Whilst most health care professionals are increasingly adept at managing all aspects of diabetes, what is often overlooked is the fact that the patient lives with the condition 24/7, the majority of this time away from their diabetes team. Most of patients are able to manage their diabetes without a problem but for some, living with a long term condition can cause a variety of psychological problems which impact on their diabetes control as well as their quality of life. Whilst patient education and empowerment can help with coping strategies, for some patients, this is not enough and they need access to more professional psychological help. Indeed access to psychological therapies is a recommendation within the National Service Framework back in 2001. Following this, NICE guidance regarding the management of Type 1 diabetes highlighted the importance of psychological support.
Common reasons for requiring psychological support include dealing with the diagnosis of diabetes, managing insulin, needle phobias and dietary changes, the latter including difficulties in managing a changing diet. A specific group where this is an issue is in young women who often omit insulin to avoid weight gain with acute and long term consequences. Depression is also a common problem in diabetes where its prevalence is double that of the general population. Over and above the severe impact of these psychological problems, the costs of depression are high. This is due to its negative impact on self care and subsequent hyperglycaemia with subsequent physical symptoms. This is also exacerbated by medication adherence issues. Psychological therapy techniques include motivational interviewing and cognitive behavioural therapy.
Unfortunately, despite the importance of psychological therapy, its provision is patchy. A survey from Diabetes UK in 2009 revealed that many teams lack even basic elements of this support with only ~10% using tools to screen for psychological needs. Only 31.5% of diabetes services had access to psychology whilst only 25% actually had a named contact. As a result 85% of patients with diabetes had no access to psychological support or, at best, only a generic service. This gap in service is well recognised with the majority of diabetes MDTs feeling that they lack this support and that it should be integral to their team.
Identifying the need is one thing but filling it is another especially with the growing number of patients with diabetes. Whilst most psychological services are concentrated in secondary care, the transfer of patients into primary care will clearly magnify any deficit. CCGs should commission services in keeping with the NSF and NICE guidance, taking into account the skill mix of HCPs trained in managing diabetes.
Dr. Mark Freeman