Diabetes

CoUNTerINg ANxIeTy IN PeoPle wITh DIAbeTeS

Jackie Sturt sets out how and why she helped to establish support services to address the emotional and psychological needs of patients with diabetes
Summary
Patients with diabetes often face anxiety, low mood and emotional burden as a result of their condition. Healthcare professionals need to be aware of this and the ways in which they can provide help. This article looks at the possible problems facing patients and the solutions professionals can offer. Keywords Diabetes, depression, anxiety, primary care, secondary care PeoPle who have diabetes are often highly anxious during their consultation. This can be the result of a recent diagnosis, not knowing what to eat, or fear of needles, hypoglycaemia or losing their feet, their eyes or their kidney function. Anxiety is just one of several common emotional and psychological burdens faced by people with diabetes. Many of these problems can strongly affect their ability to manage their condition, leading to poorer glycaemic control and long-term complications. These issues have been of such concern that two organisations, Diabetes UK and NhS Diabetes, convened a working group in 2008 to examine the literature and good practice in this area, determine the prevalence of emotional and psychological problems relating to diabetes and put forward recommendations for the competencies and types of interventions required to address the problem. The working group was jointly chaired by Diabetes UK and NhS Diabetes, with a literature review led by researchers at the warwickshire Institute of Diabetes, endocrinology and Metabolism (wISDeM), a clinical academic collaboration between the University of 16 June 2011 | Volume 21 | Number 5 warwicks Medical School and University hospitals Coventry and warwickshire NhS Trust (UhCw). The group found compelling evidence that services need to be developed to enhance care and support, and to improve the psychological wellbeing and outcomes for people with diabetes (NhS Diabetes and Diabetes UK 2010). It also suggested ways in which professionals in primary care could better meet the emotional and psychological needs of patients with diabetes and, in doing so, improve clinical outcomes.

Quantifying the problem

The emotional and psychological needs of people with diabetes run on a continuum from healthy coping through diabetes-related distress to depression and other conditions sometimes requiring specialist psychological and psychiatric support. The needs of a patient on the continuum are influenced by various factors and may change over time. Needs will always be shaped by the demands of the condition and of life, and the interaction between these demands. They arise in contexts such as interpersonal relationships, family life, employment and education. They may be shaped by the cultural context of the individuals life, the meanings ascribed to the condition and by religious or spiritual beliefs. In addition, emotional and psychological issues are reported by people with diabetes and those who live with or care for people with the condition. These issues affecting people with diabetes include depression, eating disorders, anxiety, needle phobia and severe mental health conditions. Depression is at least twice as common in people with diabetes as in those without it, and studies suggest between 30 and 50 per cent of this depression goes undetected (Ali et al 2006).
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Acknowledging that emotional and psychological issues have a place in consultation can be a first step towards addressing those problems

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Diabetes
Figure 1 Pyramid describing the prevalence of emotional and psychological problems in relation to their severity specialist psychiatric or psychological intervention are relatively infrequent but severe. level 1 problems will be encountered by 60 per cent of people with diabetes at some point in their lives. emotional or psychological needs at every level are likely to make the core of diabetes care everyday self-management harder to achieve. The provision of emotional and psychological treatment and support has been found to reduce psychological distress and improve hbA1c, a measure of glycaemic control, over six to ten weeks in a variety of contexts (Alam et al 2009, winkley et al 2006). however, the working group found there were major gaps in the provision of emotional and psychological care for people with diabetes (NhS Diabetes and Diabetes UK 2010). Trigwell et al (2008) showed that 85 per cent of people with diabetes in the UK have either no defined access to psychological support and care, or access only to a local generic mental health service at best. Part of the brief of the working group was to put forward recommendations for commissioners to ensure services meet the entire spectrum of needs.

Level 5 Severe and complex mental illness, requiring specialist psychiatric intervention(s) Level 4 More severe psychological problems that are diagnosable and require biological treatments, medication and/or specialist psychological or psychiatric interventions Level 3 Psychological problems that are diagnosable/ classifiable but can be treated solely through psychological interventions, eg mild and some moderate cases of depression, anxiety st,ates and obsessive/compulsive disorders Level 2 More severe difficulties with coping, causing anxiety or lowered mood, with impaired ability to care for self as a result Level 1 General difficulties coping with diabetes and perceived consequences of this for lifestyle. Problems at a level common to many or most people receiving the diagnosis
(Adapted from Trigwell et al 2008)

