Effect of cognitive behavioral therapy on improving mental health outcomes in adolescents with type 2 diabetes: A systematic review protocol

Abstract

Depression and anxiety are among the most common mental health outcomes experienced by young individuals with type 2 diabetes. Cognitive behavioral therapy (CBT) has been proven to be an effective intervention for depression and anxiety. This review shall summarize the evidence for the effectiveness of CBT for depression and/or anxiety among adolescents with type 2 diabetes. This systematic review aims to summarize evidence for the effectiveness of cognitive behavioral therapy compared to treatment as usual or no treatment on improving depression and anxiety in adolescents with type 2 diabetes. To be included in the review, a study design must be used to test the effectiveness of CBT on depression and/or anxiety in adolescents with type 2 diabetes. Also, studies must be published in peer-reviewed journals in the English language between 2014 and 2023. Studies examining the effectiveness of CBT for conditions other than depression and/or anxiety shall be excluded. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and guideline checklist (2020) shall be used to select studies for this systematic review. A comprehensive search shall be conducted on electronic databases such as APAPsycINFO, APA PsycARTICLES, CINAHL, and MEDLINE to identify studies that fit the selection criteria. Data to be extracted for analysis shall include the study aim, sample, research design, intervention modality, comparators, and outcomes. Two independent authors shall perform data extraction. An acceptable checklist for randomized controlled trials and quasi-experimental studies will be used to assess the quality of the studies.

Introduction

Diabetes mellitus (DM) is a chronic metabolic disorder that affects millions of individuals worldwide and is characterized by elevated blood glucose levels. Among those affected, adolescents face unique challenges in managing diabetes due to various physical, emotional, and social factors at play.[1] Adolescents with diabetes often experience increased stress levels, anxiety, depression, and overall psychological distress, which can significantly impact their overall health and well-being.

Mental health concerns among adolescents with diabetes are not only a result of the physical demands of managing their condition but also influenced by psychosocial factors such as the fear of complications, the stigma associated with diabetes, and daily self-care requirements.[2,3] These psychological stressors can negatively affect glycemic control and lead to suboptimal health outcomes. Additionally, they contribute to a reduced quality of life for these young individuals.[4,5]

One promising approach to address the mental health challenges faced by adolescents with diabetes is cognitive behavioral therapy (CBT). CBT is a well-established therapeutic approach known for its effectiveness in treating various mental health conditions, such as anxiety and depression.[6,7,8,9] It focuses on identifying and modifying negative thought patterns and behaviors, helping individuals develop adaptive coping strategies to manage stress and emotional distress. Although there is substantial literature on CBT’s effectiveness in managing mental health conditions, there is a lack of understanding of its specific application in adolescents with type 2 diabetes. Previous studies have mainly concentrated on adults or broader populations, neglecting the unique needs of this younger group. This gap emphasizes the necessity for a systematic review to evaluate the effectiveness of CBT in improving psychological outcomes, specifically for adolescents with type 2 diabetes, addressing the unresolved question of how CBT can be adapted for this population.

While CBT has been extensively studied in the context of mental health treatment, its specific application for adolescents with diabetes requires further investigation. Previous research has shown that CBT interventions can improve psychological well-being and glycemic control among adults with diabetes.[10,11,12,13] Moreover, numerous studies have examined the effectiveness of CBT in improving psychological outcomes in individuals with diabetes. However, the literature lacks a specific focus on adolescents, and this systematic review aims to bridge that gap.

One systematic review and meta-analysis of randomized controlled trials by Uchendu and Blake[14] focused on the effectiveness of CBT on glycemic control and psychological outcomes in adults with DM. Although this study specifically targeted adults, it provides valuable insights into the potential benefits of CBT in improving psychological outcomes in individuals with diabetes. The findings of this review suggest that CBT can be effective at improving psychological outcomes, including anxiety and depression, in individuals with diabetes. It is important to note, however, that the provided resources in the systematic review and meta-analysis do not directly explore the effectiveness of CBT in reducing depression and anxiety in adolescents with type 2 diabetes, indicating the need for further research. Another systematic review and meta-regression analysis by Oud et al.[15] examined the effectiveness of CBT for children and adolescents with depression. While this study did not specifically focus on individuals with type 2 diabetes, it provides evidence of the effectiveness of CBT in improving depressive symptoms in young populations. Given the overlap between depression and anxiety in adolescents with type 2 diabetes, the findings of this study can be extrapolated to suggest that CBT may also be effective at improving anxiety symptoms in this population.

