Embedding psychological care in diabetes services: Why it's time to innovate and integrate

Abstract

Aims

This narrative review synthesizes current knowledge on the psychological dimensions of diabetes care, identifies gaps in evidence and practice and proposes innovative pathways for embedding psychological care into routine diabetes services.

Methods

Drawing on the authors' expertise in diabetes and behavioral science, complemented by a semi‐structured literature search, the review integrates findings from quantitative studies, qualitative research, clinical experience and lived experience perspectives. Evidence was analyzed across domains of care models, research and evaluation, implementation and policy and advances in person‐reported outcome measurement.

Results

Psychological care in diabetes appears most effective when delivered through layered models: routine distress assessment, frontline psycho‐education and access to specialist therapies when needed. Evidence suggests such approaches reduce distress and depressive symptoms, though glycaemic effects remain variable. Integration is constrained by structural barriers such as fragmented health systems, limited reimbursement and shortages of trained professionals. Scientific gaps include underrepresentation of older adults, migrant populations and rare diabetes subtypes, as well as a lack of longitudinal studies. Practical challenges (time pressures in clinics, digital inequality, stigma) further hinder uptake. Assessment issues also persist, with lengthy tools limiting routine use. Moving forward requires interdisciplinary and stepped/matched care models, inclusive and participatory research and policy frameworks that support reimbursement and workforce development. Advances in adaptive, streamlined and culturally sensitive measurement tools are essential to ensure psychological needs are systematically identified and addressed.

Conclusions

Psychological care is not a luxury in diabetes care but a core component of effective, person‐centred practice, critical to achieving holistic, equitable and sustainable services.

What's new?

What is known

• Diabetes‐specific distress, depression and anxiety are common in diabetes and negatively affect self management and outcomes. Integration of psychological care has shown promise in other chronic conditions, but diabetes services remain fragmented and inconsistent.

What this study found

• This narrative review synthesizes evidence across assessment tools, interventions and implementation strategies. It highlights that layered models (routine assessment, frontline psycho‐education and specialist therapies) appear most effective, yet structural, scientific and practical gaps persist.

What are the implications

• Embedding psychological care as a core component of diabetes care requires stepped/matched models, inclusive research, supportive policy and infrastructure and culturally sensitive measurement.

1. INTRODUCTION

Diabetes continues to represent one of the most urgent global health challenges, with prevalence still rising across regions and age groups. The International Diabetes Federation Diabetes Atlas 2025 reports that over 10% of people worldwide are living with some type of diabetes. ¹ Evidence shows that psychological comorbidities may lead to disengagement from self care activities and that they are bidirectionally linked with suboptimal outcomes including glucometrics, complications and quality of life. ² , ³ , ⁴ People living with diabetes (PWD) often experience stress related to daily self management, heightened risk of depression and anxiety, stigma in social and professional contexts and even burnout from the demands of care. ⁵ This underscores the need for integrated, person‐centred care models that address not only the biomedical aspects of diabetes, but also the associated psychological burden. ⁶ , ⁷ , ⁸

Despite guideline recommendations to position psychological care as a core component of comprehensive routine diabetes services, the influence of psychological factors on medical outcomes and quality of life is often overlooked, while psychological care remains underutilized and inconsistently integrated into diabetes services. ⁵ Embedding psychological perspectives into everyday pathways is needed to ensure that services respond to the realities of living with diabetes, supporting both clinical outcomes and person‐reported well‐being. ⁹ Required pathways include the establishment of routine distress assessments, provision of frontline psychoeducation and timely access to specialist therapies when indicated. ⁸ Measurement and open discussion of psychological concerns are critical to make PWD's needs visible and ensure appropriate action is taken. Validated tools, brief screening questions and conversational approaches can normalize dialogue about mental health and help clinicians tailor support and diabetes care to the needs of PWD. ² Furthermore, a range of psychological interventions such as structured therapies and counseling approaches have demonstrated promise in reducing distress and improving aspects of self management. ¹⁰ , ¹¹ , ¹² Their impact does depend on being embedded within routine care rather than offered in isolation. ¹³ , ¹⁴ There is a growing number of innovative initiatives worldwide to embed psychological care in diabetes services, but sustainable implementation remains challenging due to a variety of barriers including fragmented health systems, limited resources and variability in training. ¹³ , ¹⁵ , ¹⁶

