Joint liaison psychiatry-diabetes clinic: a new specialist service

A pilot study of an integrated mental health, social and medical model for diabetes care in an inner-city setting: Three Dimensions for Diabetes (3DFD)

AIMS

We examined the effectiveness of a service innovation, Three Dimensions for Diabetes (3DFD), that consisted of a referral to an integrated mental health, social care and diabetes treatment model, compared with usual care in improving biomedical and health economic outcomes.

METHODS

Using a non-randomized control design, the 3DFD model was offered in two inner-city boroughs in London, UK, where diabetes health professionals could refer adult residents with diabetes, suboptimal glycaemic control [HbA_1c ≥ 75 mmol/mol (≥ 9.0%)] and mental health and/or social problems. In the usual care group, there was no referral pathway and anonymized data on individuals with HbA_1c ≥ 75 mmol/mol (≥ 9.0%) were collected from primary care records. Change in HbA_1c from baseline to 12 months was the primary outcome, and change in healthcare costs and biomedical variables were secondary outcomes.

RESULTS

3DFD participants had worse glycaemic control and higher healthcare costs than control participants at baseline. 3DFD participants had greater improvement in glycaemic control compared with control participants [-14 mmol/mol (-1.3%) vs. -6 mmol/mol (-0.6%) respectively, P < 0.001], adjusted for confounding. Total follow-up healthcare costs remained higher in the 3DFD group compared with the control group (mean difference £1715, 95% confidence intervals 591 to 2811), adjusted for confounding. The incremental cost-effectiveness ratio was £398 per mmol/mol unit decrease in HbA_1c , indicating the 3DFD intervention was more effective and costed more than usual care.

CONCLUSIONS

A biomedical, psychological and social criteria-based referral system for identifying and managing high-cost and high-risk individuals with poor glycaemic control can lead to improved health in all three dimensions.

Unnatural deaths in a national cohort of people diagnosed with diabetes

OBJECTIVE

To examine risk of unnatural death among people diagnosed with diabetes irrespective of disease type.

RESEARCH DESIGN AND METHODS

We conducted a matched cohort study of the entire Swedish population using interlinked national registers. From the National Diabetes Register we identified 252,191 people diagnosed with diabetes (type 1 or 2) during 1996-2009. Each cohort member was matched for age, sex, and county of birth to five unaffected individuals randomly sampled from the Total Population Register. Mortality was examined with complete ascertainment, and risk ratios (RRs) for all unnatural deaths and for specific causes (suicide, accident, homicide, and iatrogenic effects) were estimated using conditional fixed-effects Poisson regression.

RESULTS

Risk of any unnatural death was elevated versus the general population: 77.3 versus 32.1 per 10,000 (RR 2.2 [95% CI 2.1-2.4]), and these deaths occurred at a younger age in the diabetes cohort. Risk was increased for suicide (RR 3.4 [95% CI 3.0-3.8]), accident (RR 2.0 [95% CI 1.9-2.1]), homicide (RR 3.1 [95% CI 1.6-6.1]), and iatrogenic effects (RR 2.4 [95% CI 1.9-3.2]). It was greatly elevated for fatal poisoning from a variety of agents, including psychotropic drugs and "other and unspecified medication," as well as narcotics, alcohol, and carbon monoxide. Almost 9% of all fatal poisoning cases in the diabetes cohort were identified as overdoses of insulin or oral hypoglycemic drugs.

CONCLUSIONS

Various causes of unnatural death, in particular deliberate and accidental poisonings, occur more frequently among diabetic patients. Before preventive strategies can be implemented, a deeper understanding of the risk factors and causal mechanisms explaining the marked elevations in risk is needed.

Cases for change in mental health: partnership working in mental health services

This article examines our current state of knowledge about partnership working between health and social care in UK adult mental health services. Drawing on a narrative review of the literature commissioned by the National Institute for Mental Health, this paper focuses on 43 documents from the review which discuss partnership issues. After exploring the rationale for partnership working, potential barriers and possible ways forward, the paper identifies gaps in the existing literature and discusses the implications of the review for current health and social care policy.

Reducing risks in diabetes self-management: a systematic review of the literature

OBJECTIVE

The purpose of this systematic review was to review published literature on risk-reducing interventions as part of diabetes self-management.

DATA SOURCES

Medline (1990-2007), CINAHL (1990-2007), and Cochrane Central Register of Controlled Trials (first quarter 2007) databases were searched. Reference lists from included studies were reviewed to identify additional studies.

STUDY SELECTION

Intervention studies that addressed reducing risks to help prevent or minimize diabetes complications were included.

DATA EXTRACTION

Study design, sample characteristics, interventions, and outcomes were extracted.

DATA SYNTHESIS

Thirty-three studies, represented by 39 articles, met the criteria for inclusion and were classified as smoking cessation (n = 3), eye examination (n = 2), foot care (n = 10), oral health (n = 2), vaccination (n = 1), cardiovascular risk reduction (n = 9), and comprehensive risk reduction (n = 6). Only 46.3% of the 283 outcomes measured in the 33 studies were significantly improved.

CONCLUSIONS

Reducing risks involves implementing effective risk reduction behaviors to prevent or slow the progression of diabetes complications. Recognizing risk factors for complications and what constitutes optimal preventive care is an important part of managing diabetes. Intervention studies are lacking in some areas of reducing risks. Further studies are needed to test specific interventions to reduce the risks of diabetes complications.

Persistent poor glycaemic control in adult Type 1 diabetes. A closer look at the problem

Around 25% of the adult Type 1 diabetes population is in persistent poor glycaemic control and thus at increased risk of developing microvascular complications. We here discuss correlates of long-standing poor glycaemic control and review the efficacy of clinical strategies designed to overcome persistent poor control. Only a few studies have identified determinants and correlates of long-standing poor glycaemic control in Type 1 diabetes. There is some evidence implicating genetic factors, as well as lower economic status, and psychological factors, including lack of motivation, emotional distress, depression and eating disorders. Ways of improving glycaemic control include strategies to enable self-management, e.g. motivational strategies, coping-orientated education, psychosocial therapies, and/or intensifying insulin injection therapy plus continuous subcutaneous insulin infusion. Long-standing poor glycaemic control appears to be a heterogeneous and complex phenomenon, for which there is no simple, single solution. Comprehensive psycho-medical assessment in diabetes care may prove useful in tailoring interventions. Further research is warranted, to increase our understanding how psychosocial and biomedical factors, separately and in interaction, determine poor outcomes in Type 1 diabetes.

Cognitive-behavioural interventions in a patient with an anxiety disorder related to diabetes

This study extends the data on the efficacy of cognitive interventions for patients with chronic medical problems and describes the case of a 37-year-old woman with an anxiety disorder related to diabetes. The effects on panic frequency, use of safety behaviour and related beliefs were investigated after the introduction of two main cognitive-behavioral interventions. The results are consistent with predictions from the cognitive model of panic. This case demonstrates the usefulness of directly challenging the 'meaning' of the feared situation in order to produce clinically significant improvements in the management of physical disease.