CBT may help type 1 diabetes patients with chronic fatigue
medwireNews: Findings from a randomized trial suggest that cognitive behavioral therapy (CBT) may significantly alleviate chronic fatigue in patients with type 1 diabetes.
The researchers – Hans Knoop (VU University Medical Center, Amsterdam, the Netherlands) and colleagues – cite studies reporting chronic fatigue in up to 40% of type 1 diabetes patients.
The study, which is published in The Lancet Diabetes & Endocrinology, was relatively small, with 60 patients assigned to each group. But speaking to medwireNews, Katharine Barnard, Professor of Health Psychology at Bournemouth University, UK, said that one of the most important aspects of the publication is that “it highlights that [fatigue] is a real problem for people.”
She noted that the disease burden of diabetes extends beyond simply managing blood glucose levels. “It’s relentless,” she said. “And it’s not that it’s going to be relentless for 6 months, it’s going to be with you for the rest of your life.”
Barnard’s previous research has shown how anxiety about nocturnal hypoglycemia often drives diabetes patients and their parents or partners to wake in the night to test their blood glucose levels, leading to chronic sleep disturbance and fatigue. This in turn has “all sorts of really unpleasant side effects,” including reduced cognitive function, making it harder for patients to calculate their insulin boluses.
Of the current study, Barnard believes that “the methodology is robust, and I think it’s interesting that they’re trying a therapy that is well established, is well proven, and we know works for fatigue in a number of chronic conditions.”
The research found that CBT had large positive effects for the patients assigned to receive it, both for fatigue severity and for functional impairment. Over 5 months, during which the patients undertook up to eight CBT modules, their average score on the fatigue severity subscale of the Checklist Individual Strength fell from 45.9 to 26.5, whereas that for the patients assigned to a waiting list for CBT changed only slightly, from 46.0 to 40.4.
A clinically significant improvement in fatigue severity, defined as a statistical improvement plus a score below 35, occurred in 77% of patients in the CBT group, compared with 25% of the control group. Likewise, functional impairment scores on the Sickness Impact Profile-8 fell from 929 to 326 in the CBT group, versus a much smaller change of 855 to 792 in the control group.
Six months after the CBT, the patients’ fatigue scores had deteriorated somewhat, but were still markedly better than at baseline, with most (61%) patients maintaining a clinically significant improvement.
However, Medicine Matters advisory board member Bill Polonsky (Associate Clinical Professor in Psychiatry at the University of California, San Diego, USA) pointed out that patients in a trial such as this are very self-selecting, comprising only those willing to commit to a time-intensive intervention such as CBT.
“Almost by definition, the people we most need to see are the people least interested in coming to see us,” he said, noting the need for “more achievable” interventions, which require less time commitment and can be delivered remotely.
The scope for designing such interventions is limited by not knowing which particular aspect of CBT is effective in which patients, and how it leads to lessened fatigue. “Were sleep patterns changed as a consequence [of CBT] or did people just feel better about not having enough sleep?” asked Barnard.
This uncertainty is partly because it is not clear what causes the fatigue in the first place, and both Barnard and Polonsky are keen to see more research into the issue. “Is it truly distinct from depression?” asked Polonsky. “Is it truly distinct from diabetes distress and diabetes burnout?”
Barnard would also like to see longer-term studies, with outcomes including sleep diaries and glycated hemoglobin. But she believes that the current study adds “a very valuable piece of information into the jigsaw that is the burden of self-management of type 1 diabetes – both for people living with it and for people caring for them.”
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