APPENDIX
Summary
Summary
Diabetes mellitus is a highly prevalent chronic somatic disease with a complex
treatment regimen that requires daily attention to diet and physical exercise. The
burden of diabetes and its complex treatment makes diabetic patients vulnerable to
comorbid psychological disorders, such as depression. Previous research has found
that diabetes increases or even doubles the risk of developing major depression or
having elevated depressive symptoms as compared to people without a chronic
disease. Comorbid depressive symptoms in patients with diabetes have been related
to lower adherence to medication, dietary and exercise recommendations, poorer
glycemic control, and increased health care costs. Given the high prevalence and the
short- and long-term diabetes related complications of poor glycemic control and
depression, identifying interventions that are effective in improving glycemic control
and reducing depressive symptoms is of utmost importance. Psychological treatment
has been found promising in diabetic patients. Cognitive Behavior Therapy (CBT) is the
most commonly used and evidence-based form of psychological treatment that is
effective in treating a variety of problems. Mindfulness-Based Cognitive Therapy
(MBCT) is another form of treatment that currently receives more attention and was
found to be effective in reducing depressive symptoms.
In a systematic review and meta-analysis, the current evidence for the treatment of
depressive symptoms and poor glycemic control was evaluated. The results of this
study are presented in Chapter 2. Sixteen studies were eligible for the review, nine in
which CBT was used to improve poor glycemic control, six in which CBT was used for
treating depressive symptoms, and in one study CBT was used to treat both poor
glycemic control and depressive symptoms. Main finding of this study was that CBT
outperformed other types of treatment or no treatment in reducing both HbA1c values
and depressive symptoms in patients with elevated baseline scores. It was concluded
that CBT should have a more prominent role in the treatment of patients with type 1
or type 2 diabetes mellitus to assist them in improving glycemic control and reducing
depressive symptoms.
CBT can be delivered both as a group or individual intervention. MBCT, however, is
developed as a group intervention and has until now only been tested as such. In a
pilot study in Chapter 3, we examined the feasibility and acceptability of individual
MBCT in patients with diabetes and elevated levels of diabetes-related distress and/or
depressive symptoms. A consecutive sample of patients with diabetes type 1 or 2 was
screened on psychological symptoms and when reporting elevated levels of symptoms,
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was approached for the intervention trial. Patients completed self-report
questionnaires pre- and post-intervention regarding psychological functioning (i.e.,
depressive symptoms, diabetes-related distress), mindfulness (i.e., act with awareness,
accept without judgment), and attention regulation. Twenty-four patients were eligible
and were randomized to either individual MBCT (n = 12) or a waiting list control
condition (n = 12). Results revealed that individual MBCT was acceptable to patients. In
addition, compared to controls, patients receiving MBCT reported significant
reductions in depressive symptoms and diabetes-related distress and improvements in
act with awareness and attention regulation. With these findings, we provided
encouraging evidence for the feasibility, acceptability, and effectiveness of individualbased MBCT.
The promising results of the pilot study on individual MBCT warranted a bigger trial
in which individual MBCT would not only be compared to a passive control condition,
but also to another active, evidence-based intervention like CBT. Accordingly, the
Mood Enhancement Therapy Intervention Study (METIS) was developed to test the
effectiveness of individually administered CBT and MBCT in comparison to a waiting
list control condition with respect to reducing the severity of depressive symptoms in
patients with diabetes. Furthermore, the aim was to explore several potential
moderators and mediators of change underlying treatment effectiveness, as well as
the role of common factors and treatment integrity. The study protocol of the METIS
trial is presented in Chapter 4. In this RCT, Dutch adult outpatients with diabetes type 1
or 2 and depressive symptoms (i.e., a BDI-II score ≥ 14) were randomized to an 8-week
individual MBCT condition, an 8-week individual CBT condition, or a waiting list control
condition. Patients in the control group were randomized again after the waiting
period (i.e., three months) and received either CBT or MBCT. Primary outcome
measure was depressive symptoms, assessed by self-report (BDI-II) and a semistructured clinical interview (HAM-D7). Secondary outcomes were well-being (WHO-5),
generalized anxiety (GAD-7), diabetes-related distress (PAID), and glycemic control as
indicated by HbA1c values. Assessments took place at pre-treatment, at several time
points during treatment, at post-treatment, and at 3-months and 9-months follow-up.
Chapter 5 reports on the short-term outcomes of the METIS trial. We hypothesized
that both individual CBT and individual MBCT would be effective in reducing
depressive symptoms in comparison to the waiting list control condition. In total, 94
participants were included in the study; 32 patients were allocated to CBT, 31 to
MBCT, and 31 to the waiting list condition. Findings showed that, concordant with our
hypothesis, patients in both the CBT and MBCT condition displayed greater reductions
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Summary
of depressive symptoms as compared to the waiting list control condition, directly
after the intervention. Neither CBT nor MBCT was superior over the other. Both
interventions were also effective in improving a wider range of patient relevant
outcomes, including increases in well-being as well as reductions in anxiety and
diabetes-related distress. No effects were found for HbA1c values. Given the
effectiveness of CBT and MBCT and the fact that both interventions are short,
structured 8-week interventions delivered on an individual basis, they could be
implemented in optimizing psychological care for depressed patients with diabetes.
Depression is characterized as a chronic disease as many patients show a relapse of
symptoms. Therefore, it is important to examine whether treatment effects are
sustained after cessation of the intervention. In Chapter 6, we investigated the longterm effects of CBT and MBCT up to 12 months after baseline. For this study, all
eligible participants that received CBT or MBCT, either directly or after the waiting
period, were included in the analyses. As three patients did not meet inclusion criteria
(i.e., had no elevated scores of depressive symptoms after the waiting period), the
sample consisted of 91 patients, with 45 being allocated to CBT and 46 being allocated
to MBCT. Both individual CBT and MBCT were found effective in sustaining the gains
that were reached post-intervention on all psychological outcome measures. Again, no
effect was found on glycemic control.
Despite the general effectiveness of CBT and MBCT, little is known about which
intervention works best for whom. Effectiveness may be influenced to some degree by
the traits and characteristics of the participants. Specifically, these characteristics can
either generally predict treatment outcome (i.e., prognostic predictors), or indicate
which treatment is most beneficial for a given patient (i.e., prescriptive predictors).
