Mental Health Needs of Patients Living with Diabetes in the Long-Term Care Context: A Comment on Sears and Schmidt.

Abstract

In their recent review, Sears and Schmidt (1) noted the nature and frequency of mental health concerns among older individuals living with diabetes. We agree that the needs of older adults with diabetes are important to consider, for reasons both medical and relating to quality of life. One gap in the literature pertains to how confident and knowledgeable front-line workers (i.e. registered nurses, registered practical nurses and personal support workers) are with respect to the mental health needs of this group of patients in the long-term care setting. We recently conducted a survey of front-line diabetes clinicians (registered nurses, registered practical nurses, personal support workers) in 2 publicly funded long-term care facilities in southern Ontario, Canada (N=87; response rate 79%) (2). As part of this survey, front-line workers estimated the proportion of long-term care patients with diabetes in need of psychological or psychiatric services and rated their own confidence in their abilities to manage patients’ mental health needs. The perceived need for psychological/ psychiatric services was quite high: nearly two-thirds of patients were estimated to be in need (62.83%); a full 34.5% of front-line workers believed that all (i.e. 100%) of long-term care residents with diabetes were in need of some psychological/psychiatric assistance. Confidence levels in managing the mental health needs of patients with diabetes in this setting were variable; 68.9% reported being moderately confident, but only 6.9% reported being very confident and 11.5% reported being not at all confident. According to respondents, access to mental health service providers was variable. Respondents indicated that 62.2% had access to a psychiatrist consultation, and 64.8% had access to a psychiatric nursing consultation. Only 26.5% reported having access to a psychologist, and only 34.8% reported having access to a mental health counselor. The greater access to medically trained mental health professionals is not surprising, but it does not take into consideration patients’ preferences, which may or may not match this bias in access. It is often assumed that older adult patients would prefer medication, but that assumption is mostly untested. Moreover, from a strictly medical perspective, theremay be some concern about adding psychotropic medications to treatment profiles for patients with diabetes who already have complex regimens. Barriers to effective psychiatric and psychological management identified by respondents included perceived compliance issues (n=11), referral time problems (n=8) and lack of staffing (n=6). Communication problems and presence of comorbidities were also identified as barriers. However, the most commonly endorsed response was “unknown,” indicating a lack of certainty about the barriers that stood in the way of effective management of psychiatric/ psychological issues. Suggestions for improvement were similarly inconclusive, with “unknown” being the most common response. Beyond this, more staff (n=7) and increased access to existing staff (n=8) were the most common solutions proposed. Additional proposed solutions included reduced referral time (n=3), staff education (n=2) and communication assistance (n=1). Perhaps 1 of the more important questions to ask in relation to the needs of long-term care residents with diabetes is the following: Why do they need mental health services in the first place? As indicated by Sears and Schmidt, those living with diabetes have higher rates of anxiety and depressive disorders than the general population. Such affective syndromes are common manifestations of adjustment problems (changes in life circumstances, roles or daily routines), but it is also the case that long-term care residents are typically older and have poorer health status than their communitydwelling counterparts. They also struggle with multiple comorbid medical conditions beyond the diagnosis of diabetes, most commonly obesity, hypertension and renal disease as well as a variety * Address for correspondence: Peter A. Hall, PhD, CPsych, University of Waterloo, Applied Health Sciences, BMH 1117, 200 University Avenue West, Waterloo, Ontario, N2L3G1, Canada. E-mail address: pahall@uwaterloo.ca Can J Diabetes 40 (2016) 490–491