This narrative review aims to synthesize current knowledge on the role of psychological care in diabetes care, identify gaps in evidence and practice and propose pathways for innovation and integration. The review draws on the authors' expertise in diabetes and behavioral science, complemented by a semi‐structured search of the literature. Evidence from quantitative studies, qualitative research, as well as clinical and lived experience perspectives is considered to provide a broad and inclusive understanding of the field. Because this narrative review integrates empirical evidence, clinical experience and lived experience perspectives, we clarify how these different forms of knowledge are used throughout the paper. The sections on care models and person‐reported outcome measurement primarily synthesise empirical evidence. Interpretive claims (such as implementation barriers) reflect the authors' clinical and behavioural science expertise. More aspirational elements, including proposed future directions for stepped/matched care, interdisciplinary models and policy reform, are forward‐looking recommendations rather than established evidence.

2. WHAT IS KNOWN

2.1. Psychological dimensions of diabetes

The psychological burden of living with diabetes is well documented. Rates of depression and anxiety among PWD are around 10–40% and generally higher compared to the general population. ¹⁷ , ¹⁸ , ¹⁹ Diabetes distress (the emotional strain associated with the ongoing demands of living with and self‐managing diabetes) is now recognized as a distinct construct with significant clinical relevance. ² , ⁸ These challenges are directly related to self management behaviors and engagement with care. Evidence suggests that individuals experiencing high levels of distress or depressive symptoms are more likely to struggle with glucose monitoring, food choices and treatment routines, which in turn can affect glycaemic outcomes and increase risk of complications. ²⁰ , ²¹ , ²² At the same time, the demands of self care in itself can generate stress, frustration and feelings of burnout. ² , ²³ While there are common experiences across diabetes types and populations such as distress related to the cumulative demands of daily glucose management and societal stigma, there may be differences related to e.g., specific treatment modalities (such as insulin injections), eating behavior, body weight and prejudice with respect to perceived personal responsibility. ²⁴ , ²⁵ , ²⁶ Rarer forms such as Maturity‐Onset Diabetes of the Young (MODY) or Latent Autoimmune Diabetes in Adults (LADA) bring additional uncertainty, with limited public awareness and fewer tailored resources. ²⁷ , ²⁸ Age, gender and cultural background further shape how psychological challenges are experienced. For example, younger people may struggle with peer acceptance and independence, women often report higher distress linked to social roles and health demands, while cultural norms and health literacy influence how distress is expressed and whether support, if available, is sought. ²⁹ , ³⁰ , ³¹ , ³² , ³³ , ³⁴

2.2. Integrating psychological care into medical care: State of the evidence

Across diverse medical fields, the trajectory of psychological care has shifted from being a stand‐alone specialty to becoming an embedded component of routine care. Oncology and cardiology services illustrate this evolution in different ways, yet the underlying lessons converge. First, systematic monitoring of psychological distress in these fields is becoming reasonably standard (though even here, room for improvement remains, particular within certain subgroups), enabling early identification of people at risk of suboptimal health outcomes or diminished quality of life. ³⁵ , ³⁶ Second, psycho‐education and supportive counseling delivered by nurses and allied health professionals have proven feasible and effective, extending psychological principles into everyday care encounters. ³⁷ , ³⁸ Third, (elements of) psychological therapies such as CBT, mindfulness and Acceptance and Commitment Therapy are increasingly integrated into multidisciplinary programs, demonstrating improvements in emotional well‐being and often also medical outcomes. ³⁹ , ⁴⁰ The important lesson we learn from this is that integration appears most effective when it operates on multiple levels: routine assessment of distress, frontline psycho‐education and easy access to specialist interventions when indicated. This multilevel model ensures that psychological needs are addressed proactively rather than reactively and that care teams share responsibility for mental health alongside medical management. While stepped‐ or matched care approaches show promise, much of the existing evidence comes from high‐resource specialist settings. These studies primarily demonstrate proof‐of‐concept and local feasibility rather than effectiveness at scale. As such, these models should not be assumed to be universally applicable or readily transferable across diverse health‐system contexts.

