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16 June 2011 | Volume 21 | Number 5 PRIMARY HEALTH CARE

Diabetes

PP 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 NS 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 NS Diabetes, with a literature review led by

researchers at the arwickshire Institute of Diabetes,

ndocrinology and Metabolism (ISDM), a clinical

academic collaboration between the University of

CUNTIN ANIT INPP IT DIATSJackie 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

arwicks Medical School and University ospitals

Coventry and arwickshire NS Trust (UC).

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 (NS 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 problemThe 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 al2006).


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PRIMARY HEALTH CARE June 2011 | Volume 21 | Number 5 17

Acknowledging that emotional and psychological

issues have a place in consultation can be a first

step towards addressing those problemsCorbis


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June 2011 | Volume 21 | Number 5 PRIMARY HEALTH CARE18

Diabetes

Figure 1 Pyramid describing the prevalence of emotional and psychological

problems in relation to their severity

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)

In one ongoing ISDM study, we took a

sample of people from three Coventry P 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 pidemiologic Studies

Depression Scale (adloff 1977).

NS 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

specialist psychiatric or psychological intervention

are relatively infrequent but severe. evel 1 problems

will be encountered by 60 per cent of people with

diabetes at some point in their lives.

motional 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 bA1c, a measure of glycaemic

control, over six to ten weeks in a variety of contexts

(Alam et al2009, inkley et al2006). owever, the

working group found there were major gaps in the

provision of emotional and psychological care for

people with diabetes (NS 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 serviceat 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.

Meeting the needFor some commissioners, NS Diabetes and Diabetes

UK (2010) may suggest the need for a complete

overhaul of the way diabetes care is managed.

owever, 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 havetype 2 diabetes, and many of the emotional and

psychological problems they present will be at

levels 1 and 2 of the pyramid model.

esearch has shown that peer support can be

extremely helpful. Programmes such as DSMND,

DAFN and -PT (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 eight atchers 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. ne of the most effective interventions


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June 2011 | Volume 21 | Number 5 PRIMARY HEALTH CARE2020

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 al2009) 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 individualsattending external training sessions. This helps to

embed an understanding that diabetes care involves

elements of clinical and psychological care.

Future of diabetes careThere 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. owever, 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 conditionmeans 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

efforts of people who are not adequately trained orsupported to carry out that work.

ISDM continues to focus on assessing patients

for diabetes-related distress using the Problem Areas

in Diabetes Scale (Polonsky et al1995). It offers them

the support they need through one-to-one sessions

with diabetes listeners (ox 1) and/or directing

them to other services. ISDM has more work to

undertake, but these first steps are imperative to

making a difference to patients.

Alam R, Sturt J, Winkley K (2009) An updatedmeta-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 TherapiesTeam (2010) NS: IAPT. www.iapt.nhs.uk (ast

accessed: February 7 2011.)

NHS Diabetes, Diabetes UK (2010) motional

and Psychological Support and Care in Diabetes:

eport from the motional and Psychological

Support orking roup of NS Diabetes and

Diabetes UK. www.diabetes.org.uk/Documents/

eports/motional_and_Psychological_Support_

and_Care_in_Diabetes_2010.pdf (ast accessed:

February 7 2011.)

Patient UK (2010) Diabetes Education and

Self-management Programmes.

www.patient.co.uk/doctor/DSMND.htm(ast 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 CS-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/eports/

Minding_the_ap_psychological_report.pdf (ast

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.

References

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

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 theDiabetes 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 maintainher 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.

This article has beensubject to double-blind

review and checked using

antiplagiarism software


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