Meeting the need

For some commissioners, NhS Diabetes and Diabetes UK (2010) may suggest the need for a complete overhaul of the way diabetes care is managed. however, there are a number of simple, immediate ways in which healthcare professionals can better meet the emotional and psychological needs of people with diabetes, particularly in primary care. Most patients with a diagnosis of diabetes receiving treatment in primary care will have type 2 diabetes, and many of the emotional and psychological problems they present will be at levels 1 and 2 of the pyramid model. research has shown that peer support can be extremely helpful. Programmes such as DeSMoND, DAFNe and x-PerT (Patient UK 2010) ensure this type of support is readily available. Moreover, social and peer support beyond these formal programmes can be effective in helping people to manage diabetes-related distress. Perhaps because they underestimate the extent to which peer and social support can be of help, many healthcare professionals do not ordinarily point patients towards these kinds of resources. Not all the solutions are strictly psychological or therapeutic in nature: for example, joining organisations such as weight watchers and rambling groups can help people manage their condition. The voluntary sector can also be a valuable ally, with organisations such as Diabetes UK offering support in the form of volunteer support groups and patient information. one of the most effective interventions
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In one ongoing wISDeM study, we took a sample of people from three Coventry gP practices and screened them for depression. They all had type 2 diabetes, had been diagnosed for at least six months, were not receiving treatment for depression and had expressed an interest in taking part in a psychological intervention. Forty per cent of those tested demonstrated clinically important levels of emotional distress or depressive symptoms measured on the Center for epidemiologic Studies Depression Scale (radloff 1977). NhS Diabetes and Diabetes UK (2010) looked at models that have attempted to depict the trajectory of emotional and psychological needs and found Figure 1 to be useful in describing the prevalence of certain problems some formally diagnosable, some not in relation to their severity. It illustrates the diversity of need and the broadly inverse relationship between prevalence and severity of need. At the base of the pyramid (level 1), needs are common but not severe, such as general difficulties with coping; at the top (level 5), needs such as possibly requiring 18 June 2011 | Volume 21 | Number 5

Table 1

Emotional and psychological interventions that have demonstrated effectiveness Prevalence 60% Examples of effective interventions Peer support Diabetes education Group coping skills training Clinician competency examples by level, assuming competencies at all previous levels Communication skills to include establishing rapport, empathy and reflective listening Goal-related discussions Signposting Adequate knowledge of diabetes Extended communication skills including counselling with supervision Effective information giving Problem formulation and solution-focused therapy

Pyramid level 1

40%

Cognitive behavioural approaches Blood glucose awareness training

20%-30%

Assessment for psychological distress using Group or individual psychotherapy established measures Cognitive behaviour therapy (group and individual) Advanced counselling Family therapy Cognitive behaviour therapy Motivational interviewing Antidepressant therapy Cognitive behaviour therapy Collaborative, stepped-care programmes Integrated psychiatric referral and liaison Lack of randomised controlled trial evidence Assessment, case formulation and treatment Psychiatric diagnosis and prescribing Multiple therapeutic management approaches Collaborative case management Selection and delivery of a range of intervention types Liaison psychiatry services

10%-15%

10%-15%

can be to improve a patients understanding of the condition to help them to manage it more effectively. A large part of the challenge is the need to direct patients to the most appropriate resources. This requires gP practices to use their knowledge of local statutory and voluntary resources, and to communicate their therapeutic value to patients. There is a tendency to see one-to-one psychological therapy as the first port of call, whereas social and peer support or an education group might resolve these emotional and psychological issues. Table 1 gives examples of the emotional and psychological interventions that have demonstrated effectiveness at each of the five levels. Further references for these interventions can be found in NhS Diabetes and Diabetes UK (2010). As the pyramid model suggests, a number of patients will require more specialist help. Part of the role of healthcare teams, particularly in primary care, will be to identify when this is the case. The working group found that in many cases organisations have access to specialist resources such as liaison psychiatry or the Improving Access to Psychological Therapies (IAPT) Team (2010), but the challenge lies
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in recognising that these help people to manage diabetes and in referring patients for expert help at the appropriate junctures. Timely and appropriate intervention when patients first encounter emotional and psychological problems in relation to their diabetes can improve their diabetes-related and pyschological outcomes at an earlier stage (Alam et al 2009, winkley et al 2006, Steed et al 2003).

