 Mae'r ddechrau yn gweithio a'r diabod yma yn unrhyw ar ôl y Ddyddion Tîr. Rwy'n gweld i'r ddigon, ac mae'r dweud o'r ddiddor yn gweithio arall, ond oedd y ddiddor yn ei gweithio ar waith. Rydyn ni'n gofio arweithio i'r ddiddor, ac mae'n gofio'r ddiddor arweithio arweithio arweithio arweithio. Oherwydd mae'n gweithio arweithio arweithio arweithio. I'm going to talk a little bit. First of all, about my work in London, looking at psychosocial factors in young people with type 1 diabetes. Then I'm going to move on and talk a little bit about my work in Pittsburgh, followed by my last stop in Birmingham where I went back to look at young people again with type 1 diabetes and also did some work with one Now, there is a brilliant person that is here, who will get him mentioned later, looking at how we can include South Asians in our research. So first up, what is diabetes? Well, there are three main types of diabetes. I am sure many of you will know this. They all have a common factor, and that is that the pancreas does not produce any insulin any more. i'w ni'n siwn i diabetaeth, y panchrist yn ni'n ddysgu'r ddysgu'r diabetaeth wedi ei botwch ar draws, dylai'r ddysgu'r diabetaeth gennym panchrist yn gyfrifoedd. A по i mi'n ddysgu'r 2 diabetaeth, y panchrist gallwch i ddysgu'r ddysgu'r diabetaeth, ond mae'n nol o'r hwn, oedd mae'n ddigweon gyflym o'r ym�u. O bobl yn gwneud gyrffyn awaspoddiadau ddysgu'r diabetaeth, ac mae'n gweithio bod yw'r hyn yn ffregnans. A dywedd yn Llywodraeth yn ymddiol yn gweithio'r ffregnans. Felly, yn 2015, y Ffedderau Ffregnans yng Nghymru, dwi'n credu ym mwyaf o'r 11 o'r ffregnans yw'r ffregnans. Ond mae'n ddod yn ddod, mae'n ddod o'r 2040, mae'n ddod o'r 10 o'r 1. Felly mai nid yw'r rhaniaid. Mae cyfredogynau ŵr. Mae'nалоadaeth re academia retreaturol. Mae'n infl富 Squeyr wasgar wych itw'r intyn glyweithio'r rhaniaid. Maen nhw'n c refreshing mewn nesafod. Rhaid am y dyfu rhywledd i'r bydd pethau o'r prynhaabe図 wedi'i gynff receiving arwad o'r tyn arwad y maen nhw i'w trefn amgylch yn rydyn ni wedi chi hyn ac i fyny'ch ond gwneud â'r pethau a'r hyn o wneud ar y dyfu rhywledd a'i rhwng o'r gilyniadau'r brif, ydych chi fwyaf o'r wneud ym lŷch am gweithio yn y rhai ystyried. Y fan hyn e'r defnyddio efallai rydych chi'n ei boc. Mae hwn y gallu ymaeth a'r bydd maen nhw i'r bwysig, ar gyfnod oherwydd ond mae'r cyfnod yn gwybod. Mae'r cyfnod yn 95% eich cyfnod yn cyfnod. Ac rwy'n gwybod yw hyn yn gweithio. Mae'r cyfnod gyfnod yn cyfnod y bydd ychydig ar gyfer 65,000 o'ch gyfnod ac 80,000 o'ch gyfnod y Blwg Hose-testig ar gyfer hynny. Mae'r cyfnod yn gweithio. Mae'r cyfnod o'r cyfnod a llunio'r cyfreithio eich cyfnod like heart disease and kidney failure and blindness, and that's particularly common in those with persistently poor diabetic control, so persistently high blood glucose levels. There's also an impact on psychological and emotional well-being. Feeling overwhelmed, worrying about the future and struggling with self-management. We often call this diabetes-related distress. Of course there's other psychological problems such as depression which, as you know, I'm focusing on today. these are the main symptoms of depression, feeling sad, having a depressed mood, lack of interest or enjoyment in things that you are normally enjoying. Problems with sleeping, lack of energy, problems, lost of appetite and in very more severe cases, recurrent thoughts about death and suicide Roedd ownodd iawn diabeti wedi gweithio gwybod mai yw ni wedi'r diabeti fel gyda'l ymddangos. Mae'n dda ni fod ar-gwisiddol â'r collaig ar y cyfrifau 2013 ac i'w gwirio i'w gwirio i'r dyma at y rhaid o gweithio cyfrifau degolio'r ffordd yn iawn gweithio i yma'n diabeti, ychydig yn y parameters o gyfrifau dros amgyrchu'r diabeti, oherwydd byddwch bod ni fel'r rhaid. a'r llwy o'r llwy fyddion ydy iawn ar fallogi'r drosynfael arda i ni, yn ydych chi'n dechrau iawn ar eu gyflwysoedd. Byddwn i'n ymweliadau'r grwyloed methu eu dżedol, yn ddod y ddysganio mewn cyffredinatwch. Uwch chi'n eich meddwl i'r drosynfael ar gyflwysoedd i ni wneud ar gyflwysoedd.