Roles and competencies of the clinical psychologist in adult diabetes care-A consensus report.

AIMS: Psychological care is recognised as an integral part of quality diabetes care. We set out to describe the roles and competencies of the clinical psychologist as a member of the multidisciplinary adult diabetes care team, focused on secondary care. METHODS: The authors are clinically experienced psychologists involved in adult diabetes care, from Australia, Europe and North America, and active members of the international psychosocial aspects of diabetes study group. Consensus was reached as a group on the roles and competencies of the clinical psychologist working in adult diabetes secondary care, building both on expert opinion and a selective review and discussion of the literature on psychological care in diabetes, clinical guidelines and competency frameworks. RESULTS: The clinical psychologist fulfils multiple roles: (1) as a clinician (psychological assessment and therapy), (2) as advisor to the healthcare team (training, consulting), (3) as a communicator and promotor of person-centred care initiatives and (4) as a researcher. Four competencies that are key to successfully fulfilling the above-mentioned roles in a diabetes setting are as follows: (a) specialised knowledge, (b) teamwork and advice, (c) assessment, (d) psychotherapy (referred to as STAP framework). CONCLUSIONS: The roles and competencies of clinical psychologists working in diabetes extend beyond the requirements of most university and post-graduate curricula. There is a need for a comprehensive, accredited specialist post-graduate training for clinical psychologists working in diabetes care, building on the proposed STAP framework. This calls for a collaborative effort involving diabetes organisations, clinical psychology societies and diabetes psychology interest groups.

Economic Evaluation of a Web Application Implemented in Primary Care for the Treatment of Depression in Patients With Type 2 Diabetes Mellitus: Multicenter Randomized Controlled Trial.

BACKGROUND: Depressive disorder and type 2 diabetes mellitus (T2DM) are prevalent in primary care (PC). Pharmacological treatment, despite controversy, is commonly chosen due to resource limitations and difficulties in accessing face-to-face interventions. Depression significantly impacts various aspects of a person's life, affecting adherence to medical prescriptions and glycemic control and leading to future complications and increased health care costs. To address these challenges, information and communication technologies (eg, eHealth) have been introduced, showing promise in improving treatment continuity and accessibility. However, while eHealth programs have demonstrated effectiveness in alleviating depressive symptoms, evidence regarding glycemic control remains inconclusive. This randomized controlled trial aimed to test the efficacy of a low-intensity psychological intervention via a web app for mild-moderate depressive symptoms in individuals with T2DM compared with treatment as usual (TAU) in PC. OBJECTIVE: This study aimed to analyze the cost-effectiveness and cost-utility of a web-based psychological intervention to treat depressive symptomatology in people with T2DM compared with TAU in a PC setting. METHODS: A multicenter randomized controlled trial was conducted with 49 patients with T2DM, depressive symptoms of moderate severity, and glycosylated hemoglobin (HbA1c) of 7.47% in PC settings. Patients were randomized to TAU (n=27) or a web-based psychological treatment group (n=22). This web-based treatment consisted of cognitive behavioral therapy, improvement of diabetes self-care behaviors, and mindfulness. Cost-effectiveness analysis for the improvement of depressive symptomatology was conducted based on reductions in 3, 5, or 50 points on the Patient Health Questionnaire-9 (PHQ-9). The efficacy of diabetes control was estimated based on a 0.5% reduction in HbA1c levels. Follow-up was performed at 3 and 6 months. The cost-utility analysis was performed based on quality-adjusted life years. RESULTS: Efficacy analysis showed that the web-based treatment program was more effective in improving depressive symptoms than TAU but showed only a slight improvement in HbA1c. Incremental cost-effectiveness ratios of 186.76 for a 3-point reduction in PHQ-9 and 206.31 for reductions of 5 and 50 percentage points were obtained. In contrast, the incremental cost-effectiveness ratio for improving HbA1c levels amounted to €1510.90 (€1=US $1.18 in 2018) per participant. The incremental cost-utility ratio resulted in €4119.33 per quality-adjusted life year gained. CONCLUSIONS: The intervention, using web-based modules incorporating cognitive behavioral therapy tools, diabetes self-care promotion, and mindfulness, effectively reduced depressive symptoms and enhanced glycemic control in patients with T2DM. Notably, it demonstrated clinical efficacy and economic efficiency. This supports the idea that eHealth interventions not only benefit patients clinically but also offer cost-effectiveness for health care systems. The study emphasizes the importance of including specific modules to enhance diabetes self-care behaviors in future web-based psychological interventions, emphasizing personalization and adaptation for this population. TRIAL REGISTRATION: ClinicalTrials.gov NCT03426709; https://clinicaltrials.gov/study/NCT03426709. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/S12888-019-2037-3.