Although the call for integration of psychological care has figured in treatment guidelines for many years, the diabetes field has been relatively slow to adopt recommendations in clinical care. Early work suggested that distress and depression screening (e.g., ⁴¹ , ⁴² ) improved detection but did not reliably enhance psychological or medical outcomes when follow‐up pathways were absent. Subsequent studies found that discussing measurement results was generally appreciated and could strengthen communication with care teams. ⁴³ , ⁴⁴ Building on these insights, studies have shifted towards implementation science, examining how screening can be embedded into routine services with actionable follow‐up. In the UK, for example, the ongoing D‐stress program focuses on whether routine distress screening combined with structured follow‐up can improve well‐being and self management in adults with type 1 diabetes. ⁴⁵ In the United States, the ARISE trial (scheduled to begin recruitment in 2026) will evaluate whether systematic screening linked to intervention improves both emotional and metabolic outcomes in type 2 diabetes. ⁴⁶ Evidence for the impact of embedding psychologists within diabetes teams remains limited, but emerging data are encouraging. In the international SWEET pediatric registry analysis by Chobot et al., centres with ready access to psychological services showed lower rates of ketoacidosis and slightly lower HbA_1c levels. ⁴⁷ Although observational, these findings provide rare large‐scale evidence that integrated psychological care may contribute to better clinical outcomes in children and adolescents.

Psycho‐educational interventions embedded in routine diabetes care (typically delivered by nurses and diabetes educators) appear to effect small‐to‐moderate improvements in diabetes‐specific distress and depressive symptoms and, in some studies, glycaemic outcomes as well. ¹² , ⁴⁸ Specialist therapies should be accessible for people experiencing persistent distress or comorbid mental health conditions, including depression, anxiety disorders, trauma‐related symptoms, disordered eating and other forms of psychopathology that commonly co‐occur with diabetes. These presentations often require tailored, evidence‐based psychological interventions delivered by appropriately trained professionals. Therapies such as cognitive behavioral therapy, mindfulness and Acceptance and Commitment Therapy have been evaluated mostly in adults. Reviews confirm that interventions targeting psychological distress in diabetes may reduce emotional burden, with variable effects on glycaemic outcomes. ¹⁰ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ The challenge for diabetes care is to move from fragmented, trial‐based interventions to systematic integration across health services and age groups, ensuring that psychological care is embedded as a standard component of diabetes management. ⁸

2.3. Assessing and discussing psychological outcomes

Measuring person‐reported outcomes (PROs) is essential for embedding psychological care into diabetes services. ⁸ , ⁵⁴ To avoid conflating different forms of person‐reported data, it is important to distinguish PROs and person‐reported inputs or experiences of care (sometimes called ‘PREMs’). PROs capture health status, symptoms, quality of life and other outcomes that matter to people living with diabetes. In contrast, person‐reported inputs reflect what people want, need, or value in their care, including preferences, priorities and experiences of interaction. ⁵⁵ , ⁵⁶ These inputs are essential for shaping personalised care and cannot be reduced to outcome measurement alone. Our focus in this review is primarily on PROs as tools to support clinical conversations and guide individualised treatment decisions, while we recognize that person‐reported inputs are equally critical for responsive, person‐centred diabetes care.

