Psychosocial interventions for reducing diabetes distress in vulnerable people with type 2 diabetes mellitus: a systematic review and meta-analysis

Figures & data

Table 1 Literature search

#	Keywords	Inclusion
1	Patients	Type 2 diabetes; type 2 diabetes mellitus; diabetes, type 2; T2DM; diabetes T2; diabetes mellitus; vulnerable population [MeSH]; diabetes mellitus, type 2 [MeSH]
2	Interventions	Psychological intervention; psychological feedback; psychotherapy; psychological techniques; digital intervention; internet; cognitive focused intervention; cognitive intervention; cognitive therapy; cognitive behavior therapy; behavioral intervention; emotional focused intervention; cognitive behavior therapies [MeSH term]; feedback, psychological
3	Outcomes	Diabetes distress; distress; diabetes-related distress; problem areas in diabetes; Diabetes distress scale; PAID; DDS; HbA1c; hb A1c; glycosylated hemoglobin A; medication adherence [MeSH]; health related quality of life; quality of life [MeSH]; patient compliance [MeSH]
		# 1 AND 2 AND 3.

Figure 1 PRISMA.

Source: From Mohen D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6):e1000097. doi:10.1371/journal.pubmed1000097. For more information, visit www.prisma-statement.org.

Table 2 Characteristics of included studies

Author, year, country	Total (n)	Attrition at final follow- up (%)	HbA1c (mmol/mol) at baseline	Diabetes distress, baseline (Scale)	Vulnerability criteria	Duration, T2DM (years)	Mean Age	Intervention	Standard care	Outcomes	Follow- up time point (months)
Anderson et al,^Citation52 2009, USA	310	20	7.6% (60)	28 (PAID)	Low socioeconomic African American (AA)	8	56	One monthly phone call from DSM consultant	Mailed reports on diabetes status	HbA1c, PAID, PHQ-9	24
Beverly et al,^Citation45 2013, USA	134	10	8.4% (68)	34 (PAID)	BMI 34	13	59	Conversation map group sessions	Sessions focusing on DSME	HbA1c, PAID, DQOL	3, 6, 12
D’Eramo et al,^Citation53 2010, USA	109	28	8.2% (66)	57 (PAID)	Low socioeconomic black women	NR	48	Coping skill training group sessions	Ten 2-hour group sessions providing DSME	HbA1c, PAID, SF36	12
Gabbay et al,^Citation51 2013, USA	545	23	9.0% (75)	29 (PAID)	Socioeconomic deprived	NR	58	Individual sessions with nurse trained in MI	Usual care	HbA1c, PAID, C-DES	24
Heisler et al,^Citation42 2014, USA	188	6	8.2% (66)	35 (PAID)	Low income Latino and AA	9	NR	Idecide web decision support tool.	Idecide print version	HbA1c and PAID	3
Hermanns et al,^Citation46 2012, Germany	186	10	8.3% (67)	51 (PAID)	Comorbidity	14	63	Skill training, social and psychological support	Sessions focusing on DSME	HbA1c, PAID; SF12	6
Ing et al,^Citation40 2016, USA	47	24	10.0% (86)	34 (PAID)	Hawaiian, Samoan BMI 36	NR	55	Social support group sessions	Postcard reminder	HbA1c and PAID	6
Kleinman et al,^Citation47 2017, India	91	25	9.3% (78)	10 (PAID short)	Low educational level	NR	48	Empowerment app for patients	Free consultations and lab tests	HbA1c, PAID	3, 6
McEwen et al,^Citation50 2017, USA	157	1	10.0% (86)	14 (DDS)	Mexican American adults BMI 33	12	54	Dyad of patient with supportive family member	Waitlist group	HbA1c and DDS	6, 9
McMahon et al,^Citation44 2012, USA	101	1	9.6% (81)	26 (PAID)	Veteran Affairs Department, BMI 34	NR	60	Online care group	Web training	HbA1c and PAID	12
Spencer et al,^Citation43 2011, USA	164	18	8.6% (70)	13 PAID at log scale	Low income, AA and Latino	8	53	Culturally tailored group intervention	Delayed control group	HbA1c and PAID	6
Sperl-Hillen et al,^Citation41 2013, USA	623	0 (ITT)	8.3% (67)	30 (PAID)	Low educational status	NR	NR	Conversation map	Standard care	HbA1c, PAID, and PHQ-9	12
Tang et al,^Citation56 2013, USA	382	0 (ITT)	9.3% (78)	NR	Comorbidity	NR	54	MI web-based intervention	Standard care	HbA1c, DDS, and PHQ-9	6
Trief et al,^Citation54 2016, USA	186	0 (ITT)	9.1% (76)	2.3 (DDS)	65% <college degree BMI 36	12	57	Couples calls	Diabetes education	HbA1c, DDS and PHQ-9	4, 8, 12
Wagner et al,^Citation49 2016, USA	107	23	8.5% (69)	6.5 (PAID short)	Deprived Latino population. 85% <high school	NR	60	Eight CHW Diabetes education+ stress management	One 2½ hours group session diabetes education	HbA1c, PAID, PHQ-9	3
Welch et al,^Citation48 2015, USA	399	12	9.0% (75)	59vs 51.9 control (PAID)	Latino population	NR	55	Clinician used dashboards+ educational content+ peer support groups	Usual care	HbA1c, PAID (five- item short version), PHQ-9	6
Whittemore et al,^Citation55 2004, USA	53	8	7.7% (61)	42.3 control vs 59.9 (PAID)	Low socioeconomic status BMI 36	NR	58	Six nurse coaching visits	Waitlist group design	HbA1c, PAID	3, 6
Welch et al,^Citation57 2011, USA	234	22	8.9% (74)	42 (PAID)	BMI 35	7	56	Four 30–60 minute visits DSME+ MI	Four 30–60 minutes DSME	HbA1c and PAID	6