Accordingly, a secondary objective of the METIS trial was to investigate factors that
influence response to CBT and MBCT. These predictors are examined in Chapter 7. A
broad range of demographics, clinical factors, disease-related and personality
characteristics were assessed as potential predictors. Also in this study, the pooled
sample of 91 participants was used for the analysis. It was found that history of
treatment and diabetes-related distress were general prescriptive predictors,
indicating that patients who previously received psychological or psychiatric therapy or
had high levels of diabetes-related distress at baseline, were less likely to respond to
treatment. This effect was found for both CBT and MBCT. Next, results showed that
patients with a lower education or those with an insecure anxious attachment style
fared better with CBT as compared to MBCT. CBT is a structured and goal-directed
143
intervention and might therefore be easier to understand and less threatening than
the experiential MBCT.
To conclude, our studies showed that both CBT and MBCT are promising
interventions for reducing depressive symptoms, generalized anxiety, and diabetesrelated distress as well as increasing well-being in patients with diabetes in the shortand long-term. No influences were found on glycemic control. Moreover, individuals
with lower education or who score high on attachment anxiety might improve more
from CBT as compared to MBCT. Patients with a previous history of psychological or
psychiatric treatment or with high baseline levels of diabetes-related distress might
benefit less from treatment, irrespective of the intervention However, the majority of
predictors did not yield significant results, suggesting that both individual MBCT and
individual CBT are effective interventions for a broad population.
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Samenvatting
Samenvatting
Diabetes mellitus is een veel voorkomende chronisch-somatische ziekte die hoge eisen
stelt aan patiënten. Diabetespatiënten worden geacht om dagelijks aandacht te
besteden aan hun voedingspatroon, moeten voor voldoende lichaamsbeweging zorgen
en met behulp van medicatie en/of insuline-injecties hun bloedglucose onder controle
houden. Veel patiënten hebben moeite zich aan de behandeling te houden en hebben
als gevolg daarvan een slechte glykemische controle (aangegeven door hoge HbA1c
waardes). Daarnaast zijn diabetespatiënten kwetsbaar voor comorbide psychische
stoornissen, zoals depressie. Eerder onderzoek heeft aangetoond dat diabetes het
risico op depressie of depressieve klachten verhoogt of zelfs verdubbelt in vergelijking
met mensen zonder chronische ziekte. Comorbide depressieve klachten bij patiënten
met diabetes zijn gerelateerd aan slechtere zelfzorg, minder lichaamsbeweging en
slechtere glykemische controle. Gezien de hoge prevalentie en de nadelige korte- en
lange-termijn gevolgen van een slechte glykemische controle en depressie, is het
belangrijk om effectieve interventies te identificeren die helpen bij het verbeteren van
de glykemische controle en bij het verminderen van depressieve klachten.
Psychologische behandelingen zijn hierbij veelbelovend. Cognitieve gedragstherapie
(CGT) is de meest gebruikte, evidence-based vorm van psychologische begeleiding die
effectief is gevonden voor de behandeling van verschillende psychische klachten.
Mindfulness-Based Cognitive Therapy (MBCT) is een nieuwere vorm van behandeling
die momenteel meer aandacht krijgt en ook effectief is gebleken in het verminderen
van depressieve klachten.
Om meer inzicht te krijgen in de huidige literatuur over de effectiviteit van CGT bij
diabetespatiënten, hebben wij in een systematische review en meta-analyse de
effecten van op cognitieve therapie gebaseerde interventies op patiënten met slechte
glykemische controle en/of depressieve klachten onderzocht. Deze literatuurstudie
wordt beschreven in Hoofdstuk 2. In totaal werden er zestien onafhankelijke studies
geïncludeerd. In negen studies werd CGT ingezet om slechte glykemische controle te
verbeteren, in zes studies werd CGT onderzocht voor de behandeling van depressieve
klachten en in één studie werd CGT gebruikt om zowel slechte glykemische controle als
depressieve symptomen te verbeteren. Belangrijkste bevindingen van deze studie
waren dat CGT beter werkte dan andere vormen van behandeling of geen behandeling
in het verminderen van zowel HbA1c waardes als depressieve symptomen bij
patiënten met verhoogde scores voorafgaand aan de behandeling. CGT zou dus een
meer prominente rol in de behandeling van patiënten met type 1 of type 2 diabetes
147
mellitus kunnen krijgen om hen te helpen bij het verbeteren van de glykemische
controle en het verminderen van depressieve symptomen .
CGT wordt vaak gegeven in een groep met lotgenoten of als individuele
behandeling. MBCT daarentegen is ontwikkeld als groepsinterventie en is tot nu toe
ook alleen onderzocht als zodanig. In een pilotstudie bij diabetespatiënten met
verhoogde diabetes gerelateerde-stress en/of depressieve symptomen, hebben wij de
haalbaarheid en de acceptatie van individuele MBCT onderzocht De resultaten van
deze studie staan beschreven in Hoofdstuk 3. Een consecutieve steekproef
diabetespatiënten werd gescreend op psychische klachten en bij het rapporteren van
symptomen, benaderd om deel te nemen aan de studie. Vierentwintig patiënten
werden gerandomiseerd en kregen individuele MBCT (n = 12) of kwamen terecht in
een wachtlijst controlegroep (n = 12). Patiënten werden vervolgens gevraagd om
direct voor en na de behandeling/wachtlijst en drie maanden later een vragenlijst in te
vullen over hun psychisch functioneren (d.w.z. depressieve symptomen, diabetesgerelateerde-stress), mindfulness (d.w.z. handelen met bewustzijn, accepteren zonder
oordeel), en aandacht-regulatie. Uit de resultaten bleek dat de meeste patiënten
tevreden waren met de training. Daarnaast vertoonden patiënten in de MBCT conditie
een grotere afname van depressieve symptomen en diabetes-gerelateerde stress en
meer verbeteringen in handelen met bewustzijn en aandacht-regulatie dan patiënten
in de wachtlijst conditie. Dit was de eerste gerandomiseerde studie waarin individuele
MBCT werd onderzocht en de resultaten zijn bemoedigend met betrekking tot de
acceptatie en de haalbaarheid. Daarnaast suggereren de resultaten ook dat individuele
MBCT effectief is in het verbeteren van psychologisch functioneren.