óy gwerthfawr y Llywodraeth Cymru yma ar gyflwysoedd ychydig i wasgofiter yw ddyn nhw y gwneud yw 1.8 miliwn i'n ddyn ni i'r byw. mawr Bond, wrth gwasanaeth y taill i rhan o'r Reddyll hefyd yn ei ddiabetes. Ond rydym i'n gobeithio ym mwyn lleiwyr o'r rhaglenau plant o gyffredig sy'n cael eu ddysgu o gyffredig hefyd. felly mae'n da, dweud, cael y rhan o hefyd i greu hefyd a gennym ni ddim yn ddeinbwynt. Felly yn gweithio'r hwn, mae y diabetes i UK a'r Reddyll hefyd yn alleys. Mae'r rhan o'r dechrau'n sicr o cael ei dderbydd eich diabetes yna. ac fyddwch i wneud o bobl efo phoenu'r ddengylchedg. The American Diabetes Association say that that care should be integrated within a patient-centered model of care and provided to everybody with diabetes. We've got these recommendations from these really important bodies. At the same time, depression often goes unrecognized. There are several reasons for this. Mynd i ddweud o'r ddiabethau a'r clinitiadau i fynd i'r pethau sydd yn gwneud o'r ddiabethau. A dwi'n dechrau o bach o'r Llyfrgellau Llefwyr, oedd yna'r ddweud o'r cyfleidau o'r ddweud o'r ddweud, rhaid o'r ddweud o'r ddweud o'r ddweud o'r ddweud o'r cyflogi. Felly mae'n gallu gwneud o'r ddweud o'r ddweud o'r ddweud o'r clinitiadau, o oed o ddweud o'r clinitiadau, mwy fwy fydiodd o ballach neu broughtoddo i Llyfrgellau neu rhaid i fusiog pethau o'r ddweud. Rhaid o'r ddweud fynd wedi'i singosol ddweud a hynny gweld ei dron yn hynny o fech? Felly ddim iaeth i sgolod am y Com sydd i ddweud berm dysgol fel y cyflogolod oher אפethau sydd gyda hyn pobiddhaff인지ft o ddweud o dechrau o ddweud. Felly mae hyn o'r eu figuredau fifleu peraboddol i fynd datwen nhyn! Onthis slide quite busy just tries to show you some of the symptoms ofletturasion and how they might overlap with symptoms of distress and these are from two very commonly used scales that measure depraudience or symptoms of depression and symptoms of diabetes related distress. And you can see straightaway this one of the symptoms of depression or depressed of depression or depressed mood. And here you can see a similar kind of thing with diabetes related distress so feeling depressed when you think about living with diabetes worrying about the future. This one here problems with appetite, do the poor appetite are over eating and with stress feeling constantly concerned about food and eating so you can see there's an overlap straightaway. And these are some of the comments Caerdyddio. Mae'n gwenyrau inniadol i ddiabetes ac y bod yn hynod yn gywyddiadol. Byddwn ni'n ardynt gweithio'r hwn yn gallu'n mynd i'w gwneud. Dybeithio'r hwn, bufyn, unadol y byddwch i mi ac yn amlwg i ni'n gwneud hynny. Dwi'n gweithio fel cyfoedd ar y gael, dyfyn nhw'n meddwl i'r ddiabetes, ypwyntiau ac ydweud. Felly mae'r hyn yn cym乎 yn ei ddelch yn ymddiadol sydd lefyddo i'w gofyn. Ac ydw i'n rhan o'r bod yn unrhyw gyrsbydd hynny. Y dda'i ddiabeth sydd yw ni'n gwybodion hwn yn ei ddysgu, mae'n hynny'n gallu i gŷnodd ac yn hwnnw gyd yn ddysgu. Yn cael ei gydag i gydag i gydag i gydag i gydag i gydag i gydag i gydag i gydag i gydag i gydag i gydag i gydag i gydag. Yn 2015, Frank Snook i'r colegau i'r cyflawn i ddechrau, ac yn gallu gwneud bod ychynig o blygu o'r gwneud yn ddierbyteidio'r populatio, ..dleidon ni, neu dleidon ni wedi'u wasbudd o drafyn... ..y thysg wybodaeth a phoedd ychydig wedi'i wneud a ddweud 70%... ..o bobl ddweud gennych ddweud, ei ddweud olyn nhw'n ddeuamser. Rhaid i fewn o ddweud 10%... ..o ddweud o'r dydweud nad yr olydon ni wedi'u wasbudd. A bydda'r 15% ar gyfer wahanol... ..angos ei meddwl sydd ar gyfer dyraedd ddweud. a hynny'r gweithio cyfnod 5% a'r gweithio cyfnod ar hyn o bobl, ychydig yn gweithio'r gwaith ac mae'n gyfnod am gweithio, rydyn ni'n gweithio'n gweithio'r gweithio. Mae'r gweithio'r gweithio gweithio eu hynny. Mae'r gweithio'r gweithio'r gweithio'r gweithio i'n gweithio. Down here, you've got the people who report higher diabetes-related distress calls which are indicated by a score above 40, but low levels of depression. This group here are reporting high levels of symptoms of depression but lower diabetes-related distress. And there is this smaller group here, those who report both, so it really does match Frank Sn inicialgyt. Rhaedon yw'r cyfrifod ddod, rhai i mi'n gwneud yng Nghymru. Rhaedon yw'n gwneud eich ffyrdd o'r wirdd ffordd eu gwirionedd yw'r profesyll John Fuller, wedi bod yn ystyried hwn yn gwybod, ond yw'n eich flaenologicolau'r cyfrifod. Yr hyn yn gwybod, rhaedon yw'r cyfrifod yw'r cyfrifod. Yr ymddangos gwirionedd John o'r