The Effects of Multisystemic Therapy on Diabetes Stress Among Adolescents With Chronically Poorly Controlled Type 1 Diabetes: Findings From a Randomized, Controlled Trial

Abstract

ABSTRACT. Objective. The goal of this study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could decrease diabetes-related stress among adolescents with chronically poorly controlled type 1 diabetes. Stress was also evaluated as a mediator of the effect of MST on adherence and metabolic control.Methods. A randomized, controlled trial was conducted with 127 adolescents with type 1 diabetes mellitus and chronically poor metabolic control (hemoglobin A1c levels of >8% at study enrollment and for the past 1 year) who received their diabetes care in a children's hospital located in a major Midwestern city. Participants assigned randomly to MST received treatment for ϳ6 months. Data were collected at baseline and at a 7-month posttest (ie, treatment termination). Changes in diabetes-related stress, as measured with a self-report questionnaire, were assessed. Structural equation models were used to test the degree to which changes in stress levels mediated the ability of the MST intervention to improve adherence and metabolic control.Results. In intent-to-treat analyses, participation in MST was associated with significant reductions in diabetes-related stress. Tests for moderation found no significant effects of age, gender, or ethnicity, which suggests that the intervention was equally effective in reducing diabetes stress for all participants. However, structural equation modeling did not provide support for diabetes stress as the mechanism through which MST improved health outcomes. Rather, the final model suggested that MST improved metabolic control through increased regimen adherence.Conclusions. Intensive, home-based psychotherapy reduces diabetes-related stress among adolescents with chronically poorly controlled type 1 diabetes. Such stress reductions are important for the psychological wellbeing of a subset of youths with diabetes who are at high risk for future health complications. A dolescents with type 1 diabetes mellitus face a number of stressors and challenges as a result of their chronic illness. [1][2][3][4] These include the need to manage a complex medical condition that requires daily completion of multiple selfcare behaviors, the impact of diabetes on social interactions with family members, peers, and teachers, and the interference of symptoms such as hypoglycemia with daily activities.Previous studies investigated the impact of stress on health outcomes among persons with type 1 diabetes. The effects of stress on regimen adherence and metabolic control have been of particular interest. Stress has the potential to affect metabolic control directly through its impact on cortisol and other catabolic hormones that interfere with insulin metabolism. It may also affect metabolic control indirectly, by interfering with completion of self-care tasks. However, prior findings have been mixed, with some studies supporting a direct relationship between stress and metabolic control, some suggesting that adherence mediates the relationship between stress and me...

Psychological interventions for parents of children and adolescents with chronic illness

“…There were 22 studies that delivered cognitive behavioural therapy (CBT) (Allen 1998; Ambrosino 2008; Barakat 2010; Barry 1997; Connelly 2006; Duarte 2006; Gulewitsch 2013; Hicks 2006; Hoekstra-Weebers 1998; Kashikar-Zuck 2005; Kashikar-Zuck 2012; Laffel 2003; Levy 2010; Marsland 2013; Niebel 2000; Olivares 1997; Palermo 2009; Robins 2005; Sanders 1994; Shekarabi-Ahari 2012; Stehl 2009; Tsiouli 2014), eight studies delivered family therapy (FT) (Celano 2012; Kazak 2004; Lask 1979; Lehmkuhl 2010; Ng 2008; Saßman 2012; Wysocki 1999; Wysocki 2006), 12 studies delivered problem-solving therapy (PST) (Antonini 2014, Askins 2009; Mullins 2012; Nansel 2009; Nansel 2012; Sahler 2002; Sahler 2005; Sahler 2013; Seid 2010; Wade 2006a; Wade 2006b; Wade 2011), four studies delivered multisystemic therapy (MST) (Ellis 2004; Ellis 2005; Ellis 2012; Naar-King 2014) and one study delivered an exclusively behavioural intervention (Stark 2005). …”

“…As a result, complete or partial data were available to extract from 37 (n = 2985) of the 47 studies (n = 3778) included in this review. Twenty-eight trials produced complete outcome data in their published paper (Allen 1998; Barakat 2010; Connelly 2006; Ellis 2004; Ellis 2005; Gulewitsch 2013; Hicks 2006; Hoekstra-Weebers 1998; Kashikar-Zuck 2005; Kashikar-Zuck 2012; Laffel 2003; Levy 2010; Marsland 2013; Nansel 2009; Ng 2008; Palermo 2009; Sahler 2013; Sanders 1994; Saßman 2012; Seid 2010; Shekarabi-Ahari 2012; Stehl 2009; Tsiouli 2014; Wade 2006a; Wade 2006b; Wade 2011; Wysocki 1997; Wysocki 2006) and nine authors responded to our requests for data (Ambrosino 2008; Antonini 2014; Askins 2009; Ellis 2012; Mullins 2012; Naar-King 2014; Niebel 2000; Sahler 2002; Sahler 2005). Other authors were unable or unwilling to provide additional data or did not respond.…”

“…Problem-solving therapy (PST) has also been used to reduce distress in parents of children with various chronic illnesses (D’Zurilla 1971; Sahler 2002). Other treatments have emerged from a family-systems approach that focuses explicitly on the family as a unit of intervention (Ellis 2005; Wysocki 2000) such as multisystemic therapy (MST) or family therapy (FT).…”

The Interface of Child Mental Health and Juvenile Diabetes Mellitus

“…97 It has been adapted to treat chronically poorly controlled adolescents with T1DM. [98][99][100] The intensive home-based psychotherapeutic approach includes a wide menu of interventions appropriate to the individual patient and family. Family interventions included parent training regarding monitoring and improving communication.…”

Multisystemic Therapy (MST)

“…MST was selected as the platform for this work because of its capacity to overcome barriers to service access and to address the multidetermined nature of difficulties in following complex medical adherence regimens. Ellis, Naar-King, and their colleagues evaluated the capacity of MST-HC to improve the health status of adolescents with type 1 diabetes who had chronically poor metabolic control, and significant findings favoring the MST-HC condition emerged for several key outcomes (Ellis, Frey et al, 2005a, 2005b. Youths in the MST-HC condition, in comparison with counterparts receiving standard care alone, had improved metabolic control, engaged in blood testing more frequently, reported less diabetes-related stress, and had fewer diabetes-related inpatient hospitalizations, which led to significantly lower medical charges and direct care costs (Ellis, Naar-King, et al, 2005).…”