Abstract
Psychological distress is common in adults with diabetes and is associated with poorer clinical outcomes and increased healthcare costs. Whilst previous work has indicated that psychotherapy treatments such as Cognitive Behavioural Therapy (CBT) are effective at improving some psychological outcomes in diabetes, the effect of this on diabetes-related distress is unclear. Furthermore, currently in England, the clinical need for effective psychological support within routine diabetes care is not met. Research indicates that internet-enabled CBT may provide an effective, accessible, and scalable model for providing psychological support for adults with diabetes in routine practice. However, more work is needed to explore how an internet-enabled CBT intervention can be implemented in routine psychological care for adults with diabetes. Therefore, this PhD investigated the implementation of a digital CBT intervention named COMPASS, designed to treat psychological distress in the context of Long-Term Conditions (LTC) into routine care for adults with diabetes and co-morbid psychological distress.First, study 1 (presented in chapter 2) performed a systematic review with meta-analysis to explore the efficacy of CBT and third-wave CBT interventions on diabetes-related distress, for adults with diabetes. This review also explored the efficacy of these interventions on depression, anxiety, and glycated haemoglobin (HbA1c). The review also explored active intervention components that may be most useful in treating diabetes-related distress. The findings demonstrated that traditional CBT effectively improves diabetes-related distress and depression in adults with diabetes. Third-wave CBT for diabetes-related distress effectively improved anxiety, however more work is needed to confirm this. Furthermore, CBT interventions that had a digital component, included behavioural activation, and were delivered by a psychological practitioner bolstered treatment effectiveness. Preliminary evidence
indicated that studies which targeted diabetes-related distress as the primary outcome had larger treatment effects when compared with those that did not. This points to the potential benefit of COMPASS as a treatment for adults with diabetes and co-morbid psychological distress because of its tailored nature.
Study 2 (presented in chapter 4) used mixed methods and the RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework to explore the implementation of COMPASS for adults with diabetes and co-morbid psychological distress, within two distinct care pathways in England (Talking Therapies; primary care and a diabetes psychology clinic within a physical health service; secondary care). The findings of this study demonstrated poor reach, adoption, and implementation of COMPASS. This is despite preliminary treatment effects indicating that COMPASS may be effective at improving psychological outcomes, illuminating a research to practice gap. The study also identified key barriers and facilitators to the implementation of COMPASS from the perspective of adults with diabetes such as the importance of human contact in digital therapy, non-acceptability of digital interventions, a desire for COMPASS to include more self-management content. However, many of the barriers to the implementation of COMPASS identified in this study did not occur at the patient-level. For example, the route to mental health support prior to accessing COMPASS influenced the implementation of COMPASS. Hence, this study also identified contextual, service, and systemic level factors impacting implementation. Therefore, it was not possible to elucidate if the identified barriers and facilitators were unique to people with diabetes or if they were unique to COMPASS, a digital CBT treatment.
To explore this further and to attempt to contextualise the findings presented in study 2, a cross-sectional study was conducted using routinely collected Talking Therapies data. Study 3 (presented in chapter 5) examined associations between having an LTC including diabetes (vs not having an LTC) on i) assessment attendance ii) treatment engagement (attending two or more treatment sessions) and iii) the intervention modality offered (i.e., digital vs face-to-face). Across the whole sample of 17,095 referrals to talking therapies, there were no significant differences between those with an LTC vs those who did not have an LTC in terms of attendance at assessments and treatment engagement. Across the whole sample, rates of internet-enabled treatment receipt were low. Regardless of LTC status receiving a digital treatment appeared to bolster engagement; however, adults who reported having a LTC were less likely to receive internet-enabled therapy in Talking Therapies. This suggests that barriers to engaging with COMPASS may not be wholly specific to living with an LTC such as diabetes. However, it appears that having an LTC may add an additional level of complexity which may reduce future implementation.
Finally, chapter 6, (study 4) examined the barriers and facilitators to implementing COMPASS, as perceived by in-service clinicians and wider stakeholders. The findings indicate recognition among stakeholders of the benefits of tailored digital interventions like COMPASS to increase access to psychological support for adults with diabetes and to assisting services to address clinical needs. However, several challenges to implementing COMPASS were identified, including concerns regarding its digital format and the complexities of integrating mental and physical health care within the current healthcare system. Negative attitudes surrounding digital treatment and integrated working, as well as deficiencies in clinician knowledge, confidence, and skills, were identified as barriers to implementation. Furthermore, structural obstacles such as inadequate funding, resources, and incongruence with existing care pathways and service objectives were highlighted.
Taken together, these studies contribute to the literature on the implementation of COMPASS an internet-enabled CBT intervention for adults with diabetes into routine care. The findings highlight both the significant barriers and facilitators associated with applying COMPASS in real-world practice settings. If these are not addressed, research will not translate into practice and clinical need will remain unmet. Therefore, future work should develop implementation strategies to overcome the barriers and enhance the facilitators identified in this thesis.
| Date of Award | 1 Oct 2024 |
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| Original language | English |
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| Supervisor | Ruth Hackett (Supervisor), Joanna Hudson (Supervisor) & Rona Moss-Morris (Supervisor) |