De veelbelovende resultaten van deze pilotstudie vragen om een grotere RCT
waarin MBCT niet alleen wordt vergeleken met een passieve controle groep, maar ook
met een andere actieve, evidence-based interventie zoals CGT. De Mood Enhancement
Therapy Intervention Study (METIS) werd ontwikkeld om de effectiviteit van
individuele CGT en MBCT te vergelijken met een wachtlijst controle-conditie met
betrekking tot het verminderen van de ernst van depressieve symptomen bij
diabetespatiënten. Daarnaast werd de invloed van verschillende potentiële
moderatoren en mediatoren onderzocht, evenals de rol van gemeenschappelijke
factoren en behandelintegriteit. Het design van de METIS-trial wordt beschreven in
Hoofdstuk 4. In deze RCT werden volwassen patiënten met diabetes type 1 of 2 en
depressieve symptomen (d.w.z. BDI-II score ≥ 14) gerandomiseerd in een 8-weekse
individuele MBCT groep, een 8-weekse individuele CGT groep, of een wachtlijst
controle-conditie. Patiënten in de controlegroep werden na afloop van de wachttijd
148
Samenvatting
(d.w.z. drie maanden) opnieuw gerandomiseerd en kregen alsnog ofwel CBT ofwel
MBCT. Primaire uitkomstmaat was depressieve symptomen, gemeten met behulp van
zelfrapportage (BDI-II) en een semigestructureerd klinisch interview (HAM-D7).
Secundaire uitkomstmaten waren welzijn (WHO-5), gegeneraliseerde angst (GAD-7),
diabetes-gerelateerde stress (PAID), en glykemische controle aangegeven door HbA1c
waardes. Meetmomenten waren voorafgaand aan de behandeling, op verschillende
momenten tijdens de behandeling, direct na afloop van de behandeling en op een 3 en
9 maanden follow-up.
In Hoofdstuk 5 worden de directe effecten van de METIS trial gepresenteerd. De
hypothese was dat zowel individuele CGT als individuele MBCT effectief zouden zijn in
het verminderen van depressieve klachten. Uiteindelijk hebben er 94 patiënten
deelgenomen aan de METIS-trial; 32 patiënten werden ingedeeld in CGT, 31 in MBCT
en 31 kwamen op de wachtlijst. In overeenstemming met onze hypothese toonden
patiënten in zowel de CGT als ook in de MBCT conditie een grotere vermindering van
depressieve klachten aan in vergelijking met patiënten in de wachtlijst conditie. Beide
interventies bleken even effectief. Daarnaast hadden CGT en MBCT een positief effect
op andere psychologische uitkomstmaten, namelijk op welzijn, angst en diabetesgerelateerde stress. Er werden geen effecten gevonden op de HbA1c waardes. Gezien
de effectiviteit van CGT en MBCT en het feit dat beide interventies korte,
gestructureerde en individuele interventies zijn, kunnen zij worden ingezet in het
optimaliseren van psychologische zorg voor depressieve diabetespatiënten.
Depressie wordt gekenmerkt als een chronische ziekte en veel patiënten vertonen
een terugval van symptomen na oorspronkelijk herstel. Daarom is het belangrijk om
langdurige effecten van CGT en MBCT bij diabetespatiënten te onderzoeken. In
aanvulling op het onderzoek naar de korte termijn effecten, hebben we de lange
termijn effecten van CGT en MBCT tot negen maanden na afloop van de behandeling
onderzocht. De resultaten van deze studie worden besproken in Hoofdstuk 6. Voor
deze studie werden alle geschikte proefpersonen geïncludeerd die ingedeeld waren in
CGT of MBCT, hetzij rechtstreeks, hetzij na de wachttijd. Drie patiënten voldeden na
afloop van de wachtlijst periode niet meer aan de inclusiecriteria (d.w.z. hadden geen
depressieve klachten meer), daarom bestond de steekproef uit 91 patiënten, waarvan
45 toegewezen werden aan CGT en 46 aan MBCT. Zowel individuele CGT als MBCT
bleken effectief in de instandhouding van de winsten die direct na de interventies
werden bereikt, met betrekking tot alle psychologische uitkomstmaten. Ook op de
lange termijn werd er geen effect gevonden op de glykemische controle.
149
De bevinding dat CGT en MBCT in het algemeen effectief zijn, wil niet zeggen dat
iedereen op dezelfde manier baat heeft bij de therapieën. Effectiviteit kan beïnvloed
worden door de eigenschappen en kenmerken van de personen. Deze kenmerken
kunnen zowel het algemene behandelingsresultaat voorspellen (d.w.z. prognostische
voorspellers), of aangeven welke behandeling het meest geschikt is voor een bepaalde
patiënt (d.w.z. prescriptieve voorspellers). Dienovereenkomstig was een secundaire
doelstelling van het METIS onderzoek om factoren te onderzoeken die de effecten van
CGT en MBCT beïnvloeden. Deze werden geëvalueerd in Hoofdstuk 7. Een breed scala
aan demografische karakteristieken, klinische factoren, ziekte-gerelateerde en
persoonlijkheidskenmerken werden onderzocht als mogelijke voorspellers. Uit de
resultaten kwam naar voren dat patiënten die eerder psychologische of psychiatrische
begeleiding hadden ontvangen, minder baat hadden bij de behandelingen. Daarnaast
werd gevonden dat patiënten met hoge niveaus van diabetes-gerelateerde stress
voorafgaand aan de behandeling ook minder profijt hadden bij zowel CGT als MBCT.
Wat betreft de prescriptieve voorspellers toonden de resultaten aan dat patiënten met
een lagere opleiding of een angstige hechtingsstijl meer baat hadden bij CGT in
vergelijking met MBCT. CGT is een gestructureerde en doelgerichte interventie en
daardoor wellicht makkelijker te begrijpen en minder bedreigend dan MBCT.
