A vast amount of information needs to be uncovered in a diabetes consultation. In the short period of time available, we need to provide individual consultations and deliver care plans that support self-management and take the whole person and their needs into account.
When someone has both diabetes and a mental health condition, the treatment targets and discussions may be different and need to be considered on an individual basis (Hutter et al, 2010). It is important to recognise the concept of “right person, right drug, right dose and right time” when providing medication. It can be useful to apply the same concept when completing the diabetes review in someone who also has a mental health condition. This article will discuss some of the issues and anxieties that need consideration in such people.
Right person
It is hard to believe when sat in the clinic that the person in front of you has seen no improvement in glycaemic control, even though you have provided all the information that should deliver good results, several times. Often mental health is blamed for poor adherence to treatment regimens and lifestyle advice, but this may be too simplistic. In people with mental health problems, many complex facets need to be considered before the diabetes is addressed. Recognition of their social situation, cognitive ability and family support is important in addition to the mental health condition. These factors can have an impact on motivation and may influence a person’s appreciation of the situation, for instance, when other elements of their health and lifestyle need addressing.
Using the most appropriate language to discuss concerns
If you do not choose appropriate language, there is a chance the person will nod, “agree” and respond with the words they think you want to hear. Some of the medications taken by a person with a mental health problem may also have a major impact on their cognitive ability, specifically, their ability to understand new information. To help with communication, some nurses find that using similar words or phrases can help get their message across. Consider how often we use different words to mean the same thing, for example, glucose, sugar, carbohydrate or energy. Using different words can quickly lead to confusion so it helpful to stick to some key phrases. Furthermore, not everyone understands medical words such as titration, HbA1c, urine or lipids, so it important to check understanding and explain certain terms frequently throughout the consultations.
If negative emotions are driving their concerns surrounding a diagnosis of diabetes (Suls and Bundle, 2005), it may be difficult to fully support the person’s needs, even with the latest educational packages. An understanding of the coexisting mental health condition is needed when considering the management options.
Anxiety and depression often occur together and can markedly affect motivation to manage physical health problems. If someone is feeling anxious, their mind may be full of busy, repetitive thoughts, which make it hard to concentrate, relax, or sleep. They can have physical symptoms, such as headaches, aching muscles, sweating and dizziness, which can cause physical exhaustion and general ill health disturbances (Darton, 2012). Anxiety and depression in diabetes is particularly problematic due to the complex nature of diabetes management and the number of things to consider on a day-to-day basis.
Paranoid schizophrenia brings its own problems, especially when someone is acutely unwell. The motivation to make and maintain healthy lifestyle choices, willingness to engage with healthcare professionals, high smoking risk and possible use of second-generation antipsychotic medication associated with the condition, can all interfere with the management of the individual’s health (Connolly and Kelly, 2005). Adding more diabetes medication can further increase the burden on the individual without them truly understanding the importance or relevance of the treatment and lifestyle choices.
A condition like bipolar disorder will require different diabetes management in the manic and depressed phases of the condition. Someone in the manic cycle, for example, could use vast amounts of energy and experience disturbed sleep during periods of higher than normal activity (Timms, 2012). There needs to be a consideration of the risk of diabetes treatments (especially hypoglycaemia) for a person in the manic phase, as opposed to the depressive phase, which can involve extended periods of inactivity, lethargy or reduced motivation for a healthy lifestyle, and potentially hyperglycaemia.
Collaboration with healthcare professionals working in psychiatry is essential to provide the integrated care that these people need. When acutely mentally unwell, the diabetes medication and healthy lifestyle choices can often be the first things to disappear. These changes can have detrimental effects on the risk of long-term complications and confusion, or over-treatment when the medications are reintroduced (Weinger and Beverly, 2010).
Right drug
Diabetes is a complex condition; however, healthcare professionals can often forget how complex the medications can be, especially with the increasing number of agents available (Hill, 2013).
It is important to consider all medications, while recognising that, in particular, injecting medication can be an anxiety-provoking process. As it may be vital for some people that they are treated with injectable therapies, they may need additional support or reassurance to ensure they are treated correctly. Mental healthcare professionals are skilled at this type of supportive management, and whilst it is not advisable to go to the community psychiatric nurse with an insulin start request, they may be able to provide some advice on how best to manage the situation. Mental health professionals are often in a better position to support the individual with anxiety management and reassurance of outcomes, and to support the diabetes nurse with information regarding the social situation and what additional resources would be needed to support adherence.
Consideration also needs to be given to the impact on the diabetes when the person’s mental health acutely worsens and the prompt changes that may be needed. For example, it would be appropriate to have a plan of action, including details of the appropriate healthcare professional to involve and the best method to manage the episode.
