Internet Intervention for Diabetes Distress

Acceptability and Clinical Feasibility of an Internet-delivered Intervention for Psychological Distress in Patients With Type 2 Diabetes

Diabetes distress is a psychological phenomenon associated with the self-management of the disease and is characterised by feelings of anxiety, guilt, helplessness, defeat, and depression. Research suggests that internet-delivered interventions have the potential to increase people's ability to self-manage their symptoms, but whether they are effective is largely unknown. This study is designed to investigate the potential effectiveness of an internet-delivered intervention for diabetes distress in patients with type 2 diabetes.

Diabetes is a chronic metabolic endocrine disorder characterised by the inability to metabolise glucose effectively. It is associated with reduced life expectancy, significant morbidity due to specific diabetes related complications, and increased risk of complications such as heart disease, stroke, and diminished quality of life. The incidence of diabetes is on the increase with approximately 347 million adults affected worldwide. Type 2 diabetes accounts for 90-95% of these cases and figures are estimated to increase to 552 million by 2030. Lifestyle changes such as a reduction in exercise and an increase in dietary intake over the past number of years have been flagged as being responsible for this dramatic surge in the prevalence of Type 2 diabetes on a global scale. Because diabetes is a chronic and progressive condition people not only require regular access to medical care, but the ability to self-manage symptoms on a daily basis is now considered to be an essential part of treatment. Self-management involves the continuous monitoring of dietary intake, physical activity, general health, stress levels, blood sugar levels, and adherence to medication regimens. Diabetes is a demanding illness that requires complex self-management maintenance/care on a daily basis. Coping with these demands and maintaining lifestyle changes can often be overwhelming for individuals and this can result in significant distress that includes feelings of anxiety, guilt, helplessness, defeat, and depression. Research has demonstrated that those who display high levels of such symptoms are not necessarily clinically depressed; rather they experience high levels of emotional distress related to diabetes and their management of the disease. Diabetes distress is a distinct condition that directly relates to diabetes outcomes. It is characterised by unique emotional issues that directly relate to the burden of living with diabetes such as worry, frustration, concern and aspects of burnout. Several factors prevent people with diabetes from accessing support and treatment for any distress they may experience in self-managing, such as poor education, personal finances, physical access to services, lack of social support, poor motivation, low self-efficacy, and negative attitudes to treatments. In addition the concept of diabetic distress is relatively new and unknown. This highlights the growing need to develop effective treatment options to overcome barriers to access for people with type 2 diabetes. A significant amount of research in recent years has focused on diabetes self-management education and its effectiveness for improving diabetes care and glycemic control. Face-to-face lifestyle interventions with a particular focus on behaviour change are not new in the treatment and management of type 2 diabetes. In recent years, computer-based interventions have been shown to be effective for behaviour change (e.g. in smoking cessation). Researchers are now investigating whether there is a practical and cost-effective use for computer-based interventions to address more complex behaviour change such as that required in chronic disease self-management such as Type 2 diabetes . Previous reviews of internet-delivered interventions for people with diabetes demonstrated some effects on physical and lifestyle self-management but failed to have any great impact on psychological outcomes. Previous work seems to demonstrate the need for further more integrated approaches that considers both health behaviours and their modification and behavioural health, specifically addressing significant distress that includes feelings of anxiety, guilt, helplessness, defeat, and depression. However, can an internet-delivered intervention address the self-management of diabetes through a comprehensive consideration of the distress that so often underlies the dysregulation of self-management regimes and the inevitable consequences of that? The current study seeks to begin an attempted answer by considering the clinical feasibility of a newly developed intervention called Space from Diabetes. Design: A mixed-method approach will be used that captures both quantitative and qualitative data. After completing screening questionnaires, eligible patients will be invited to use the intervention over an 8 week period. Sample: The investigators intend to recruit participants from Enfield Community Service. A sample size of 35 participants is proposed. This sample size will allow us to estimate the standard deviation of the symptom outcome measures for a future RCT. Procedure: Eligible patients will be invited to use the intervention over an 8 week period. The program will be advertised to patients through Enfield Community Service and GP surgeries via leaflets distributed by staff members. Participant information sheets will be administered before beginning the programme and consent forms will be obtained at the point of sign-up online. Participants can sign up online using the link provided on the leaflet to get access to the program. Participants will sign the consent form and complete screening measures online before beginning the program. Participants will then be referred to a supporter from within Enfield Community Service. Participants' post outcome measures will be gathered 8 weeks after their initial login or activation of the programme. Ethical considerations: Information made available to all prospective participants will inform them of exactly what is involved in participating, including the objectives of the trial and its importance. Informed consent will be obtained from each participant before they begin to use the programme. Participants will know that their involvement is voluntary and they can withdraw their participation at any time without prejudice. In order to record participant data gathered during the survey questionnaire and focus groups, participants will be fully informed about all the material that is recorded. Moreover, data will be anonymised and stored in a secure and encrypted server and retained for seven years as original source. Postal information will be collected for the purpose of participant remuneration only. This data will be kept on a separate secure and encrypted server with unique identifiers. All materials will be submitted to appropriate ethics committee for review and approval.