Concluderend kan worden gezegd dat individuele CGT en individuele MBCT
effectieve behandelingen zijn voor het verbeteren van depressieve symptomen bij
diabetespatiënten. Bovendien helpen beide interventies bij het verminderen van
gegeneraliseerde angst, diabetes-gerelateerde stress en het verbeteren van welzijn,
zowel op de korte als de lange termijn. Geen invloeden werden gevonden op de
glykemische controle. Daarnaast hebben personen met een lagere opleiding of een
hoge score op angstige hechtingstijl meer baat bij CGT in vergelijking met MBCT.
Patiënten die al eerder onder behandeling waren of hoge niveaus van diabetesgerelateerde stress voorafgaand aan de behandeling vertoonden, hadden minder
profijt bij de behandelingen. Aangezien de meeste onderzochte voorspellers echter
geen effect hadden op de behandeling, kan worden gesteld dat zowel CGT als ook
MBCT effectief zijn voor een brede populatie.
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Zusammenfassung
Zusammenfassung
Diabetes mellitus ist eine sehr weit verbreitete chronische Erkrankung, die hohe
Anforderungen an Patienten stellt. Von Patienten wird erwartet dass sie die
wesentlichen Therapiemaßnahmen des Diabetes dauerhaft und eigenverantwortlich in
ihrem persönlichen Alltag umsetzen. Diabetiker müssen nicht nur auf ihre Ernährung
und genügend Bewegung achten, sondern auch mehrmals täglich ihren Blutzucker
kontrollieren und Medikamente einnehmen oder Insulin spritzen. Viele Patienten
haben Schwierigkeiten im Umgang mit den Anforderungen der Diabetestherapie und
leiden unter häufig erhöhten Blutzuckerspiegeln (erhöhte HbA1c-Werte). Dies erhöht
das Risiko für langfristige Komplikationen (z.B. Folgeerkrankungen, schwere
Unterzuckerungen). Durch die Verbesserung des Selbstmanagements in Bezug auf die
Blutzuckerkontrollen kann die Entwicklung solcher Komplikationen verhindert werden.
Darüber hinaus macht die Belastung durch Diabetes und seine komplexe Behandlung
Patienten anfällig für psychologische Erkrankungen. Im Vergleich zu Menschen ohne
chronische Krankheit, haben Menschen mit Diabetes daher ein etwa doppelt so hohes
Risiko an einer Depression zu erkranken. Das Auftreten einer Depression geht häufig
einher mit Problemen bei der Therapiedurchführung im Alltag und einer erheblichen
Verminderung der Lebensqualität. Angesichts der hohen Prävalenz und der negativen
Konsequenzen von Diabetes und schlechter Blutzuckerkontrolle oder Depression, ist es
wichtig Interventionen zu identifizieren die wirksam sind bei der Verbesserung der
glykämischen Kontrolle und Verringerung der depressiven Symptome. Psychologische
Behandlungen wie Kognitive Verhaltenstherapie (KVT) und Achtsamkeitsbasierte
Kognitive Therapie (Mindfulness-Based Cognitive Therapy - MBCT) scheinen
vielversprechend.
In einer systematischen Literaturstudie und Meta-Analyse in Kapitel 2 wurden die
Effekte von KVT bei häufig vorkommenden Problemen des Diabetes erforscht.
Sechzehn Studien wurden inkludiert; in neun Studien wurde KVT eingesetzt um die
Blutzuckerkontrolle zu verbessern, in sechs Studien wurde KVT verwendet für die
Behandlung von depressiven Symptomen und in einer Studie wurde KVT angewandt
um sowohl schlechte Blutzuckerkontrolle als auch depressive Symptome zu behandeln.
Das Hauptergebnis unserer Literaturstudie war, dass KVT effektiver ist als andere Arten
der Behandlung sowohl bei der Reduzierung des HbA1c-Wertes als auch der
depressiven Symptomatik bei Patienten mit erhöhten Ausgangswerten. Folglich sollte
die KVT eine stärkere Rolle in der Behandlung von Patienten mit Typ 1- oder Typ 2Diabetes Mellitus haben, um sie bei der Verbesserung der glykämischen Kontrolle und
Verringerung der depressiven Symptome zu unterstützen.
153
KVT wird als Therapieform entweder individuell oder in einer Gruppe angeboten.
MBCT hingegen wurde entwickelt als Gruppentherapie und wurde bislang auch nur als
solche evaluiert. In Kapitel 3 untersuchten wir die Akzeptanz und Effektivität von
individueller MBCT in einer Pilotstudie mit Diabetes-Patienten die erhöhte
diabetesbezogene Belastungen und/oder depressive Symptome aufwiesen.
Vierundzwanzig Probanden wurden mittels Randomisierung zwei Gruppen zugeordnet:
einer individuellen MBCT-Gruppe (N = 12) oder einer Warteliste (N = 12). Es wurden
psychometrische Fragebögen eingesetzt um diabetesbezogene Belastungen (PAID),
depressive Symptome (CES-D) und Achtsamkeit (FFMQ) zu erfassen. Die Probanden
wurden zu Therapiebeginn, Therapieende und drei Monate nach Therapieende
befragt. Die Ergebnisse zeigten, dass die meisten Patienten mit MBCT zufrieden waren.
Des Weiteren fanden sich signifikante Unterschiede zum Therapieende zwischen MBCT
und der auf der Warteliste Stehenden für depressive Symptome und diabetesbezogene
Belastungen.
Die vielversprechenden Ergebnisse dieser Pilotstudie ebnen den Weg für eine
größere Studie in der MBCT nicht nur mit einer passiven Warteliste verglichen wird,
sondern auch mit einer anderen aktiven psychologischen Behandlung. Aufgrund
dessen wurde die Mood Enhancement Therapy Intervention Study (METIS) entwickelt
um die Effektivität von individueller KVT und individueller MBCT im Vergleich zu einer
Kontrollgruppe auf einer Warteliste bei depressiven Diabetes-Patienten zu
untersuchen. In Kapitel 4 wird das Protokoll der METIS vorgestellt. Probanden dieser
Studie waren Patienten mit Diabetes Typ 1 oder 2 und depressiven Symptomen (d.h.
