In uncontrolled type 2 diabetes, CBT improved glycemic control and reduced depression

Safren SA, Gonzalez JS, Wexler DJ, et al. A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in patients with uncontrolled type 2 diabetes. Diabetes Care. 2014;37:625-33.

Clinical impact ratings: F ★★★★★★✩ M ★★★★★★★★ e ★★★★★★✩ Question

Main results

In patients with uncontrolled type 2 diabetes and depression, does adding cognitive–behavioral therapy for adherence and depression (CBT-AD) to enhanced usual care (EUC) reduce depression and improve glycemic control?

Adding CBT-AD to EUC reduced depression and depressionrelated impairment and improved glycemic control (Table).

Methods Design: Randomized controlled trial. NCT00564070. Allocation: Unclear allocation concealment.* Blinding: Blinded* (patients, interventionists, dietitians, and outcome assessors). Follow-up period: 4 months (immediately after treatment). Later follow-up assessments are not reported here because follow-up was < 80%. Setting: Massachusetts General Hospital, USA. Patients: 87 adults 18 to 70 years of age (mean age 57 y, 51% men) who had suboptimally controlled type 2 diabetes (hemoglobin A1c [HbA1c] ≥ 7%) despite treatment with an oral hypoglycemic; depression; and stable use of antidepressant, oral hypoglycemic, and insulin therapies for 2 months. Exclusion criteria included severe depression; current or previous CBT for depression; or active and untreated major mental illness, bipolar disorder, eating disorder, dementia, mental retardation, or suicidality. Intervention: CBT-AD plus EUC (n = 45) or EUC alone (n = 42). EUC comprised a meeting with a nurse diabetes educator, nutritional assessment and goal-setting with a dietitian, and a CBT intervention designed to increase adherence to medical recommendations and self-management goals. CBT-AD comprised 8 to 11 additional sessions, which included motivational interviewing for behavior change, mood- and thought-monitoring, increasing pleasurable activities, cognitive restructuring, problemsolving, and relaxation training. Outcomes: Depression (Montgomery-Asberg Depression Rating Scale), depression-related impairment and distress (Clinical Global Impression), and glycemic control (HbA1c). Patient follow-up: 90% at 4 months (intention-to-treat analysis). Cognitive–behavioral therapy for adherence and depression (CBT-AD) plus enhanced usual care (EUC) vs EUC alone in uncontrolled type 2 diabetes with depression† Outcomes

Mean adjusted scores

Difference in P value scores at 4 mo (95% CI)

CBT-AD + EUC alone EUC Depression (MADRS)‡



6.2 (2.3 to 10.6)


Clinical Global Impression‡



0.7 (0.2 to 1.3)


HbA1c (%)



0.72 (0.3 to 1.2)


†Hb = hemoglobin; MADRS = Montgomery-Asberg Depression Rating Scale; CI defined in Glossary. All scores adjusted for baseline values. ‡Lower scores indicate less depression or impairment. Clinical Global Impression score possible range was 1 (not ill) to 7 (extremely ill).

19 August 2014 | ACP Journal Club | Volume 161 • Number 4

Conclusion In patients with uncontrolled type 2 diabetes and depression, adding cognitive–behavioral therapy for adherence and depression to enhanced usual care reduced depression and improved glycemic control. *See Glossary.

Sources of funding: National Institute of Mental Health; Harvard Catalyst, Harvard Clinical and Translation Science Center; National Institutes of Health. For correspondence: Dr. S.A. Safren, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA. E-mail [email protected]

Commentary CBT is useful for patients with chronic diseases who have comorbid psychiatric disorders, difficulty adjusting to illness, or suboptimal compliance with treatment regimens (1). Safren and colleagues developed an integrated CBT intervention tailored for patients with suboptimally controlled type 2 diabetes and mild to moderate depression. This is an important group of patients given the increased risk for depression in type 2 diabetes (2) and the negative effect of depression on diabetes treatment adherence and glycemic control (3). Surprisingly, the study did not report adherence to, or new prescriptions for, antidepressants during the trial, which may have had an effect on depression outcomes. The trial results support using CBT in this common clinical setting. However, one cannot discern whether any face-to-face intervention that added 9 to 12 visits over 4 months would have yielded similar outcomes for adherence and diabetes control. Although the results are promising, the availability of skilled therapists and time during typical diabetes management clinical encounters are both limited, which makes including CBT by primary providers less feasible. Use of Web-based, self-paced CBT is a promising approach for treating depression and diabetes-related emotional distress in patients with type 1 and type 2 diabetes (4). However, withdrawal rates are high and access may be limited for disadvantaged minorities as well as patients who are elderly, have lower incomes, or are less educated. David L. Bronson, MD, MACP Kathleen S. Franco, MD, FACP Cleveland Clinic, Cleveland, Ohio, USA References 1. White CA. Chronic Behaviour Therapy for Chronic Medical Problems. New York: John Wiley & Sons Ltd; 2001. 2. Nouwen A, Winkley K, Twisk J, et al; European Depression in Diabetes (EDID) Research Consortium. Diabetologia. 2010;53:2480-6. 3. Pouwer F, Nefs G, Nouwen A. Endocrinol Metab Clin North Am. 2013;42:529-44. 4. van Bastelaar KM, Pouwer F, Cuijpers P, Riper H, Snoek FJ. Diabetes Care. 2011;34:320-5. © 2014 American College of Physicians

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