Clinical practice
Starting with the diabetes outcome
Mental-health services usually identify people through psychological or psychiatric symptoms.
Diabetes psychiatry can also work in the opposite direction.
A serious or repeatedly adverse diabetes outcome may provide a reason to look for psychological, psychiatric, cognitive or social processes that have not previously been recognised.
The physical-health outcome does not tell us what the underlying problem is.
It tells us where to look.
Recurrent DKA
Repeated DKA should prompt a psychological and psychiatric question.
Rather than asking only:
“What caused this episode?”
ask:
“Why does DKA keep happening to this particular person?”
A pragmatic case-finding threshold is two or more DKA episodes within two years.
This is not a diagnostic definition. It identifies a population in whom systematic assessment may be useful.
The assessment should reconstruct what actually happens before DKA, understand insulin behaviour and help-seeking, and ask what psychological, psychiatric or social processes may be maintaining recurrence.
Severe Persistent Hyperglycaemia
A very high HbA1c is an outcome. It is not an explanation.
An isolated very high HbA1c may have many causes and may respond readily to conventional diabetes intervention.
Persistent or repeatedly returning severe hyperglycaemia raises a different question:
Why has severe hyperglycaemia become this person's usual state?
An HbA1c of ≥100 mmol/mol can provide a pragmatic starting point for identifying this population, while recognising individual treatment targets, frailty and clinical context.
Trajectory matters.
The aim is not to psychiatrise a laboratory result. It is to identify people whose continuing physical-health risk may require a different kind of explanation and intervention.
Severe Hypoglycaemia
Repeated severe hypoglycaemia may sometimes involve more than insulin adjustment alone.
Cognition, impaired awareness, neurodevelopmental factors, psychiatric illness, alcohol or substance use and the person's relationship with diabetes may all be relevant.
A dedicated clinical framework will be added as this work develops.
Type 1 Diabetes and Eating Disorders
Insulin has a unique position in eating disorders associated with type 1 diabetes: it is simultaneously an essential treatment and something capable of influencing weight.
Assessment may therefore need to integrate eating-disorder psychopathology with detailed understanding of insulin behaviour, diabetes risk, affect and interpersonal functioning.
Further clinical resources are in development.
Reading the Diabetes Record
In diabetes psychiatry, the physical-health record is not simply background information. It is the beginning of the psychological formulation.
Before meeting someone, reconstructing their diabetes trajectory over time can help understand a person’s struggle with diabetes and may indicate clinical risk. I look at HbA1c, episodes of DKA and their severity, severe hypoglycaemia and ambulance call-outs, C-peptide and autoimmune status, ACR and eGFR, retinal disease and other complications.
The important information is often not an individual result, but the relationship between results and how they change over time.
An HbA1c of 45 mmol/mol may look excellent until it is placed alongside four ambulance-treated severe hypos.
Six episodes of DKA, an ITU admission and a presenting pH of 6.9 describe something very different from a single uncomplicated DKA.
A first DKA several years after diagnosis may initially look like new disengagement. But if the person has had an HbA1c above 100 for years, previously retained endogenous insulin production and now has a low C-peptide, another possibility emerges: the behaviour may not have changed as much as the biology has. Residual insulin production may previously have protected them from the consequences of inconsistent insulin use.
Similarly, years of extreme hyperglycaemia followed by rising ACR or falling eGFR show the point at which glycaemic exposure may be translating into measurable physical consequence.
These patterns do not provide the psychological explanation. They generate questions.
A very low pH does not prove that someone delayed seeking help for psychological reasons. A low HbA1c with recurrent severe hypoglycaemia does not prove perfectionism. A very high HbA1c does not tell us why insulin is not being taken.
They tell us where to become curious.
Read the trajectory, not the result
The purpose of reviewing the diabetes record is not to formulate somebody before meeting them. It is to understand their physical-health trajectory well enough to ask better psychological questions when we do.
The principle
Not every adverse diabetes outcome requires psychiatric treatment.
The purpose of case finding is to discover when psychological or psychiatric processes are sufficiently important that understanding and treating them becomes part of treating the diabetes outcome itself.
The physical phenotype identifies the problem. Assessment determines whether diabetes psychiatry has something useful to offer.