Iran J Psychiatry 2017; 12: 4: 278-283

Short Communication

Improving Depression, and Quality of Life in Patients with

Type 2 Diabetes: Using Group Cognitive Behavior
Therapy
1 2* 3 1
Zahra Noroozi , Sajedeh Hamidian , Niloofar Khajeddin , Mahnaz Mehrabi Zadeh Honarmand ,
1 4 2
Yadollah Zargar , Homeira Rashidi , Behrooz Dolatshahi

Abstract

Objective: Depression is a chronic condition comorbid with diabetes type 2 that often remains untreated. Dealing with
diabetes is a challenging task for patients and can lead to depression in long term. These two conditions have a negative
influence on each other and on the individual’s quality of life. The purpose of this study was to investigate the effect of
group cognitive behavior therapy on depression, quality of life in women with diabetes type 2.
Method: We conducted a clinical trial among 30 women with diabetes type 2 comorbid with depression. The women
were divided randomly into the two groups of intervention and control. Each group consisted of 15 individuals. The
intervention group received 10 sessions of group cognitive behavior therapy while the control group didn’t.
Results: The results suggested that group cognitive-behavior therapy decreased depression symptoms (F=72.17,
p<0.001), and improved quality of life of the patients (F=8.82, p<0.05) of the intervention group compared to the control
group.
Conclusion: The results shows that group cognitive behavior therapy can affect depression symptoms, and
consequently patients’ quality of life with diabetes type 2.

Key words: Type II Diabetes, Depression, Cognitive Behavior Therapy, Group Psychotherapy

Diabetes and depression are 2 chronic conditions of Living with diabetes is associated with emotional
public health, which are increasingly growing and have a distresses such as difficulty related to the treatment
large burden on the patients’ lives and society (1, 2). regimen and self-care behaviors (1). It negatively affects
According to Centers for Disease Control and patients’ quality of life, increases functional disability,
Prevention (2011), Type 2 diabetes mellitus (T2DM) and reduces life expectancy. Some studies reported that
constitutes 90% to 95% of newly diagnosed cases of people with diabetes (either Type 1 or Type 2) are twice
diabetes in adults (4). Type2 diabetes starts smoothly more vulnerable to depression than individuals without
usually in overweight individuals and in adults older diabetes (1,7).
than 30 years, and its most common primary symptom is Several studies have suggested a range of 24% to 30%
lack of symptom. so, diagnosis and treatment of this for depression in T2DM (2).
disease requires careful considerations(1).

1. Department of Psychology, Shahid Chamran University, Ahvaz, Iran.

2. Department of Clinical Psychology, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
3. Department of Psychiatry, Jundishapur University of Medical Sciences, Ahvaz, Iran.
4. Health Research Institute, Diabetes Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.

*Corresponding Author:
Address: Department of Clinical Psychology, University of Social Welfare and Rehabilitation Sciences, Koodakyar Alley, Student Blvd.,
Evin, Tehran, Iran.
Tel: +989173915289, Email: Sajedeh.hamidian@gmail.com

Article Information:
Received Date: 2016/10/31, Revised Date: 2017/06/18, Accepted Date: 2017/07/12
 Improving Depression and Quality of Life