Standardized PRO assessment allows clinicians to objectify levels of distress, depression, anxiety and quality of life and provides a framework for monitoring the impact of interventions and overall care quality. Several validated instruments are widely used in research, such as the Diabetes Distress Scale (DDS), the Problem Areas in Diabetes (PAID) scale and general measures including the PHQ‐9 for depressive symptoms and GAD‐7 for anxiety. ⁵⁷ , ⁵⁸ , ⁵⁹ For children and adolescents, age‐specific tools such as the Mind Youth questionnaire have been developed to capture psychological dimensions of living with diabetes while being young. ⁶⁰ , ⁶¹ While the evidence base for these instruments is fair to strong in research settings, their implementation in routine practice remains limited. Consequently, the psychological burden may remain invisible at the clinical level, leading to under‐recognition and delayed intervention or missed opportunities for prevention. ⁶² , ⁶³ Understanding what the barriers for implementation of PROs in diabetes care are and bridging this gap is critical to ensure that psychological outcomes are systematically monitored and addressed as part of integrated diabetes care. ⁸ It is important to note that PROs and related instruments serve as a means to an end rather than an end in themselves; they function as a starting point for meaningful dialogue between PWD and healthcare professionals.

2.4. The role of the psychologist

Embedding psychological care requires an interdisciplinary psychological workforce, with each discipline bringing distinct strengths to specific contexts. Beyond clinical psychologists, health psychologists may contribute expertise in behaviour change and intervention design; counselling psychologists support adjustment and emotional processing; and community psychologists address contextual, cultural and structural determinants of distress. The current role of psychologists in diabetes care remains heterogeneous across settings. A recent consensus report outlined the core roles and competencies of the clinical psychologist in adult diabetes care, emphasizing contributions to assessment of distress and depression, delivery of evidence‐based psychological interventions, training of multidisciplinary teams and advocacy for integrated psychological care. ⁵ Yet, implementation varies widely. In 2024–2025, the international Psychosocial Aspects of Diabetes (PSAD) Study Group mapped the local situation in different countries. Findings revealed striking between‐ and within‐country variation: in some clinics psychologists are scarcely involved or lack diabetes‐specific expertise, while in others they are embedded as permanent members of the diabetes team. The PSAD Study Group is likely to issue this state‐of‐care report in the course of 2026. Findings have important implications for embedding psychological care in diabetes services and meeting the core roles set in the consensus report, including recommended sensitivity to locality and contextuality.

While psychologists play an important role in diabetes care, especially in complex cases and in training and supervision, the evidence increasingly shows that effective psychological care does not need to be delivered exclusively by psychologists. Scalable models rely on psychologists providing training, consultation and oversight, while frontline psychological and psycho‐educational interventions are delivered by other health professionals or trained peers. The LISTEN trial exemplifies this approach: a low‐intensity, telehealth problem‐solving intervention delivered by trained diabetes educators, nurses and dietitians was more effective in reducing mild to moderate diabetes distress than usual care. ⁶⁴ Such findings highlight that sustainable, accessible psychological care in diabetes requires a diversified workforce in which psychologists enable, rather than solely deliver, care.

3. WHERE ARE THE CURRENT BARRIERS

Although the importance of psychological care in diabetes services is increasingly recognized, significant barriers remain that hinder effective integration. Structural and organizational barriers, scientific limitations, practical challenges and issues related to psychological assessment are the main topics. Addressing them is essential if psychological care is to be embedded sustainably and equitably in diabetes care.

3.1. Structural and organizational barriers

Structural and organizational barriers are among the most pressing. Health systems in many countries remain fragmented, with psychological care often separated from routine diabetes services. This fragmentation makes it difficult to establish integrated pathways where psychological needs are identified and addressed alongside medical management. ¹⁴ Infrastructure is another challenge: many clinics lack the physical space, digital systems, or staffing models to accommodate embedded psychological services. Funding and reimbursement mechanisms are also insufficient. ¹⁴ In numerous health systems, psychological care is not reimbursed at the same level as medical care, creating disincentives for integration. Finally, there is a shortage of trained professionals with diabetes‐specific expertise. Workforce modelling underscores the scale of psychological need in diabetes care. Segal et al. estimated that approximately two full‐time equivalent psychologists per 1000 people with diabetes would be required to meet population‐level psychological needs in a primary care context. ⁶⁵ Based on the prevalence rates of common psychological problems, needs are likely to be even higher in secondary or tertiary care settings. No health system currently approaches this level of provision, highlighting the structural gap between need and available workforce capacity. Furthermore, as highlighted in the previously mentioned consensus report, psychologists require specialized competencies to work effectively in diabetes care, yet training opportunities remain limited and unevenly distributed across countries. ⁵ This shortage constrains the scalability of integrated models.