ymgylchedd yng Nghymru, ac y Hysbeth Mydlysig Cedru, yn y cyflwydoedd relativell ddechrau a fyrdd maen nhw'n hutiadau rydyn nhw. ac mae'n mynd i'n meddwl ygoi gynhyrchu o dysbydd o'r ochr gyffredin, o'r gwyllgor o'r cymru yn y ddych chi ddechrau ac mae'n rhan o'r dyma'r cyhoedd, sy'n gwneud ei wneud o'r hunodol gan oedd cyf foldadau a'r gynnugi a'r llunio. Mae'r gynhyrchu ymgylch yn mynd oedd gripynol fydda'n fod o'r hyn. Byddwn yn gweithio gwybod arall y bydd yn oed, oherwydd yr oedden nhw nad yw rhai ar y cwestiynau yn gwybod ar ganwethaf. Chwiseg, mae'm yn ffrind o'r gwaith yn gyfrifeddau. Ac rwy'n gweithio'n fath o gynnig gael yma. Rwy'n credu chi, ac rwy'n eistedd i'n gweithio i gyd yn ganddo a gydaw'n gweithio'n cyrraedd yn gweithu. Rwy'n gweithio ond byddwn yn cael gynhygr ychydig. a byddai'r cyfnodd yr ystod. Ac mae'n rhaid i'n argymwysgol iawn o'r llallogau ac oedd o gyflymdiadau a rhywbeth hynny o hynny o'r gwaith o ymlog i gyflymdiadau hynny o ffwysgol, hwnnw, a'r cyfnodd, hwnnw, a'r cyflodiad sydd yn ymwysig ac yn ymwysig o'r cyflodiad o'r cyflodiad o'r cyflodiad ac yn ymwysig o'r cyflodiad, oherwydd drwy'n rhoi ymwysig, ac maen nhw'n gweld i'r ddweud o'r ddeiligau ac mae'r gweld i'n gweld i'r ddweud. Mae'n ddweud, mae'n ddweud i'r ddweud. Gallwn wedi cael ei gyrraedd yn ein gweithio ar y cyfnodd gweithio, mae'r rhan i'n meddwl i'w gweithio, rydyn ni'n gweithio chi. Mae'r ddweud i'r dddiniedigau yn ddiogel. Mae'n ddweud i'r ddweud o'r ddweud. I don't know whether that still happens quite so much today when there's more awareness, but I found that quite shocking. They're reporting not wanting to have close relationships. I've learnt not to be close to anyone. I don't want to get hurt. More likely to have a fear of intimacy. This young woman said, I think it's best to only be close to your family, boyfriend wise. I don't think that's too wise. You never know what they might say or do. OK, so I finished my work there and I have to thank John for funding my PhD there and he threatened to make me pay for it if I didn't finish it. So there was a huge incentive there, so very relieved. So off I went to Pittsburgh and I worked there with somebody called Trevor Orchard who's a professor in the Department of Public Health and Epidemiology at the University of Pittsburgh. Now he knew John, so it was one of those sort of serendipitous occurrences where John had been working with Trevor and said I know someone who could do with a little bit of experience in an epidemiological study. So I set off, I'd never flown before and I went out there for a couple of months and I obviously did quite well because as soon as I got my PhD he asked me to come back and he got an American Diabetes Association Mentor-based Fellowship which I had and I started to lead part of this study, the Epidemiology of Diabetes Complications Study and that's a 30 year perspective study of people with type 1 diabetes. So it's 30 years up to now. When I joined it was literally in its first couple of years. So we'd got some baseline measurements looking at quality of life and depression but also measuring heart rates, kidney function, blood glucose levels. So there was quite a mishmash of things that we were looking at. Now Trevor, I think he's on a stadium today as well, he actually used to call, I'm sure he won't mind me saying this, he used to call depression a wishy washy risk factor for coronary heart disease but the more I demonstrated in my research the importance of depression, he's now a total convert, absolutely total convert. So we measured all these things and I particularly wanted to look at quality of life and depression. So this slide shows depression scores, quality of life scores and the number of diabetes complications that the people we were investigating had. Now all these people had had diabetes, this group had had diabetes for more than 25 years so they weren't people with a very short duration of diabetes. And as you can see the more complications people have the higher their poor quality of life scores. I know that doesn't sound very good does it? But the higher the score shows the poorer quality of life. So you can see that quality of life scores were much poorer in those with more complications and also depressive symptoms scores were much higher. And you'd expect that really, the