Mitigating Severe Hypoglycemia in Users of Advanced Diabetes Technologies:Impaired Awareness of Hypoglycemia and Unhelpful Hypoglycemia Beliefs as Targets for Interventions

Objective: A subgroup analysis of the Hypoglycemia Awareness Restoration Programme for people with type 1 diabetes and problematic hypoglycemia persisting despite optimized care (HARPdoc) trial was conducted to explore the impact of Blood Glucose Awareness Training (BGAT, a hypoglycemia awareness training program) and the HARPdoc (a psychoeducation addressing unhelpful hypoglycemia beliefs) in reducing severe hypoglycemia (SH) in individuals using advanced diabetes technologies (ADTs). Methods: Data from trial participants who utilized ADTs, including continuous glucose monitors or automated insulin delivery systems, were extracted. Generalized linear mixed-effects models with Poisson distribution or linear mixed-effects models were used to evaluate SH incidence, and Gold questionnaire, Attitudes to Awareness of Hypoglycemia (A2A), Problem Areas in Diabetes (PAID), Hospital Anxiety and Depress Scale (HADS)-anxiety, and HADS-depression scores as measures of hypoglycemia awareness, unhelpful hypoglycemia beliefs, diabetes distress, and anxiety and depression symptoms, respectively. Results: In the 45 participants using ADTs, the BGAT and HARPdoc interventions both reduced SH incidence by more than 50% (P &lt; 0.0001) and yielded improvements in hypoglycemia awareness (P &lt; 0.05). HARPdoc outperformed BGAT in reducing SH at month 24 (P = 0.01). HARPdoc also mitigated unhelpful hypoglycemia beliefs (P &lt; 0.0001), diabetes distress (P &lt; 0.05), and anxiety symptoms (P &lt; 0.05); BGAT demonstrated no significant impacts in these respects. Neither HARPdoc nor BGAT had significant effects on depression symptoms. Conclusion: Psychoeducation (BGAT and HARPdoc) was effective in reducing SH in people using ADTs. HARPdoc may also provide greater long-term SH reduction and improves psychological well-being in this patient group.</p

Assessing treatment fidelity and contamination in a cluster randomised controlled trial of motivational interviewing and cognitive behavioural therapy skills in type 2 diabetes.

BACKGROUND: Competencies in psychological techniques delivered by primary care nurses to support diabetes self-management were compared between the intervention and control arms of a cluster randomised controlled trial as part of a process evaluation. The trial was pragmatic and designed to assess effectiveness. This article addresses the question of whether the care that was delivered in the intervention and control trial arms represented high fidelity treatment and attention control, respectively. METHODS: Twenty-three primary care nurses were either trained in motivational interviewing (MI) and cognitive behavioural therapy (CBT) skills or delivered attention control. Nurses' skills in these treatments were evaluated soon after training (treatment arm) and treatment fidelity was assessed after treatment delivery for sessions midway through regimen (both arms) using the Motivational Interviewing Treatment Integrity (MITI) domains and Behaviour Change Counselling Index (BECCI) based on consultations with 151 participants (45% of those who entered the study). The MITI Global Spirit subscale measured demonstration of MI principles: evocation, collaboration, autonomy/support. RESULTS: After training, median MITI MI-Adherence was 86.2% (IQR 76.9-100%) and mean MITI Empathy was 4.09 (SD 1.04). During delivery of treatment, in the intervention arm mean MITI Spirit was 4.03 (SD 1.05), mean Empathy was 4.23 (SD 0.89), and median Percentage Complex Reflections was 53.8% (IQR 40.0-71.4%). In the attention control arm mean Empathy was 3.40 (SD 0.98) and median Percentage Complex Reflections was 55.6% (IQR 41.9-71.4%). CONCLUSIONS: After MI and CBT skills training, detailed assessment showed that nurses had basic competencies in some psychological techniques. There appeared to be some delivery of elements of psychological treatment by nurses in the control arm. This model of training and delivery of MI and CBT skills integrated into routine nursing care to support diabetes self-management in primary care was not associated with high competency levels in all skills. TRIAL REGISTRATION: ISRCTN75776892 ; date registered: 19/05/2010

Characteristics of adults with type 1 diabetes and treatment-resistant problematic hypoglycaemia: a baseline analysis from the HARPdoc RCT