A review of meta-analyses by Butler et al.[16] examined the empirical status of CBT in treating various mental disorders, including anxiety. This review revealed that CBT is currently the treatment of choice for anxiety and depressive disorders in children and adolescents. These findings suggested that CBT may be an effective intervention for improving anxiety symptoms in adolescents with type 2 diabetes. While the references provided do not directly address the effectiveness of CBT in improving depression and anxiety in adolescents with type 2 diabetes, they provide evidence of the effectiveness of CBT in improving psychological outcomes in individuals with diabetes and in young people with depression and anxiety. Based on this evidence, it can be inferred that CBT may be an effective intervention for improving depression and anxiety in adolescents with type 2 diabetes. This review aims to address the literature gap regarding CBT’s impact on this particular group.

Understanding the effectiveness of CBT in mitigating anxiety and depression among adolescents with diabetes thus has significant implications. First, this study could pave the way for a tailored, evidence-based intervention addressing the intricate interplay between mental health and diabetes management in this vulnerable population. Successful CBT interventions might not only improve mental well-being but also enhance glycemic control, thereby promoting overall health outcomes. Additionally, this study contributes to bridging a critical research gap. Despite the increasing prevalence of type 2 diabetes among adolescents, comprehensive investigations into tailored psychological interventions, specifically CBT, focused on adolescents with type 2 diabetes are notably lacking.

Objectives

This review aims to summarize the evidence for the effectiveness of cognitive behavioral therapy compared to treatment as usual or no treatment on improving depression and anxiety in adolescents with type 2 diabetes. Therefore, the review seeks to offer empirical evidence essential for guiding future interventions, ensuring that psychological support becomes an integral component of diabetes management strategies for adolescents. Ultimately, this study strives to inform clinical practices, enhance the quality of life for adolescents with diabetes, and potentially serve as a foundation for developing comprehensive guidelines for mental health interventions within pediatric diabetes care. The review also aims to answer the following questions: In adolescents aged between 10 and 19 years diagnosed with type 2 diabetes, does CBT, compared to standard care (treatment as usual) or no intervention, lead to improved mental health outcomes? (lead to a reduction in symptoms of depression and anxiety?) Does CBT, compared to standard care (treatment as usual) or no intervention, cause a significant change in the overall psychological well-being of adolescents diagnosed with type 2 diabetes?

Materials and Methods

The proposed systematic review protocol has been submitted and registered in the PROSPERO International Prospective Register of Systematic Reviews. The review shall be conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Search strategy

The search strategy will be directed toward locating published studies. A preliminary search of MEDLINE, CINAHL, and PsycARTICLES (EBSCOhost) was undertaken to identify articles on the topic. The text words in the titles and abstracts of pertinent articles, along with the index terms used to explain them, were utilized to create an encompassing search strategy for electronic databases such as APA PsycINFO, APA PsycARTICLES, CINAHL, and MEDLINE via EBSCOhost [Appendix 1]. The search strategy, encompassing all recognized keywords and index terms, will be used for each included information source. The reference lists of all studies chosen for critical examination will be scrutinized for additional studies.

Inclusion and exclusion criteria

This review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies. Reviews involving individuals aged 10–19 years with diagnosed type 2 diabetes will be examined. Studies that primarily focus on adult populations shall be excluded. The effectiveness and efficacy of CBT for depression and/or anxiety in adolescents with type 2 diabetes will be appraised. Studies that examine the efficacy of interventions other than CBT on mental health outcomes of adolescents with type 2 diabetes shall be excluded.

Studies published in the English language will be included. Studies published from 2014 will be included as recent studies within the last decade. The inclusion of studies from 2014 ensures the inclusion of recent and relevant research and advancements in CBT applications while providing a comprehensive overview of the current evidence. The study search shall be limited to published peer-reviewed articles. Dissertations, book reviews, and non-article content shall be excluded.

