How important is mental health involvement in integrated diabetes care? The Inner North West London experience

Key messages

• People with diabetes have a higher prevalence of mental health issues than the general population, but not all mental health issues constitute a formal diagnosis. They can, nevertheless, have a major impact on effective self-management.

• We found that embedding psychiatrists within the integrated care pilot for diabetes was an effective way to raise awareness of this co-morbidity in terms of detection and management.

• Outcomes as a result of our involvement:

  • mental health screening questions and a capacity flow diagram were added to the diabetes care plans in year 2 of the pilot;
  • development of specialised diabetes mental health service.

Why this matters to me

As a liaison psychiatrist I work at the interface between physical and mental health and I am passionate about ensuring that mental health issues are addressed in the management of long-term conditions, but in an integrated system where the person can be seen as a whole.

I have been attending the multidisciplinary case conferences for several groups of GP practices in NW London as part of the NW London Integrated Care Pilot since June 2011. During that time, I have been struck by how engaged clinicians become with the narrative of the patient when we allow ourselves the space to really think about the person in their entirety.

Abstract

Supported self-management is key to good diabetes care, but the high rates of mental health difficulties in diabetes can hinder effective self-management. Depression, anxiety, eating disorders and cognitive impairment, as well as interpersonal difficulties and personality disorder are all known to have a detrimental effect on effective self-care and addressing these has been demonstrated to improve health and financial outcomes. We propose that integrating mental health into the core of diabetes care is vital to improve detection and effective treatment rates of these disorders as well as improving confidence of all professionals who support people living with diabetes. We found that in 81% of all cases brought to the multidisciplinary complex case conferences, mental health issues were discussed. The majority of these were regarding reasons for people not effectively self-managing their diabetes despite having education on diabetes. We found that there was a demand for our input in case conferences, educational sessions about self-management, cognition, capacity and mental illness, and a need and demand for a specialist mental health diabetes service.

Introduction

The diabetes care pathway of the Inner North West London Integrated Care Pilot (INWL ICP) was established to address the increasing challenge of managing diabetes in the region^1,2

An economic report last year calculated that there are currently around 3.8 million people living with diabetes in the UK and, that by 2035/6, this is expected to increase to 6.25 million. The current cost of direct patient care for those living with diabetes is estimated at £9.8 billion. Much of the costs are considered in this report to be avoidable because they are spent on complications of diabetes.³

Supported self-management is considered to be essential in the management of all long-term illnesses^4–7 and thus to the aim of the INWL ICP in the diabetes care pathway.

Diagnosable mental illness, like depression, anxiety and eating disorders all have a detrimental impact on effective self-management of diabetes.⁵ These disorders are twice as prevalent in people with diabetes as they are in the general population. In addition, it is estimated that over 40% of people with diabetes suffer some sort of psychological distress which does not fulfil diagnostic criteria for mental illness, but does nevertheless have a detrimental effect on a person's motivation and ability to self-manage their condition.⁵ These ‘conditions’ are often undetected because they do not meet diagnostic criteria and therefore this cohort of people will not get access to specialist advice.

There is increasing evidence that addressing mental health issues improves diabetes outcomes^5,8,9 and that this in turn reduces healthcare utilisation and costs related to diabetes.^5,10

And yet, Minding the Gap reported in 2008 that 85% of people with diabetes do not have access to specialist mental health services.⁸

All major reports on diabetes care in recent years have stated the importance of integrated care for effective diabetes management. They also emphasised the need for training and support for diabetes healthcare professionals in mental health issues.^4–8

There are many innovative services across the UK working on integrating clinical services for people with diabetes. Several of these have mental health input and have shown promising results in diabetes parameters by addressing the mental health needs. Most of them, however, require the diabetes team to identify that there might be a mental health issue and then refer to the integrated mental health service.^11,12

The Inner North West London Integrated Care Pilot

This pilot is integrated at a number of levels and is population and condition based. Therefore, there is a unique element to the input that mental health has been able to provide via the case conferences. The case conferences are attended by a range of disciplines, all of whom are able to provide input to all of the complex cases brought. This obviates the need for the ‘referrers’ to identify ‘caseness’ and therefore all complex cases benefit from the input, whether the referrer identified that need or not.

Here, I describe our mental health trust's evolving experience of the case conference component of the diabetes pathway and the impact on the next phase of the pilot as a result of having mental health input.

Mental health input: an evolutionary process

In the beginning

Initially, it had been envisaged that the main role of the psychiatrist in the case conferences would be to provide links for people with co-existing severe mental illness and diabetes, and to discuss side effects of antipsychotic medications which cause hyperglycaemia.

The clinical query in the case conferences would almost always be directed towards the diabetologist for issues of diagnosis, medication adjustment and management of complications.

The psychiatrist, like the other disciplines present, was nevertheless able to ask questions about, for example, cognition, mood and social support, and make suggestions about other issues that might be worth considering as part of the multidisciplinary discussion.

Emerging mental health themes

Within a few months, we observed that several clinical queries started being directed towards the psychiatrist.

Patients/users not managing their diabetes effectively

It emerged that a significant number of people fitted into this group despite having been on diabetes education programmes. Discussions began to take place in the case conferences about how depression, anxiety, interpersonal difficulties, personality disorder and adverse childhood experiences could all impact on the ‘relationship’ a person has with their diabetes and their healthcare professionals. This laid the groundwork for the psychiatrist to help clinicians think about alternative ways to approach the dialogue with the person about what the underlying reasons for poor self-management might be. The case conferences were then used as places where a conversation with the patient/user might be role-played in order to facilitate a clinician to support a behaviour change with more confidence as well as screen for diagnosable mental illness (see Box 1).