The implementation of PROs in routine diabetes care requires training not only for healthcare professionals but also for people living with diabetes, ‘normalizing’ attention for the psychological aspects of diabetes in regular care. ¹⁴ Clinicians need support to interpret scores accurately, integrate them into clinical decision making and translate findings into meaningful conversations during consultations. Equally, people with diabetes benefit from guidance on the purpose of PROs, how their responses inform care and how to engage with tools such as distress scales or quality of life questionnaires. This dual training approach ensures that PROs are not perceived as administrative tasks, but as instruments that foster shared understanding, empower people with diabetes and enhance the quality of psychological care. Clinicians must also perceive the clinical relevance of PROs; without genuine engagement from healthcare professionals, even sophisticated PRO dashboards fail to translate into meaningful clinical use. Effective integration requires team leadership that is knowledgeable about (and receptive to) the value of psychological care, being fully cognizant that psychological factors have a major impact on diabetes outcomes and quality of life. ⁶⁶ Ensuring that clinicians and organizational managers recognize the necessity of addressing psychological issues is therefore essential for successful implementation.

Another key barrier in this category concerns the positioning of psychological care for caregivers (parents, partners and other close supporters). For example, in paediatric diabetes care, the psychological needs of caregivers are often substantial, ⁶⁷ yet many health‐care systems restrict access to psychological services to the child having diabetes themselves. This creates a structural gap: caregivers play a central role in daily diabetes management, but may be unable to receive support even when their own distress, anxiety or burden directly affects the well‐being of the child. Addressing this requires funding models that recognise caregivers as legitimate recipients of psychological care, as well as pathways for warm handovers to community‐based or primary‐care psychological services when support cannot be provided within diabetes teams. Strengthening caregiver access is therefore essential for truly family‐centred diabetes care.

3.2. Scientific gaps

While there is evidence for psychological interventions in type 1 and type 2 diabetes, less is known about their effectiveness in under‐researched subgroups. Older adults, migrant populations and people living with rare forms of diabetes are often underrepresented in or excluded from trials, leaving uncertainty about how best to tailor interventions to their needs. ¹³ Furthermore, psychological diabetes research rarely captures the experiences of individuals with lower socio‐economic position or limited (health) literacy, despite evidence that these socio‐economic factors are closely linked to health‐related functioning. ⁶⁸ , ⁶⁹ Moreover, most studies focus on short‐term outcomes, such as reductions in distress or depressive symptoms over several months. There is a lack of longitudinal research examining the long‐term effects of integrated psychological care on both psychological well‐being and clinical outcomes such as glyacemic outcomes, complications and healthcare utilization. Without this evidence, policymakers and funders may hesitate to invest in embedding psychological care into routine services. In this context, value‐based healthcare implies demonstrating the measurable contribution (be it quantitative or qualitative) of psychological care to meaningful outcomes in diabetes, ensuring that resources are directed towards approaches that genuinely improve PWD's lives. ⁷⁰

3.3. Practical challenges

Practical challenges are evident in everyday clinical settings. Diabetes clinics are often focused on delivering medical diabetes care, with limited consultation time for many PWD, making it difficult to incorporate psychological assessment or interventions without disrupting workflows. ⁴⁴ Digital health solutions, such as e‐health platforms and mobile apps, offer promise for scaling psychological care, but digital inequality remains a barrier. People with limited access to technology, low digital literacy or general illiteracy may be excluded, exacerbating disparities. ⁷¹ Stigma and taboos around mental health further complicate implementation. In many cultures, people may be reluctant to disclose psychological distress or seek support, reducing the effectiveness of assessment and referral systems. ⁷² Another practical challenge concerns the need for attention to psychological problems early in the care trajectory. Immediately after diagnosis, people with diabetes face an overwhelming set of medical, technical and behavioral demands, easily overshadowing psychological needs in this period. ⁷³ Ensuring that psychological care is introduced as a routine and expected component of early diabetes education therefore remains a critical implementation challenge.

