If the person is experiencing a mental health problem (e.g. eating disorder or depression) and you do not have the expertise to assist, a referral to a general practitioner (GP) or mental health professional will be necessary.
Some mental health problems require immediate attention and referral to a specialised service or admission to hospital (e.g. an eating disorder with direct risk for the person, or acute suicide risk).
Practice points
Talk with the person with diabetes about the reasons for the referral and ask them about their thoughts and feelings about this.
Continue to see the person with diabetes after the referral to help reassure them that you remain interested in their ongoing care. Take this opportunity to check their progress and revise the action plan if needed. Post-referral follow-up is important.
Maintain ongoing communication with the health professional to whom you made the referral, to ensure a coordinated approach to the person’s ongoing care.
Background
One of the challenges of attending to the emotional and mental health needs of people with diabetes is knowing which problems you can address as part of a person-centred approach to diabetes care and which problems need referral to a mental health professional.
Most people with diabetes (Level 1 of the pyramid in Box 9.1) experience only general or mild difficulties in coping with their diabetes and will benefit largely from the support and counselling that their usual diabetes health professionals can offer. Moving up the pyramid, the more severe and complex the psychological problem is, the more likely it is that the individual will
need specialist psychological support. Level 5 of the pyramid also demonstrates that severe and complex mental health problems are, fortunately, relatively rare among people with diabetes.
Psychological problems can co-exist alongside or be caused by diabetes. Even when diabetes is not a contributing factor, the more severe the psychological problem, the more likely it is that diabetes management (and consequently, diabetes outcomes) will be impaired. In most circumstances, a multidisciplinary, collaborative care model is the best approach.
Box 9.1: Pyramid of psychological problemsÂ
Level 5: Severe and  complex mental  illness, requiring  specialist psychiatric intervention(s).
Level 4: More severe psychological problems that are diagnosable and require biological treatments, medication and specialist psychological interventions.
Level 3: Psychological problems which are diagnosable/ classifiable but can be treated solely through  psychological interventions, e.g. mild and some moderate cases of depression, anxiety states  and obsessive/compulsive disorders.
Level 2: More severe difficulties with coping, causing significant anxiety  or lowered mood, with impaired ability to care for self as a result.
Level 1: General difficulties coping with diabetes and the perceived consequences of this for the person’s lifestyle etc. Problems at  a level common to many or most people receiving the diagnosis.
Making the referral
Before deciding whether to assist the person or to refer them to a mental health professional, consider the context and severity of the problem as well as your qualifications, knowledge, skills, confidence, time, and resources to address the problem. Most importantly, discuss these considerations with the person with diabetes, as they may also have their own preferences.
Tips for making a mental health referral
Where you believe a referral is required, it is important to talk about the options and processes with the person with diabetes.
Explain to the person why you believe a referral is needed. Clarify what a mental health professional can offer that you cannot, and what the expected benefits of seeing a mental health professional will be for the person. For example, will support from a mental health professional assist them with diabetes management? Or help to reduce their depressive symptoms? Or both?
Ascertain how comfortable the person feels about being referred to a mental health professional.You may prefer to take some time to first gauge an understanding of their emotional state and readiness to seek and accept such support. Then, assist them in making an informed decision about whether to seek and access appropriate support when they feel ready to do so. If they feel nervous or unsure about whether they are ready, normalise this experience for them – let them know that it is common to feel this way and give them time to think about it.
Be familiar with your local referral pathways. If you can personally recommend a particular mental health professional or service (e.g. with a specific interest in diabetes) this can be reassuring for the person with diabetes. It is helpful to be familiar with local referral pathways and to develop professional networks with appropriately trained individuals and services both inside and outside the NHS who provide psychological support and intervention to people with diabetes.
Discuss the person’s preferences for the referral.The person may have a preferred mental health professional (e.g. someone they have seen previously), or they may have specific requirements about whom they are willing to see (e.g. someone of the same gender or cultural background).
Explain that finding the ‘right match’ is important. Every health professional has an individual consultation style and approach; some will suit the individual better than others will. If the person finds that the mental health professional’s style approach does not meet their needs, or they do not feel comfortable, explain that this can happen and that you can assist them in exploring and accessing other specialists.
Prepare the person for what to expect at the mental health consultation. For example, if you have referred the person with diabetes to a psychologist for assessment, explain that they will probably be asked to complete questionnaires, and answer questions about their life, including family background, medical history, and relationships. If you have referred them to a psychiatrist, explain what a psychiatrist does and why you feel psychiatric intervention is necessary for their presenting problem. You may need to clarify the difference between a psychologist and a psychiatrist.
