Doctor2Doctor: Talking to diabetes patients about mental well-being

Although these can often be treated and even prevented, success depends on early intervention. But this is easier said than done. 

Roche spoke with UK-based professor of health psychology, Katharine Barnard-Kelly PhD, whose research focuses on the psychosocial barriers and enablers of optimal diabetes self-management. Prof Barnard-Kelly believes there’s an underlying systemic issue that needs to be addressed and she shared not only why, but also how healthcare teams can include regular mental health check-ins with their diabetes patients – even when it’s hard.

Roche: When we began raising awareness about diabetes and mental well-being, we heard from many people with diabetes from different countries that they wished it were a more integral part of their regular doctor visits. In your opinion, how is mental well-being generally approached in consultations? 

Katharine: It’s currently not addressed effectively in routine visits for people with diabetes in most places. The medical world continues to exist in a medical model of healthcare where physical outcomes, such as HbA1c1, continue to dominate, which is a mistake because the reality is that any long-term condition, especially diabetes, requires a mental, physical and social well-being approach.

Roche: How important is it to prioritise mental health check-ins during regular diabetes check-ups?

Katharine: It’s absolutely crucial. We surveyed nearly 500 people with diabetes about their perceptions on mental health in routine care last year, and the overwhelming majority stated how much they wanted their healthcare provider to ask them about their mental well-being: ‘Just ask me.’ It’s essential to show this empathy because the challenges associated with living with diabetes go way beyond the maths and the mechanisms of glycaemic control. 

Roche: Which factors may be hindering healthcare professionals from bringing up the subject of mental well-being with their diabetes patients?

Katharine: Healthcare professionals are often criticised for not touching on mental health in routine visits, but much of that criticism is unfair because they’re trained in a medical model of healthcare that hasn’t prepared them for the psychological side of living with a chronic condition. We conducted research on this and spoke to many people working in diabetes healthcare. The most common response was: ‘What will I do with that answer? If I ask, how can I support this person when I have no expertise and no resources to share?’ However, having said that, there is no need to be a psychologist to have compassion for the challenges of the daily burden of living with diabetes. I would say 80–90% of people with diabetes don’t need psychological resources, they just want to be heard and for someone to acknowledge that they're trying their best.

Roche: What should a healthcare professional (HCP) do if a patient tells them they need psychological help?

Katharine: Listening is a great place to start, and the good news is that answers and solutions don’t need to be available right away. An HCP just needs to show understanding and let their patients know that their problem is being looked into. And they can easily harness the power of their wider multidisciplinary teams by asking colleagues if they've ever come across a specific problem and what they'd recommend as a suitable next step. All they need to do is signpost safe, evidenced-based resources that can help people with diabetes, and, if somebody is struggling, a telephone call between visits to check in on them could help. It’s the little things that make a massive difference. 

Roche: What could better equip healthcare professionals to be more proactive about introducing the subject of mental well-being into discussions with their patients?

Katharine: There are evidence-based and theory-driven tools available that can transform the medical model into a physical, mental and social well-being model for every patient, in every visit. Often we hone in so deeply on glycaemic control that all the other psychosocial stuff just gets left behind. But if tools are used that help with pre-clinic planning by getting the patient to answer a set of holistic questions, this can be very insightful for the patient and connect certain dots for them. For the healthcare professional, it sets the baseline for a streamlined, solution-oriented visit where the needs of patients are understood without them having to struggle to articulate them. Resources and care pathways can be offered to those patients, and then healthcare professionals can feel like they’re delivering excellent healthcare, because they are. 

Roche: Can you give an example of how that would work?

Katharine: Often sexual health comes up for women in the pre-clinic questionnaire because 80% of women with diabetes will experience vaginal dryness at some point. If you don’t want to have sex because it’s painful, your relationship suffers, and that then brings with it a sense of low self-worth, loss of attractiveness. There’s actually a really easy fix to that, but a young woman isn’t terribly likely to tell her 60-year-old male endocrinologist: ‘I don’t wanna have sex.’ But how’s she going to know this on her own? It’s a problem directly related to diabetes but it’s never talked about. If someone’s relationship is crumbling, quite frankly, then their attention to self-management and glycaemic control is not going to be 100%. With a tool or platform, though, it’s all there in one place, and the doctor can then bring it up and explain the root of the problem and suggest how to solve it.

Roche: What changes in the healthcare system would make it easier for mental well-being to be addressed in routine visits?

Katharine: I’m a psychologist; you wouldn’t expect me to take someone’s appendix out, so why would you expect a medic to deliver psychological support? It’s wholly unfair; they don’t have the expertise, training or support. This is why it’s up to healthcare systems to take responsibility for supporting healthcare professionals in delivering more holistic care, and that includes appropriate training and feedback mechanisms so they are comfortable and confident to do so. But this requires starting right at the top. For example, we could embed psychosocial training much more deeply into medical school and then students would learn as they come through that physical and mental health need to be treated equally. Because if they’re not, then one will surely suffer as a consequence of the other.

Even though it can be really challenging for a healthcare professional to bring up the topic of mental well-being in a diabetes consultation, it’s worth the effort. It’s often the small things that can make people with diabetes feel so much better, and identifying these tiny tweaks and easy fixes that could address their unmet needs starts with just a few simple questions. 

Improving prevention practices and increasing access to mental health resources isn’t going to happen overnight. We’ll only be able to drive meaningful change for people with diabetes by working together across the industry, healthcare systems and regulatory bodies. According to Katharine Barnard-Kelly, however, one of the steps that healthcare teams can take right now is to equip themselves with the tools and strategies they need to put mental well-being on the table — at every check-up.

References

1. HbA1c refers to ‘glycated haemoglobin,’ a parameter to diagnose and monitor diabetes by identifying average plasma glucose values over a period of weeks/months.