BDI–II ≥ 14) die nach dem Zufallsprinzip einer 8-wöchigen KVT, einer 8-wöchigen MBCT
oder einer Warteliste zugewiesen wurden. Die Patienten in der Kontrollgruppe wurden
nach der Wartezeit (d.h. nach drei Monaten) erneut randomisiert und erhielten
entweder KVT oder MBCT. Primär wurde die Verringerung der depressiven Symptome
gemessen, verifiziert durch einen Fragebogen (BDI-II) und ein semi-strukturiertes
klinisches Interview (HAM-D7). Des Weiteren wurden Wohlbefinden (WHO-5),
generalisierte Angst (GAD-7) und diabetesbezogene Belastungen (PAID) in einem
Fragebogen evaluiert sowie Langzeit Blutzuckerwerte (HbA1c-Werte) bestimmt.
Darüber hinaus untersuchten wir potenzielle Moderatoren und Mediatoren die der
Wirksamkeit der Behandlung zugrunde liegen. Messmomente waren zu Beginn der
Studie, während der Behandlung, direkt nach der Behandlung und drei Monate sowie
neun Monate nach Behandlungsende.
Unser Hauptinteresse lag darin, die Effektivität von individueller KVT und
individueller MBCT gegenüber der Warteliste im Bezug auf die Verringerung der
154
Zusammenfassung
depressiven Symptome zu überprüfen. In Kapitel 5 werden die Resultate direkt nach
Abschluss der Behandlung präsentiert. Mit unserer Hypothese übereinstimmend
haben wir gefunden, dass die Verminderung der depressiven Symptome direkt nach
der Intervention bei Patienten, die entweder KVT oder MBCT erhielten, höher war als
bei Patienten in der Kontrollgruppe. Weder KVT noch MBCT war dem anderen
überlegen. Beide Behandlungen waren auch bei anderen psychologischen Symptomen
wie Wohlbefinden, Angst und diabetesbezogenen Belastungen effektiv. Die HbA1cWerte blieben konstant. Angesichts der Wirksamkeit von sowohl KVT als auch MBCT
und der Tatsache, dass beide Methoden kurze, strukturierte, individuelle
Interventionen sind, können sie für die Optimierung der psychologischen Behandlung
depressiver Diabetes-Patienten eingesetzt werden.
Da viele Patienten nach einer passageren Verbesserung der depressiven Symptome
einen Rückfall erleiden, wird die Depression oft zu einer langwierigen Erkrankung.
Deswegen ist es wichtig, auch die Langzeiteffekte von KVT und MBCT in der
Behandlung depressiver Symptome bei Diabetes-Patienten zu untersuchen. In Kapitel
6 stellen wir die Ergebnisse der Langzeiteffekte der METIS Untersuchung vor. Dabei
wurden alle geeigneten Teilnehmer berücksichtigt die KVT oder MBCT erhielten;
entweder direkt oder nach der Wartezeit. Da drei Patienten nach der Wartezeit nicht
mehr die Auswahlkriterien erfüllten (d.h. keine depressiven Symptome mehr hatten)
wurden sie in der Studie nicht weiter berücksichtigt. So wurden 91 Patienten
eingeschlossen wovon 45 KVT erhielten und 46 MBCT. Die direkt nach
Behandlungsende beobachteten positiven Effekte blieben auch bei der Untersuchung
nach drei und neun Monaten konstant. Dies galt für alle psychologischen Faktoren.
HbA1c-Werte blieben weiterhin unverändert.
KVT und MBCT sind im Allgemeinen effektive Behandlungen, das heißt jedoch nicht
dass für jeden Menschen beide Behandlungen die gleichen Effekte erzielen.
Persönliche Eigenschaften können die Wirksamkeit einer Behandlung beeinflussen.
Diese Eigenschaften können entweder allgemein Wirksamkeit vorhersagen,
unabhängig von der Form der Therapie (d.h. prognostische Prädiktoren), oder
angeben, welche Behandlung am effektivsten ist für einen bestimmten Patienten (d.h.
vorschreibende Prädiktoren). Deshalb war ein weiteres Ziel der METIS Untersuchung
diese Faktoren zu untersuchen. In Kapitel 7 werden diese Ergebnisse beschrieben. Ein
breites Spektrum an demographischen, klinischen und krankheitsbedingten Faktoren
sowie Persönlichkeitseigenschaften wurden als mögliche Prädiktoren evaluiert. Wir
haben herausgefunden, dass Patienten die in der Vergangenheit psychologische oder
psychiatrische Behandlung erhielten, oder erhöhte diabetesbezogene Belastungen
155
aufwiesen im allgemein weniger von der Behandlung profitierten. Dieser Effekt wurde
sowohl für KVT als auch MBCT gefunden. Des Weiteren wurde erkannt dass Patienten
mit niedriger Bildung oder einem ängstlichen Bindungsstil mehr Nutzen von KVT im
Vergleich zu MBCT hatten. KVT ist eine strukturierte und zielgerichtete Intervention
und daher vielleicht leichter zu verstehen und weniger bedrohlich als MBCT.
Zusammenfassend ist zu sagen dass unsere Studien gezeigt haben das sowohl KVT
als auch MBCT vielversprechende Therapieformen zur Verringerung von depressiven
Symptomen sind. Auch haben wir eine Verbesserung
in Bezug auf Angst,
diabetesbezogene Belastungen und allgemeines Wohlbefinden erkannt. Die Effekte
waren sowohl direkt nach der Behandlung als auch neun Monate nach der Behandlung
sichtbar. Keine Einflüsse ergaben sich auf die Blutzuckerkontrolle. Darüber hinaus
zeigte unsere Studie dass Personen mit niedriger Bildung oder ängstlicher
Bindungsproblematik mehr profitierten von KVT im Vergleich zu MBCT. Personen die
zuvor psychologische oder psychiatrische Behandlung erhalten hatten oder hohe
diabetesbezogene Belastungen aufwiesen zeigten weniger psychologische
Verbesserung nach den Behandlungen. Da die meisten Einflussfaktoren jedoch kein
signifikantes Resultat zeigten, sind sowohl KVT als auch MBCT effektive Behandlungen
für breite Schichten der Bevölkerung.
