Anne doherty and carol gayle - diabetes and mental health

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Better outcomes, better value: integrating physical and mental health into clinical practice and commissioning


Tuesday 24 June 2014: 15Hatfields, Chadwick Court, London

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Anne doherty and carol gayle - diabetes and mental health

  1. 1. Are our models of care truly integrated? - psychological, social and diabetes care www.kcl.ac.uk 1 Dr Carol Gayle Dr Anne Doherty
  2. 2. BMJ Awards 3DFD: Diabetes Team of the Year 2014
  3. 3. 3DFD Translation of research Cross sector integration Health inequalities Cost effective Dissemination Parsonage M, Fossey M, Tutty C. Liaison Psychiatry in the Modern NHS. Centre for mental Health, London. 2012, p35.
  4. 4. Depression is common in diabetes and associated with worse health outcomes .65.7.75.8.85.9.951 3 6 9 12 15 18 Observation time (months) Major depressive disorder Minor depressive disorder No/minimal depression A cohort study of people with diabetes and their first foot ulcer: the role of depression on mortality. Ismail et al Diabetes Care 2007 Adjusted hazard ratio 3.23 (1.39 to 7.5) Adjusted hazard ratio 2.73 (1.38 to 5.40) Cumulativesurvival 4 0
  5. 5. Social problems are common in diabetes poor housing debt social isolation inequities in access to healthcare ethnicity family roles & responsibilities employment
  6. 6. Psychological care Diabetes care Social care Parallel versus integrated services Diabetes care Psychological care Social care
  7. 7. Necessary ingredients Mental Health Diabetes & physical health Social interventions Patient
  8. 8. Diabetes care only Psychiatry Diabetes & physical health Social interventions Patient Pros: • nil Cons: • No integration • Poorer outcomes – glycaemic control, morbidity, mortality
  9. 9. IAPT Mental Health Diabetes & physical health Social interventions Patient Pros: • Psychological input Cons: • Not integrated • No social component • No evidence of improved biological outcomes • Uni-dimensional – cannot accommodate complex patients with comorbidities, requiring medications, risk issues
  10. 10. CMHT Mental Health Diabetes & physical health Social interventions Pros: • Full mental health input – psychiatry & MDT Cons: • Not integrated • No evidence of improved biological outcomes • High threshold for service
  11. 11. Liaison psychiatry model Mental Health Diabetes & physical health Social interventions Patient Pros: • Full integrated mental health input – psychiatry & MDT • Integration to varying degrees with teams in secondary care Cons: • Secondary care only • Limited social component – usually only psychiatry/ psychology for outpatients • General, not disease specific
  12. 12. Active ingredients of 3DFD • debt management • housing support • occupational rehab • literacy • Advocacy • patient-led MDT meeting • increase self efficacy for diabetes • HbA1c • medication support • biomedical monitoring • diabetes education • technology • complications • diagnostic assessment • risk management • psychotropics • brief psychological treatments • family work Mental Health Diabetes & physical health Social interventions Patient
  13. 13. Integrated across the sectors Diabetes care Psychological care Social care secondary community primary
  14. 14. Characteristic Mean (SD)/Proportion (%) Age (years) 47.4 (14.7) Gender male 129 (39.7) female 196 (60.3) Ethnic group white 121 (39.4) African/Caribbean 127 (41.4) Asian 59 (19.2) Postcode deprivation 35.2 (9.9) Type of DM type 1 102 (31.4) type 2 223 (66.8) HbA1c (mmol/mol) 95 (21) Characteristics of 3DFD referrals, n=325 (Oct 2012- Dec 2013) 129, 40%196 60% Gender Male Female 102 31%223 69% Type of Diabetes Type 1 Type 2 121 40% 127 41% 59 19% Ethnicity Caucasian African/Caribbean Asian/Other
  15. 15. Social Needs 0 5 10 15 20 25 Social supportneeds
  16. 16. Support worker assisting patient with type 2 diabetes with her housing situation
  17. 17. Psychiatric morbidity 0 20 40 60 80 100 120 Nil Known diagnosis New diagnosis New relapse N Psychiatric Diagnosis Psychiatric diagnosis: new, known or relapse
  18. 18. Main 3DFD outcomes Pre 3DFD Post 3DFD Change score p-value Mean (SD) IFCC HbA1c mmol/mol (n=185) 100 (23) 83 (22) 17 (17) <0.001 Mean (SD) Diabetes Distress Scale (n=54) 48.9 (16.2) 39.5 (19.9) -9.4 (19.3) <0.001 Mean (SD) anxiety score on GAD-7 (n=54) 9.1 (5.1) 5.8 (5.9) -3.3 (3.2) <0.001 Mean (SD) Outcomes Star score (n=54) 53.4 (11.5) 59.0 (15.9) +5.6 (9.4) <0.001 No of admissions to A&E/previous year (n=119) 141 77 -64 <0.001 No of bed days/previous year (n=119) 381 300 -81 0.08 No of recurrent admissions (days)/previous year (n=119) 10 (73) 4 (14) -6 (-59) 0.012
  19. 19. Improvements maintained at 2y
  20. 20. Comparisons 0 2 4 6 8 10 12 14 16 18 Glicazide Gliptin Dapagliflozin Lamb/Swk DICT (n=472) 3DFD (n=185) ImprovementinHbA1c,mmol/mol Agents producing improved glycaemic control Improvement in Hba1c, mmol/mol
  21. 21. Cost benefit analysis Costs £94k/borough/year • 0.5WTE Consultant liaison psychiatrist • Community outreach worker • Admin support and infrastructure Savings £127k/borough/year (-on-year) • Short term: reduction in unscheduled care • Long term: reduction in developing diabetes complications 3DFD net saving £33K/borough/year
  22. 22. Patient testimonials My name is Rochelle, I am a single parent with two children. I had difficulties controlling my diabetes. I became very depressed. 3DFD has managed to help me to overcome my fears of dealing with diabetes. I now use my insulins better..... Rochelle:(T1DM) HbA1c 15.2 to 8.7%
  23. 23. Conclusions Psychiatric morbidity is a poor prognostic factor for diabetes outcomes (and other long term conditions) Patients do not prioritise their diabetes care if they have social, psychological or psychiatric problems Integrating mental health and social welfare directly into the diabetes team is a simple solution that integrates everything from the patient’s perspective
  24. 24. 3DFD Translation of research Cross sector integration Health inequalities Cost effective Dissemination 3DFD
  25. 25. Contact us – kch-tr.3DFD@nhs.net – 0203 299 1350 – annedoherty1@nhs.net – carol.gayle@nhs.net Mental Health Diabetes Social interventions Patient

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