Research led by Professor Khalida Ismail

Our research has shown that psychological support can help people better manage their diabetes, and diabetes clinics across the country now offer psychological care.

People diagnosed with diabetes sometimes find it difficult to adapt to the demands of the condition. They have to learn how to monitor their blood glucose and inject insulin, or take other medication in order to stay well and prevent future complications.

Our researchers have shown that psychological support can help people more successfully manage their blood glucose levels.

‘People sometimes struggle to adjust to a diagnosis of diabetes and then to learn to live with it 24/7 – it means always thinking about what you eat, checking your blood sugar, taking insulin injections and medication regularly to keep blood glucose at optimum levels,’ says Professor Khalida Ismail from our Department of Psychological Medicine. ‘People can feel sad, angry, anxious, or resentful, or even try to forget their diagnosis and this can stop them managing their diabetes properly. Our studies have shown that depression is very common, and can make the symptoms of diabetes worse. People can also develop other serious mental health problems such as eating disorders and needle phobias.’

Our research has demonstrated that a combination of motivational interviewing (MI) and cognitive behaviour therapy (CBT) can make a difference to people with type 1 diabetes who find it hard to control their blood glucose. As part of the trial, diabetes nurses were trained to deliver psychological support.

Clinics offering MI and CBT are now an integral part of the diabetes service run by King’s College Hospital NHS Foundation Trust and are cited as exemplary by the national charity Diabetes UK and the NHS Confederation. Clinical guidelines in the UK and internationally, including in Canada and Australia, now recommend mental health professionals are involved in diabetes care.

‘A decade ago, there were hardly any psychological or psychiatric services of any note for people with diabetes,’ says Professor Ismail. ‘Now every diabetes team knows they need to be able to offer psychiatric and psychological care. I train liaison psychiatrists to work in this field, and psychiatrists, psychologists and diabetes teams are setting up services similar to ours all over the country.’

Professor Ismail and her colleagues have continued to develop services offering more than medical care to people with diabetes. The 3 Dimensions of Care for Diabetes (3DFD) team works with diabetes specialists in hospitals and community-based clinics in south London. The team comprises a psychiatrist and two community support workers, who offer practical help with day-to-day difficulties, including housing problems, domestic violence, benefits or debt.

‘We learned that when people are concentrating on, or worried about, these sorts of issues, diabetes takes a back seat,’ says Professor Ismail. The evaluation of the service is already showing that patients referred there are more in control of their diabetes.

Our researchers are now exploring how the internet can be used to support more people. They are working with software company uMotif and PsychologyOnline, a company that offers internet-based therapies, to develop online nurse-led CBT for people with diabetes.

Professor Ismail has also developed Depression in Diabetes, an e-learning programme that gives GPs and diabetes specialists the skills they need to diagnose and treat depression.

References

• Kan C et al A systematic review and meta-analysis of the association between depression and insulin resistance. Diabetes Care, 2013; 36: 480-89
• Winkley K et al Five year follow-up of a cohort of people with their first diabetic foot ulcer: the persistent role of depression on mortality. Diabetologia, 2012, 55; 303-10
• Patel A et al Motivational enhancement therapy with and without cognitive behavioral therapy for type 1 diabetes: economic evaluation from a randomized controlled trial. Diabetic Medicine, 2011; 28: 470-79
• Ismail K et al. Motivational enhancement therapy with and without cognitive behavior therapy to treat type 1 diabetes: a randomized trial. Annals of Internal Medicine, 2008; 149(10)
• Das-Munshi J et al. Diabetes, common mental disorders, and disability: findings from the UK National Psychiatric Morbidity Survey Psychosomatic Medicine, 2007; 69(6): 543-50
• Ismail K et al A cohort study of people with diabetes and their first foot ulcer: the role of depression on mortality. Diabetes Care, 2007; 30: 1473-479
• Winkley K et al. Psychological interventions to improve glycaemic control in patients with type 1 diabetes: systematic review and meta-analysis of randomised controlled trial. BMJ, 2006; 8: 333 (7558)
• Ismail K et al. Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. The Lancet, 2004; 363(9421): 1589-97