156
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T.P., Schroevers M.J. (2014). Individual Mindfulness-Based Cognitive Therapy (MBCT) and
Cognitive Behavior Therapy (CBT) for treating depressive symptoms in patients with
diabetes: Results of a randomized controlled trial. Diabetes Care, Epub ahead of print
Trapnell, P. D., & Campbell, J. D. (1999). Private self-consciousness and the five-factor model of
personality: Distinguishing rumination from reflection. Journal of Personality and Social
Psychology, 76(2), 284-304. doi:10.1037/0022-3514.76.2.284
Unnebrink, K., & Windeler, J. (2001). Intention-to-treat: Methods for dealing with missing values
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van Bastelaar, K. M., Pouwer, F., Cuijpers, P., Riper, H., & Snoek, F. J. (2011). Web-based
depression treatment for type 1 and type 2 diabetic patients: A randomized, controlled trial.
Diabetes Care, 34(2), 320-325. doi:10.2337/dc10-1248
van Bastelaar, K. M., Pouwer, F., Cuijpers, P., Twisk, J. W., & Snoek, F. J. (2008). Web-based
cognitive behavioural therapy (W-CBT) for diabetes patients with co-morbid depression:
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van der Feltz-Cornelis, C. M., Nuyen, J., Stoop, C., Chan, J., Jacobson, A. M., Katon, W. J., Snoek,
F., & Sartorius, N. (2010). Effect of interventions for major depressive disorder and
significant depressive symptoms in patients with diabetes mellitus: A systematic review and
meta-analysis. General Hospital Psychiatry, 32(4), 380-395.
doi:10.1016/j.genhosppsych.2010.03.011
van der Ven, N. C., Hogenelst, M. H., Tromp-Wever, A. M., Twisk, J. W., van der Ploeg, H. M.,
Heine, R. J., & Snoek, F. J. (2005). Short-term effects of cognitive behavioural group training
(CBGT) in adult type 1 diabetes patients in prolonged poor glycaemic control. A randomized
controlled trial. Diabetic Medicine : A Journal of the British Diabetic Association, 22(11),
1619-1623. doi:10.1111/j.1464-5491.2005.01691.x
van Scheppingen, C., Schroevers, M. J., Smink, A., van der Linden, Y. M., Mul, V. E., Langendijk, J.
A., Coyne, J. C., & Sanderman, R. (2011). Does screening for distress efficiently uncover
meetable unmet needs in cancer patients? Psycho-Oncology, 20(6), 655-663.
doi:10.1002/pon.1939
van Son, J., Nyklíček, I., Pop, V. J., Blonk, M. C., Erdtsieck, R. J., Spooren, P. F., Toorians, A. W., &
Pouwer, F. (2013). The effects of a mindfulness-based intervention on emotional distress,
quality of life, and HbA1c in outpatients with diabetes (DiaMind): A randomized controlled
trial. Diabetes Care, 36(4), 823-830. doi:10.2337/dc12-1477
van Son, J., Nyklicek, I., Pop, V. J., Blonk, M. C., Erdtsieck, R. J., & Pouwer, F. (2014). Mindfulnessbased cognitive therapy for people with diabetes and emotional problems: Long-term
follow-up findings from the DiaMind randomized controlled trial. Journal of Psychosomatic
Research, 77(1), 81-84. doi:10.1016/j.jpsychores.2014.03.013
Veehof, M. M., Ten Klooster, P. M., Taal, E., Westerhof, G. J., & Bohlmeijer, E. T. (2011).
Psychometric properties of the dutch five facet mindfulness questionnaire (FFMQ) in
patients with fibromyalgia. Clinical Rheumatology, 30(8), 1045-1054. doi:10.1007/s10067011-1690-9
172
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174
About the author
About the author
Annika Tovote was born on the 23rd of May
1984 in Hannover, Germany. In 2007, she
received her Bachelor’s degree in Clinical and
Developmental Psychology at the University of
Groningen. She continued her studies at the
University of Groningen and graduated from
the Research Master Human Behavior in Social
Contexts in 2009 and the Master in Clinical and
Developmental Psychology in 2010, both cum
laude. In January 2010, Annika started her PhD
project at the department of Health Psychology
at the University Medical Center Groningen, resulting in this thesis. During her PhD,
she was the coordinator of the METIS project, worked as MBCT and CBT trainer and
was a member of the SHARE PhD council. Annika is continuing on her line of research
at the University Medical Center Groningen, since July 2014.
Publications
Coyne, J.C., Bhar, S.S., Pignotti, M., Tovote, K.A., & Beck, A.T., (2011). Missed Opportunity to
Rectify or Withdraw a Flawed Metaanalysis of Longer-Term Psychodynamic Psychotherapy.
Psychotherapy and Psychosomatics, 80, 53-54.
Schroevers, M.J., Snippe, E., Bas, I.V., Tovote, K.A., & Fleer, J. (2011). Mindfulness training in
perspectief. Psychologie & Gezondheid, 39, 32-38.
Schroevers, M.J., Tovote, K.A., Keers, J., Links, T.P., Sanderman, R., & Fleer, J. (2013). Individual
Mindfulness-Based Cognitive Therapy for people with diabetes: a pilot randomized
controlled trial. Mindfulness, doi: 10.1007/s12671-013-0235-5
Fleer, J., Tovote, K.A., Keers, J.C., Links, T.P., Sanderman, R., Coyne, J.C., & Schroevers, M.J.
(2013). Screening for depression and diabetes-related distress in a diabetes outpatient clinic.
Diabetes Medicine, 30, 88-94.