Prepare the person for what will be expected of them. Inform them that mental health interventions vary in their duration and course, depending on the type of problem. There will also be a time commitment required for the initial consultation (e.g. 45-60 minutes) and subsequent consultations; the duration of the therapy will be decided together with the mental health professional. There may also be tasks they need to complete between consultations (e.g. keeping a record of their mood).
Explain waiting times and service limitations. You may need to continue to see the person until they can see the mental health professional so that they remain supported and do not fall between service gaps.
If the person is reluctant or chooses not to consult a mental health professional at this time, explain the limitations of your expertise (e.g. you are not an expert in managing mental health problems) and provide them with basic support (e.g. give them the opportunity to talk about how their problems are impacting on their diabetes). Monitor the person and make a plan to revisit the option of a mental health referral at another time, as needed.
Writing the referral
After agreeing with the person with diabetes that referral is the best option, you can then write a referral letter. In addition, you may also choose to have a telephone or Skype conversation about the presenting problem with the mental health professional to whom you are referring the person. Retain a copy of the letter in the person’s file and send a copy of the letter to the GP and, if appropriate, the person with diabetes themselves.
Once you have made a referral, it is your responsibility to ensure that it has been received and accepted. If the person with diabetes is placed on a waiting list, both service providers should agree who is responsible for monitoring the individual. It is important that the person is not left waiting for their appointment without anyone to support them, especially if you have concerns for their well-being or safety.
Continue to support the person with regular appointments especially while they are establishing a therapeutic relationship with the mental health professional. When you see the person with diabetes:
Talk about their experience of the mental health intervention. For example, ‘You had a few sessions with the psychologist. How is that working out for you? How have things been since you’ve been talking about things? Keep in mind that the issues discussed with the mental health professional may be highly sensitive and respect the person’s right to privacy.
If the person with diabetes does not feel the intervention is helping them, find out why. Let them know that there are other options and that you are happy to explore these options with them. For example, you might say something like ‘It can take time to find a [psychologist] that you feel comfortable with. Sometimes, it takes a bit of trial and error to find the right person; this is normal and there is no need for this to stop you from seeking help’.
If psychotropic medication(s) have been prescribed, enquire about these. For example,‘How have you been feeling since starting your medication(s)?Have you noticed any changes in how you feel – positive or negative?’ Some psychotropic medications can impact on blood glucose levels, so check that the medication has not had a negative impact on the person’s diabetes management.
Maintain ongoing communication with the referring health professional to review the referral and person’s progress, and to ensure a coordinated approach.
Crisis referrals
A crisis referral must be considered when:
someone feels they are no longer able to cope
someone is fearful they might lose control
someone is expressing strong suicidal feelings or are experiencing visual or auditory hallucinations.
If you feel someone is at risk to themselves, or to someone else, you must refer them to a mental health service. Check whether the person is already known to mental health services. If so, contact that particular service.
In England, you can call NHS 111 if someone requires urgent, but not life threatening, care. For example:
if they have an existing mental health problem and symptoms are getting worse
if they are experiencing a mental health problem for the first time
if someone has self-harmed but it does not appear to be life-threatening, or is talking about wanting to self-harm
if a person shows signs of onset dementia
if a person is experiencing domestic violence or physical, sexual or emotional abuse
Alternatively, contact their GP practice and ask for an emergency appointment with the first available doctor.
A mental health emergency needs to be taken as seriously as a medical emergency. Call 999 (from anywhere in the UK) if someone is experiencing an acute life-threatening mental health emergency. People in crisis can be directed to the nearest Accident and Emergency (A&E) department if immediate help is needed or if you are worried about their ability to keep themselves safe.
Many hospitals now have a liaison psychiatry team to address mental health issues that present to Accident and Emergency If this service is not available, the A&E team will contact the local on-call mental health services, such as the Crisis Resolution and Home Treatment Team (CRHTs).
When to contact social services?
Beyond a crisis situation, it may be more appropriate to call social services if you have urgent concerns about someone's social or domestic circumstances, such as vulnerable children and young people, vulnerable adults or people with learning disabilities. Social services can be contacted out-of-hours. Social services may also be involved in the assessment of people in crisis through the legislation of the Mental Health Act.
Disclaimer: Please note you may find this information of use but please note that these pages are not updated or maintained regularly and some of this information may be out of date.