3.4. Challenges in psychological assessment

While validated instruments are widely used in research, their uptake in routine practice is limited. People often experience burden from lengthy questionnaires, leading to low completion rates. ⁷⁴ Many tools and interventions also lack cultural validation, raising concerns about their applicability in diverse populations. ³³ Even when tools are used, healthcare professionals may not receive sufficient training to interpret scores or translate them into actionable care pathways. ¹⁴ As a result, assessment risks becoming a ‘tick‐box exercise’ rather than a meaningful component of integrated care. While advances in PROs and streamlined assessment tools offer important opportunities, measurement itself is not neutral. The act of completing a questionnaire can shape the clinical conversation, foreground certain issues while sidelining others and risk constraining person‐centred dialogue if used inflexibly. Moreover, there are situations in which not measuring may be the more ethical or appropriate choice, for example when emotional safety, cultural context, or acute clinical priorities require a more open, narrative approach. Integrating PROs into diabetes care therefore requires not only better tools, but also careful judgement about when measurement adds value, when it risks becoming performative or burdensome, how results are meaningfully discussed and in which situations an interview is more appropriate.

Taken together, these gaps highlight the complexity of embedding psychological care into diabetes services. Structural barriers require policy change and investment in workforce development. Scientific gaps call for more inclusive and longitudinal research. Practical challenges demand innovative models that balance efficiency with equity, while measurement issues necessitate streamlined, culturally sensitive tools and training for clinicians. Importantly, solutions must be tailored to local contexts, ensuring that strategies are feasible and effective within specific health systems.

4. HOW DO WE MOVE FORWARD?

The integration of psychological care into diabetes services is no longer a question of ‘if’ but of ‘how’. Moving forward requires innovation in care models, rigorous research and evaluation, thoughtful implementation and policy and advances in assessment of psychological outcomes. Each of these domains offers opportunities to strengthen the psychological dimension of diabetes care and to ensure that services are both evidence‐based and contextually relevant.

4.1. Innovation in care models

Implementing psychological care in diabetes services does not necessarily depend on new funding streams but on redesigning existing workflows and reallocating resources. Innovation in this context refers to integrating brief, scalable psychological practices into routine care, supported by task‐sharing and stepped‐ or matched care principles. Sustainable implementation requires de‐implementation of low‐value activities (such as generic education sessions with limited behavioural impact, fixed consultation lengths) and organizing glucose management support in a more data‐driven and risk‐stratified way, to free time and capacity for psychological input. This shift is further supported by the increasing use of automated insulin delivery systems and remote care models, which potentially reduce the burden of routine glucose management and create additional space for staff to deliver psychological support. Practical strategies include embedding routine distress assessment within existing consultations, using brief asynchronous digital interventions, training diabetes nurses, educators and/or doctors in brief evidence‐based techniques (e.g., problem‐solving, motivational interviewing) and reserving specialist psychological expertise for complex presentations. Such approaches allow psychological care to be delivered within current staffing and budget structures while improving the behavioural and emotional components of diabetes management.

One of the most promising directions is the development of interdisciplinary teams in which psychologists and specialized nurses are embedded within diabetes clinics. ⁵ Given the global shortage of psychologists with diabetes‐specific expertise, it may be more feasible to invest in training nurses and diabetes educators to deliver psycho‐educational interventions and other basic psychological interventions. Psychologists can then provide supervision, consultation and care for more complex cases, creating a tiered model of expertise. Stepped‐ or matched care approaches are particularly well suited to the diabetes field. ¹⁶ These models ensure that people receive the least intensive, yet effective, care first, with escalation to more specialized care if needed. For example, routine distress assessment could trigger nurse‐led psycho‐education, while persistent or severe distress would warrant referral to a psychologist. Blended care models, combining online and face‐to‐face interventions, also hold promise. Digital platforms can deliver scalable psycho‐educational content, while in‐person sessions provide individualized care. This hybrid approach may reduce barriers related to time, travel and workforce shortages. Finally, community‐based and peer‐led interventions should be expanded. Peer support may enhance self efficacy, reduce isolation and ‘normalize’ psychological challenges in diabetes. ⁷⁵ , ⁷⁶ Embedding peer programs within community organizations or advocacy associations can extend the reach of psychological care beyond the clinic walls.