Study selection and quality assessment

All recognized citations will be gathered and input into EndNote version 20 after the search, and duplicates will be removed. Two independent reviewers, namely, S.F. and M.P., will vet the abstracts and titles after a pilot test, for assessment in line with the inclusion criteria.[17] Two independent reviewers will gauge the chosen citations against the inclusion criteria, and the reasons for excluding studies that fail to meet the inclusion criteria will be documented and included in the systematic review. In any case of conflicts between reviewers, discussion will be utilized, or a third reviewer (A.O.) will be consulted. A PRISMA flow diagram will display the full details of the outcomes of the search, the study selection, and the inclusion process.[18]

Studies comparing CBT to treatment as usual (standard care), physical therapy, or other psychotherapy, or no intervention for depression and/or anxiety in adolescents with type 2 diabetes will be evaluated. Studies incorporating the following outcomes will be appraised: the effectiveness of CBT on depression or anxiety or both as measured by reduction in symptoms of depression and anxiety accounted for by CBT in adolescents with type 2 diabetes.

Two independent reviewers will use standardized critical appraisal instruments for experimental, quasi-experimental, and observational studies to thoroughly examine suitable studies for methodological quality. In the case of missing data or the need for additional data, authors of papers will be communicated with for delineation. In any case of conflicts between reviewers, discussion will be utilized, or a third reviewer (A.O.) will be consulted. A table with a synchronizing narrative will present the outcomes of the critical examination.

Following critical appraisal, studies that do not meet a certain quality threshold will be excluded. This decision will be based on quality cut-off score of 6/10.

Data extraction

Two independent reviewers will extricate data from studies. The data extracted will include specific details about the populations, study methods, interventions, and outcomes of significance to the review questions 1 and 2. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. In the case of missing data, or the need for additional data, authors of papers will be communicated with for delineation.

Data synthesis

Studies will be bunched with statistical meta-analysis, where needed. Effect sizes will be conveyed as final post-intervention mean differences, and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard χ² and I² tests. Statistical analyses will be performed using random or fixed effects.[19] Subgroup analyses will be conducted where there are sufficient data to investigate intervention outcomes in early adolescents versus late adolescents and across high versus low and middle-income countries. Sensitivity analyses will be conducted to test decisions made on study quality. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation, where appropriate.

A funnel plot will be generated GraphPad Prism version 9 (GraphPad Software, Inc.) to assess publication bias if there are 10 or more studies included in a meta-analysis. Statistical tests for funnel plot asymmetry (Egger test) will be performed where appropriate.

Assessing certainty in the findings

To evaluate the certitude of collaboration, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach will be acted in accordance with[20] and the GRADEpro GDT 4 (McMaster University, ON, Canada) will be used to generate a Summary of Findings. The Summary of Findings will present the following information where appropriate: absolute risks for the treatment and control, estimates of relative risk, and a ranking of the quality of the evidence based on the risk of bias, directness, heterogeneity, precision, and risk of publication bias of the review results. The outcomes reported in the Summary of Findings will be: (1) a reduction in symptoms of depression and anxiety accounted for by CBT in adolescents with type 2 diabetes and (2) an increase in overall psychological well-being.

Author contributions

SF and MP initiated the protocol, conceptualized the research plan for the proposed systematic review, wrote the manuscript and reviewed it for important intellectual content. PT and AO critically reviewed the methodology, wrote the manuscript and reviewed it for important intellectual content. All authors read and approved the final manuscript.

Conflicts of interest

There are no conflicts of interest.

Appendix I.

Search strategy

Search		Query		Records retrieved
#1		“Cognitive behavio* therap*” OR “cognitive therap*” OR “cognitive behavio* psychtherap* OR “cognition therap*” OR “CBT “		14,428
#2		“Type* (“2” or “II” or “two) “diabete*” OR “diabetic” OR “DM” OR “non-insulin diabete*”		46,373
#3		“Depression” OR “depressive disorder” OR “depress” OR “affective disorder” OR “anxiety” OR “anxious”		162,888
#4		#1 AND #2 AND #3		547
Limited to 2014 – 2024. English language, peer-reviewed articles

APAPsycINFO (EBSCOhost), PsycARTICLES (EBSCOhost), CINAHL (EBSCOhost), and MEDLINE (EBSCOhost)

The search shall be conducted on July 2024

Funding Statement

We thank the Covenant University Centre for Research, Innovation and Discovery for their research assistance and financial support in the publication of this paper.