mental health



Bringing together physical and mental health

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improving psychological functioning




providing practical assistance to address social problems.

Psychological treatment typically involves CBT to treat a range of problems. These

can be motivational issues, depression, anxiety, family conflict or unhelpful health

beliefs. Diabetes-specific issues include difficulty in accepting the diagnosis, needle

phobia, fear of insulin, and eating disorders (among other things). Examples of

social issues that can prevent successful self-management of diabetes include

problems with housing or debt. The support workers can provide direct support for

these issues or signpost to other services.

Patient-led case meetings are held regularly with members of the multidisciplinary

team. The purpose of these meetings is to plan and co-ordinate care. By encouraging

the patient to lead the meeting, the team can obtain in-depth knowledge of the

problems faced by each individual and tailor the support and treatment accordingly.

Meetings allow patients to maintain relationships with routine care teams, which

helps them to re-engage with them during recovery. Upon discharge, individuals

return to routine diabetes care in the hospital, community or in primary care.


An evaluation of phase 1 (August 2010 to March 2012) and phase 2

(September 2012 to March 2014) found very promising results in relation to

improved outcomes (Doherty et al 2016). For example, the average reduction in

HbA1c from referral to six months later was greater than the improvements seen

with the introduction of new medication and greater than improvements achieved

by local community diabetes clinics. Reduction in HbA1c levels can reduce the

likelihood of developing complications such as retinopathy and cardiovascular

disease. A 1 per cent reduction can decrease rates of diabetes-related complications

by up to 40 per cent (UKPDS Group 1998). In addition, statistically significant

improvements were achieved in psychological scores relating to depression (PHQ-9

scale), anxiety (GAD7 scale) and diabetes-specific distress (Diabetes Distress Scale).

Improvements in social functioning were measured on the ‘Outcomes Star’ scale

across multiple domains, including accommodation, personal responsibility and

social networks.

Appendices: case study site profiles 75

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