1. Dr. Paul Chadwick Clinical and Health Psychologist Royal Free Hampstead NHS Trust, & Camden and Islington MHSCT & Centre for Behaviour Change University College London.

2. Understand the range of emotional issues faced by people with Diabetes. Be aware of the impact of those needs on their physical health. Understand the challenges of talking about emotional issues with people with diabetes. Have a range of strategies to be able to approach the issue. Understand the range of psychological services available to support individuals with diabetes, and know how to access them.

3. There is no cure for it. It is unpredictable – what you need to do to manage it successfully can change from day to day. There is no escape from it – the consequences of not managing it are really serious and irreversible. It is progressive. It can affect your mood – making everything that much harder to do. In order to manage it you have to pay attention to several things all at the same time. It has its onset in childhood or adolescence – when you are just trying to figure out who you are. It can negatively affect your sex life. It is really complicated to manage properly, but this is rarely appreciated by other people.

4. Level 1 Coping & Adjustment Difficulties Level 2 Moderate coping difficulties resulting in affect disturbance and impaired self-care Level 3 Mild to moderate psychological difficulties: anxiety, depression, eating disturbance. Level 4 Moderate/Severe psychological difficulties specialist interventions required. Level 5 Severe & enduring Mental Health Problems 60% 40% 20- 30% 10- 15% Overall need: 4336 pts Overall need: 2890 pts T1 females ED: (14%) - 505 pts T2 females ED: (21%) 759pts Overall need: 1445 – 2168 pts Depression: 433 (6%) – 1011 pts (14%) Anxiety: 1011 (14%) pts T1 females ED BN: 361 (10%) – 1011 (28%) pts Overall need: 723 – 1084 pts * Assuming 7227 people with diabetes in Camden at 4.7% prevelence (YHPO)

5. Depression is more likely, lasts longer, comes back more often and is generally missed in 2/3 cases. For both T1 and T2DM, the presence of depression is associated with increased: Mortality Cardiac events Hospitalisation Complications (retinopathy, neuropathy, nephropathy – in fact, all the opathies!) Functional impairment Healthcare costs Medical symptom burden

6. Distress associated with the condition and its management is common – Diabetes Related Distress (DRD). DRD is possibly more closely associated with disease progression than depression. May mediate the relationship between depression and glycaemic outcomes in treatment trials. Fisher et al (2007/2008) van Bastalaar et al (2010), Levya et al (2011).

7. 1. Not having clear and concrete goals for your diabetes care? 2. Feeling discouraged with your diabetes treatment plan? 3. Feeling scared when you think about living with diabetes? 4. Uncomfortable social situations related to your diabetes care (e.g., people telling you what to eat)? 5. Feelings of deprivation regarding food and meals? 6. Feeling depressed when you think about living with diabetes? 7. Not knowing if your mood or feelings are related to your diabetes? 8. Feeling overwhelmed by your diabetes? 9. Worrying about low blood sugar reactions? 10. Feeling angry when you think about living with diabetes? 11. Feeling constantly concerned about food and eating? 12. Worrying about the future and the possibility of serious complications? 13. Feelings of guilt or anxiety when you get off track with you diabetes management? 14. Not "accepting" your diabetes? 15. Feeling unsatisfied with your diabetes physician? 16. Feeling that diabetes is taking up too much of your mental and physical energy every day? 17. Feeling alone with your diabetes? 18. Feeling that your friends and family are not supportive of your diabetes management efforts? 19. Coping with complications of diabetes? 20. Feeling "burned out" by the constant effort needed to manage diabetes?

8. High prevalence levels, similar to depression. Proportionally less attention paid to anxiety, although can be equally as devastating for disease progression. Disease-specific forms of anxiety exist: Fear of hypoglycaemia Psychological insulin resistance

9. Fear of starting to take insulin. 17 – 40% of individuals with T2DM may try to avoid taking insulin. Consequence is persistent hyperglycaemia, increased risk of progression to complications, and higher levels of diabetes-related distress. PIR is associated with: Depression Negative beliefs about insulin Injection anxiety Beliefs about disease progression and personal failure.

10. In the LAST MONTH… Diabetes-related distress Have you felt overwhelmed by the demands of living with diabetes? Have felt that you that you are failing to manage your diabetes effectively? Depression Have you often been bothered by feeling down, depressed, or hopeless?” Have you often been bothered by having little interest or pleasure in doing things? Anxiety Have you felt more anxious or nervous than usual? Have you had a spell or attack where all of a sudden you felt frightened, anxious, or uneasy? Have you been bothered by nerves or feeling anxious or on edge? And then…. I am sorry to hear that, tell me about it….

11. ??% patients report being asked about their well-being in the last year. ??% health professionals report that they regularly ask about how diabetes affects peoples lives. Holt et al., (2013), Kovacs et al., (2013)

12. ??% patients report being asked about their well-being in the last year. 52% health professionals report that they regularly ask about how diabetes affects peoples lives. Holt et al., (2013), Kovacs et al., (2013)

13. 24% patients report being asked about their well-being in the last year. 52% health professionals report that they regularly ask about how diabetes affects peoples lives. Holt et al., (2013), Kovacs et al., (2013)

14. Fear of stigmatising and alienating patients Opening “Pandora’s Box” Don’t feel equipped to handle the conversation Well-being is at the end of the checklist Tools are too blunt an instrument Dislike of mechanistic processes Normalising distress Barriers to talking about well-being Maxwell et al., 2013; Coventry et al., (2011)

15. We realise that a referral to psychological services may not be straightforward. If you are referring to the Hub tell us if you think a psychological opinion would be helpful. If you are referring to your practice-based service, discuss the case with the practitioner. If you can’t talk ‘anxiety or depression’ talk about ‘stress’ and strategies to manage it.

16. In primary care, IAPT Services have been trained to help deal with anxiety and depression in the context of diabetes. Diabetes IAPT Services are located: In primary care practices At the Diabetes Immediate Care Hub at Mary Rankin, SPH. IAPT services can act as a conduit to other services that can address psychological issues. RFH has a limited specialist Clinical Health Psychology Service for Diabetes.