Psychotherapeutic Interventions for Type 2 Diabetes Mellitus

*Keisha C. Gobin, Jennifer S. Mills and Joel D. Katz*

#### **Abstract**

This chapter explores the efficacy of psychotherapeutic interventions for patients with type 2 diabetes mellitus (T2DM). This condition can lead to serious adverse health outcomes (e.g., cardiovascular disease, blindness, loss of limbs, etc.). Medical interventions alone are often not sufficient to manage the disease. Psychotherapy can promote behavioral change that improves medication adherence, dietary choices, exercise, stress, and other variables that affect blood sugar levels. The current chapter summarizes the trends in recent research for psychotherapeutic interventions for the management of T2DM. The results from 16 randomized controlled trials on cognitive-behavioral therapy, motivational interviewing, counseling, and mindfulness-based therapies are discussed. These interventions varied in length (3 to 18 months) and were conducted in many geographic regions (e.g., Australia, Netherlands, Saudi Arabia, Thailand, and more). Changes in biological health outcomes (i.e., HbA1c levels) were the primary focus of this chapter, but diabetes-related behavioral changes (e.g., diet and exercise) and psychological variables (e.g., stress, depression, and well-being) are also discussed. This chapter highlights that recent research has provided the most support for mindfulnessbased therapies for improving blood sugar levels in patients with T2DM.

**Keywords:** Type 2 diabetes mellitus, psychotherapy, intervention, diet, exercise

### **1. Introduction**

Diabetes mellitus is a condition marked by an inability to produce or properly use insulin, a hormone that allows cells to use glucose for energy [1]. Approximately 3 million Canadians, or 8% of the general population, are living with diabetes, with the prevalence increasing with age [1]. The condition usually develops in middle aged or older adults, and men are slightly more likely to be diagnosed with this condition (8.7%) than are women (7.6%) [1]. There are two types of diabetes mellitus: type 1, where the body cannot produce a sufficient amount of insulin, and type 2, where the body cannot use the insulin it produces effectively, resulting in high blood sugar levels [1]. Accordingly, blood glucose levels are the most reliable physiological marker by which to diagnose diabetes mellitus [2] and are also used to monitor patients' management of their condition. The main criterion for a diagnosis of diabetes mellitus is a hemoglobin A1c [HbA1c] level above 6.4%, indicating above-average blood sugar levels, for the past 2–3 months. Interventions that produce lower HbA1c levels indicate efficacy at improving patient self-management of their diabetes mellitus. If left untreated or if poorly managed, diabetes mellitus can

lead to serious health conditions such as heart disease and stroke, blindness, nerve damage, and loss of limbs [1].

About 90% of people with diabetes mellitus have type 2 (T2DM). This is a chronic disease, which must be carefully managed on an ongoing basis by the patient and/or their caregivers. The biopsychosocial approach combines the use of medication and insulin with self-management behaviors for the purpose of regulating blood glucose levels. Lifestyle changes that are generally recommended for people at higher risk of diabetes and those who are newly diagnosed include sufficient moderate to high intensity exercise, and dietary considerations such as increased intake of fiber and reduced intake of fats (especially saturated fat). As well, overweight individuals are advised to lose weight gradually to achieve a body mass index in the healthy range. Health care professionals working with patients with T2DM aim to teach and encourage appropriate eating habits and physical activity to help patients achieve better glycemic control. However, implementing and adhering to these lifestyle changes is often difficult. Many individuals with T2DM do not adhere to the recommended nutrition and physical activity guidelines. Specifically, many patients exceed the recommended fat and sodium intake, and do not consume enough grains, dairy, fruits and vegetables [3]. Stress is also recognized as a variable that can exacerbate T2DM. Stress triggers the release of hormones that produce a surge in blood glucose levels. For this reason, stress management is considered to be part of a biopsychosocial approach to the management of T2DM. Due to the prevalence and manageability of this type of diabetes mellitus through lifestyle modifications alone, this chapter will focus solely on T2DM.

In addition to pharmacological interventions, various psychotherapeutic interventions are used and have been studied to help people with T2DM achieve better glycemic control. In theory, psychotherapy can promote behavioral changes that would improve medication adherence, dietary choices, exercise, stress levels, and other variables that affect blood sugar levels. Within this chapter, we review various psychotherapeutic interventions that are commonly used for the management of T2DM, including cognitive-behavioral therapy, motivational interviewing, counseling, and mindfulness-based therapies. This chapter explores the trends in recent research to understand the evidence base for various psychotherapeutic interventions in the management of T2DM. Change in HbA1c level is the primary focus of this chapter, since HbA1c is commonly measured and is the most objective and standardized outcome measure across studies. However, trends in diabetesrelated behavioral changes (e.g., diet and exercise) and psychological variables (e.g., coping, stress, depression, and well-being) are also discussed.