more complications you have the more you would expect them to have feelings of depression and have poor quality of life. But we wanted to look at the different complications and whether there was a difference within the actual different complications that we were measuring on this study. And as you can see here, so again quality of life is in the red, depression is in the brown colour. And as you can see the ones with the poorest quality of life and the poorest depression scores are those who had coronary artery disease. And that includes angina, it includes heart attacks and stroke. So we wanted to look at this a little bit more in depth. So we looked at incidents of coronary artery disease by depression score. So along the bottom you have quartiles of depression. So these would be the ones with the lowest depression scores and these will be the ones with the highest. And we looked at all coronary artery disease, hard end points, so that's the stroke and heart attacks and angina. And as you can see compared with the first quartile the people with the highest depressive symptoms scores were more likely to have coronary artery disease, whether it was all CAD, hard end points, heart attacks and strokes or just angina. But we found it wasn't just those with the really severe levels of symptoms. If you can see here, actually those who had slightly lower levels of depressive symptoms also what a greater risk of having coronary artery disease. So we started to think well it's not just those that are clinically diagnosed, it's lower levels of symptoms that can have a real impact on people's coronary artery disease risk. Okay, I had to come home at some point but as you can see I didn't come home on my own just with my luggage. I came home with a different bit of luggage, my bundle of joy there. Hello, somewhere out there. So my final stop was Birmingham, so I came back to Birmingham and I worked here with two very special people, Professor Tony Barnett and Shanaaz Magal, who's in the audience. I am so pleased that you're here today, I know I'm embarrassing you. I learnt so much from Shanaaz when I was working at Heartlands Hospital. I couldn't have done my research without her and I really, she told me like it was all the way through. She kept me in order and she really educated me in my research. Tony Barnett as well, absolutely amazing person, really, really supported my research. So thank you very much to both, I'll stop embarrassing you now. So I got an R.D. Lawrence Fellowship, just kind of got it, you know, as you do, from Diabetes UK. It was the first R.D. Lawrence Fellowship from Diabetes UK that was funded for a psychosocial project. So I was really proud of that, quite shocked really. And what I wanted to do, I wanted to look at stressful experiences and glycemic control by diabetic control. Again in young adults with type 1 diabetes. So I wanted to go back and look again at what was happening with these young people. But this was a different cohort, this was in Birmingham in a much more deprived area actually than even the one I'd been working in before. And I recruited these young people through Birmingham Heartlands Hospital Diabetes Centre. And again I sat them down and did in-depth interviews to look at stressful life events over time. And I also measured their blood glucose levels because I wanted to see if there was a relationship between the two. And I divided my stress measurements into negative life events and difficulties, which I called severe personal stressors. So interpersonal conflict, separation, death of a close tie, divorce, those sorts of occurrences. And then positive life events, for example a promotion at work, passing exams, becoming engaged. And these were young people. So there was a lot going on in their lives. And I actually didn't expect to find quite so much going on. And this slide, I know it looks quite old but it was made quite a while ago. And this slide shows four groups of young people. Those whose blood glucose levels improved over time. Those whose blood glucose levels remained fair. Those whose blood glucose levels remained poor. And those who had a deterioration in their blood glucose levels. Now as you can see, for those whose blood sugar levels improved, they were much more likely to report positive life events. So no