A Randomized Controlled Trial of Cognitive Behavioral Therapy for Adherence and Depression (CBT-AD) in Patients With Uncontrolled Type 2 Diabetes
- Steven A. Safren1⇑,
- Jeffrey S. Gonzalez2,3,
- Deborah J. Wexler4,
- Christina Psaros1,
- Linda M. Delahanty4,
- Aaron J. Blashill1,
- Aleksandra I. Margolina1 and
- Enrico Cagliero4
- 1Behavioral Medicine Service, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- 2Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY
- 3Diabetes Research Center, Albert Einstein College of Medicine, Yeshiva University, Bronx, NY
- 4MGH Diabetes Center, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
- Corresponding author: Steven A. Safren, .
OBJECTIVE To test cognitive behavioral therapy for adherence and depression (CBT-AD) in type 2 diabetes. We hypothesized that CBT-AD would improve adherence; depression; and, secondarily, hemoglobin A1c (A1C).
RESEARCH DESIGN AND METHODS Eighty-seven adults with unipolar depression and uncontrolled type 2 diabetes received enhanced treatment as usual (ETAU), including medication adherence, self-monitoring of blood glucose (SMBG), and lifestyle counseling; a provider letter documented psychiatric diagnoses. Those randomized to the intervention arm also received 9–11 sessions of CBT-AD.
RESULTS Immediately after acute treatment (4 months), adjusting for baseline, CBT-AD had 20.7 percentage points greater oral medication adherence on electronic pill cap (95% CI −31.14 to −10.22, P = 0.000); 30.2 percentage points greater SMBG adherence through glucometer downloads (95% CI −42.95 to −17.37, P = 0.000); 6.44 points lower depression scores on the Montgomery-Asberg Depression Rating Scale (95% CI 2.33–10.56, P = 0.002); 0.74 points lower on the Clinical Global Impression (95% CI 0.16–1.32, P = 0.01); and 0.72 units lower A1C (95% CI 0.29–1.15, P = 0.001) relative to ETAU. Analyses of 4-, 8-, and 12-month follow-up time points indicated that CBT-AD maintained 24.3 percentage points higher medication adherence (95% CI −38.2 to −10.3, P = 0.001); 16.9 percentage points greater SMBG adherence (95% CI −33.3 to −0.5, P = 0.043); and 0.63 units lower A1C (95% CI 0.06–1.2, P = 0.03) after acute treatment ended. For depression, there was some evidence of continued improvement posttreatment, but no between-group differences.
CONCLUSIONS CBT-AD is an effective intervention for adherence, depression, and glycemic control, with enduring and clinically meaningful benefits for diabetes self-management and glycemic control in adults with type 2 diabetes and depression.
This article contains Supplementary Data online at http://care.diabetesjournals.org/lookup/suppl/doi:10.2337/dc13-0816/-/DC1.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health/National Institute of Mental Health; LifeScan, Inc.; or the Harvard Catalyst.
- Received April 5, 2013.
- Accepted October 20, 2013.
- © 2014 by the American Diabetes Association.
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