#### **2. Psychotherapeutic interventions for type 2 diabetes mellitus**

Previous review papers have demonstrated that psychotherapeutic interventions in general are effective at improving health outcomes for individuals with T2DM. A 2004 meta-analysis of 12 randomized control trials (RCT) of psychological interventions (i.e., cognitive behavior therapy, counseling, or psychodynamic therapy) found lower HbA1c levels and psychological distress compared to different control groups (i.e., treatment as usual, an education group, attentional control, or waitlist control) [4]. There was no difference between treatment groups on weight gain and blood glucose concentration, suggesting that there was no clearly superior psychological intervention for the management of T2DM. A 2013 systematic review similarly concluded that psychotherapy is effective in supporting healthy coping among individuals with diabetes mellitus [5]. More recently, a 2020 meta-analysis of 70

*Psychotherapeutic Interventions for Type 2 Diabetes Mellitus DOI: http://dx.doi.org/10.5772/intechopen.97653*

RCTs found that psychological interventions, such as cognitive behavioral therapy, self-help materials, and counseling, were generally effective in reducing HbA1c levels over and above usual care [6].

These research findings cited above support the general use of psychotherapeutic interventions in the management of diabetes mellitus. However, it would be helpful to know whether and how specific interventions can enhance care for patients with T2DM so as to assist with treatment planning. In this chapter we analyze the recent literature on the efficacy of psychotherapeutic interventions for the care of T2DM. There have been 16 relevant RCTs published within the past 8 years (see Appendix A for details of the search strategy), which represent the most up-to-date published scientific findings on the topic. These studies and time period were deemed to give a valid snapshot of the recent literature. The results of specific studies are discussed, and we summarize the most noteworthy findings within each type of psychotherapeutic intervention. The effects of specific interventions on various outcomes relevant to patients with T2DM are discussed in detail. See **Table 1** for a summary of the reviewed studies.

#### **2.1 Cognitive-behavioral therapy**

Cognitive-behavioral therapy (CBT) is an umbrella term that encompasses various cognitive and behavioral techniques to identify and transform negative thinking patterns. CBT has been used to promote behavioral change in patients with diabetes mellitus [7]. A goal of CBT is to help individuals understand barriers to their own diabetes mellitus self-management and to provide them with the skills necessary to cope with these barriers. For example, a patient with diabetes mellitus may think, "I have a terrible chronic condition and there is nothing I can do about it." This type of cognition can lead to poor treatment adherence, low confidence, and/or high levels of stress. Within a CBT protocol, the therapist helps the patient to identify thinking errors or "cognitive distortions" (e.g., anticipating the worst outcome, focusing on the negative, and thinking in all-or-nothing terms) and to use strategies to challenge these beliefs (e.g., "what evidence is there for and against this thought?"). In addition to developing more balanced or rational thoughts, the therapist and the patient can also work on behavioral changes. They may engage in gradual exposure to challenging activities (e.g., walking for 5 minutes a day, then 10 minutes, then 20 minutes, until they can walk for one hour) or behavioral experiments (e.g., writing down how they feel before and after taking medication in order to help identify that anticipatory anxiety is often worse than any discomfort they feel during or after the avoided task). In CBT, patients receive emotional and psychological support while learning strategies to overcome avoidance and to adhere to their medication, dietary intake, and physical activity goals. CBT for the management of T2DM can be done in weekly individual or group sessions, and is traditionally done in-person with a therapist and over the span of several weeks to months.

For many years, CBT was the most commonly investigated form of psychotherapy for T2DM (for example, see [4–6]) and results confirmed its efficacy in increasing positive outcomes. In recent years, the literature has shifted away from investigating CBT in its traditional application. Instead, new research has begun to examine CBT in alternative delivery formats in an effort to boost accessibility. For instance, a 6-month web-based CBT intervention was found to be more effective than a control group in lowering HbA1c levels (*p* = .002) among T2DM patients in Saudi Arabia [8]. It also resulted in better diabetes mellitus knowledge (*p* = .004) and self-efficacy (*p* < .001) relative to a control group, suggesting that CBT can produce a meaningful change in cognitions that are related to successful self-


#### *Psychology and Pathophysiological Outcomes of Eating*


#### *Psychotherapeutic Interventions for Type 2 Diabetes Mellitus DOI: http://dx.doi.org/10.5772/intechopen.97653*


#### *Psychology and Pathophysiological Outcomes of Eating*