There are conflicting approaches about the relationship excluded from the study. The remaining 30 participants
between diabetes and depression. Some researchers were referred to Behavioral Sciences Research Center
believe that depression results from diabetes, and some of Ahvaz to take the blood sugar test, and then they
others state that depression is an important risk factor were asked to fill out the questionnaire of quality of
for progression of diabetes, through disturbances in life. Then, they were assigned into the case and control
health care behaviors that have widely been observed groups and the intervention was conducted on the case
in depression. Moreover, biochemical changes related group, while the control group remained on the waiting
to depression such as hypercortisolemia, inflammation, list .
and sympathetic nervous system activation Measures :
mechanisms that impair insulin sensitivity and glucose 1. 13-item Beck Depression Inventory: It is a shortened
metabolism may contribute to development of diabetes. version of 21-item form (Beck, 1961), which was
(9). presented in 1972. The questions include concepts such
Prognosis of both depression and diabetes in a as sadness, pessimism, frustration, dissatisfaction, guilt,
comorbid condition is worsened compared to each of self-hatred, self-destruction, seclusion, indecisiveness,
these diseases separately (10). Several studies revealed self-image, problem in working, exhaustion, and
that psychological factors have a powerful influence on appetite. It was validated among a sample of students
controlling diabetes (1, 13-15). Crews et al. (2016) of Ahvaz. Using Cronbach’s alpha method, the final
discussed anout the potentially significant correlations coefficient of 0.89 and using bisection method, the
between psychological factors, neuropathy, body mass final coefficient of 0.87 was reported. To ensure
index, and physical inactivity in patients with diabetes reliability, Sharifnia (2000) used the Beck
(3) Disappointment Questionnaire and reached the
These psychological factors can interfere with the usual reliability coefficient of 0.92(21).
medical treatment, 14, 16). Thus, psychological 2. World Health Organization Quality of Life
interventions along with medical therapy are found to (WHOQOL): This questionnaire includes 26 items in
be much more influential and more stable than just Likert scale ranging from 1 to 5. The questions
medical treatment (17). evaluate emotions and behaviors of patients in the 2
One proposed psychological method for diabetes recent weeks in aspects including hygiene and physical
treatment with noteworthy impact on psychological and health, psychology, social relations, and social
behavioral factors (sleep hygiene, diet, and physical environment (22). For each area, scores from 4 to 20
activity) involved in glucose regulation is cognitive can be achieved, representing the worst and the best
behavior therapy (17-20). condition in each area, respectively. Theses scores can
Therefore, considering the adverse effects of diabetes be converted into scores ranging from 0 to 100. To
mellitus on quality of life, patients need to learn the ensure the reliability of the scale, Nasiri (2006) used 3
best method to care for themselves. Hence, the present methods: retest (with 3 weeks interval), bisection, and
study was conducted to find whether group cognitive Cronbach's alpha, the reliability of each was 0.67, 0.87,
behavior therapy could provide those women with and 0.84, respectively (23).
Type 2 diabetes with self-care methods and increase The Intervention Program
their quality of life to overcome depression. The guidelines of the intervention program were
arranged based on “Cognitive Behavioral Group
Materials and Methods Therapy for Adolescents with Type I Diabetes.” by
This was a clinical trial study with a control group and Wildermuth (2008) and consisted of 10 sessions each
pretest- posttest design. Convenience sampling method lasting for 1.5 hours. A summary of the sessions’
was used to select female patients with Type 2 diabetes content is demonstrated in Table 1(3).
who referred to Diabetes Association of Ahvaz, Iran. Statistical Analysis:
We selected 70 individuals aged 18 to 49 years, who Before conducting ANCOVA, to ensure that the
had at least high school diploma education level. After variables had the assumptions underlying a covariance
explaining the study process to the participants, they analysis, Klomograf-Smirnov test was conducted,
were enrolled in the study and were invited to fill out which showed normal distribution of the variables
the 13-item Beck Depression Questionnaire; those with (Z>0.05). Levin test results revealed no significant
scores higher than 5 were evaluated through a semi- difference between group variance in homogeneity of
structured interview by the psychiatrist of the project to the variance (P>0.05).
detect the criteria for major depression disorder based
on DSM-IV-TR. In addition, participants were Results
excluded if they had axis II personality disorders, Data analysis was performed on data gathered from 30
psychosis, or addiction that could prevent regular participants (15 individuals in each group) using SPSS
participation and attendance in the sessions. Finally, 35 software Version 16. Prescriptive data are depicted in
participants were diagnosed with depression, among Table 2. The mean score of depression severity and
whom 1 participant, due to travel, 3 due to lack of quality of life in posttest significantly improved
coordination of the meeting sessions with their working compared to pretest in the case group after the
time, and 1 due to unwillingness to cooperate, were intervention, a trend that was not seen in the control

