomes when mental health conditions are left untreated. On the positive side, there is an openness for effective and engaging digital mental health interventions to help address this. The study shows that ieso are in a unique position to do so.”
With the study providing evidence that integrated approaches for mental healthcare in patients with diabetes can improve patient outcomes in both mental and physical health, is there now cause for optimism that further research into other long-term physical conditions such as cancer, may yield similar results? At ieso, we think so and will continue to explore this further.