Reshaping services
Part of the challenge for diabetes care in the UK is at a fundamental level reorganising services so that diabetes teams work more closely with psychological and mental health professionals and other support services. In the short term, however, there is much that can be done to enhance existing provision. For example, a 2009 Diabetes UK policy forum attended by people with diabetes, carers and healthcare professionals identified two key requirements in addressing the issue: Training and support for healthcare professionals. The allocation of sufficient time for consultations (NhS Diabetes and Diabetes UK 2010). In many cases, more effective treatment was
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Diabetes
achieved by changing the focus of the consultation, rather than its length, so that appointments are not centred purely on the clinical requirements of monitoring diabetes. Acknowledging that emotional and psychological issues have a place at these consultations can help to address the problems. Training in areas such as communication and patient empowerment is common practice in primary care, and these skills can improve service provision for diabetes. Additional techniques, such as goal-related discussions, counselling skills and solution-focused therapy, can easily be practised by non-specialist practitioners (Alam et al 2009) and teams can also be given better guidance on how to identify more severe emotional and psychological issues that require specialist intervention. In these cases, it tends to work better if skills and competencies development focuses on whole teams in organisations, rather than selected individuals attending external training sessions. This helps to embed an understanding that diabetes care involves elements of clinical and psychological care. Box 1 Theory in practice The author has helped reshape and pioneer support services for people with diabetes in her area of Coventry and Warwickshire, recently setting up a diabetes listening service for people with diabetes who are struggling with emotional and psychological problems. This service consists of 45-minute appointments in the Diabetes WISDEM Centre. These are available to anyone with the condition, regardless of type or severity. The initial sessions focus on listening and using person-centred counselling skills. Over time, they become more action-orientated to help people find coping mechanisms for managing their life with diabetes. People can book up to six appointments. Suzy (named changed) was referred by her diabetologist with high anxiety regarding fear of nocturnal hypoglycaemia. She spent several nights a week alone with her young daughter, which fuelled her fear of the conditions possible consequences. During two 45-minute consultations. Suzy was able to articulate attitudes to eating, insulin and weight that were unexplored. She recognised her evening snacking was linked to loneliness and boredom, rather than to ensure high blood glucose levels at bedtime. She implemented a home exercise regime. She found other ways to occupy her evenings, which helped reduce boredom and snacking, and maintain her weight. She arranged to text a friend each morning to say everything was alright if she did not, her friend would raise the alarm. Over the sessions her fears began to diminish. Bob (name changed) who had bilateral amputations eight months before his referral, was struggling to come to terms with his disability and this was affecting his diabetes control. Through a series of sessions, healthcare professionals explored the broad aspects of his life that his disability was affecting. He began to come up with solutions and develop confidence in his abilities, despite his new health status. Instead of being overwhelmed by all his issues, he began to approach them sequentially, in line with the natural rise and fall of his prioritisation. His aim is to be sufficiently calm about these issues so that he can think about his diabetes again. efforts of people who are not adequately trained or supported to carry out that work. wISDeM continues to focus on assessing patients for diabetes-related distress using the Problem Areas in Diabetes Scale (Polonsky et al 1995). It offers them the support they need through one-to-one sessions with diabetes listeners (box 1) and/or directing them to other services. wISDeM has more work to undertake, but these first steps are imperative to making a difference to patients.
This article has been subject to double-blind review and checked using antiplagiarism software Jackie Sturt is associate professor in social and behavioural science and the primary care research group lead at the Health Sciences Research Institute, Warwick Medical School, and a diabetes listener at the WISDEM Centre, University Hospital, Coventry

Future of diabetes care

There is a relatively clear distinction between the care offered by primary and secondary organisations in managing diabetes. The latter handle almost all the care requirements for type 1 diabetes, while the former tend to encounter mostly type 2 diabetes patients. however, a shift in service commissioning is seeing more type 1 patients treated by primary care services. An increase in the number of type 2 patients receiving insulin therapy to manage their condition means primary care teams increasingly have the competencies and confidence to handle more complex diabetes issues. These changes make it even more important that primary care organisations are well equipped to identify and cope with the range of emotional and psychological problems associated with diabetes. People with diabetes should not have to rely for their psychological help and treatment on the best

References
Alam R, Sturt J, Winkley K (2009) An updated meta-analysis to assess the effectiveness of psychological interventions delivered by psychological specialists and generalist clinicans on glycaemic control and on psychological status. Patient Education and Counseling. 75, 1, 25-36. Ali S, Stone MA, Peters JL et al (2006) The prevalence of co-morbid depression in adults with type 2 diabetes: a systematic review and meta-analysis. Diabetic Medicine. 23, 11, 1165-1173. Improving Access to Pyschological Therapies Team (2010) NhS: IAPT. www.iapt.nhs.uk (last accessed: February 7 2011.) NHS Diabetes, Diabetes UK (2010) emotional and Psychological Support and Care in Diabetes: report from the emotional and Psychological Support working group of NhS Diabetes and Diabetes UK. www.diabetes.org.uk/Documents/ reports/emotional_and_Psychological_Support_ and_Care_in_Diabetes_2010.pdf (last accessed: February 7 2011.) Patient UK (2010) Diabetes Education and Self-management Programmes. www.patient.co.uk/doctor/DeSMoND.htm (last accessed: February 7 2011.) Polonsky WH, Anderson BJ, Lohrer PA et al (1995) Assessment of diabetes-specific distress. Diabetes Care. 18, 6, 754-760. Radloff LS (1977) The CeS-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement. 1, 3, 385-401. Steed L, Cooke D, Newman S (2003) A systematic review of psycholigical outcomes following education, self-management and pyschological intervention in diabetes mellitus. Patient Education and Counseling. 51, 1, 5-15. Trigwell P, Taylor J-P, Ismail K et al (2008) Minding the Gap. The Provision of Psychological Support and Care for People with Diabetes in the UK. www.diabetes.org.uk/Documents/reports/ Minding_the_gap_psychological_report.pdf (last accessed: February 7 2011.) Winkley K, Eisler I, Ismail K (2006) Psychological interventions to improve glycaemic control in patients with type 1 diabetes: systematic review and meta-analysis of randomised controlled trials. British Medical Journal. 333, 7558, 65.

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