Participants will be assigned the 'Space from Diabetes' intervention in a supported mode for 8 weeks. Participants are assigned a clinical supporter, who will be a psychological well-being practitioner in an NHS Mental Health Service. As the participant works through the programme content, the supporter will provide them with a review of their progress and interactions with the platform 6 times over the 8 week supported period.

Space from Diabetes is an internet-delivered cognitive behaviour therapy-based programme for symptoms of depression, anxiety, & diabetes distress in people with type 2 diabetes mellitus.

Diabetes Distress Scale (DDS; Polonsky et al., 2005; Fisher et al., 2008) is a 17-item measure that focuses on 4 aspects of distress associated with diabetes: emotional burden, regimen distress, interpersonal distress and physician distress. The measure and its 4 subscales have demonstrated good internal consistency (α > .87) and convergent validity with the Center for Epidemiological Studies Depression Scale, meal planning, exercise and total cholesterol (Polonsky et al., 2005).

Patient Health Questionnaire-9 (PHQ-9; Kroenke, Spitzer, & Williams, 2001; Spitzer, Kroenke, & Williams, 1999) is a self-report measure of depression that has been widely used in screening, primary care, and research. The PHQ-9 items reflect the diagnostic criteria for depression outlined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition - Text Revision (DSM-IV-TR) (American Psychiatric Association [APA], 2000). Summary scores range from 0-27, where larger scores reflect a greater severity of depressive symptoms. The PHQ-9 has been found to discriminated well between depressed and non-depressed individuals using the clinical cut-off of total score ≥10, with good sensitivity (88.0%), specificity (88.0%) and reliability (.89) (Kroenke et al., 2001; Spitzer et al., 1999).

Generalized Anxiety Disorder-7 (GAD-7; Spitzer, Kroenke, Williams, & Löwe, 2006) GAD-7 comprises 7 items measuring symptoms and severity of GAD based on the DSM-IV diagnostic criteria for GAD. The GAD-7 has good internal consistency (α = .92) and good convergent validity with other anxiety scales (Spitzer et al., 2006). Higher scores indicate greater severity of symptoms. The GAD-7 has increasingly been used in large-scale studies as a generic measure of change in anxiety symptomatology, using a cut-off score of 8 (Richards & Suckling, 2009).

Work and Social Adjustment (WASA; Mundt, Marks, Shear & Greist, 2002) is a simple, reliable and valid measure of impaired functioning. It is a simple and reliable (α >.75) 5-item self-report measure which provides an experiential impact of a disorder from the patient's point of view. It looks at how the disorder impairs the patient's ability to function day to day on five dimensions: work, social life, home life, private life and close relationships.

The Satisfaction with Treatment (SAT; Timulak & Richards, 2012) measure contains several questions that aim to assess patient satisfaction with the iCBT intervention received. The measure consists of two qualitative questions and several quantitative questions, centering on what the patients liked or disliked about the iCBT intervention.

The EuroQol 5D5L (EQ5D5L) (Rabin, Oemar, Oppe, & on behalf of the EuroQoL Group, 2011) is a measure of health-related quality of life. The first part of the measure consists of five self-report items measuring the domains of mobility, self-care, usual activities, pain/discomfort, anxiety/depression). Each item has a possible five responses, which rank in severity (no problems - extreme problems). From these results, a societal index can be obtained, allowing for further analysis. The second part of the measure records self-reported health state on a visual analogue scale (VAS), a vertical line where the best and worst imaginable health states score 100 and 0, respectively.

Inclusion Criteria: Aged between 25-80. Have type 2 diabetes for five years or more. Have internet access Exclusion Criteria: Outside of age criteria. Does not have type 2 diabetes for five years or more. No internet access

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