Providing holistic care is essential; however without truly understanding the day-to-day issues someone faces it can be difficult to identify the most appropriate treatment. During all consultations, and especially those with someone who has mental health problems, it is important to understand how their overall health and diabetes fit into their lifestyle. As diabetes healthcare professionals, we may forget that diabetes may not be the most important aspect of an individual’s life. Diabetes practitioners should use tailored methods to ensure that treatment fits in with an individual’s life. It may be helpful to gain insight from carers about the individual in order to develop achievable goals and outcomes.
Bear in mind that individuals with mental health issues, as with other people, will worry about the risk of side-effects, and this concern may have a negative impact on their willingness to adhere to treatment. Increasingly, the use of sulphonylureas is dismissed (especially in relation to people with a mental health condition) due to the high, associated risk of side-effects (Campbell, 2009). It would be inappropriate to recommend a drug that is associated with a high risk of weight gain and hypoglycaemia when lifestyles of people with mental health issues can be chaotic, erratic or unpredictable.
When considering medication options, the simplified Diabetes Update guidelines (Diabetes UK, 2011; 2012) are available and provide a concise overview of information. These can help you:
- Revisit available medication options.
- Consider different treatment options, especially when given with mental health medication.
- Truly understand the side-effect profile and consider the additional risks and monitoring requirements that are achievable.
- Recognise and utilise combination treatments to reduce daily dose amounts to support the person’s lifestyle and help engagement.
Before ending the consultation it is vital to review the information regarding all the medication choices with the individual and decide with them if the treatment choice will be suitable for their lifestyle.
Right dose
With the General Medical Services 2 contract, Quality Outcomes Framework points and NICE guidelines suggesting that the recognised HbA1c target for diabetes is 48–58 mmol/mol (6.5–7.5%; NICE, 2009; NHS England et al, 2011), it can be tempting to push people with diabetes too far. For someone who has a mental disorder as well as diabetes, it can be extra difficult to maintain tight targets, and suboptimal readings can lead to them feeling that they are continually failing (Broom and Whittaker 2004). While some people with a long-term mental health problem may never be suited to perfect control, this should not be seen as negative. There are times when suboptimal doses are wholly appropriate to maintain safety.
Good management should involve understanding what is realistic, reachable and what has already been achieved. Achieving an HbA1c of 68 mmol/mol (8.4%) from 108 mmol/mol (12%) is better than withdrawal of consent with a refusal for further cooperation, or multiple hypoglycaemic events, that impact on the individual’s well-being and adherence to treatment.
Right time
This section discusses the right time to explain about the issues of diabetes, including the right time to start a medication and the right time to give the prescribed medication. Providing a consultation at the wrong time of day, or in the wrong situation, for someone with a mental health problem can lead to poor retention of information or forgetfulness (Lieberman et al, 2005). During the first few weeks after diagnosis of any condition, the ability to truly take in new information about the condition is difficult (Davies et al, 2008). A type 2 diabetes diagnosis may be accompanied by guilt, judgement from peers and family, and a sense of blame (Dunn et al, 1986).
The choice of when to commence medication should be considered. Different people can be fully functional and most alert at different times of day and this will have an impact on the effectiveness of the treatment. Often, without thinking, we commence medication in the morning but this may be inappropriate; for example, someone with mental health problem may take a mental health medication that can make them groggy in the morning. I frequently see people who find it really difficult to take medication or food in the morning; therefore medication may be forgotten first thing and the person may feel anxious about whether to take it later or omit the dose if breakfast is delayed. A mental health condition may also have an impact on the person’s body clock. Do we have to schedule medication first thing in the morning, or can we change this to 10.30 am or 11.30 am? Often this small change, or giving “permission” to have the medication to suit individual lifestyles, can improve
self-management. The use of a dosette box can also help ensure people take the right treatments, the right amount and can check that the dosage has been taken.
Right goal
The complexity of having a mental health condition is multifaceted; often the diabetes goals that are recommended appear confusing to the individual or too difficult to follow, and so are ignored.
Goals really need to be focused with the individual in mind, and not the condition, to ensure an appropriate management plan is reached (Box 1). We should be bold enough to recognise that, when targets set for someone with diabetes and a mental health problem are not achieved, the targets may be wrong rather than the individual being “non-concordant” with the treatment plan. Managing someone’s diabetes when they have a mental health problem takes time, understanding and support from multiple organisations and agencies. Although the task can seem overwhelming to the diabetes practitioner, if managed well it can have the most positive effect on that person’s life and wellbeing.
Mental health should not be seen as a barrier to good management but as an additional feature, which, if conquered, can provide the most rewarding outcome for both the professional and the person with diabetes.
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