Tovote, K.A., Fleer, J., Snippe, E., Bas, I.V., Links, T.P., Emmelkamp, P.M.G., Sanderman, R., &
Schroevers, M.J. (2013). Cognitive behavioral therapy and mindfulness-based cognitive
therapy for depressive symptoms in patients with diabetes: design of a randomized
controlled trial. BMC Psychology, doi: 10.1186/2050-7283-1-17
Hansen, N., Postmes, T., Tovote, K.A., & Bos, A. (2014). How Modernization Instigates Social
Change: Laptop Usage as a Driver of Cultural Value Change and Gender Equality in a
Developing Country. Journal of Cross-Cultural Psychology, doi: 10.1177/0022022114537554
Tovote, K A., Fleer, J., Snippe, E., Peeters, A C.T.M., Emmelkamp, P.M.G., Sanderman, R., Links,
T.P., & Schroevers, M.J. (2014). Individual mindfulness-based cognitive therapy (MBCT) and
cognitive behavior therapy (CBT) for treating depressive symptoms in patients with diabetes:
Results of a randomized controlled trial. Diabetes Care, [Epub ahead of print]
177
Dankwoord
Dankwoord
Het schrijven van een proefschrift is heel goed vergelijkbaar met het maken van een
puzzel waarvan je het plaatje van tevoren niet kent. In het begin weet je niet wat je
kunt verwachten en wat je dan nodig hebt om het proces optimaal te laten verlopen
zijn: tijd, geduld, motivatie, een beetje geluk, doorzettingsvermogen, goede copingstrategieën bij frustraties en andere mensen die met je mee denken of je
ondersteunen. De hulp, begeleiding, advies en aanwezigheid van zulke personen is niet
vanzelfsprekend en daarom wil ik een aantal in het bijzonder hartelijk bedanken.
Allereerst wil ik de patiënten bedanken die aan mijn onderzoek hebben
deelgenomen. We zijn door ons onderzoek meer te weten gekomen over
behandelmethoden voor depressie en ik hoop van harte dat u, en de generatie na u
hier baat bij zullen hebben.
De grootste dank voor de ondersteuning tijdens het schrijven van dit proefschrift
gaat uit naar mijn begeleiders. Mijn eerste promotor Robbert, bedankt voor jouw
deskundige feedback. De combinatie van jouw humor en diepgaande gedachtegang
heeft mij op de juiste momenten bereikt. Paul, ik heb heel veel geleerd van jouw
kennis en ervaring. Jouw expertise heeft mij geleerd een symbiose te creëren tussen
klinische praktijk en wetenschappelijk onderzoek. Thera, toen ik jou voor het eerst zag
was ik onder de indruk van jouw vakkennis en persoonlijkheid. In de loop van de jaren
werd mijn bewondering alleen maar groter. Mijn dank voor jullie fantastische
begeleiding, feedback en steun in al die jaren! De mensen die wellicht de zwaarste
taak aan mijn begeleiding hebben gehad zijn Joke en Maya. Wat was en ben ik blij met
jullie! Joke, van jouw structuur en organisatorisch talent mocht ik profiteren. Maya,
jouw oog voor details heeft mij steeds weer aan het denken gezet. Ik heb heel veel van
jullie geleerd; niet alleen op wetenschappelijk gebied. Ik dank jullie beiden van harte!
Daarnaast wil ik de mensen bedanken die hebben bijgedragen om het METIS
project te laten slagen. Evelien, samen hebben wij dit project met al zijn ups en downs
doorstaan. Jij had altijd een luisterend oor en bent heel dierbaar voor mij geworden.
Zonder jou was dit project niet zo een succes geweest. Fijn dat je ook mijn paranimf wil
zijn! Verder hebben er in verschillende ziekenhuizen artsen, verpleegkundigen,
secretaresses en therapeuten geholpen om de studie op te zetten en uit te voeren.
Mijn dank gaat in het bijzonder uit naar Bruce Wolffenbuttel en Irina Bas in het UMCG,
Annemieke Roos en Klaas Hoogenberg in het Martini Ziekenhuis, Nynke Rauwerda en
Rachel Klokman in het Ziekenhuis Rivierenland Tiel en Jet de Hoop, Ingrid van Netten
en Saskia Nummerdor in het Medisch Centrum Leeuwarden. Ook wil ik alle
therapeuten bedanken die vaak vrijwillig (!) MBCT en CGT hebben gegeven. Gillian
179
Kreugel, Willeke Kasje, Kim van der Schoot, Gemma Maters, Willem Swaak, Anne
Oosterink, Jan Voorwinden, Linda Geerligs, Hanna Tjalma, Nynke Groenewold, Anne
Heideveld, Anne Louwerse, Loes Claessen, Joost Willems en Saskia Visser, dank voor
jullie inzet. Eveneens wil ik Grieteke bedanken voor de ondersteuning op klinisch
gebied en de supervisie.
Verder zijn er een paar mensen van de afdeling Gezondheidspsychologie die ik wil
bedanken. Mijn sport- en bakvriendin Moniek, fijn dat jij er bent. Niemand zou het nut
van een cheesecake-feestje zo goed begrijpen als jij. Lei, I enjoyed being your roomie
and I will miss you when you leave! Annemieke, Carin en Renate, jullie wil ik bedanken
voor de steun op organisatorisch gebied. Truus, bedankt voor je inzet bij het zoeken
van geschikte literatuur en je gezelligheid. Eric, dank voor alle discussies. Onze klinisch
relevante gesprekken hebben een significant verschil voor mij gemaakt. Ook mijn
andere collega’s Adelita, Adriana, Angélica, Ans, Fabiola, Franziska, Katerina, Mariët,
Marike, Marrit, Martine, Meirav, Monica, Somayeh, Vicky en Yvette wil ik bedanken
voor de leuke lunches, etentjes, borrels en (vrouwelijke) gezelligheid.
Ook buiten het werk in het UMCG zijn er mensen te bedanken. Tijdens mijn studie
heb ik vrienden ontmoet die Nederland tot mijn thuis maken. Mijn vriendinnen van de
Bachelor, jullie staan altijd voor me klaar -zowel onderzoeksgerelateerd als niethiervoor wil ik jullie bedanken. Marieke, jij hebt mij laten zien dat je leuk kunt zijn én
wetenschapper. Charmaine, you are the perfect combination of fun en depth. Steffie,
jij inspireert mij door jouw belangstelling en organisatorisch talent. Lieve Elisa, mijn
zussie, ik bewonder je voor je zachtheid en liefheid. Dank je dat je als paranimf aan
mijn zijde staat! I also would like to thank my friends from the Research Master! Elisa,
Lobke, Marii, Mayra, and Mechteld, together we went through so many adventures
(resulting in the simple question: Why?). Selma, jij hebt altijd in mij geloofd, dank je
wel. Nina, bij jou kan ik, als geen ander, zijn zoals ik me voel. Dank hiervoor!
