Mental health in vulnerable people: warning signs and strategies to improve health outcomes

In many instances, definitions of vulnerable populations in healthcare settings lack precision. Vulnerable individuals are identified in the literature with terms such as underserved, marginalised, at risk or disadvantaged. This term may, therefore, suggest ethnic minority groups, children, the elderly, those with chronic diseases (e.g. diabetes), immigrants, those affected by natural disasters and people from conflict zones.

The field of vulnerability study is ever-growing, and is influenced by social, environmental and psychological elements, amongst others. As such, a framework may be applied to explain the adversities faced by vulnerable individuals. The framework can provide explanations of the interrelationships between vulnerability, culture, history, biology, public health, sociology, psychology and demography. It allows for the introduction of life-course perspective, which considers the paradigm of understanding people by analysing their social circle, mental and physical health, built environment and developmental stages. 

The pyramid of emotional and psychological needs in diabetes, developed in 2008 by Diabetes UK, updated in 2010 and adapted by Sachar and colleagues (2020), considers the warning signs of mental illness in individuals with diabetes. The pyramid (Figure 1) illustrates the diversity of psychological needs present in any population or, over time, in any individual with diabetes. It has five levels that require different degrees of care, with the base representing common but not severe needs (such as difficulties with coping), while at the top needs are severe but relatively infrequent (such as those that may require specialist psychiatric or psychological intervention).

The early identification of the warning signs and risks factors of mental distress is crucial for the well-being of both the individual and the community. Such indicators in people with diabetes include:

• Recurrent diabetes emergencies (e.g. diabetic ketoacidosis, hyperglycaemic hyperosmolar state or hypoglycaemia).
• Difficulty in controlling blood glucose levels.
• Difficulty transitioning from child to adult services.
• Fear of starting treatment to limit complications.
• Evidence of depression, anxiety or poor self-care. 

Because of the great challenges to mental health that vulnerable people face, identifying the early symptoms is important, and may help to reduce the risk of developing comorbidities in people with diabetes. The relationship between diabetes and mental health is complex and two-way. Poor glucose control may lead to a deterioration in the mental health of a person with diabetes, while the poor mental health of an individual may affect attendance at medical appointments, the uptake of continuous blood glucose monitoring, or the ability to manage their hyperglycaemia.

A service providing culturally competent care, which is sensitive to people’s cultural identity or heritage, is likely to see greater patient satisfaction and adherence to treatment in vulnerable groups. Such care can improve outcomes in people living with chronic diseases who may otherwise, for example, receive treatment that does not conform to their linguistic, psychosocial or social needs. Leaders, managers and staff all need to have a good understanding of and be properly trained in cultural competency and how it relates to mental health. 

Integrating diabetes care and mental health care requires support from clinicians, psychiatrists, psychologists, local diabetes networks, diabetes specialists and commissioners. There is a need for early clinical engagement and collaboration between different stakeholders. This allows service gaps to be addressed, and leads to improved healthcare delivery. 

The use of evidence-based interventions is essential in the field of mental healthcare and chronic diseases, such as diabetes. A resilient health system that meets the mental health needs of the vulnerable must be well resourced and embody the equitable distribution of those resources. It must be able to communicate effectively with all groups within the population and to provide comprehensive training of healthcare professionals in order to do so.