Healthcare professionals' experiences in identifying and supporting mental health problems in adults living with type 1 diabetes mellitus: A qualitative study

HCPs discussed that appointments were primarily focused on physical health checks leaving limited to no time for discussions around mental health. It was also recognised that discussions around mental health were often time consuming. As a result, many HCPs chose not to raise the topic with patients, for fear of running behind in their clinics.

It won't be a 5-min conversation … I get quite a lot of time with my patients, and I still struggle to get through all the things that I want to go through with them … bring mental health into that, that could potentially take longer … There is a fear that if your clinic's running late and you say ‘hey and how are you doing?’ And then they burst into tears. It's like it [the clinic] will be running really late now (Diabetes Specialist Consultant, P11).

Sometimes there's this pressure to … cover everything regarding diabetes … the physical side of managing like the injection sites, checking blood glucose levels … if you're then talking about how someone's mood has been, sometimes there's that fear that my goodness I'm not going to cover everything that I needed to do in the diabetes clinic (Specialist nurse, P4).

HCPs expressed frustration with the long waitlists for people who needed more immediate support.

The sad thing is you refer people to get help they then say ‘well there aren't any appointments for six months’. When people have mental health issues, they need that help now not in six months' time (Specialist nurse, P5).

There is often big waiting lists for counselling unless you're going to pay for it privately … It's a challenge and you do feel a bit down and despondent in some ways in that you know you can't just book them an appointment the next week (Specialist nurse, P7).

Inadequate knowledge resulting from a lack of training and education was raised by all HCPs as a barrier to identification and subsequent support offerings related to mental health and type 1 diabetes.

I don't feel like I'm really equipped to have those conversations because I've never had that training (Specialist nurse, P3).

Nurses in particular expressed that despite not having any formal training they often learnt from experience.

We didn't have any training … it's generally what I've experienced in previous roles … I've learned a lot of the things along the way by speaking to people who are living with these conditions (Specialist Nurse, P4).

For some HCPs the absence of knowledge and training in mental health and type 1 diabetes resulted in a lack of confidence and feeling ill equip to initiate and manage conversations around an individual's mental health.

Sort of feeling awkward talking about it … worry about quite what to do with it if you unearth an issue. You have to assess that risk and what to do about that: Are they high risk? What sort of assessment should you be doing? Are you worried about suicide and things like that? Are they OK to go home? (Diabetes Specialist Consultant, P11)

It is difficult because I'm not massively confident when it comes to mental health. I've never had any training. (Community diabetes specialist nurse, P3)

A lack of communication between services was raised by all HCPs. Frustration was expressed in terms of the divide between different HCPs and referral systems.

There isn't really a proper system that you feel that ‘OK. I have put this patient on that track and I'm happy that his mental health is going to be dealt with.’ (Acute medicine consultant, P8)

‘I don't want to talk to anyone else’. I've heard that a few times: ‘I don't want to keep going over my story. I don't want to keep saying this to different people. It's not getting me anywhere’. I have heard that before and I guess that's when joining them [services] would be really useful. Like having a link nurse between the physical or mental health teams (Specialist nurse, P4).

All HCPs raised that there were often unclear care pathways and that often do not know what services are available.

If people are coming to us and saying, ‘do you know what, I'm going to be open and honest …’ And then we kind of go ‘oh, that's great, but we don't really know where we can send you’ … it's not giving the patients best care (Specialist Nurse, P3).

It was also highlighted that for patients it is unclear what services are available and how to access them. GPs were often thought to be the best point of contact in relation to mental health concerns however, many patients expressed to HCPs not wanting to ‘burden’ GPs with mental health concerns.

I think they don't know where to access help and have to jump through so many hoops to get that help … I think that's probably the biggest barrier that they just don't know where to go and then how to access it (Specialist nurse, P3).

People are finding it really difficult just to communicate with their primary care. They feel they can't get through to their GP … I think that might be another barrier in that it's not so easy to access your GP…just getting through on the telephone is difficult (Specialist nurse, P7).

Several HCPs expressed frustration with the lack of specialised care for people with type 1 diabetes and mental health concerns.

Mental health teams … seem to get a bit nervous if someone has a chronic medical problem, so they will often refer back to us. Because the mental health part may be understood but they get slightly panicked by a chronic medical problem … so I think it makes it more complicated trying to access the services (GP, P12).

