20181105 Claire BorthwickAt The State Hospital, a high-security forensic mental health service for patients from Scotland and Northern Ireland, our team used SIGN 116 guidelines for the management of diabetes to develop our service.

The following recommendation was identified as a clinical need: Children and adults with type 1 and type 2 diabetes should be offered psychological interventions (including motivational interviewing, goal setting skills and CBT) to improve glycaemic control in the short and medium term.

“A range of professionals were willing to provide input during the development phase and their expertise and contributions were integral to the successful development of the programme manual.”

The lead dietician approached me (a trainee health psychologist) with a request for a group psychological intervention to be developed for patients in our service with diabetes.

This intervention was to be evidence-based, drawing on appropriate psychological theory and suitable for inpatients with a mental illness.

I reviewed relevant literature for evidence of psychological interventions that promoted self-management and improved glycaemic control. I sought input from a range of professionals during the development phase and contributions were offered from a Professor of Health Psychology, chartered Health Psychologist, Consultant Clinical Psychologist, Lead Dietician and Practice Nurse. The programme that we developed adopted a cognitive-behavioural approach and was underpinned by health psychology models of illness and behaviour. The 5-week intervention was piloted with a group of participants and evaluated using a mixed-methods design.

A range of professionals were willing to provide input during the development phase and their expertise and contributions were integral to the successful development of the programme manual. I would therefore recommend multi-disciplinary team consultation to anyone undertaking a similar piece of work. The State Hospital clinical teams were supportive of the new initiative and willing to refer patients to the pilot group which also helped the project to run well.

In terms of challenges, I found that finding clear evidence to support the use of a particular psychological theory or behaviour change strategy for improving glycaemic control was difficult. As this was an in-patient setting with a smaller population of diabetes patients than may be observed in a community setting, the focus of the programme was to be suitable for individuals with both Type 1 and Type 2 diabetes, which added additional complexity.

“In addition to clinical benefits, developing this psychological group programme has allowed the service to meet a recommendation outlined by SIGN 116 guidelines and increase the range of available treatment options.”

The pilot evaluation that we carried out yielded positive results, with BMI reducing slightly in 80% of the pilot group over 12 weeks. HbA1c (the measure of the amount of glucose in the blood) was also reduced in 60% of patients, although for some patients this improvement was small. As this was a new initiative, only a small number of patients attended the pilot group so these shifts in HbA1c and BMI were not statistically significance.

However, as there appeared to be some positive outcomes, and the intervention was deemed acceptable to patients attending the group, we intend to roll the programme out across the hospital. This now gives clinical teams responsible for direct patient care an additional treatment option that they are able to refer patients with diabetes to.

In addition to clinical benefits, developing this psychological group programme has allowed the service to meet a recommendation outlined by SIGN 116 guidelines and increase the range of available treatment options.

Patients now have access to a wider range of services to help with diabetes management. The programme was well received and appeared acceptable to the patients who attended the pilot group. During post-group interviews, patients reflected on the benefits of having a shared group experience which appeared to enhance their motivation and learning.

As the patient feedback was largely positive, this group programme will continue to be offered within our service although we acknowledge that group work isn’t suitable for all patients. We plan to continue considering ways of adapting diabetes support to ensure that it is accessible to all patients within our service.

Claire Borthwick is a trainee health psychologist at The State Hospital, Carstairs.