Iranian J Psychiatry 12: 4, October 2017 ijps.tums.ac.ir 279

Noroozi, Hamidian, Khajeddin, et al.

group. The results of ANCOVA in Table 3 respectively. The statistical power of both tests was
demonstrate that the intervention provided to the case equal to 1, meaning that the results can be attributed to
group resulted in a significant difference between the 2 the effect of the intervention not errors.
groups. According to Table 2, the case group's mean The effect size in Table 3 indicates that 0.73 and 0.25
scores of depression and quality of life have of the difference between the 2 groups in depression
considerably decreased compared to those of the and quality of life, respectively, was due to the
control group; and according to Table 3, the difference intervention.
was statistically significant at p = 0.001 and p = 0.006,

Table 1. Content of the group cognitive behavior therapy Sessions

Session Content
Session 1 Introduction and definition of the therapy and disease, objectives, and rules of the group
Session 2 The relationship between thoughts, feelings and behavior, dysfunctional thinking styles, cognitive
errors, and homework
Session 3 Cognitive restructuring, identifying symptoms and thoughts associated with depression, and
homework
Session 4 Chain of antecedents, responses and consequences, breaking the destructive chain
Session 5 Information about carbohydrates metabolism, the differences between Type I and II diabetes, nutrition
and exercise, and benefits of exercise for patients with diabetes
Session 6 Definition of assertiveness, negative thoughts and self- talking that prevents assertion; the difference
between passivity, aggression, and assertiveness
Session 7 Managing impulsivity, self-control strategies, enhancing mood and increasing pleasant events
Session 8 Stress, stressors and management, problem- solving, relaxation training
Session 9 Self-esteem, the negative impact of self-evaluation on self-esteem
Session 10 Planning for relapse prevention, and the need to practice the acquired skills

Table 2. The Mean and Standard Deviation of the Study Variables in the Case and Control Groups
Before and After the Group Cognitive Behavior Therapy
Group Case Control
Pretest Posttest Pretest Posttest
Statistics Mean(SD) Mean(SD) Mean(SD) Mean(SD)
Variable
Depression 11.4(4.08) 3.53(1.4) 9.13(3.88) 9.93(3.05)
QOL 74.6(7.56) 81.3(10.39) 73.73(6.67) 71(5.26)

Table 3. Covariance Analysis on the Mean Scores of the Posttest for Depression and Quality of Life
Variables
Variable

