Young adult patients with diabetes presenting to a university health clinic with depression and anxiety

ABSTRACT: At the University of Victoria Health Services clinic from May 2015 to September 2016, psychiatrists saw a number of young adult students with type 1 diabetes presenting with serious major depression and anxiety, and poor blood glucose monitoring. Clinic staff found that psychotherapy not only addressed mental health concerns but gave patients an opportunity to understand their experience growing up with diabetes. Some suggestions based on student experience included better education about glucose metabolism in adolescence and the effects of alcohol and drug use on diabetes, and more use of group treatment to permit contact with a core group of friends available to discuss diabetes-related issues throughout life. Student experience also suggested that it might be worthwhile to have intergenerational events for people with type 1 diabetes so that patients could share their knowledge and learn what to watch for as they grow older and their bodies change.


Psychotherapy was found to help postsecondary students with type 1 diabetes address mental health concerns and better understand their experience of growing up with a condition that requires careful monitoring of blood glucose levels.


Findings from the National Health Services in the UK[1] suggest there is a need for transformational, widespread health care reform to address the problems of constantly growing demands and limited resources. This reform will come, in part, from health care professionals sharing what we learn as we “work smarter, not harder.” An example of this can be seen in suggestions from young adult patients presenting to a university health services clinic. In 2015, the University of Victoria Health Services clinic received a grant from the Specialist Services Committee, a joint collaborative committee of Doctors of BC and the British Columbia Ministry of Health, to build a more comprehensive, multidisciplinary mental health service on campus.

Patient concerns
At the University of Victoria Health Services clinic from May 2015 to September 2016, psychiatrists saw a number of young adult students with type 1 diabetes presenting with serious major depression and anxiety, some of whom were not testing their blood glucose for months at a time. Clinic staff found that psychotherapy not only addressed mental health concerns but gave patients an opportunity to understand their experience growing up with diabetes and  to discuss common concerns not often heard in a diabetes clinic.

Some patients recalled when they were first diagnosed with diabetes as children and described seeing helpful educational videos. By contrast, they identified several areas of unmet need when they reached adolescence. First, they missed being educated about what would happen to their glucose metabolism as they became pubescent and experienced menstrual cycles and growth spurts. Patients said they would have benefited from another age-appropriate educational video during adolescence. Second, they wished they had been taught about the effects of alcohol and drug use on diabetes. Patients noted that Internet searches for this information were unhelpful. Third, they wondered if group treatment for diabetes in adolescence would have provided them with a core group of friends to stay in contact with and discuss diabetes-related issues with as they got older.[2,3]

Moving away to university or college offers new opportunities and challenges to young adults. It is often their first time away from home and their first chance to control their social activities and their academic schedule. For young adults with diabetes, eager to prove their capacity for successful independence, it can be especially challenging to maintain their physical well-being. While these young adults typically seek information about safe substance use and alcohol consumption,[4] physicians often hesitate to discuss these topics with them. In addition, some postsecondary students struggling with diabetes management describe consistently maintaining glucose levels of 13.0 mmol/L as a major achievement. Yet after these patients  achieve and maintain a level of 13.0, they are advised by their endocrinologist to “get to 8.0.” These patients lament the lack of celebration for the achievement of stabilizing at 13.0 and say there is no support or advice about how to “get stepwise to 8.0.”

As exhausted students struggle to earn good marks, study long hours, and manage on little money for food and supplies, they see wildly inconsistent glucose values and soon give up measuring their levels even once a day. 

Suggestions
Student experience discussed with caregivers at University of Victoria Health Services suggests it may be useful to set up regular clinics so that all youth with diabetes are kept together in a room separate from their parents as they rotate through their visits with health professionals. If youth are in the same room with their peers during breaks, they may form friendships or have discussions about diabetes and their lives. This approach may work better than formal group sessions as youth would not feel the need to compare themselves or be perfect before going to a group. This could also help those who are shy and unwilling to attend groups to make contact with others managing their diabetes, which could then be maintained easily via social media networking. 

Another suggestion based on student experience is to have more open clinics where friends can attend with patients and be educated about diabetes. Having events where children, adolescents, and adults can come together to learn about type 1 diabetes could increase awareness of the condition. As well, some intergenerational events for people with type 1 diabetes could help patients share their knowledge and learn what to watch for as they grow older and their bodies change.

Improving education about diabetes for adolescents and providing support groups and specialized services to postsecondary students managing their diabetes could contribute to patient well-being. The student suggestions reported here could lead us to ways that lessen the burden of diabetes on patients and hence caregivers, thus freeing up resources and allowing us to “work smarter, not harder” in other aspects of diabetes care. 

The Specialist Services Committee hopes the model used at University of Victoria Health Services can be replicated on other postsecondary campuses.

Competing interests
None declared.

Acknowledgment
Funding for this initiative was provided by the Specialist Services Committee, one of four joint collaborative committees representing a partnership of Doctors of BC and the Ministry of Health.


This article has been peer reviewed.