4.2. Research and evaluation

Future progress depends on robust evidence. For policymakers and insurers, randomized controlled trials (RCTs) remain the gold standard. Following their line of reasoning, more RCTs would be needed to evaluate integrated psychological care models, particularly in diverse populations and across different health systems. At the same time, RCTs alone cannot capture the complexity of real‐world implementation. Frameworks such as the UK Medical Research Council (MRC) guidance on complex interventions and realist evaluation offer valuable tools. ⁷⁷ , ⁷⁸ These approaches emphasize mixed‐methods research, exploring not only whether an intervention works, but how, for whom and under what circumstances. Such insights are critical for tailoring psychological care to local contexts. Participatory research is another priority. ⁷⁹ Involving people with diabetes in co‐creation ensures that interventions are relevant, acceptable and grounded in lived experience. This participatory approach can also help address stigma and cultural barriers by giving voice to lived perspectives. Furthermore, the use of real‐world data and digital monitoring should be expanded. Electronic health records, portals and wearable devices can provide (semi‐)continuous information on distress, mood and self management behaviors. These data can complement trial evidence, offering insights into long‐term outcomes and enabling adaptive care models. Finally, there is a clear need for research examining the cost–benefit profile of psychological care in diabetes, including the potential economic advantages of reallocating certain components of routine care towards enhanced psychological care. Early psychological assessment (e.g., PRO measures) and intervention should be considered a first‐line response when medical treatment targets are not met. Strengthening psychological care may, in some cases, offer a more cost‐effective strategy than expanding traditional clinical staffing, such as regular nursing capacity, while simultaneously addressing the behavioral and emotional factors that drive suboptimal outcomes.

4.3. Implementation and policy

Even the most effective interventions will fail without supportive implementation strategies and policy frameworks. It is essential that clinicians and service managers fully recognize the importance and necessity of implementing psychological care within diabetes services. Guidelines, such as the first clinical practice guideline on diabetes distress to be released by the European Association for the Study of Diabetes in 2026, will play a crucial role in reinforcing this need. ⁸ Training for healthcare professionals and capacity building (specialized nurses, psychologists) are also important. The full diabetes team needs skills in recognizing distress, using assessment tools and initiating supportive conversations. Training can be delivered through workshops, online modules, or supervision models and should emphasize both technical competencies and communication skills. Understanding and (basically) addressing the psychological aspects of diabetes should also be a regular part of medical educational programs. Policy recommendations must address reimbursement, guidelines and quality indicators. Without financial coverage, psychological care will remain inaccessible for many people. National and international diabetes guidelines should explicitly recommend distress screening and psychological care as part of routine care. Quality indicators could include rates of distress assessment, referral to psychological services and person‐reported outcomes. Learning from international perspectives and best practices is also crucial. Countries vary widely in how psychologists are integrated into diabetes teams, from minimal involvement to full embedding. Comparative studies and cross‐national collaborations can identify models that are both effective and feasible, while highlighting the importance of locality and contextuality in implementation.