Internet-based cognitive-behavioral therapy is effective in reducing depressive symptomatology in type 1 diabetes: results of a randomized controlled trial.

Objective: Depression in people with diabetes is associated with poorer health outcomes. Although web programs integrating cognitive-behavioral therapy with diabetes education have shown good results, no similar approach has been implemented in Spain. This aim of this study was to administer an Internet-based cognitive-behavioral therapy program (CBT) for the treatment of mild-moderate depressive symptomatology in individuals with type 1 diabetes (WEB_TDDI1 study) and evaluate the efficacy of this program. Research design and methods: A pre-post randomized controlled study was conducted. The sample comprised 65 people with type 1 diabetes and mild-moderate depressive symptoms: 35 treatment group (TG) and 30 control group (CG). The following effects of the nine-session program were analyzed: depression (Beck Depression Inventory Fast Screen, BDI-FS), metabolic variables (glycosilated hemoglobin, HbA1c), and other psychological variables including anxiety (State Trait Anxiety Inventory, STAI), fear of hypoglycemia (Fear of Hypoglycemia Questionnaire, FH-15), distress (Diabetes Distress Questionnaire (DDS), quality of life (Diabetes Quality of Life Questionnaire, DQOL),and treatment adherence (Diabetes Self-Care Inventory-Revised questionnaire, SCI-R). Results: At the end of the treatment program, only 28 people were evaluated (TG=8; CG=20). However, a significant reduction was found in both groups in BDI-FS and STAI-T scores, which was significantly greater in the TG. Significant improvements were also found in the TG in DQOL, FH-15, DDS and SCI-R scores. The percentage change in these variables was also statistically significant in the TG versus the CG. However, no significant results were found in HbA1c. Conclusions: The Internet-based cognitive-behavioral therapy program for the treatment of mild-moderate depressive symptomatology in people with type 1 diabetes (WEB_TDDI1 study) is effective in reducing depressive symptomatology in the sample that completed the study. Positive results are also produced in other variables associated with depression in this population such as diabetes-related distress, trait anxiety, fear of hypoglycemia, quality of life, and adherence to diabetes treatment. Although new studies would be necessary to support the results of this platform, the results obtained are positive and support the use of this platform as an appropriate treatment for this population. Clinical trial registration: ClinicalTrials.gov; identifier NCT03473704.

Internet-based Cognitive-behavioral therapy (CBT) for depressive symptomatology in individuals with type 1 diabetes (WEB_TDDI1 study): A randomized controlled trial protocol.

BACKGROUND: Professionals need adequate tools to help patients with diabetes and depression. Although web programs integrating cognitive-behavioral therapy with diabetes education have shown good results, no similar approach has been performed as yet in Spain. The objective is to develop an Internet-based program for the treatment of mild-moderate depressive symptomatology in individuals with type 1 diabetes (WEB_TDDI1 study) based on Cognitive-behavioral therapy (CBT) and assess its results. METHODS: A 2-arm randomized controlled trial will be conducted. Adults with type 1 diabetes and mild-moderate depressive symptoms will be screened to participate in the study and randomly assigned to either the treatment group (TG) that will use a Web-based application for a specific 9-week intervention in depression and type 1 diabetes or the control group (CG) that will be on the waiting list during that time. RESULTS: Data on the primary variable (depressive symptoms) and secondary variables (treatment-related distress, anxiety, fear of hypoglycemia, quality of life, treatment adherence, coping strategies and glycemic control) will be collected from the TG at the beginning/baseline, at the end of treatment and at 3, 6 and 12 months after treatment. The CG will be assessed at the beginning and at the end of the TG intervention. On completion of the program by the TG, the treatment will then be carried out in the CG. CONCLUSIONS: The new web application developed is expected to be effective for the treatment of mild-moderate depressive symptoms in adults with type 1 diabetes, reducing depressive symptoms and improving the rest of the analyzed variables. TRIAL REGISTRATION: Registry: NCT03473704 (March 21, 2018); ClinicalTrials.gov.

