The association between diabetes and mental health is well recognised, both widely referenced in the literature, and witnessed first-hand by clinicians in their day-to-day working. North East Essex (NEE) collaborated with the local ‘Health in Mind’/‘Improving Access to Psychological Therapies’ (IAPT) team to improve access, care and outcomes for those living with diabetes in the region. Initially IAPT therapists were invited to diabetes patient education events but this led to development of new clinics, a specific diabetes/well-being course and much more. The main outcomes were improved access, improved psychological well-being scores and better diabetes self-management.
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The initial meeting was used to brainstorm, agree actions and set up ongoing meetings to keep the project on track. It was agreed that NEE diabetes service (NEEDS) clinicians would visit IAPT whole service meetings and deliver ‘round table’ training sessions. Topics covered included: basic what is diabetes/the difference between T1 and T2; daily diabetes routine and understanding medications, plus common issues seen in patients with diabetes (DKA/Hypo/burnout). The IAPT team would update the NEEDS team on new pathways, what they offered, how to prepare patients, ways to encourage patients to attend, plus basic mental health first aid. A ‘managing stress’ workshop provided the team with skills to suggest to diabetic patients. The diabetes therapists would shadow DAFNE, DESMOND and some NEEDS clinics to gain better general diabetes knowledge and gain insight into the patients’ experience. Further, they would be signposted to the Diabetes UK website and resources and discussion with the NEEDS DSN. A dedicated diabetes practitioner worked with the therapist to develop the diabetes and wellbeing course content and structure. Meetings were held between the therapists and a link DSN from NEEDS for ongoing CPD/updates and forward planning. A new mental health nurse (MHN) was recruited and upskilled to work within the NEEDS team to improve MH care. Updates were made to referral paperwork and process. Now, either the NEEDS team directly refers, or patients who mention their diabetes at screening are put on the separate IAPT diabetes pathway. The new pathway includes fast-track appointments and a separate waiting list from ‘general IAPT’, with upskilled practitioners based in a familiar location. Clinics with diabetes practitioners were put in place once the basic upskilling and pathways were ready, about six weeks after the initial meeting. A further pathway was developed, including the new steps of MH practitioner in NEEDS, the wellbeing course and the new clinics.
The project reviewed scores for levels of anxiety, depression and diabetes-specific measures, for diabetic patients in the NEE IAPT Service. Integrating support from NEEDS with the psychological care from the IAPT service broke down psychological barriers for diabetes patients accessing medical care, resulting in improved glycaemic control and reduced psychological stress, ultimately reducing health service costs. Sources of referrals and recovery rates for diabetes patients were reviewed between 1 April 2018 and 31 March 2019. The main sources of referrals were self-referrals, followed by referrals from GPs, Colchester General Hospital and NEEDS. Over 90% of self-referrals were signposted by NEEDS. The number of referrals with diabetes increased from 20 to over 300 in the first year (partly attributed to improved screening questions and form). A total of 64% of diabetes patients had a primary diagnosis of depression and 26% had a primary diagnosis of Generalised Anxiety Disorder (GAD). A reduction was seen in pre and post anxiety and depression scores following psychological intervention, with recovery rates of 65.96% for depression and 68.09% for GAD. For patients who attended a diabetes co-location clinic at step 3 between 7 February 2018 to 17 May 2019, the average reduction for depression was 8.29 and 8.86 for anxiety. A reduction was seen in diabetes-specific measures (Diabetes Distress Scale and/or PAID Scale) for patients who attended the diabetes co-location clinic, highlighting the effectiveness of psychological talking therapies for reducing emotional burden, regimen distress, interpersonal distress, physician distress and diabetes-related emotional distress. In addition, DNA rates reduced, reflecting national evidence suggesting that people are more likely to attend psychological therapies delivered in a familiar location.
Sustainability and Spread
This work will continue in order to help IAPT increase access to those with LTCs and help NEEDS continue to improve diabetes outcomes. Treatment is more specific to patients’ individual needs and targeted interventions can be delivered. Sustainability of staff training is easy, as shadowing can be arranged at any time and routine CPD is offered as a shared approach, e.g. an IAPT therapist can attend primary care or specialist team training sessions.
Following Covid-19, IAPT clinical work has reduced to virtual support (phone) for those actively receiving treatment. New referrals are on hold to IAPT but are triaged and supported by the NEEDS MHN. For patients of concern she contacts IAPT to seek the support they need. The MHN has also adapted some of the national MH support tools for NEEDS clinicians to share with patients with early signs of MH issues. This signposting to self-help has also been shared on the NEEDS social media pages and website. The project is sustainable in providing some virtual/video consultation for patients and ongoing training between to two teams takes place virtually. This model is extremely flexible on both sides. Outcomes will be audited later.
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