Web-based cognitive behavioural therapy (W-CBT) for diabetes patients with co-morbid depression: design of a randomised controlled trial [ISRCTN24874457]


Depression has been shown two times more prevalent among persons with type 1 or type 2 diabetes, compared to the general population [1]. Approximately 10% of the adult diabetes patient population suffers from major depressive disorder and another 10% from minor depression [1]. Data also suggest depression to be more persistent and recurrent in people with diabetes [2]. The costs of depression in diabetes are known to be high, not only in terms of suffering and reduced quality of life, but also in view of adverse medical outcomes (e.g. hyperglycaemia, diabetes complications), and societal and economic costs [3,4].
Based on evidence to date, psychological therapy (particularly cognitive behaviour therapy, CBT) is the treatment of choice for depression [5]. Only a few randomised controlled studies have been conducted to test the efficacy of anti-depressant therapies in persons with diabetes and co morbid depression [6-8].
Not surprisingly, depressive symptoms are likely to co-occur with high levels of diabetes-related emotional distress, as was confirmed in a recent international study [9]. While the optimal treatment for depression in diabetes is still being sought [10], there is good reason to assume that the efficacy of anti-depressant psychotherapy in diabetes can be enhanced when specific issues associated with the burden of living with this chronic disease are adequately addressed [11].
We recently conducted a study to test the effectiveness of a group Cognitive Behaviour Therapy (CBT) developed for patients in prolonged poor glycaemic control in a RCT, and found CBT to be most effective in patients who entered the study with elevated depression scores [12,13].
Offering diabetes-specific CBT to diabetes patients with depression should thus be able to improve psychological health, self-management behaviours and subsequent medical outcomes. However, access to psychological services is limited, both in primary and secondary routine diabetes care [10]. As pointed out by Glasgow et al [14], we need to consider ways to enhance dissemination of effective psychological interventions to persons with diabetes. In this context, we believe use of modern interactive technology, such as internet-based therapy should be considered. More so, since web-based psychological interventions have shown their utility across a range of problem areas and are likely to be cost-effective [15,16].
Web-based cognitive behaviour therapy (W-CBT) is recognized as an effective treatment option for depression and appeared to be well appreciated by patients [15,17-20]. In The Netherlands, we have seen an increase of internet-use in the past years, with about 83% of the households currently being “online” [21]. Internet-based therapy therefore has great potential to reach large groups of diabetes patients with co-morbid depression. To our knowledge, we would be the first to test the effectiveness of diabetes-specific on-line CBT for depression in persons with diabetes. 

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