Box 1.

Emma is a 22-year-old Caucasian woman with type 1 diabetes since the age of 13. She has been through diabetes education programmes but is poorly engaged with services, missing 50% of her insulin injections and drinking alcohol to harmful levels. Her HbA1C is 90 mmol and she has early diabetic retinopathy.

She is discussed in the case conference, and advice is provided about motivational interviewing which is used to persuade her to see the diabetes psychiatrist. It transpires that there is a history of childhood abandonment from her mother and emotional abuse from her father, leaving Emma to become the ‘carer’ for her younger sister.

She is helped to understand how her early experiences are linked to her self-neglect in adult life and she is engaged in the local personality disorder service which provides further psychological understanding and containment.

Although HbA1C has only fallen to 88 mmol, she is now engaging with her diabetes appointments, diet and exercise programmes, and has an interest in managing her diabetes effectively.

‘Emma’ is not a real patient, but her story is illustrative of the kind of case discussed.

The brain as an end organ

Professionals looking after people with diabetes are familiar with looking for cardiac, retinal, renal and peripheral vascular complications. However, we know that the brain is just as vulnerable an end organ as any of these and yet it is not routinely thought of as an organ at risk of damage in diabetes.^14–16 The case conferences were a helpful forum to highlight this and to encourage assessment of cognitive impairment in order to help identify dementia which might in turn be a reason for ineffective self-management of diabetes.¹⁵

Capacity to consent

The Mental Capacity Act (2005)¹⁷ states that capacity must be presumed unless there is a good reason to suspect impairment. However, it is important to consider impaired capacity in cases of cognitive deficit and poor self-management. All clinicians should be able to assess capacity and yet there is evidence that many professionals lack confidence about their skills in this area¹⁸ and this was reflected in our group.

Quantitative data

In the first few months of the pilot, we compiled a list of the mental-health-related topics that were being discussed (see Figure 1). Using this list, over a nine-month period, we then documented up to a maximum of three mental-health-related issues for each person discussed in the case conferences. During this time, there were a total of 34 case conferences and 205 complex cases discussed on the diabetes pathway.

Figure 1.

Of these 205 cases, we found that there were only 38 (19%) cases in which no mental health input was required in the discussions. Mental health issues were discussed in 167 (81%) cases.

The single most significant area (65%) in which the mental health clinicians were involved was in the discussion of effective self-management (109 of 167 cases in which mental health clinicians were involved; Figure 1).

In all but 37 of these 109 cases, other mental health issues (e.g. cognitive or capacity issues, mood, personality and eating disorders) also arose.

Qualitative data

Professionals

Anonymised evaluation forms were collected from all participating professionals after every case conference.

Mental health input consistently received positive feedback across all of the MDGs. Professionals in case conferences said that they appreciated learning about:

• motivational interviewing and negotiating plans with patients/users;

• the impact of personality disorder or interpersonal difficulties on effective self-management and relationship with healthcare professionals;

• carrying out cognitive assessments;

• carrying out capacity assessments; and

• mental health services availability and how to access them.

I have found the mental health input to the case conferences highly educational. … I have found that I have made changes to my practice after every case conference. Joint working with mental health should be part of the training of any healthcare worker involved in the management of long-term conditions. (Diabetes Consultant)

…all of the psych input is really helpful—especially how to engage patients. (GP)

Patients/users

In the pilot, formal feedback from patients/users is mainly about their experience of the care plans and therefore would not have any comments about mental health input.

The comment below, however, was fedback verbally via the GP at a case conference. It is from a woman with a history of emotional neglect as a child, and self-neglect in the form of not managing her diabetes effectively as an adult.

I decided that if all of these professionals are sitting around a table trying to look after my diabetes, maybe I should try to look after my diabetes too. (Patient/user)

Tangible outcomes as a result of mental health input to the pilot

As a result of the re-evaluation of processes at the end of year 1, the following were incorporated into the electronic care planning tool for year 2 of the pilot:

• mental health screening questions for depression, anxiety, cognitive function;

• capacity assessment flow diagram;

• specialist mental health services were identified as a service gap and an innovation bid to fund a psychiatric diabetes clinic (to address complex diagnostic and medication issues) and a diabetes psychotherapist (to address complex psychological issues) was supported by the board.

Discussion

It is important to note that we are not stating that the percentages of issues discussed equate to diagnostic prevalence but are more a measure of differential diagnoses which were considered during the case conferences. Some of the people for whom a diagnosis may have been raised will not have had any difficulties in that area when the GP explored it further, but it was important for it to be explored nevertheless.

Of course, the high rates of mental health issues discussed (81% of all cases) may be a measure of how much the psychiatrist was ‘pushing their specialty’, although feedback from the clinicians would indicate that this was unlikely to be a major factor. Rather, it feels as though the repeated discussions about some of the concepts described have begun to build awareness and confidence in these areas.

We did not expect significant reduction in admissions to hospital or length of stay within the early stages of the pilot. What we had hoped for was a culture change. Professionals building relationships, knowledge and confidence to work with patients who ultimately need to be motivated and enabled to effectively self-manage their chronic conditions.

It has not been a journey without challenges, frustrations and disappointments, but we believe it has been a worthwhile endeavour and one from which we have learned a great deal.

ETHICAL APPROVAL

Under Pilot ethical approval under NRES Committee London-City and East, Southwest REC Centre (Reference number-11/LO/1918) Professor Azeem Majeed. Elisabeth Paice, guarantor.

CONSENT

Case vignette anonymised.