Effectiveness of eHealth-Based Psychological Interventions for Depression Treatment in Patients With Type 1 or Type 2 Diabetes Mellitus: A Systematic Review.

BACKGROUND: Comorbidity between diabetes mellitus and depression is highly prevalent. The risk of depression in a person with diabetes is approximately twice that of a person without this disease. Depression has a major impact on patient well-being and control of diabetes. However, despite the availability of effective and specific therapeutic interventions for the treatment of depression in people with diabetes, 50% of patients do not receive psychological treatment due to insufficient and difficult accessibility to psychological therapies in health systems. The use of information and communication technologies (ICTs) has therefore been proposed as a useful tool for the delivery of psychological interventions, but it continues to be a field in which scientific evidence is recent and controversial. This systematic review aims to update the available information on the efficacy of psychological interventions delivered through ICTs to improve depressive symptomatology in patients with diabetes. METHODS: A systematic review of the literature was performed following the PRISMA guidelines and using MEDLINE, Embase, PubMed, Web of Science, PsycINFO, Scopus, and Cochrane Library databases to search for randomized clinical trials of eHealth treatments for patients with diabetes and comorbid depression from 1995 through 2020. In addition, studies related to follow-up appointments were identified. Inclusion criteria were as follows: (a) randomized clinical trials (RCTs); (b) patients with type 1 and type 2 diabetes; (c) adult population over 18 years of age; (d) presence of depressive symptomatology assessed with standardized instruments; (e) treatments for depression based on established psychotherapeutic techniques and principles; (f) delivered through eHealth technologies. We did not limit severity of depressive symptomatology, delivery setting or comparison group (treatment as usual or other treatment). Two coauthors independently reviewed the publications identified for inclusion and extracted data from the included studies. A third reviewer was involved to discuss discrepancies found. The PEDro scale was used to assess the quality of the RCTs. No meta-analysis of the results was performed. The protocol used for this review is available in PROSPERO (Reg; CRD42020180405). RESULTS: The initial search identified 427 relevant scientific publications. After removing duplicates and ineligible citations, a total of 201 articles were analyzed in full text. Ten articles met the criteria of this review and were included, obtaining very good scientific quality after evaluation with the PEDro scale. The main results show that the eHealth psychological intervention for depression in patients with diabetes showed beneficial effects both at the end of treatment and in the short (3 months) and long term (6 and 12 months) for the improvement of depressive symptomatology. The methodology used (type of diabetes, eHealth technology used, recruitment context, implementation and follow-up) was very heterogeneous. However, all studies were based on cognitive-behavioral tools and used standardized assessment instruments to evaluate depressive symptomatology or diagnosis of MDD. Glycemic control was assessed by glycosylated hemoglobin, but no benefits were found in improving glycemic control. Only four studies included psychoeducational content on diabetes and depression, but none used tools to improve or enhance adherence to medical prescriptions or diabetes self-care. CONCLUSIONS: ICT-based psychological interventions for the treatment of depression in people with diabetes appear to be effective in reducing depressive symptomatology but do not appear to provide significant results with regard to glycemic control. Nonetheless, the scientific evidence reported to date is still very limited and the methodology very diverse. In addition, no studies have implemented these systems in routine clinical practice, and no studies are available on the economic analysis of these interventions. Future research should focus on studying and including new tools to ensure improvements in diabetes outcomes and not only on psychological well-being in order to advance knowledge about these treatments. Economic evaluations should also be undertaken to analyze whether these treatment programs implemented using eHealth technologies are cost-effective.

[Strategies of clinical hypothesis testing]. / Estrategias de comprobación de hipótesis clínicas.

This research examines whether Psychology students, when they test clinical hypotheses, follow either confirmatory or disconfirmatory reasoning strategies. Two hundred and six psychology students, divided in four groups, participated. One group received information about the probability that the hypothesis was correct by means of verbal labels, and another group, by means of numerical expressions. An additional group received the information that getting a precise diagnosis was clinically important. In a last group, diagnostic tests allowed them to increase certainty about the hypothesis. Results show a partial use of confirmatory strategies because, although participants did not seek confirming information, they indeed avoided collecting disconfirming information. When the information increased certainty about the hypothesis, confirmatory strategies became more likely. Neither the increase in the task importance nor the numerical expression of the likelihood that the hypothesis was correct seemed to affect the testing strategy used.