Source of Sum of Degree of Mean Statistical P-

F coefficient Effect size
change squares freedom squares power value

Pretest 30.48 1 30.48 6.7 0.20 0.70 0.016

Depression

Group 328.24 1 328.24 72.17 0.73 1 0.001

Error 118.24 26 4.54

pretest 18.99 1 18.99 0.41 0.01 0.09 0.526

QOL

Group 405.17 1 405.17 8.82 0.25 1 0.006

Error 1193.9 26 45.92

QOL = Quality of Life

280 Iranian J Psychiatry 12: 4, October 2017 ijps.tums.ac.ir

 Improving Depression and Quality of Life

Discussion encountering of the patient with his conflicts and

The results of the present study about the effectiveness guides him to break such kinds of vicious circles.
of group cognitive behavior therapy on depression and It is a matter of debate whether depression and
quality of life in women with Type 2 diabetes is in line diabetes-specific emotional distress in diabetic patients
with the study of Esbitt et al.(2015), Bastelaar (2008) are a unit component or different entities that must be
and Skinner (2002). In their studies, they found that dealt with separately. Fisher et al. have assumed an
the effect of psychological interventions, specifically underlying construct for both of them (32). Some other
cognitive-behavioral ones, on patients with diabetes theorists considered these 2 factors to be isolated from
could decrease depressive symptoms and diabetes- each other (33). It seems that regardless of which of
specific distress on one the hand and could improve this hypothesis is a better description of the nature of
the patient’s adherence to medical treatment on the the relationship, treatment should focuse on stress
other hand (24-26). management and self-care behaviors associated with
As it was depicted in the results, the case group scores the disease as well as cognitive and behavioral
of depression and quality of life was significantly interventions related to depression. Thus, the
improved after the intervention; and this could be intervention group in this study received information
attributed to cognitive behavioral interventions, which about carbohydrates and sugar metabolism in Type 2
has broadly endorsed to be effective on primary and diabetes.
secondary depressive symptoms (27, 28). Diabetes- As studies suggest that stress could mediate the link
specific emotional distress was targeted by training between cognitive distortions and adherence to
skills such as stress management, problem solving, and treatment(31), interventions in diabetes should address
skills for interpersonal interactions. The case group several domains including depression and diabetes-
participants were also given information about sugar specific emotional distress, which is related to
metabolism and healthy nutrition for Type 2 diabetes . glycemic control(1, 33).
Increasing the quality of life of the case group patients Endevelt et al. stated that both individual and group
after the intervention could be related to decreasing the therapy are equally influential in achieving outcomes in
emotional burden of diabetes, which increased the controlling diabetes and given that group therapy is
patients’ adjustment; and consequently, improved their more cost effective, it is preferable(34, 35). In the
quality of life (29). Approaches to the quality of life present study, using group cognitive behavior therapy
can be considered it in both objective and subjective and through normalizing and evaluating evidences, the
aspects. The objective dimension includes participants observed the behavior of others with the
environmental conditions and access to health services same problem, and as a result, their dysfunctional
and information. Because this dimension remained thoughts about the disease and considering diabetes as
unchanged in the present study, the most impacts were weakness and inadequacy were changed.
seen in the subjective and attitude areas. Among the The use of such psychological treatments for patients
subscales of the quality of life, social relationships and with health problems on the one hand increases their
physical health have mostly benefited from the compliance with the medical therapy, and on the other
intervention, which could be due to applying anger hand, with improving the psychological aspects related
management, assertiveness, and impulse control in to the issue, it facilitates the healing process.
interpersonal relationships . Psychological treatments also help improve the quality
About the potential underlying mechanisms that link of life despite the disease through increasing patients’
diabetes to depression, Moulton et al. (2015) acceptance about the symptoms.
enumerated psychological and physiological factors.
Among psychological factors, dysfunctional Limitation
assumptions about the disease such as “Will my Because of using convenience sampling, the results of
diabetes condition get worse gradually whether I use this study should be generalized with caution. To
medications or not” could have considerable direct and control the nonspecific effects of the psychotherapy
indirect impacts on diabetes (30) . method, the design of the present study could be
The assumption of cognitive behavioral theory is that replicated by adding another group who receive a
the way people think affects their behavioral choices. different method of psychotherapy. It is suggested that
For example, when blood sugar and nutritional and this study be replicated by using a large sample size,
medical diets control in these individuals is disrupted, multi-center, cohort design, and subtype classifications
cognitive distortions of those who have little self- of patients. Conducting the study only on females was
control lead to feeling of futility of medical efforts and another limitation of the present study.
hopelessness. Hence, they are more likely to drop out
of treatment and show poor adherence. Following poor
treatment adherence, metabolic dysregulation would Conclusion
occur that endorses the cognitive distortions and Cognitive-behavioral therapy in depression comorbid
aggravates the existing dysfunctional thoughts (31). with T2DM, makes considerable changes in the
Cognitive-behavioral therapy facilitates the lifestyle and to the ways dealing with the disease.
Given the interaction between depression and diabetes,
such interventions target the portion of the disease

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Noroozi, Hamidian, Khajeddin, et al.

progress, which is related to psychological conditions neuropathy, and quality of life in type 2
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controlled trial of cognitive behavioral therapy
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