Systematic review and meta-analysis of randomized controlled trials of psychological interventions to improve glycaemic control in children and adults with type 1 diabetes

Abstract

Aim: We conducted a systematic review aggregate and network meta-analysis of psychological interventions for people with type 1 diabetes to assess their effectiveness in improving glycaemic levels.

Methods: We searched the following databases from 1 January 2003 to 1 July 2018: MEDLINE, CINAHL, PsycINFO, Embase, Cochrane Controlled Trials, Web of Science, clinicaltrials.gov, Dissertation Abstract International. We included randomized controlled trials (RCT) of psychological interventions for children and adults with type 1 diabetes reported in any language. We extracted data on publications, participant characteristics at baseline, intervention and control group, and data for the primary outcome, change in glycaemic control [HbA_1c (mmol/mol/%)]. Study authors were contacted for missing data. The review was registered with international prospective register of systematic reviews registration (PROSPERO) CRD42016033619.

Results: Twenty-four adult RCTs and 23 of children with type 1 diabetes were included in the systematic review. In aggregate meta-analysis there was no overall effect of psychological intervention compared with control on HbA_1c [adults, nine RCTs, n = 1102, pooled mean difference -0.12, 95% confidence intervals (CI) -0.27 to 0.03, I² = 29.0%, P = 0.19; children, 20 RCTs, n = 2567, -0.09, 95% CI -0.22 to 0.04, I² =54.0% P=0.002]. Network meta-analysis suggested that probability and rank-ordering of effectiveness is highest for attention control groups (b = -0.47, 95% CI -0.80 to -0.12) followed by cognitive behavioural therapy (CBT) (-0.26, 95% CI -0.45 to -0.06) compared with usual care for adults.

Conclusions: Overall psychological interventions for children and adults with type 1 diabetes do not improve glycaemic control. For adults, CBT-based interventions have the potential to be effective.

Figure 1

Qualitative and quantitative flowchart for all type 1 diabetes studies. *Reasons for exclusion: protocol (n = 41), conference abstracts (n = 37), outcome of interest reported in separate paper (n = 22), intervention not defined as psychological (n = 215), glycaemic control not measured (n = 47), not RCT (n = 25), unable to access study (n = 10), no diabetes (n = 8), type 2 diabetes (n = 95). **Fourteen type 1 diabetes adult studies and two type 1 diabetes child/adolescent studies were papers that included populations with type 1 and type 2 diabetes where separate analysis per diabetes type could not be obtained. The remaining single type 1 diabetes adult study and two type 1 diabetes child/adolescent studies that were not included in meta‐analysis, did not provide enough information for meta‐analysis. ***Three type 1 diabetes adult studies had populations with type 1 and type 2 diabetes where separate analysis per diabetes type was obtained.

Figure 2

Forest plot for a random‐effects meta‐analysis of standardized mean difference in HbA_1c comparing psychological intervention vs. control group for adults with type 1 diabetes. References can be found in the online Supporting Information (Doc. S1).

Figure 3

Forest plot for a random‐effects meta‐analysis of standardized mean difference in HbA_1c comparing psychological intervention vs. control group for children and adolescents with type 1 diabetes. References can be found in the online Supporting Information (Doc. S1).