Despite major medical advances in treatment, about half of people with diabetes still struggle to achieve effective blood glucose control, and this increases their risk of developing diabetes complications. The element frequently overlooked is the influence of the psychological state.
Diabetes distress
Diabetes distress is a term used to describe the sense of frustration, anger and disillusionment that can lead to neglecting the condition over time. Although very common, it is often not picked up by DSNs or GPs for a number of reasons. Firstly, there is not enough time in an appointment to ask a individual how they are feeling or if they are coping and, secondly, many DSNs have told me that they feel ill-equipped to cope with the response.
Coming to terms with the implications of life with diabetes takes a considerable adjustment. There is some psychological support for paediatric patients, but for adults there is very little. If low mood and depression are detected, some people are referred to the NHS Improving Access to Psychological Therapies programme, but as the therapists are not medically trained they cannot integrate the psychological care with the diabetes care.
A major opportunity to help people with diabetes maintain good glycaemic control is being lost. The problem often starts from the point when diabetes is diagnosed. Diabetes is a life-long condition, yet the person often has little support in coming to terms with it. It is unlike a cancer diagnosis, which is governed by well-established, psychologically informed procedures, in which the person involved is taken to a separate room, given a detailed explanation of what to expect and supplied with leaflets and access to support services.
Type 1 diabetes is a progressive disease and the person with type 1 diabetes has considerable responsibility in managing their own care. Symbolically, it can be equated to being given care of a baby that is never going to grow up.
It is common for people with diabetes to have anxieties that are specific to the condition. One person I saw recently had a needle phobia and was scared to inject herself. On further discussion, it was revealed that she had only one eye, so the issue was more that she did not have depth of vision and so was concerned about injecting too deeply and injuring herself.
The condition also involves adopting new roles. One woman explained that during the day she could manage well – checking her blood glucose before a meal and working out her doses – but that she forgot to do this in the evening. We talked and I found that she resented the time the condition took when she wanted to just be a wife to her husband, who was working long hours. Understanding this allowed her to make the necessary adjustment.
Cognitive behavioural therapy
A type of psychological therapy called cognitive behavioural therapy (CBT) is particularly beneficial for these types of anxieties. It is a collaborative process in which the therapist helps their patients to understand the reasons for their anxiety and supports them in adjusting their thinking. It is a very effective treatment that typically requires about 10–20 sessions.
I was, therefore, very interested to work with PsychologyOnline – a provider of CBT over the internet – on a new pilot project funded by Small Business Research Initiative for Healthcare (SBRI Healthcare), an NHS-related funding scheme, to see whether online therapy could benefit people with diabetes. Previous research at King’s College Hospital has shown that specially trained DSNs delivering face-to-face CBT can help people improve their blood glucose management (Ismail et al, 2010).
The issue for people with diabetes is that many have busy lives and that attending more appointments requires expense, several hours of travel and time off work or other duties. Often they are reluctant to go, as they do not want their employer to know. All of this is understandable.
For these reasons, online CBT – for which neither the therapist nor the person with diabetes needs to travel – has numerous benefits, particularly if it can be delivered by someone who has a good knowledge of the medical aspects of diabetes. The online sessions are one-to-one with specially trained DSNs using instant messaging within a secure online consulting room. All the person requires is a computer or mobile device with access to the internet, and they can take the sessions whenever is convenient to them. PsychologyOnline has found over 60% of appointments occur outside of office hours.
PsychologyOnline was used in a clinical trial of 300 people at Bristol University, with excellent results. An average of just six sessions of online therapy was needed for recovery. Follow-up client assessments at 4 and 8 months confirmed that the benefits were maintained. The results of the trial were published in The Lancet in 2009 (Kessler et al, 2009).
Diabetes Online Therapy
Kaylee Lovie is one of three DSNs at King’s College Hospital to be trained within the project called Diabetes Online Therapy (DOT). She explains:
“We have ongoing training sessions with the psychiatrists, as well as lots of practice online and learning sessions from an information guide.”
The patients are selected by consultant psychiatrists to make sure they will benefit from CBT and are not experiencing severe psychiatric problems. They need to be computer savvy, but age should not be a limitation. Many studies have found that older people respond well to CBT, and unpublished internal data from PsychologyOnline show that over sixties have good recovery rates. Kaylee says:
“Living with diabetes requires life-long skills in calculating insulin doses and carbohydrate portions, taking into account physical activity. It is therefore understandable that some patients may need psychological support from time to time to help them build their confidence towards looking after their health and developing a better relationship with their diabetes.Their negative thoughts and feelings can get in the way of managing this chronic condition. For example, if they start fearing that they always get readings showing their sugar levels are too high, they might stop testing them altogether. The online therapy helps them overcome those negative thoughts which prevent them managing their condition better.”
At the start of the course, the individuals choose goals that they want to work towards, such as the acceptance of diabetes or the self-monitoring of blood glucose, which they work to achieve by the end. All communication, consultation and appointments are carried out via the online system. PsychologyOnline is text-based, and for each session there is a transcript. Kaylee adds:
“Patients are able to complete homework that I set in between the sessions to build on the work done online, and they can also access the system at any time to remind them of their goals. They are also able to take another look at the consultations at a later date, which can be very helpful if they find themselves slipping back into some of the negative thoughts and behaviours.”
At the end of the pilot project, DOT will be assessed to find out whether it is an effective intervention for improving glycaemic control, and then its scope will be extended with a much larger group of patients.
Further information
PsychologyOnline (www.psychologyonline.co.uk) was founded by two chartered psychologists who worked for the NHS in England. Recognising the scarcity of available psychological support they developed PsychologyOnline to provide a top quality psychological therapy service that is easily accessible to all. It uses text-based therapy within a secure online environment. The Cambridge-based company operates to the code of conduct, ethical principles and guidelines of the British Psychological Society and adheres strictly to NHS standards of clinical and information governance.
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