There is an increasing need for psychologists to work in diabetes. Diabetes UK (2017, 2019a) report that at least three in five people with diabetes experience emotional and psychological problems and this can significantly affect their self-management. They recommend that emotional and psychological wellbeing be considered alongside the medical management of diabetes.

However, there are not nearly enough psychologists working with people with diabetes and far fewer working specifically with diabetic foot complications. You may think that that is unsurprising – why would a psychologist have a role in the foot clinic at all? The answer, however, is clear – some diabetic foot patients find themselves at risk of amputation, and others bear the burden of wearing a cast for a long period of time; each foot condition potentially impacting mobility, independence, quality of life, relationships and, all too often, earning potential. 

Some patients may become depressed or anxious because of their foot complications. Others may have underlying mental health issues which have interacted with high blood sugars over many years. Low motivation is a symptom of depression and can result in an individual not taking diabetes medication, not testing blood sugars, not exercising and/or missing hospital appointments. Overeating due to low mood can lead to a rise in blood sugars. Stress and anxiety can lead to blood sugar changes and being stressed for a long time can keep blood sugars high, putting someone at higher risk of diabetes complications.

The ‘Too Often Missing’ report (Diabetes UK 2019b) highlights a gap in the provision of emotional and psychological support as reported by people with diabetes and their healthcare providers. The Kings Fund (2016) shows that there needs to be greater integration between mental and physical healthcare. Asking about emotional and psychological wellbeing needs to be an integral part of diabetes care; helping a team incorporate a more holistic perspective.

Diabetic distress is a concept that refers to the emotional distress resulting from living with diabetes and includes the burden of relentless daily self-management (Polonsky 2005). So, there may be a complex interaction between a diabetes foot patient’s level of distress and their self-management. By the time they reach the foot clinic, some people with diabetes experience feelings of failure resulting from their struggles with good self-management. For some individuals, this can amplify earlier life losses or disappointments. Other people have tried their best to manage their blood sugars over a number of years but feel as though they are failing due to the onset of diabetes foot complications. Sometimes attending clinic appointments may be difficult, triggering feelings of regret, guilt, or self-criticism. Recognising such anguish through a compassionate healthcare lens helps a patient be more forgiving to themselves and build a kinder relationship with their diabetes.

What can I do as a diabetic healthcare professional?

To help a patient self-manage, a team should always ask their patient how they feel about their diabetes. Sometimes such conversations can feel difficult due to time pressures or fears of where such a conversation may lead. However, the routine administration of a brief screening tool such as the two item Diabetes Distress Screening instrument or DDS2 (Fisher et al 2008) can help a team put well-being on the diabetes agenda. It is quick to administer and can identify those patients who may be struggling to cope. Diabetes UK (2019b) have put together a handbook for diabetes healthcare professionals to help them address important issues about diabetes and emotional health.

What does a diabetes psychologist do?
If a patient scores high on the diabetes distress measure and is clearly struggling, a referral should be made to the team psychologist if they have one. The psychologist conducts an assessment, considering all aspects of a person’s life; medical, home, relationships, work, social support as well as motivation to make changes. The psychologist will try to understand what a person thinks about their diabetes, their self-management and how they feel they are coping generally. The aim of treatment will be to enhance diabetes self-management by reducing diabetes distress, depression, or anxiety and/or identify aspects of a person’s life which may be getting in the way of the best self-care.

The psychologist also provides psychological support, advice, consultation, and training to the team.

Conclusion

• A brief screening questionnaire such as the DDS2 can help a healthcare provider begin a conversation about how their patient feels about their diabetes. 
• If a patient discloses life-events affecting their diabetes self-management or reports feelings of depression or anxiety, the healthcare provider should refer them to the team psychologist if they have one, or signpost them to the most appropriate mental health service.
• Remind your patient that diabetic distress is an understandable response to coping with the demands of diabetes. Listening to your patient non-judgementally and understanding their diabetes within the context of their wider lives can only help you to help your patients to better self-manage.

References

Diabetes UK. (2017). Three in five people with diabetes experience emotional or mental health problems. London: Diabetes UK.

Diabetes UK. (2019a). diabetes and emotional health - a practical guide for healthcare professionals supporting adults with type 1 and type 2 diabetes. London: Diabetes UK.

Diabetes UK. (2019b). Too Often Missing: Making emotional and psychological support routine in diabetes care. London: Diabetes UK.

Fisher L, Glasgow R, Mullan J, Skaff M, Polonsky W (2008) Development of a Brief Diabetes Distress Screening Instrument. Annals of Family Medicine, 6 (3): 246-252

Polonsky, W. H. (2005). Assessing psychosocial distress in diabetes: development of the diabetes distress scale. Diabetes Care, 28(3), 626-631. doi:https://10.2337/diacare.28.3.62

The Kings Fund. (2016). Bringing Together Physical and Mental Health: a new frontier for integrated care. London: Kings Fund. Retrieved from https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Bringing-together-Kings-Fund-March-2016_1.pdf