"Bridging the Gap". Developing Integrated Pathways and Interventions in Diabetes Psychology.

Mental health difficulties are by now considered the norm in diabetes, not the exception and there is a call for more integrated interventions and care pathways for this group (Amrit et al 2023). As a diabetes psychologist at the Diabetes Integrated Care Ealing (DICE) service in Southall, London, I have noticed the need for psychological support in this service echoes the gap identified nationally (Askew et al. 2019). In a recent audit by one of my colleagues, it was found that 80% of people referred to our service also had a mental health condition (Gomwe, 2022) and we are working on developing and integrating care pathways to better meet this need. The "Adapted 5-Level Pyramid of Psychological Needs in People with Diabetes" (Sachar et al. 2020) illustrates five levels of psychological needs (outlined below) among people with diabetes. I have used this as a framework to illustrate how provision is currently met in this service and thoughts on how pathways could be further integrated and developed: Level 1) General difficulties with coping with diabetes. Common to most people receiving a diagnosis of diabetes. Likely to increase at each significant life stage and each significant change in diabetes progression/ /No specific psychological support is offered on this level. Level 2) Psychological problems related to diabetes like anxiety, depression, diabetes distress, phobias, and some disordered eating// Provision here met by Increased Access to Psychological Therapies (IAPT) Level 3) Psychological problems related to diabetes like anxiety, depression, diabetes distress, phobias, some disordered eating// Provision met by diabetes psychology service (individual or group intervention*) Level 4) Significant difficulties coping and self-caring in the context of multiple complexities like substance misuse, complex trauma, and social difficulties. +/- depression, anxiety, diabetes distress/ Provision met by diabetes psychology service (individual or group intervention *). Some referred to secondary mental health services at this level**. Level 5) Severe Mental illness, dementia, or eating disorder, +/- in acute mental health crisis // Provision** here needs further integration. Not only due to complexity but also to manage risk. Presently managed on a case-by-case basis and involves screening by diabetes psychologist. The common thread across levels is diabetes distress (here defined “as the unique, often hidden emotional burdens and worries specific to people with diabetes”) across all levels of severity. I believe integrated interventions addressing both the psychology and physiology of diabetes could halt the intensity likely to exacerbate any other conditions and issues on all levels. With this in mind, and as a service development initiative I am presently offering a structured education group* adapted for people with diabetes who also have a psychological condition of varying severity. Outcome measures used in both individual - as well as group- interventions involve both general psychological screening tools, more specific diabetes distress measures as well as physical measures of diabetes. Preliminary evaluations of such looks promising. I hope to develop diabetes psychology interventions further through more formal research using a co-production design involving the views of people with diabetes and healthcare professionals.