4.4. Innovation in PRO assessment

Repeated assessment of PROs, used as a tool for initiation of the conversation and linked to stepped‐ or matched care pathways, is central to embedding psychological care in diabetes services. To overcome limitations of current instruments, one innovation is the use of short index questions followed by targeted follow‐up items when a positive response is detected. This reduces participant burden while ensuring that relevant issues are explored in depth. Computerized Adaptive Testing (CAT) offers another solution. CAT dynamically adjusts the questionnaire based on participant responses, reducing the number of items while increasing precision. However, CAT is not without drawbacks, including potential bias if item banks or algorithms are not broadly validated. ⁸⁰ Conversation tools, such as discussion cards, digital apps or chatbots, may make distress more visible and easier to discuss. ⁸¹ Integrating these tools into consultations may help translate scores into meaningful dialogue, fostering person‐centred care. Implementation in routine care requires integration into electronic health records, with automatic alerts for clinicians when scores on distress or depression items exceed thresholds. This addresses provider inertia, ensuring timely intervention and facilitating monitoring at the system level. Additionally, assessment innovation should embrace the perspective of people with diabetes. Embedding lived experience into measurement design helps make tools more effective. Finally, even in low‐ and middle‐income countries or similar settings with limited resources available for specific tools, a ‘simple’ discussion focusing attention on the psychological aspects of diabetes may be much appreciated.

5. CONCLUSION

The case for embedding psychological care into diabetes services is compelling and urgent. Psychological dimensions (e.g., distress, depression, anxiety, burnout) are not peripheral concerns but central determinants of self management and clinical outcomes. Lessons from other chronic care fields demonstrate that integration of psychological care is most effective when layered: routine assessment of distress, frontline psycho‐education and access to specialist therapies when needed. Unfortunately, implementation in the diabetes setting remains uneven and fragmented. Despite progress, significant gaps persist. Structural barriers such as fragmented health systems, insufficient infrastructure, inadequate reimbursement and shortages of trained professionals limit scalability. Scientific gaps include the lack of evidence for under‐researched groups (people from disadvantaged backgrounds, older adults, migrant populations, those with rare forms of diabetes) as well as the absence of longitudinal studies on long‐term outcomes. Practical challenges arise in busy clinics, where time constraints, digital inequality and stigma hinder uptake. Assessment issues further complicate integration: questionnaires can be burdensome, culturally insensitive, or poorly translated into actionable care. Without addressing these barriers, psychological care risks remaining a peripheral add‐on rather than a core component of diabetes services.

Moving forward requires coordinated innovation. Interdisciplinary and stepped or matched care models, supported by nurses and peer networks, can extend psychological care despite workforce shortages. Research must combine randomized controlled trials with realistic and participatory approaches, ensuring interventions are both evidence‐based and contextually relevant. Real‐world data and digital monitoring can complement trial evidence, capturing long‐term impact and enabling adaptive care models. Implementation depends on training and capacity building for healthcare professionals, organizational and reimbursement structures that value psychological care and guidelines that embed psychological care as a standard of practice. Advances in PRO measurement (adaptive assessment, conversation tools, co‐created instruments) will help ensure that psychological needs are systematically identified and addressed.

The core message is clear: psychological care is not a luxury in diabetes care, but an essential element of effective, person‐centred practice. For researchers, the call is to generate robust, inclusive evidence; for clinicians, to integrate psychological care into everyday encounters; and for policymakers, to create structures that make psychological care accessible and sustainable. Above all, integration must remain grounded in dialogue and connection. Assessment tools are valuable, but they must serve the conversation, not replace it. Only by embedding psychological care as a living, relational component of diabetes services can we achieve care that is truly holistic, equitable and transformative.

FUNDING INFORMATION

This research received no specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors.

CONFLICT OF INTEREST STATEMENT

PW, HJA, CF and GN: Employees of Diabeter, an independent clinic which was acquired by Medtronic. The research presented here was independently performed and there are no conflicts of interest. HJA: Member of advisory boards (Sanofi, Medtronic) and gave invited lectures. All activities are paid to employer Diabeter and not the individual. GN: Independently involved in a producer‐initiated study with Inreda Diabetic B.V., for which she receives no renumeration other than (co‐)authorship. Industry research discounts (Dexcom; appr. EUR 5000 on the purchase of sensors) and speaker fees (Dexcom, Sanofi) were paid directly to employer Radboudumc.