DKA, mental health and future mortality

1. DKA, mental health and future mortality YDEF March 26th, 2019 Dr Chris Garrett, PhD MRCP MRCPsych Consultant in diabetes psychiatry chrisgarrett@nhs.net

4. Known mental health problem Previous episode? Future cost Mortality risk DKA – clinical iceberg Untreated mental health problem

5. Epidemiology of DKA in UK

6. England: DKA incidence Zhong et al: Diabetes Care, 2018

7. Wales: DKA incidence Abdulrahman et al: Diabetes research and clinical practice, 2013

8. Mental health and DKA/rDKA • Bryden, Diabetes Care, 2003 • Randall, Diabetes Care, 2011. • Rewers, JAMA, 2002. • Shulman, Diabetic Medicine 2017.

9. Mortality

12. Health service use and costs

13. Study 2:10 year service use and health economic data in patients with and without recurrent diabetic ketoacidosis: A case-control and cohort analysis

14. 1279 DKAs (608 patients) Other CCGs 256 DKAs (194 patients) Neighbour CCGs 239 DKAs (126 patients) Home CCGs 784 DKAs (288 patients) Matched controls • Cohort analysis • 1 DKA 174 • 2-4 DKAs 78 • 5-7 DKAs 19 • 8+ DKAs 17 Case-control analysis DKA vs non DKA

15. DKA recurrence associated with greater unscheduled attendances

16. Patients / DKAs

17. Non DKA inpatient episodes / year

18. AE presentations / year

19. Median no. outpatient apps / year

20. % DNA appointments

21. Costs (£) per year

22. Mental health & rDKA Mental health presentation

23. ?

24. Study 3: Case-control study assessing psychopathology of patients with rDKAvs no rDKA

25. Objectives:Compare the mental health of patients who have had 2 or more DKA in a year vs patients with no or one DKA.

26. Inclusion criteria:Type 1 ≥ 2 years18+ years old≥2 DKA in <12 months, occurring in last 3 years

27. Exclusion criteria:Schizophrenia, Established severe LD ie IQ <35

29. Study procedure:DKA list from EPR, patients written to then called. Invited to attend appt

30. At assessment: (1.5 hrs) Meter downloadHbA1c12 self-rated psychological Qs1 observer rated reading assessment

31. rDKA associated with higher rates of diabetes distress, anxiety, emotion dysregulation and 75% screen +ive for a personality disorder

32. 23 cases vs 23 controls

34. Personality disorder clusters

35. SAPAS – PD screening tool • In general, do you have difficulty making and keeping friends? • Would you normally describe yourself as a loner? • In general, do you trust other people? • Do you normally lose your temper easily? • Are you normally an impulsive sort of person? • Are you normally a worrier? • In general, do you depend on others a lot? • In general, are you a perfectionist?

36. Known mental health problem Previous episode? DNA Gluc test Future cost Mortality risk DKA – clinical iceberg Untreated mental health problem

37. Attachment

38. Study 4: Feasibility of a mental health intervention for rDKA

39. Objectives:This study will investigate the feasibility of a psychological intervention to reduce DKA episodes in patients with rDKA.

40. Study procedure:Patients with rDKA first invited for introductory meeting and if agreeable signed up for psychological intervention lasting 40 sessions.

42. Attendance to therapy intervention of enrolled rDKA patients P1-40 P6-13 P2-17 P7-13 P3-5 P8-29 P4-1 P9-0 P5-34 P10-7

43. DKA episodes per quarter Quarters

44. DKA, other IP & AE per quarter Quarters

45. In summary • DKA and rDKA is associated with high mortality • rDKA is associated with greater diabetes distress, anxiety, emotion dysregulationand personality disorder • And is potentially treatable through a MH intervention

46. What’s next? • Data, data, data • Coherent response to information? • Psychiatric referral for each admission, similar to assessment post self-harm? Or screening scales?

47. Thank youchrisgarrett@nhs.net, @psychdiab