A project in London has developed a model for diagnosing and treating the mental health co-morbidities of diabetes. Steven Reid explains

It goes without saying that mental health and physical health are inextricably linked. Nowhere is this better demonstrated than in the management of long term physical health conditions such as diabetes, arthritis, cardiovascular disease and chronic obstructive pulmonary disease.

More than 15 million people in England have at least one long term condition and it seems not a week passes without yet another report that provides yet more evidence for the importance of good mental health in this group of patients.

‘Co-morbid mental health problems result in increased use of health and social care for physical problems’

Surveys consistently report a two- to threefold increased risk of depression in people with a range of long term conditions in comparison with the general population.

The impact of unidentified and untreated mental health problems are well known, and include poorer self-management, clinical outcomes and quality of life.

The wider cost

At a time when the NHS faces huge financial pressures, the economic case is especially pertinent. Co-morbid mental health problems result in increased use of health and social care for physical problems, and, in particular, unscheduled care.

The King’s Fund and Centre for Mental Health reviewed the evidence and in 2012 calculated that around £1 in every £8 of NHS expenditure spent on long term conditions is linked to poor mental health and wellbeing. This figure does not include the associated wider costs of reduced employment and social security benefits.

In the face of so much evidence, there seems to be a compelling case for change in the way we provide support for the psychological and mental health needs of people with long term conditions. After all, we have a range of cost effective interventions and service models that demonstrably lead to improved outcomes in both mental health and physical health.

‘People with diabetes experience disproportionately high rates of mental health problems’

Calls for better integration of physical and mental healthcare have become familiar to the point of banality, yet provision remains patchy and inconsistent.

The London Mental Health Strategic Clinical Network set out to look at what system changes are required by initially focusing on one long term condition: diabetes. There is evidence that psychological interventions not only benefit emotional wellbeing, but also have a direct impact on control of blood sugar.

People with diabetes experience disproportionately high rates of mental health problems. Depression and anxiety are particularly common but a range of other difficulties are encountered, from problems adjusting or coping with the diagnosis to phobias, eating disorders and sexual dysfunction.

And, unlike cardiovascular disease and lung disease, diabetes is a long term condition that has a significant impact on young people, particularly in the transition through adolescence.

‘There is evidence that psychological interventions not only benefit emotional wellbeing, but also have a direct impact on control of blood sugar’

Diabetes presents a particular challenge in London. A young and transient population makes service delivery and the development of care pathways difficult.

The capital’s ethnic diversity is also important: there is a six-fold increase in risk of type 2 diabetes in people of south Asian origin, and a three-fold rise in people of African and African-Caribbean origin.

Care pathways

Our aim was to produce guidance for commissioners and service providers in London to support the development of accessible, consistent and effective psychological support for diabetes care pathways across the capital.

Three strands of work informed the guidance.

First, we worked with Diabetes UK, and patients and their carers to identify gaps in provision, and obtain a patients’ perspective on what was needed to improve services.

Second, we carried out a survey of commissioners and service providers to map current provision.

Finally, we developed a directory of case studies of service models in an effort to demonstrate “what good looks like”.

Recommendations for commissioners

1. People with diabetes should have access to a range of interventions for emotional and psychological problems according to need and severity.

Pyramid of psychological problems (Adapted from Minding the gap: A report for Diabetes UK)

Pyramid of psychological problems (adapted from Minding the gap: A report for Diabetes UK)

The “pyramid” model of psychological problems provides a framework for the organisation of provision. It should recognise that level of need and severity is likely to change with time, personal circumstances, and the effects of diabetes.

2. Universal access for diabetic patients to emotional and psychological support should be readily available, regardless of postcode.

Service development should be coordinated to allow for commissioning in partnership across geographical boundaries where that may be of benefit.

3. Specific groups should be actively supported.

Services must be proactive in enabling emotional and psychological access to these groups:         

  • Young people at the stage of transition from children’s to adult services
  • Black and minority ethnic groups
  • People with severe and enduring mental illness
  • People with learning disabilities
  • People with sensory impairments
  • Families and carers

4. Co-production by people with diabetes and mental health problems, as well as their carers and families should be integral to service development.

Co-production acknowledges that people with diabetes have a degree of expertise that is best placed to inform how services can be improved. This process enables people to support each other and fosters the development of resilient communities.

5. Commissioners should ensure that services provide timely, effective and safe care in accordance with the National Institute for Health and Care Excellence (NICE) national quality standards for diabetes.

These outline the provision required in developing appropriate services for people with diabetes. Outcomes should take account of patient experience and align with the NHS outcomes framework.

6. Individual packages of care should be developed to “wrap around” individuals and their carers, promote emotional wellbeing, and involve social care and the third sector.

They should not be limited to people with criteria based psychiatric disorders but should include provision for problems adjusting to diagnosis, general coping difficulties and lifestyle changes.

7. Self-management should be encouraged.

Commissioning should support the development of services that promote mental health awareness at diagnosis, resilience and self-management. Self-management has the potential to improve health outcomes and patient experience. It can be supported through expert patient programmes, peer support and social media.

8. Screening tools should be used to improve the recognition of psychological and emotional problems.

Screening should be included as part of the review of care for people with diabetes, community and hospital-based diabetes services.

9. Staff and organisations that provide care for people with diabetes should have training and education that enables them to identify emotional problems and provide psychological support at an appropriate level.

The aim is to ensure that emotional wellbeing is considered everyone’s business. Specific expertise in diabetes should be sought to ensure services that provide emotional and psychological support have sufficient knowledge. Shared experience of diabetes management is essential for an appropriate understanding of the issues people with diabetes face.

Service model

These commissioning recommendations suggest what psychological support for people living with diabetes could and should look like.

Although the focus was on diabetes, we would argue that these recommendations have wider relevance for all long term conditions. 

Dr Steven Reid is clinical director, psychological medicine, at Central and North West London NHS Foundation Trust