Aims/hypothesis Problematic hypoglycaemia still complicates insulin therapy for some with type 1 diabetes. This study describes baseline emotional, cognitive and behavioural characteristics in participants in the HARPdoc trial, which evaluates a novel intervention for treatment-resistant problematic hypoglycaemia. Methods We documented a cross-sectional baseline description of 99 adults with type 1 diabetes and problematic hypoglycaemia despite structured education in flexible insulin therapy. The following measures were included: Hypoglycaemia Fear Survey II (HFS-II); Attitudes to Awareness of Hypoglycaemia questionnaire (A2A); Hospital Anxiety and Depression Index; and Problem Areas In Diabetes. k-mean cluster analysis was applied to HFS-II and A2A factors. Data were compared with a peer group without problematic hypoglycaemia, propensity-matched for age, sex and diabetes duration (n = 81). Results The HARPdoc cohort had long-duration diabetes (mean ± SD 35.8 ± 15.4 years), mean ± SD Gold score 5.3 ± 1.2 and a median (IQR) of 5.0 (2.0–12.0) severe hypoglycaemia episodes in the previous year. Most individuals had been offered technology and 49.5% screened positive for anxiety (35.0% for depression and 31.3% for high diabetes distress). The cohort segregated into two clusters: in one (n = 68), people endorsed A2A cognitive barriers to hypoglycaemia avoidance, with low fear on HFS-II factors; in the other (n = 29), A2A factor scores were low and HFS-II high. Anxiety and depression scores were significantly lower in the comparator group. Conclusions/interpretation The HARPdoc protocol successfully recruited people with treatment-resistant problematic hypoglycaemia. The participants had high anxiety and depression. Most of the cohort endorsed unhelpful health beliefs around hypoglycaemia, with low fear of hypoglycaemia, a combination that may contribute to persistence of problematic hypoglycaemia and may be a target for adjunctive psychological therapies

Mindfulness based cognitive therapy : a two-part investigation of the benefits and challenges for mental health professionals.

There has been a growing interest in incorporating mindfulness into clinical interventions in medicine and psychology (Baer, 2003). One such approach is Mindfulness Based Cognitive Therapy (Segal et aL, 2002). The mindfulness component of this treatment approach has its roots in Eastern meditative practices, which has implicationsf or practitioners as well as clients. The focus of this research is the relationship between MBCT and mental health professionals' personal and professional development. This was explored in two related studies. Study 1 used a repeated measures design to assess changes in mindfulness and psychological well-being in mental health professionals 18 months after attending an MBCT programme. Results showed that some of the improvements found at 3-month follow-up (by Ruths et al., 2005) had persisted at 18-month follow-up. The relationship between these improvements and other variables such as meditation practice and life events was less straightforward. Study 2 was a qualitative study which used Interpretative Phenomenological Analysis to explore the personal and professional experiences of Clinical Psychologists after attending the MBCT programme cited above. Participants reported continued use of meditation techniques in an informal or ad hoc way and this was associated with improved psychological functioning. In terms of professional development, participants introduced mindfulness into their clinical work in a tentative way and spoke about the challenges and benefits of this integration. Separating mindfulness from its spiritual roots was not viewed as problematic, within the context of a credible evidence base. In conclusion, MBCT appears to benefit mental health professionals as well as clients. The relationship between the development of mindfulness and the need for formal practice is questioned by the research. The accounts of Clinical Psychologists provide useful insights into how a spiritual 'technology' is being integrated into the NHS. The implications for future research and clinical practice are discussed

Mindfulness based cognitive therapy : a two-part investigation of the benefits and challenges for mental health professionals

There has been a growing interest in incorporating mindfulness into clinical interventions in medicine and psychology (Baer, 2003). One such approach is Mindfulness Based Cognitive Therapy (Segal et aL, 2002). The mindfulness component of this treatment approach has its roots in Eastern meditative practices, which has implicationsf or practitioners as well as clients. The focus of this research is the relationship between MBCT and mental health professionals' personal and professional development. This was explored in two related studies. Study 1 used a repeated measures design to assess changes in mindfulness and psychological well-being in mental health professionals 18 months after attending an MBCT programme. Results showed that some of the improvements found at 3-month follow-up (by Ruths et al., 2005) had persisted at 18-month follow-up. The relationship between these improvements and other variables such as meditation practice and life events was less straightforward. Study 2 was a qualitative study which used Interpretative Phenomenological Analysis to explore the personal and professional experiences of Clinical Psychologists after attending the MBCT programme cited above. Participants reported continued use of meditation techniques in an informal or ad hoc way and this was associated with improved psychological functioning. In terms of professional development, participants introduced mindfulness into their clinical work in a tentative way and spoke about the challenges and benefits of this integration. Separating mindfulness from its spiritual roots was not viewed as problematic, within the context of a credible evidence base. In conclusion, MBCT appears to benefit mental health professionals as well as clients. The relationship between the development of mindfulness and the need for formal practice is questioned by the research. The accounts of Clinical Psychologists provide useful insights into how a spiritual 'technology' is being integrated into the NHS. The implications for future research and clinical practice are discussed.EThOS - Electronic Theses Online ServiceGBUnited Kingdo