Use of Multisystemic Therapy to Improve Regimen Adherence among Adolescents With Type 1 Diabetes in Chronic Poor Metabolic Control

Ellis DA, Frey MA, Naar-King S, Templin T, Cunningham P, Cakan N. Diabetes Care. 2005;28:1604-1610.

Many adolescents with type 1 diabetes have difficulties adhering to treatment regimens. There is a documented subset of these high-risk adolescents who demonstrate more serious adherence problems. Chronically poor metabolic control (CPMC) patients require more active treatment intervention than do other adolescents with type 1 diabetes, usually involving both psychological therapy and family counseling. Multisystemic therapy (MST) is an intensive, group-based therapy, originally used with youths demonstrating severe mental health problems. This approach encompasses the adolescent, the family group, and the broader community systems within which the family operates (ie, school and healthcare system). MST is specified through 9 treatment principles that construct parameters for implementing interventions. Specifically, this approach examines the strengths and weaknesses of the family and broader community system, as well as tailors treatment goals based on this assessment. This study tested the efficacy of MST in improving adherence to medical regimen and metabolic control, as well as reducing the number of hospital visits among adolescents with CPMC.

A total of 127 adolescents with CPMC and their families were recruited from the endocrinology clinic of a Midwestern children’s hospital. All adolescents were between the ages of 10 and 17, with an average A1C≥8.0%. Participants who were randomized to the MST group received ~6 months of home-based psychotherapy (2-3 sessions a week) plus standard medical care consisting of quarterly medical visits with a medical team. Participants randomly assigned to the control group received standard medical care only. Data are being collected at 7, 12, 18, and 24 months, but this study only reports data from 7 months post test, as data collection is ongoing.

The results of this study suggest that MST is an effective way to improve adolescent adherence. The participants of the MST group significantly increased their frequency of blood glucose testing from baseline to 7-month follow-up when compared with the control group. Adolescents who received MST also displayed improvements in metabolic control (0.61%) from baseline to post test when compared to the control group (0.09%). Moreover, while the number of hospital admissions actually increased for the control patients (P = .101), the MST therapy group had a significant reduction in the number of admissions (P = .014) when compared with the control.

For MST to be considered a viable treatment in the real world, it would have to be established as a cost-reducing treatment. Although this trial did not directly address medical costs, adolescents in the MST group had a much lower incidence of hospital admission during the study and therefore had a lower demand for costly medical care. This evidence is promising, but a more comprehensive cost analysis is necessary to assess the true cost effectiveness of MST.