Dr. Paul ChadwickClinical and Health Psychologist

Royal Free Hampstead NHS Trust, &

Camden and Islington MHSCT

&

Centre for Behaviour Change

University College London.

The Psychological Needs of Individuals

with Diabetes

Understand the range of emotional issues faced by people with Diabetes.

Be aware of the impact of those needs on their physical health.

Understand the challenges of talking about emotional issues with people with diabetes.

Have a range of strategies to be able to approach the issue.

Understand the range of psychological services available to support individuals with diabetes, and know how to access them.

By the end of this presentation you will…

Characteristics of Illnesses that are Really Hard to Cope WithThere is no cure for it.It is unpredictable – what you need to do to

manage it successfully can change from day to day.

There is no escape from it – the consequences of not managing it are really serious and irreversible.

It is progressive.It can affect your mood – making everything that

much harder to do.In order to manage it you have to pay attention to

several things all at the same time.It has its onset in childhood or adolescence – when

you are just trying to figure out who you are.It can negatively affect your sex life.It is really complicated to manage properly, but

this is rarely appreciated by other people.

Level 1

Coping & Adjustment Difficulties

Level 2

Moderate coping difficulties resulting in affect disturbance and impaired self-care

Level 3

Mild to moderate psychological difficulties: anxiety, depression, eating disturbance.

Level 4

Moderate/Severe psychological difficulties

specialist interventions required.

Level 5

Severe & enduring

Mental Health Problems

60%

40%

20-30%

10-15%

10-15%

Overall need: 4336 pts

Overall need: 2890 pts

T1 females ED: (14%) - 505 ptsT2 females ED: (21%) 759pts

Overall need: 1445 – 2168 pts

Depression: 433 (6%) – 1011 pts (14%)

Anxiety: 1011 (14%) pts

T1 females ED BN: 361 (10%) – 1011 (28%) pts

Overall need: 723 – 1084 pts

* Assuming 7227 people with diabetes in Camden at 4.7% prevelence (YHPO)

Prevalence and type of psychological need in Camden.

The impact of depression in diabetesDepression is more likely, lasts longer, comes

back more often and is generally missed in 2/3 cases.

For both T1 and T2DM, the presence of depression is associated with increased:MortalityCardiac eventsHospitalisationComplications (retinopathy, neuropathy,

nephropathy – in fact, all the opathies!)Functional impairmentHealthcare costsMedical symptom burden

Distress associated with the condition and its management is common – Diabetes Related Distress (DRD).

DRD is possibly more closely associated with disease progression than depression.

May mediate the relationship between depression and glycaemic outcomes in treatment trials. Fisher et al (2007/2008) van Bastalaar et al (2010), Levya et al (2011).

Depression or Diabetes Distress?

Problem Areas in Diabetes1. Not having clear and concrete goals for your diabetes care?

2. Feeling discouraged with your diabetes treatment plan?

3. Feeling scared when you think about living with diabetes?

4. Uncomfortable social situations related to your diabetes care (e.g., people telling you what to eat)?

5. Feelings of deprivation regarding food and meals?

6. Feeling depressed when you think about living with diabetes?

7. Not knowing if your mood or feelings are related to your diabetes?

8. Feeling overwhelmed by your diabetes?

9. Worrying about low blood sugar reactions?

10. Feeling angry when you think about living with diabetes?

11. Feeling constantly concerned about food and eating?

12. Worrying about the future and the possibility of serious complications?

13. Feelings of guilt or anxiety when you get off track with you diabetes management?

14. Not "accepting" your diabetes?

15. Feeling unsatisfied with your diabetes physician?

16. Feeling that diabetes is taking up too much of your mental and physical energy every day?

17. Feeling alone with your diabetes?

18. Feeling that your friends and family are not supportive of your diabetes management efforts?

19. Coping with complications of diabetes?

20. Feeling "burned out" by the constant effort needed to manage diabetes?

High prevalence levels, similar to depression.

Proportionally less attention paid to anxiety, although can be equally as devastating for disease progression.

Disease-specific forms of anxiety exist:Fear of hypoglycaemiaPsychological insulin resistance

Anxiety in the context of diabetes

Fear of starting to take insulin.17 – 40% of individuals with T2DM may try to

avoid taking insulin.Consequence is persistent hyperglycaemia,

increased risk of progression to complications, and higher levels of diabetes-related distress.

PIR is associated with:DepressionNegative beliefs about insulin Injection anxietyBeliefs about disease progression and personal

failure.

Psychological Insulin Resistance

In the LAST MONTH… Diabetes-related distress Have you felt overwhelmed by the demands of living with diabetes?

Have felt that you that you are failing to manage your diabetes effectively?

Depression Have you often been bothered by feeling down, depressed, or hopeless?”

Have you often been bothered by having little interest or pleasure in doing things?

Anxiety Have you felt more anxious or nervous than usual?

Have you had a spell or attack where all of a sudden you felt frightened, anxious, or uneasy?

Have you been bothered by nerves or feeling anxious or on edge?

And then…. I am sorry to hear that, tell me about it….

Questions to start the conversation…

How well are we supporting people with Diabetes?

??% patients report being asked about their well-being in the last year.

??% health professionals report that they regularly ask about how diabetes affects peoples lives.

Holt et al., (2013), Kovacs et al., (2013)

How well are we supporting people with Diabetes?

??%patients report being asked about their well-being in the last year.

52% health professionals report that they regularly ask about how diabetes affects peoples lives.

Holt et al., (2013), Kovacs et al., (2013)

How well are we supporting people with Diabetes?

24% patients report being asked about their well-being in the last year.

52% health professionals report that they regularly ask about how diabetes affects peoples lives.

Holt et al., (2013), Kovacs et al., (2013)

Fear of stigmatising and

alienating patients

Opening “Pandora’s Box”

Don’t feel equipped to handle the

conversation

Well-being is at the end of the

checklist

Tools are too blunt an

instrument

Dislike of mechanistic processes

Normalising distress

Barriers to talking about well-being

Maxwell et al., 2013; Coventry et al., (2011)

We realise that a referral to psychological services may not be straightforward.If you are referring to the Hub tell us if you

think a psychological opinion would be helpful.If you are referring to your practice-based

service, discuss the case with the practitioner.

If you can’t talk ‘anxiety or depression’ talk about ‘stress’ and strategies to manage it.

Making referrals count…

In primary care, IAPT Services have been trained to help deal with anxiety and depression in the context of diabetes.

Diabetes IAPT Services are located:In primary care practicesAt the Diabetes Immediate Care Hub at Mary

Rankin, SPH.IAPT services can act as a conduit to other

services that can address psychological issues.

RFH has a limited specialist Clinical Health Psychology Service for Diabetes.

Beyond identification