HCPs expressed stigma experienced from a patient perspective may be an additional barrier to the identification and management of mental health concerns. It was discussed that although HCPs felt there has been a reduction in stigma around helpseeking for mental health concerns it was still a very pervasive barrier.

Mental health still has a stigma attached to it and no matter how much people try to remove that stuff it's still there. So, they're living with one chronic condition already and if you try to potentially diagnose them with another diagnosis I think there can be reluctance (GP, P12).

Several nurses raised how physical and mental health were treated as distinct realms by many HCPs. It was also raised that from a patient perspective, HCPs often recognised that individuals might not feel they can discuss their mental health during diabetes appointments which may be perceived as purely physical health focused.

May be the barriers they perceive are that doctors in diabetes or diabetes specialists only really care about their blood sugars and the numbers. I don't know whether it's from past experience but they think that all we want to hear about is their good numbers and good readings and think we'll tell them off. So I think they come into clinic and expect to have a conversation about their blood sugars, not about their mental health. (Diabetes Registrar, P9).

All HCPs discussed the importance of education and its role in facilitating identification and care for people living with co-morbid mental health problems at type 1 diabetes.

There is a real need for training the whole workforce, because otherwise all that's going to happen is you're going to put layer upon layer upon layer of different sorts of healthcare professionals and the poor person with diabetes getting pushed (Specialist nurse, P2).

We have lots and lots of education and training around the medications that we use… and how to conduct consultations and how to get the best effective time out of what you're doing. But I feel like maybe we need to delve into how and when those questions are asked, how do you direct the patients? (Community diabetes specialist nurse, P3).

The importance of acknowledging the burdensome nature of diabetes management was discussed as a key facilitator. By acknowledging potential diabetes-related stress and other mental health problems associated with diabetes, this may allow patients to feel more supported in discussing concerns with their HCPs, in turn assisting HCPs to then guide support.

Just being open as a clinician to talking about it is probably the first and most important step, because given the opportunity, I think people are quite eager to talk about that element of their care. So if you obviously don't provide it, it will never come up … So if it's at least flagged routinely as part of diagnosis, this support is available…I think just encouraging people that it's normal and it's appropriate to seek support as much as we can. (GP trainee, P15)

Acknowledging that the diagnosis has a significant psychological impact … psychological well-being can improve control. So preparing people for it when they had the diagnosis, saying actually we need to be providing you with holistic care to manage a chronic condition (GP, P13).

The importance of facilitating a trusting and safe relationship between HCP and patient was highlighted as imperative. HCPs of various roles shared different ways in strengthening relationships and building.

If we've known the patient for a long time and the patient feel more comfortable with the staff who seeing them or their health care professionals seeing them, they might feel a little bit more comfortable bringing it up. (Acute Medicine Consultant, P8)

Relationships are so important because if you haven't built that trusting relationship, and you don't really know the person that you're seeing…it takes a lot of time to be able to build that trust, and for someone to recognise as well when things aren't going so great for you. (Specialist nurse, P4)

Screening tools were discussed as a means of assisting in structuring the limited time of consultations and appointments and direct discussions around mental health specific to each person.

…a possible intervention would be a pre clinic questionnaire that would flag up mental health issues so you aware to discuss them when you saw them in clinic. (Diabetes registrar, P9)

It was suggested that mental health screening be incorporated into annual patient appointments and alongside already utilised diabetes health checklists.

In the GP setting there are prompts so obviously your annual review of diabetes in routine checks… if one of those is always to check-in for mental health concerns and coping and then just to make it as readily accessible as possible … I think if you're having your annual review, that is a really valuable opportunity to touch base… to talk someone every year or every six months. (GP trainee, P15)

When discussing long waitlist to accessing mental health services, and limited-service availability, there was agreement that enhancing ease of access to patients would facilitate engagement with mental health services.

I think getting the mental health care when they need it, in a timely way. I think if you're feeling depressed, you need help now, you don't need help in three months' time… like you would if you break your leg you get it straight away, wouldn't you? (Specialist nurse, P7)

Many HCPs discussed the importance of considering mental health and diabetes care together.

We should never just refer someone with type 1 diabetes to psychologist or mental health team that doesn't have experience in type 1 diabetes. So, I think there is something around a team of people that have psychological or mental health skills that understand how type one diabetes symptoms and management overlap, how they merge, how they you know if you already got a self-harming type of character, personality trait whatever that might be… I think that that other barrier is shared knowledge (Specialist nurse, P2).