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Frontline Reports   |    
Use of CBT in a Walking Program for Veterans With Diabetes and Depression
John D. Piette, Ph.D.
Psychiatric Services 2005; doi: 10.1176/appi.ps.56.3.355
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Diabetes is a common comorbid illness among persons with major clinical depression. Physical activity can improve outcomes of both diabetes and depression. University of Michigan researchers developed an intervention that used a cognitive-behavioral therapy (CBT) model to promote walking among individuals with comorbid diabetes and depression.

The intervention—the Michigan VA Positive Steps Program—was tested in a pilot program at the Department of Veterans Affairs (VA) Health Services Research and Development Center for Excellence in Ann Arbor in 2003. Individuals with both diabetes and depression were identified by their primary care provider, and interested individuals were subsequently screened for eligibility. Eligible participants met with a member of the research team to complete the enrollment and written informed consent process.

The CBT was delivered individually in 12 weekly one-hour telephone sessions by a trained nurse-clinician. Two different CBT-trained nurse-clinicians delivered the intervention. One of the barriers to psychiatric care in the VA system is the fact that patients often live relatively far from the regionalized medical centers. Therefore, all CBT sessions were conducted by telephone. The first six weeks focused on managing depression symptoms. For the sixth session, participants were given a pedometer and asked to fill out a written step-count log. During subsequent sessions, the nurse reviewed CBT concepts with the patient and also encouraged the patient to gradually increase his or her daily step counts.

A workbook and therapist handbook were designed specifically for individuals with both diabetes and major clinical depression. The intervention materials were modified from existing CBT manuals. Specific information about diabetes and about the walking program was added. The physical activity component of the intervention was objectively assessed by analyzing the daily step counts logged by participants during the final six weeks of the intervention. Eleven individuals began the pilot program, but three dropped out before starting the physical activity component. Of the eight who completed the study, five recorded pedometer data for both the sixth and 12th week. Initially, participants walked an average of 6,562 steps per day. Six weeks later, the average step count was 8,829 steps per day (t=3.05, df=4, p=.039). The average difference of 2,266 steps represents an increase of 20 minutes of walking each day at three miles per hour.

Dr. Piette is affiliated with the Department of Veterans Affairs Health Services Research and Development Center of Excellence, P.O. Box 130170, Ann Arbor, Michigan 48113-0170 (e-mail, jpiette@umich.edu). He is also with the department of internal medicine at the University of Michigan in Ann Arbor.

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