Meine liebe Familie, ihr habt mich zu dem Menschen gemacht der ich heute bin
und zeigt mir immer wieder wie wichtig Lachen ist. Ilka und Felix, zu allen Zeiten wart
ihr für mich da! Luca und Michèle auch euch möchte ich in meinem Leben nicht mehr
missen. Liebe Mama, lieber Papa, mein ganzes Leben habt ihr mir das Gefühl gegeben
geliebt zu werden und genau richtig zu sein. Bessere Eltern kann ich mir nicht
vorstellen. Ich danke euch von ganzem Herzen!
Joki, du bereicherst mein Leben. Danke dass es dich gibt!
180
SHARE – previous dissertations
Research Institute SHARE
This thesis is published within the Research Institute SHARE of the University Medical Center
Groningen / University of Groningen.
Further information regarding the institute and its research can be obtained from our
internetsite: www.rug.nl/share.
More recent theses can be found in the list below.
((co-) supervisors are between brackets)
2014
Suwantika AA
Economic evaluations of non-traditional vaccinations in middle-income countries: Indonesia as a
reference case
(prof MJ Postma, dr K Lestari)
Behanova M
Area- and individual-level socioeconomic differences in health and health-risk behaviours; a
comparison of Slovak and Dutch cities
(prof SA Reijneveld, dr JP van Dijk, dr I Rajnicova-Nagyova, dr Z Katreniakova)
Dekker H
Teaching and learning professionalism in medical education
(prof J Cohen-Schotanus, prof T van der Molen, prof JW Snoek)
Dontje ML
Daily physical activity in patients with a chronic disease
(prof CP van der Schans, prof RP Stolk)
Gefenaite G
Newly introduced vaccines; effectiveness and determinants of acceptance
(prof E Hak, prof RP Stolk)
Dagan M
The role of spousal supportive behaviors in couples’ adaptation to colorectal cancer
(prof M Hagedoorn, prof R Sanderman)
Monteiro SP
Driving-impairing medicines and traffic safety; patients’perspectives
(prof JJ de Gier, dr L van Dijk)
Bredeweg S
Running related injuries
(prof JHB Geertzen, dr J Zwerver)
Mahmood SI
Selection of medical students and their specialty choices
(prof JCC Borleffs, dr RA Tio)
Krieke JAJ van der
Patients’ in the driver’s seat; a role for e-mental health?
(prof P de Jonge, prof M Aielllo, dr S Sytema, dr A Wunderink)
183
Jong LD de
Contractures and hypertonia of the arm after stroke; development, assessment and treatment
(prof K Postema, prof PU Dijkstra)
Tiessen AH
Cardiovascular risk management in general practice
(prof K van der Meer, prof AJ Smit, dr J Broer)
Bodde MI
Complex Regional Pain Syndrome type 1 & amputation
(prof JHB Geertzen, prof PU Dijkstra, dr WFA van der Dunnen)
Lakke AE
Work capacity of patients with chronic musculoskeletal pain
(prof JHB Geertzen, prof MF Reneman, prof CP van der Schans)
Silarova B
Unraveling the role of sense of coherence in coronary heart disease patients
(prof SA Reijneveld, dr JP van Dijk, dr I Rajnicova-Nagyova)
Weening-Dijksterhuis E
Physical exercise to improve or maintain Activities of Daily Living performance in frail
institutionalized older persons
(prof CP van der Schans, prof JPJ Slaets, dr MHG de Greef, dr W Krijnen)
Koolhaas W
Sustainable employability of ageing workers; the development of an intervention
(prof JJL van der Klink, prof JW Groothoff, dr S Brouwer)
Flach PA
Sick leave management beyond return to work
(prof JW Groothoff, prof U Bültmann)
2013
Bosker BH
Pitfalls in traditional and innovative hip replacement surgery
(prof SK Bulstra, dr CCPM Verheyen, dr HB Ettema)
Holwerda A
Work outcome in young adults with disabilities
(prof JJL van der Klink, prof JW Groothoff)
Mohseninejad L
Uncertainty in economic evaluations: implications for healthcare decisions
(prof E Buskens, dr TL Feenstra)
Cornelius LR
A view beyond the horizon; a prospective cohort study on mental health and long-term
disability
(prof JJL van der Klink, prof JW Groothoff, dr S Brouwer)
Sobhani S
Rocker shoes for ankle and foot overuse injuries: a biomechanical and physiological evaluation
(prof K Postema, prof ER van den Heuvel)
184
SHARE – previous dissertations
Pitel L
Sociocultural determinants, gender and health-related behaviour in adolescence
(prof SA Reijneveld, dr JP van Dijk, dr A Madarasova-Geckova)
Majerníková M
Sef-rated health and mortality after kidney transplantation
(prof JW Groothoff, dr JP van Dijk, dr J Rosenberger, dr R Roland)
Verschuren J
Sexuality and limb amputation: perspectives of patients, partners and professionals
(prof JHB Geertzen, prof PU Dijkstra, prof P Enzlin)
Riphagen-Dalhuisen J
Influenza vaccination of health care workers
(prof E Hak)
Hasselt FM van
Improving the physical health of people with severe mental illness; the need for tailor made care
and uniform evaluation of interventions
(prof AJM Loonen, prof MJ Postma, dr MJT Oud, dr PFM Krabbe)
Piening S
Communicating risk effectively
(prof FM Haaijer-Ruskamp, prof PA de Graeff, dr PGM Mol, dr SMJM Straus)
Siebelink MJ
The child as a donor; a multidisciplinary approach
(prof HBM van de Wiel, prof PF Roodbol)
Sidorenkov G
Predictive value of treatment quality indicators on outcomes in patients with diabetes
(prof FM Haaijer-Ruskamp, prof D de Zeeuw)
For more 2013 and earlier theses visit our website
185

Publications by MSc students of the Research Master Social and

Cursus Mindfulness (MSBR/MBCT) voor (G)Gz

APPENDIX - Dissertations

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