Reliability and validity of the Chinese version of the new fear of hypoglycemia scale: FH-15.

OBJECTIVE: This study aimed to evaluate the reliability and validity of the Chinese version of the Fear of Hypoglycemia scale with 15 items (FH-15). METHODS: After obtaining the original author's authorization, the English version of the FH-15 scale was translated, back translated, and culturally debugged to obtain the Chinese version of FH-15. A convenient sampling method was used to extract patients with type 2 diabetes from four tertiary hospitals in Tianjin. A total of 408 patients with type 2 diabetes were investigated in the hospital to test the reliability and validity of Chinese version FH-15 scale. RESULTS: The content validity index of the scale was 0.92, and the content validity index of each item was 0.8-1.0. The exploratory factor analysis extracted three common factors (fear, avoidance, and interference), which contained 15 items, and the cumulative variance contribution rate was 71.245%. The confirmatory factor analysis results showed that the model fit was better at 1.981 χ 2/df, GFI = 0.901, CGI = 0.962, TLI = 0.952, and RMSEA = 0.070. The cut-off value for the total hypoglycemia fear scale was 30.5. The Cronbach's α coefficient of the three dimensions of the scale was 0.918, the Cronbach's α coefficient of each dimension is 0.876-0.916, the test-retest reliability was 0.903, and the test-retest reliability of each factor was 0.733-0.930. CONCLUSION: The Chinese version of the FH-15 scale can be considered reliable and valid. The item expression is concise, clear, and easy to understand. It is suitable for clinical practice as an initial screening tool to identify and evaluate the severity of fear of hypoglycemia in patients with type 2 diabetes.

[Accuracy of diagnosis of depression in patients with Type 1 diabetes mellitus]. / Precisión del diagnóstico de depresión en pacientes con diabetes mellitus tipo 1.

This study assesses the clinical accuracy of physicians (Specialists in Endocrinology and Nutrition: SEN) to make the diagnosis of depression in patients with Type 1 diabetes mellitus (DM1). This study involved 11 SEN physicians, and 153 patients with DM1. The diagnosis of depression was performed using the SCID-1 structured interview and clinical assessment. From the initial sample, 50 patients were randomly selected (imposing the condition that it was included 25 patients with depression and 25 without depression). The results show that clinicians performed a higher percentage of negative diagnoses (patients without depression) than positive ones (patients with depression). A significant percentage of patients with depression were not diagnosed (25%). It therefore seems necessary to provide adequate clinical protocols to evaluate the presence of this disorder in DM1, as well as continuing research into the diagnostic process for clinical decision making.

Development of a new fear of hypoglycemia scale: FH-15.

Hypoglycemia is the most common adverse event associated with insulin treatment in diabetes. The consequences of hypoglycemia can be quite aversive and potentially life threatening. The physical sequelae provide ample reason for patients to fear hypoglycemia and avoid episodes. For these reasons, our purpose in this study was to develop a new measure that explores specific fear of hypoglycemia (FH) in adult patients with type 1 diabetes and to examine its psychometric properties. The instrument developed to assess FH was initially made up of 20 items, of which 18 were negative and 2 were positive, assessed on a 5-point Likert scale (1-5). This scale was completed by 229 patients with type 1 diabetes. Additionally, a structured interview and a closed question called subjective fear of hypoglycemia were included as diagnostic criteria. A factor analysis employing the principal-components method and promax rotation was carried out, resulting in a new scale composed of 15 items. Three factors (fear, avoidance, and interference) were obtained and explained 58.27% of the variance. The scale showed good internal consistency (Cronbach's α = .891) and test-retest reliability (r = .908, p < .001), as well as adequate concurrent and predictive validity. The cutoff score that provided the highest overall sensitivity and specificity was set at 28 points. The Fear of Hypoglycemia 15-item scale (FH-15) demonstrated good reliability and validity. This study suggests that the new instrument may serve as a valuable measure of specific FH for use in research and clinical practice.