Psychological and behavioural interventions

People with hypoglycaemia unawareness, which can co-occur with fear of hypoglycaemia, may be treated using an evidence-based structured intervention to help re-establish awareness of symptoms of hypoglycaemia and reduce fear of hypoglycaemia.

HARPdoc is a facilitated course that uniquely addresses how people think about their hypoglycaemia and its avoidance. It uses psychological theory to address unhelpful health beliefs that act as barriers to hypoglycaemia avoidance and recovery of awareness. It works as an adjunct to structured education, and optimisation of monitoring and insulin delivery technologies.

Consider structured education to prevent hypoglycaemia.
Consider glucose-lowering and glucose-monitoring technologies to reduce time below range and improve glycaemic control.

Members of diabetes professional teams should be alert to the possibility of bulimia nervosa, anorexia nervosa and disordered eating in people with type 1 diabetes with:

• over-concern with body shape and weight
• low BMI
• hypoglycaemia
• suboptimal overall blood glucose control.

Disordered eating in young people with type 1 diabetes may be screened using the Diabetes Eating Problem Survey tool. 

Further advice and recommendations are available in SIGN 164: eating disorders.

Think about making an early (or if needed, urgent) referral to local eating disorder services for adults with type 1 diabetes with an eating disorder.

Providing a care plan and diabetes-focussed education to healthcare professionals with limited diabetes experience may help to better support people with type 1 diabetes and/or eating disorders.

Further advice and recommendations on disordered eating in people with type 1 diabetes are available in SIGN 164: eating disorders.

Integrated intensive specialist care with the combined involvement of diabetes professionals and mental health professionals with experience in managing eating disorders is recommended to support people with type 1 diabetes and an eating disorder or compulsive insulin omission for weight control. Some patients may benefit from a specialist inpatient eating disorders service.

To access the source guideline, see section 8.1 of the PDF linked below.

Further advice and recommendations are available in SIGN 164: eating disorders.

Healthcare professionals should consider managing control of insulin administration in an inpatient setting alongside psychological interventions to address motivation, distress tolerance and to build trusting relationships with professional and lay carers.

To access the source guideline, see section 8.1 of the PDF linked below.

Evidence shows that inpatient programmes, delivered in specialist eating disorders units which last several months, and consist of daily interventions such as psychoeducation, CBT, family therapy and regular nurse supervision of insulin control result in a moderate improvement in HbA1c control.

Providing a care plan and diabetes-focussed education for healthcare professionals with limited diabetes experience may help to better support people with type 1 diabetes and/or eating disorders.

Refer children and young people with type 1 diabetes and suspected anxiety or depression promptly to child mental health professionals who have significant experience in diabetes.

The Paediatric Index of Emotional Distress (PI-ED) is a brief, valid and reliable clinical screening tool for emotional distress in children and young people.

The PedsQL Measurement Model is a modular approach to measuring health-related quality of life in healthy children and adolescents and those with acute and chronic health conditions.

Referrals for treatment of depression or anxiety should be made to mental health services with experience using cognitive behavioural therapy or other evidence-based treatment approaches in conjunction with collaborative care with the person’s diabetes treatment team.

It is acknowledged that there is geographical variation in service provision and referral pathways (eg between primary and secondary care).

Screening should not be in isolation. Appropriate care pathways should be in place when screening for mental health patient reported outcome measures. Should someone meet clinical thresholds, discuss their experiences and explore what support they can access. The Scottish Diabetes Group Short Life Working Group on Mental Health Screening in Diabetes has listed appropriate screening tools to identify individuals with depression or anxiety.

If adults with diabetes have an elevated HbA1c or other significant diabetes-related problems, in addition to clinical levels of anxiety and/or depression, they should ideally receive psychological treatments from practitioners who also have significant expertise in diabetes. This is because these professionals can alleviate mental health problems whilst simultaneously supporting individuals to manage their diabetes-related challenges (including improving glycaemic control, where necessary).

The Matrix is designed to support evidence-based delivery of psychological therapies and interventions in NHSScotland.

The Scottish National Trauma Training Programme includes resources to promote and implement trauma-informed practice within Scotland. 

Offer specific family-based behavioural interventions, such as behavioural family systems therapy, if there are difficulties with diabetes distress.

The NICE guideline group suggested that family therapy, with involvement, where appropriate, of other agencies such as schools, would be appropriate use of multisystemic therapy for children and young people with type 1 diabetes. They note that a practical example might be the involvement of the school to facilitate insulin injections.
Providing a care plan and diabetes-focused education to healthcare professionals with limited diabetes experience may help support people with type 1 diabetes to achieve better outcomes.

• Provide the family with contact details for their local Diabetes UK family support group. Support from other parents and carers and sharing experiences can help families feel less isolated and stressed and may contribute to reducing conflict or distress.
• Where possible, offer group training sessions for children and their parents or carers both together and separately for managing diabetes and include how to manage diabetes in family life.

The Matrix is designed to support evidence-based delivery of psychological therapies and interventions in NHSScotland.

Consider a programme of behavioural intervention therapy or behavioural techniques for children and young people with type 1 diabetes if there are concerns about their psychological wellbeing. Choose a type of therapy based on what the child or young person needs help with:

• health-related quality of life – for example, counselling or cognitive behavioural therapy (CBT), including CBT focused on quality of life
• adherence to diabetes treatment – for example, motivational interviewing or multisystemic therapy
• blood glucose management if they have high HbA1c levels (above 69 mmol/mol [8.5%]) – for example, multisystemic therapy.

The Matrix is designed to support evidence-based delivery of psychological therapies and interventions in NHSScotland.