Abstract
<ns5:p> <ns5:bold>Why did we do this research?</ns5:bold> </ns5:p> <ns5:p> People with severe mental illness, including schizophrenia or bipolar disorder, often have shorter lives than the general population. This is largely due to physical conditions like type 2 diabetes. Managing diabetes demands daily tasks, such as: <ns5:list list-type="bullet"> <ns5:list-item> <ns5:p>Regular exercise </ns5:p> </ns5:list-item> <ns5:list-item> <ns5:p>Dietary changes </ns5:p> </ns5:list-item> <ns5:list-item> <ns5:p>Blood sugar monitoring</ns5:p> </ns5:list-item> </ns5:list> </ns5:p> <ns5:p> These tasks are made harder by: <ns5:list list-type="bullet"> <ns5:list-item> <ns5:p>Mental health symptoms</ns5:p> </ns5:list-item> <ns5:list-item> <ns5:p>Medication side-effects</ns5:p> </ns5:list-item> <ns5:list-item> <ns5:p>Social problems</ns5:p> </ns5:list-item> <ns5:list-item> <ns5:p>Poor access to healthcare</ns5:p> </ns5:list-item> </ns5:list> </ns5:p> <ns5:p>Standard NHS care often does not meet the needs of this group. DIAMONDS sought to address this unfairness by developing a support package to help people with severe mental illness manage their diabetes better.</ns5:p> <ns5:p/> <ns5:p> <ns5:bold>Living with mental and physical health conditions</ns5:bold> </ns5:p> <ns5:p> We reviewed existing research and interviewed patients, carers, and staff. They reported an "inescapable", constant struggle where mental and physical health problems are linked making self-care difficult. The challenges are made worse by difficult social situations, including: <ns5:list list-type="bullet"> <ns5:list-item> <ns5:p>Financial hardship</ns5:p> </ns5:list-item> <ns5:list-item> <ns5:p>Housing insecurity</ns5:p> </ns5:list-item> <ns5:list-item> <ns5:p>Loneliness </ns5:p> </ns5:list-item> </ns5:list> As a result, people often give more importance to staying stable in the short-term and neglect the long-term care of their health. </ns5:p> <ns5:p/> <ns5:p> <ns5:bold>Designing and testing the DIAMONDS Programme</ns5:bold> </ns5:p> <ns5:p>We ran workshops where patients, healthcare staff and researchers worked together to develop the support package, taking account of the challenges of living with both mental and physical health conditions. </ns5:p> <ns5:p/> <ns5:p> The resulting DIAMONDS Programme offered flexible support including: <ns5:list list-type="bullet"> <ns5:list-item> <ns5:p>One-to-one weekly coaching sessions with a trained DIAMONDS Coach </ns5:p> </ns5:list-item> <ns5:list-item> <ns5:p>Workbook for tracking progress and learning</ns5:p> </ns5:list-item> <ns5:list-item> <ns5:p>'Change One Thing', an optional mobile app version of the workbook</ns5:p> </ns5:list-item> </ns5:list> </ns5:p> <ns5:p>Coaching focused on helping people work toward their chosen goals, such as managing mood or taking medicine. </ns5:p> <ns5:p/> <ns5:p>We tested this DIAMONDS support package in a small study. Coaches were able to deliver sessions, mostly as planned, and participants engaged with them. They suggested small changes such as offering more flexibility in the frequency, number and duration of sessions.</ns5:p> <ns5:p>We then carried out a large trial to see if the DIAMONDS support package helps people with mental illness and diabetes manage their blood sugar (measured using a blood test called HbA1c) better. We randomly split participants into two groups: one group received the DIAMONDS programme for 6 months and the other continued with their usual NHS care. We measured blood sugar levels and did other checks of mental and physical health at 6 and 12 months. </ns5:p> <ns5:p/> <ns5:p> <ns5:bold>The DIAMONDS Trial Findings</ns5:bold> </ns5:p> <ns5:p>The DIAMONDS group had slightly lower blood sugar levels at 12 months, but the difference was small and could have been due to chance. In other studies, this size of change has not been linked to better diabetes health.</ns5:p> <ns5:p/> <ns5:p>There were no meaningful differences between the two groups in other areas of physical or mental health or self-care of diabetes at 6 or 12 months. </ns5:p> <ns5:p/> <ns5:p>We found the DIAMONDS support package is unlikely to offer value for money for the NHS compared with usual care. </ns5:p> <ns5:p/> <ns5:p>We estimated the lifetime health and financial costs are notably higher for people with both severe mental illness and diabetes compared with having just one of these conditions. Most individuals with both conditions will face serious complications, especially kidney disease, leading to shorter and less healthy lives and higher healthcare costs.</ns5:p> <ns5:p/> <ns5:p>In the trial, most people attended coaching sessions as planned. However, app use was very low, with most not using it at all. </ns5:p> <ns5:p/> <ns5:p>Interviews showed that participants, carers and coaches valued the one-to-one sessions, but found the written materials and app more difficult due to reading or thinking challenges. Staying on track was hard because of mental health crises, housing issues, and loneliness. Poorly connected health services made care hard to coordinate; support from families varied.</ns5:p> <ns5:p/> <ns5:p> <ns5:bold>Adapting for people with multiple conditions</ns5:bold> </ns5:p> <ns5:p>People with severe mental illness are more likely to live with several long-term health conditions. We therefore developed a broader, flexible support package based on the DIAMONDS coaching model for diabetes and heart and lung disease. We created a guide and workbook to show how this approach can be used for other illnesses. </ns5:p> <ns5:p/> <ns5:p> <ns5:bold>Involving patients and the public </ns5:bold> </ns5:p> <ns5:p>We involved people with lived experience of mental illness in the research from the start. This was mainly through 'DIAMONDS Voice'- a group of individuals with mental illness, their carers, and family members. DIAMONDS Voice helped to shape the research, make sure the study put the needs and views of people with mental illness first, and remained relevant to real life. In 2020 DIAMONDS Voice received a national award, and many other studies have asked for their help. </ns5:p> <ns5:p/> <ns5:p> <ns5:bold>What this means for practice and research</ns5:bold> </ns5:p> <ns5:p>Our research shows the intense daily struggles of people with severe mental illness and the urgent need for more tailored, intensive support.</ns5:p> <ns5:p/> <ns5:p>Even though people used the support package, it did not lead to clear improvements in blood sugar, diabetes self-care or overall health. This suggests such support alone is not enough to overcome the complex challenges of managing diabetes alongside mental illness. </ns5:p> <ns5:p/> <ns5:p>The programme proved that people with severe mental illness, who are often left out of research, can and will take part. By delivering the largest trial of its kind, we helped NHS sites build skills to support this group to take part in future research.</ns5:p> <ns5:p/> <ns5:p>Healthcare staff also gained coaching skills, and the confidence to support people with mental illness, potentially boosting morale, job satisfaction and career progression. </ns5:p> <ns5:p/> <ns5:p>Future care and research should use a "whole system" approach, which combines support for self-care with medication, and at the same time, links to social care services. Newer medications that help with weight loss could also be paired with coaching to sustain the benefits of these agents for people with mental illness. </ns5:p> <ns5:p/> <ns5:p>This “whole system” approach will also be needed for other co-existing health conditions- like heart or lung disease. We have developed a flexible guide to help adapt the support package for these and other conditions. </ns5:p> <ns5:p/> <ns5:p>Given the scale of the health problems faced by people with severe mental illness, further urgent work is now needed to turn these insights into practical support that closes the gap in life expectancy for this group.</ns5:p>