Abbreviations: BMI, body mass index; ; CHW, certified health worker; DSM, diabetes self-management; DSME, diabetes self-management education; DQOL, Diabetes Quality of Life; MI, motivational interviewing; NR, not reported; PAID, Problem Areas in Diabetes; PHQ, Patient Health Questionnaire.

Figure 2 Meta-analysis: intervention vs standard care on diabetes distress at 3, 6, 12, and 24 months follow-up; (1) Means converted from scale with range 0-100 with positive outcomes reflecting a higher number; (2) 24 weeks follow-up; (3) SDs calculated from Cls using Revman 5.3; (4) Measured DDS at 8 months FU (ITT); (5) SDs calculated from SE using Revman 5.3; (6) Significant difference at baseline; PAID 59.9 intervention group versus 42.3 in the control group; (7) Means+SDs from Cochrane review (Chew et al. 2017); (8) Measured with DDS at 9 months follow-up; (9) online care (intervention) versus web training (control); (10) Means+SDs from Cochrane review (chew et al. 2017); (11) Measured with DDS (ITT). Risk of bias legend: (A) Random sequence generation (selection bias); (B) Allocation concealment (selection bias); (C) Blinding of participants and personnel (performance bias); (D) Blinding of outcome assessment (detection bias); (E) Incomplete outcome data (attrition bias); (F) Selective reporting (reporting bias); (G) Other bias.

Figure 3 Meta-analysis: intervention vs standard care on HbA1c at 3, 6, 12, and 24 months follow-up; (1) SDs calculated from CI using Revman 5.3; (2) At 8 months followup (ITT); (3) Mean+SDs calculated from within group differences; (4) SDs Calculated from SE using Revman 5.3; (5) Means+SDs from Cochrance review (Chew et al. 2017); (6) At 9 months follow-up; (7) Means+SDs from Cochrance review (Chew et al. 2017); (8) ITT; Risk of bias legend; (A) Random sequence generation (selection bias); (B) Allocation concealment (selection bias); (C) Blinding of participants and personnel (performance bias); (D) Blinding of outcome assessment (detection bias); (E) Incomplete outcome data (attrition bias); (F) Selective reporting (reporting bias); (G) Other bias

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