Mental health care may benefit younger diabetics

Psychological interventions can translate into better blood sugar levels, but access to these therapies may be an issue.

By Victoria Stagg Elliott — Posted Aug. 14, 2006

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A new study shows that, especially for young people who have type 1 diabetes, mental and physical health may be part and parcel.

Specifically, a meta-analysis, published in the July 8 British Medical Journal concluded that psychological interventions can lead to an average half-point reduction in the hemoglobin A1c levels of children and adolescents with this illness. Such efforts were also shown to significantly lower the distress associated with confronting a chronic illness.

These approaches, which included cognitive behavioral, family systems and psychodynamic therapy, however, did not have the same impact among adults with type 1 diabetes. The researchers did find previously, though, that such interventions offered benefits for people of all ages who had type 2 diabetes.

Overall, experts said that -- when it comes to chronic disease -- these findings highlight the need to attend to the mind and the body to help patients accomplish the daily steps necessary to stay healthy.

"It is increasingly clear that there is a connection between glycemic control and psychological state for patients with diabetes," said Susan Frayne, MD, MPH, a staff physician at the VA Palo Alto Health Care System and an associate professor of medicine at Stanford University, both in California.

But while some view this meta-analysis as adding to the body of evidence supporting psychological interventions, they also see it as bringing to light holes in the research.

"The quality of the research is relatively low," said Alan M. Jacobson, MD, professor of psychiatry at the Joslin Diabetes Center and Harvard Medical School in Boston. "That reflects a problem in the field. Part of [it] is that it's difficult to get funding. ... And often, for a variety of reasons, the studies are not well carried out."

Experts also said that this study created more questions than answers because it was unclear who benefited the most from the various interventions. For instance, did the therapies really help everybody or did they just reach those whose disease was uncontrolled and who may have had comorbid mental health conditions? Or, did they help those who were close to achieving their goal actually reach it? Do they have any impact on those who are already managing their disease well?

"The patient population is so heterogeneous, it's hard to judge what you're really looking at," said Andrew Muir, MD, chief of pediatric endocrinology at the Medical College of Georgia in Augusta.

Kids showed the most benefit

There is also the question of why the impact on adults with the type 1 form of this disease was less. This meta-analysis linked the interventions with a decrease in the hemoglobin A1c score for this older age group, too, but not at a statistically significant level.

Some physicians offer possible explanations why. Many of these adults have had the condition for quite a while and may, therefore, not be willing to change how they handle it. In addition, psychological interventions for children also tend to include their parents, who may be more affected and, in turn, change the course of the child's disease.

"Adults are pretty set in our ways, and it's much harder to get us to change," said Thomas Sullivan, MD, a pediatrician in Alexandria, Va., and a member of the American Academy of Pediatrics' Committee on Psychosocial Aspects of Child and Family Health. "Adults may say, 'I know how to take care of myself.' "

And while physicians praised this study for underscoring the value of psychological interventions, many also point to the significant barriers patients with chronic medical conditions face in getting this kind of help. For starters, the whole family needs be involved and not everyone may be willing. Professionals who can provide this kind of support are in short supply. And, paying for the cost of mental health services can also be a problem.

"We do have mental health services within our own division," said Francine Kaufman, MD, head of the Center for Diabetes, Endocrinology and Metabolism at Children's Hospital in Los Angeles. "Unfortunately we cannot meet the needs of all, and some insurers won't pay for it.

Experts add that a half-point reduction is similar to improvement triggered by some of the diabetes drugs on the market -- significant enough to make the effort worthwhile.

"Reducing a half percentage point is going to reduce complications down the road," said Dr. Muir. "People truly benefit."

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Mind over diabetes

Objective: To determine whether psychological interventions affect glycemic control in people with type 1 diabetes.

Method: Researchers performed a meta-analysis of randomized controlled trials and examined the impact of counseling or various other forms of mental health interventions -- cognitive behavioral, family systems or psychodynamic therapy -- on hemoglobin A1c levels and measures of psychological distress.

Results: On average, those younger than 18 who received some sort of psychological treatment experienced a half-point reduction in A1c levels and a significant lessening of distress. These scores also were reduced in adults, but the decrease was not statistically significant.

Conclusions: Mental health services can slightly improve glycemic control in children and adolescents but not adults with type 1 diabetes.

Source: British Medical Journal, July 8

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External links

"Psychological interventions to improve glycaemic control in patients with type 1 diabetes: systematic review and meta-analysis of randomised controlled trials," abstract, British Medical Journal, July 8 (link)

"Support for young people with diabetes," extract, British Medical Journal, July 8 (link)

American Medical Association's Minority Affairs Consortium on diabetes (link)

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