Diabetes and mental ill health as comorbidities – how to integrate care and improve outcomes

Then in 2022, I started a professional doctorate in nursing and was offered the opportunity to join a research team undertaking a systematic review, looking at models of integrating mental health care into diabetes primary care.

Research shows there is a high prevalence of diabetes and mental illness comorbidity, with patient outcomes poorer in both.

Outcomes can be improved if this comorbidity is identified and managed, so the question for the systematic review was: ‘What are the models for integrating mental health expertise into diabetes primary care?’

There were four of us in the team, including two nurses, with different levels of research experience. The principal investigator was a senior lecturer and healthcare researcher, with a background in psychology. The other members of the team were a psychology PhD student with a background in education, and a nurse with an extensive background in general practice and primary care who specialises in research into diabetes care and self-management and also works as a lecturer in education and student experience.

To understand the landscape of the evidence related to our question, we started by screening titles and abstracts of 3,438 studies to see which could be included in our review.

To screen the papers we use Covidence, which is web-based software that streamlines literature and systematic reviews to make the process more efficient. After discounting studies that did not fit the inclusion criteria, we were left with 246 studies to review. We have recently finished extracting the data and critically appraising the reviews included in the study, and now plan to write a review of our findings.

Do randomised controlled trials reflect the real world?

When we started looking at the literature, we were confronted with a complexity I was not expecting, with more questions raised than answered. The term integrated care, for example, is used extensively but rarely defined, and where it is, there is a lack of consistency in the definitions.

We also questioned whether interventions tested through randomised controlled trials would work in ‘real-world’ settings. Participants in clinical trials are likely to be more engaged and motivated and many people are excluded from clinical trials, such as those with a learning disability, people over a certain age and those who are pregnant.

Some studies had little or no information about intervention fidelity – the extent to which an intervention was delivered as conceived and planned – and interventions were often poorly described. It was surprising how few studies included any qualitative elements or talked about barriers to implementing interventions.

Confusion over terminology proved challenging, with mental health being referred to as behavioural, psychological, psychiatric and neurotic, and many different outcome measures were used in the studies, such as multiple outcome measures for depression.

As a practitioner, it was frustrating to see a lack of consideration of this complexity. The lack of qualitative evidence in much of the research meant the voices of relevant people were often missing, and while some interventions appeared promising, we identified several issues that would need to be overcome for them to work in clinical practice, such as workforce issues that had not been considered.

We observed how recommendations from some of the research had not been integrated into practice, leading us to question why. With such confusion evident in the literature, perhaps it is not surprising that translation of knowledge into practice has been slow and challenging, particularly in settings other than mental health care.

Such complexity also seems to conflict with our usual practice of ‘simply’ sending a referral to a mental health service. Despite taking courses in mental health, I knew I needed more knowledge and skills in this area, to increase my confidence in caring for patients with mental health issues and improve my practice.

Review improved my practice

Being part of the systematic review enabled me to engage with the research and develop my knowledge and skills in a ‘safe’ environment before taking what I had learned back into practice.

If I hadn’t been part of this research project, I may have continued to avoid addressing mental health issues with my patients. But it made me realise there are things I can do even though I am not a trained mental health nurse, such as making better use of the mental health expertise available and signposting patients to the right services.

Since being part of the systematic review team, I have referred many more people to single or multiple services, depending on their needs. I have become more confident in working jointly with the person and the mental health practitioner once the referral has been made.

Collaborating more with the person and mental health experts has helped allay the fears I had about how the person perceives the referral, whether I have made the right assessment, whether I have referred them to the correct service in a timely fashion, and what will happen to the person while they are awaiting review.

Asking more questions has prompted deeper reflection on my practice and an awareness of where further research is needed.

Screening so many papers also highlighted research that, although not relevant to the systematic review, was relevant to my practice. One study, for example, looked at using group consultations to complete advanced care plans, which I was able to take back into practice and discuss with my colleagues.

Taking part in this process taught me that my longstanding fears about addressing a person’s mental health needs were unfounded. Acknowledging the biggest concern for the person has saved time as they can be offered the right help earlier, and without good mental health, good physical health can be hard to achieve.

Better communication and teamwork

I have also improved my communication skills and am no longer afraid to start a conversation about mental health. People are often grateful for the discussion and offer of available services.

Being part of a multidisciplinary group has improved my team-working skills and appreciation of the roles of others; we all had different knowledge, skills, experience and perspectives, which helped us to critically appraise the literature from different angles.

As well as developing my research skills, engaging with the evidence has given me the knowledge, skills, and confidence to identify and assist in managing mental health conditions, not only in diabetes care but for anyone I see in my practice.

Mental health nursing in primary care: could you take an advanced role at a GP surgery? rcni.com/mentalhealth-primarycare