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How do we recover from COVID‐19? Helping diabetes teams foresee and prepare for the psychological harms

The scale of the COVID-19 pandemic is entirely unprecedented. However, as depicted in Fig. 1, evidence from previous large-scale disasters indicates that following a first wave of admissions and deaths from COVID-19, there are likely to be subsequent waves of people with acute care needs worsened by delayed hospital treatment, and people with long-term conditions whose routine care has been disrupted [1]. People with diabetes are likely to constitute a large proportion of those with acute second- and third-wave care needs, and in many cases, management of their condition may also have been negatively affected by lockdown.

The scale of the COVID-19 pandemic is entirely unprecedented. However, as depicted in Fig. 1, evidence from previous large-scale disasters indicates that following a first wave of admissions and deaths from COVID-19, there are likely to be subsequent waves of people with acute care needs worsened by delayed hospital treatment, and people with long-term conditions whose routine care has been disrupted [1].
People with diabetes are likely to constitute a large proportion of those with acute second-and third-wave care needs, and in many cases, management of their condition may also have been negatively affected by lockdown. Many diabetes services are beginning to create recovery plans to restart clinics (albeit in a modified format) in order to mitigate risks. However, beyond the second and third waves there will be a longer-lasting wave of issues caused by the psychological effects of the pandemic and subsequent quarantines [2,3]. This paper aims to briefly outline some of the primary psychological risks, and steps that can be taken by diabetes teams to plan for and mitigate their effects.

Individual level risks
The psychological risks posed by COVID-19 can be categorized into direct psychological harms, such as increased anxiety, bereavement and trauma symptoms, and indirect psychological harms. Indirect psychological harms occur through the economic impacts of the pandemic and resulting losses of employment, financial security and housing, along with the detrimental effects of disrupted education and enforced inactivity. These harms are already being observed [4], and will disproportionately affect some of the most vulnerable in society [5], such as people with a learning *Correspondence to: Rose Stewart. E-mail: rose.stewart@wales.nhs.uk ª 2020 Diabetes UK disability, people with severe mental illness, those living in deprived areas and young adults. Many in these vulnerable groups already have poor diabetes outcomes [6][7][8]. Diabetes teams will need to be mindful that the proportion of people with significant psychological needs in their clinic is likely to increase over the coming weeks and months, as is the severity of issues experienced by people with pre-existing mental illhealth, and these issues will impact negatively on diabetes outcomes [9]. Awareness of psychological issues, and competency in basic assessment and empathic exploration of issues will become even more essential within diabetes teams. Close links with mental health and social care services will be crucial to reduce risks and ensure adequate support for those who are struggling.
Furthermore, there is evidence of increased numbers people being diagnosed with type 1 diabetes in severe diabetic ketoacidosis during the pandemic [10]; due in part to the public's avoidance of GP surgeries and hospitals for fear of contamination. This puts people at significant risk of a poor adjustment to living with their diabetes because of the traumatic start [S1], and post-diagnosis support is likely to be reduced due to decreased availability of diabetes teams and peer support groups. It may be of benefit to proactively identify those diagnosed with diabetes during COVID-19 as being particularly vulnerable to developing psychological issues, and to offer them fast access to specialist psychological care to reduce the impact of any longer-term detrimental effects.

Healthcare professional specific risks
The pandemic has placed incredible demands on healthcare professionals. Many will have worked additional hours and/ or in high-risk areas, and some will have experienced people on their clinical case-loads becoming severely unwell or dying from COVID-19. This work will have been in addition to having to deal with the personal effects of COVID-19 such as becoming infected themselves, worry about vulnerable family members, and living with the effects of lockdown.
In their document on the psychological needs of healthcare staff during the COVID-19 pandemic [S2], the British Psychological Society describe three phases of response to a crisis and corresponding psychological and emotional states (Table 1).
At the time of writing, most teams will have been through the preparation phase and be part way through the active phase. It is only later in the recovery phases that the longterm psychological impacts of the pandemic are likely to be seen; and global data are now beginning to report increased prevalence of psychological issues in healthcare professionals [S3]. Diabetes teams are likely to become increasingly busy post COVID-19, so the recovery phase may be delayed significantly. Leadership will play a key role in the management or exacerbation of the psychological fallout from COVID-19. It is essential that managers are alert to signs that their staff may be struggling, and wherever possible give staff time to safely 'decompress' from what they have been through. This will benefit both staff and the people that they care for.
Psychological professionals can play a key role in the support of people with diabetes and diabetes teams, both during and after the pandemic. In many services those working in clinical health psychology departments have been redeployed from their usual areas of work to set up or bolster existing staff support services to ensure that staff working at the frontline of COVID-19 are provided with adequate psychological care. While this is certainly essential work, long-term planning needs to ensure that diabetes psychologists are enabled to return to their original area of work without compromising the availability of COVID-19-specific support services. Additional funding may be required to fill gaps in psychological care (both new and pre-existing), and should ideally be agreed nationally to prevent service inequalities.
There may be positives from this situation. The surge in increased activity and creativity shown by teams across health services in the face of the pandemic has demonstrated the power of working outside professional silos with a shared goal, and of the value in recognizing the holistic needs of both people with diabetes and healthcare staff. If this way of working can be carried forwards beyond the pandemic, it will be to the benefit of everybody in the diabetes healthcare system as together we recover from COVID-19.

Funding sources
None.

Competing interests
None declared.