References

1.    Bevan H, Fairman S. The new era of thinking and practice in change and transformation: A call to action for leaders of health and care. Leeds: NHS Improving Quality; 2014. Accessed 24 April 2017. www.change-management-institute.com/sites/default/files/nhsiq_white_pape...
2.    Kime N, McKenna J, Webster J. Young people’s participation in the development of a self-care intervention—a multi-site formative research study. Health Educ Res 2013;28:552-562.
3.    Ammentorp J, Thomsen J, Kofoed PE. Adolescents with poorly controlled type 1 diabetes can benefit from coaching: A case report and discussion. J Clin Psychol Med Settings 2013;20:343-350.
4.    Jones E, Sinclair JM, Holt RI, Barnard KD. Social networking and understanding alcohol-associated risk for people with type 1 diabetes: Friend or foe? Diabetes Technol Ther 2013;15:308-314.


Dr Thorpe is a psychiatrist at University of Victoria (UVic) University Health Services (UHS) and a clinical assistant professor in the Department of Psychiatry at the University of British Columbia (UBC) and UVic. Ms Williams is a psychology student at UVic. Dr Singh is a fourth-year psychiatry resident at UBC. Ms Buchan is the mental health nurse at UVic UHS and acting mental health lead. Ms Olson is the mental health therapist at the UVic UHS clinic. Ms Monkman is a PhD candidate in the School of Health Information Science, Faculty of Human and Social Development, UVic, and the project manager for this initiative. Dr Borycki is a professor at the School of Health Information Science, Faculty of Human and Social Development, UVic, and is a coinvestigator on this project. Dr Kushniruk is a professor at the School of Health Information Science, Faculty of Human and Social Development, UVic, and is a coinvestigator on this project.

Marilyn Thorpe, MD, FRCPC, Holly Williams, Pulkit Singh, MD, Cathy Buchan, RN, BScN, Dawn Olson, MEd, RCC, Helen Monkman, MA, Elizabeth Borycki, RN, PhD, Andre Kushniruk, PhD. Young adult patients with diabetes presenting to a university health clinic with depression and anxiety. BCMJ, Vol. 59, No. 6, July, August, 2017, Page(s) 310-311 - Clinical Articles.



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Daniel L. Metzg... (not verified) say: reply

I read with interest the article by Thorpe and colleagues regarding anxiety and depression in young adults with type 1 diabetes in a university-clinic setting. Mental health issues are unfortunately all too common in this vulnerable age group, as young adults are negotiating the sometimes-rocky transition from pediatric to adult endocrine care. The article very rightly points out the role of the mental-health provider in helping to identify and treat the depression, anxiety, altered family dynamics and eating disorders that are observed across the age span of people living with diabetes, perhaps most so in the middle- and late-adolescent years. Unfortunately, in many areas, there is a paucity of mental-health services available to pediatric and adult endocrinologists and other specialists and diabetes educators caring for this population.

I would like to point out a few resources that may be of interest to young adults living with type 1 diabetes. The website of the Endocrinology & Diabetes Unit at BC Children's Hospital has numerous handouts for patients with type 1, their caregivers and their medical providers, available at http://www.bcchildrens.ca/health-info/coping-support/diabetes. These include handouts specifically addressing alcohol and drug use in diabetes, financial considerations for those turning 19, and social and mental-health resources available to young adults transitioning out of pediatric care. Drug Cocktails (http://www.drugcocktails.ca/) is an invaluable resource for any youth who needs information about mixing medicine with alcohol and street drugs.

Lastly, Young & T1 (https://youngandt1.com/) is an excellent social resource for those 18–35+, organized and run completely by and for young adults living with type 1 diabetes in BC. They have both in-person meet-ups and a strong Facebook presence for those living outside the Lower Mainland.

I thank the authors for reminding those professionals who follow youth with type 1 diabetes of the importance of maintaining close communication and follow-up with this high-risk group, to help prevent the development of the unwanted medical and mental-health complications than can be seen in this age group with a high risk of drop-out from diabetes care.

Daniel L. Metzger, MD, FAAP, FRCPC
Pediatric Endocrinologist, BC Children's Hospital
Clinical Professor of Pediatric, UBC

Ramya Hosak (not verified) say: reply

The article by Thorpe and colleagues regarding anxiety and depression in young adults with type 1 diabetes in a university-clinic setting was of particular interest to me.

I myself was diagnosed with type 1 diabetes in first year at Simon Fraser University and struggled with a lot of the issues described above. It led to a very difficult time period in my life, and some of the interventions described above would surely have helped. It was due to this experience that after graduating from university I co-founded the organization Young and T1 (www.youngandt1.com) with a friend of mine (Ben Mammon) who had just graduated from high school/the pediatric health care system and was about to start at University of British Columbia.

5 years later, we have about 300 members in the lower mainland now and have had a lot of positive response. I want to thank Dr. Metzger for mentioning Young and T1 above in his comment. Ben and I would love to get in touch at any point- our contact information is on our website or you can get in touch at ramya.chittha@gmail.com and b.mammon@gmail.com

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