severe life events, just positive life events. And you can see down here, they didn't report any other kinds of stress. Conversely, this end you can see for those who deteriorated, they were more likely to be reporting severe personal stressors, but no positive stressors at all, no positive life events. So it's quite stale. So how does that work? What are the relationships between stress and diabetic control? Well we know there might be a physiological pathway between stress, where there's a cortisol release, and we know cortisol does inhibit the action of insulin, which would lead to poorer blood glucose levels. But we also think there's an indirect effect. So here if you have stress or depression, or indeed diabetes-related distress, we know you're more likely to have a poorer diet, exercise less, perhaps not take your medications as well. And this was something that we found at Birmingham Heartlands in another sample actually. You might have poorer sleep patterns, and you might not cope so well. And in fact in our young people, they reported coping with their stress by denying, just not actually getting to grasp, getting to grips with their stress and how they might deal with it. So we think that's the pathway. So from stress, depression and distress, through these other factors, these other psychosocial factors, leading to poor diabetic control. And Sarah here, who's 22, this is one of the quotes from her. When I feel unhappy, I can't see it all from there, excuse me, when I feel unhappy, I don't eat, I don't inject, whenever I'm miserable, I lose my appetite. I'd skip a meal, not inject, not test. Usually I test four times a day before my injection and a meal, but if I think the results are going to be bad, I won't test. That's a very good example of what we were finding in our study. So we knew that there were high rates of depression. We've done other studies at Heartlands, and you're smiling, aren't you? We knew that there were high rates of depression in the wider patient population at the Diabetes Centre at Heartlands. And when we asked them, a third of them wanted access to psychological services if they were available. We worked hard and pushed and pushed, and we ended up with a psychology service that was established within the Diabetes Clinic. And that was one of the very, very few services that were, so that there was this multidisciplinary team working with the person with diabetes to cover all the different aspects of their care. But we knew there were still challenges within the Diabetes Clinic for those who had language or literacy differences. And there were other challenges coming up for me down there. I've always had to embarrass you as well. So I wanted to do some research working with South Asian communities in Birmingham. Now these communities, South Asians in general, are up to six times more likely to have diabetes. They're more likely to have poor control. They have a higher complication rate. And their mortality rate is nearly four times the average. So it's really, really important that we find out what's going on and how we can support these young and old people. And in the Birmingham catchment area, about 20% of the population are from Pakistani or the Bangladeshi communities. And in the Pakistani community, the spoken language is mainly mirpuri, which doesn't have an agreed written form. The written form is Urdu, but for mirpuri there isn't a standard written form. And for Bangladesh, the spoken language is Saleti, which again does not have an agreed written form. So we wanted to be able to think about these individuals and think about how we could find out more about their experiences. So, and we knew that in research, South Asian individuals who had problems with literacy or language were so often excluded from research. So we knew their voices really weren't being heard. And there were two aspects to this in research. Before anybody can participate in research, we have to get informed consent from them. So it was straight away there was a barrier. We give them written patient information sheets before they come and take part in a study. And so, of course, if their language is an only spoken one, straight away you can see we have problems. And then even if we get informed consent, actually developing culturally applicable ways of finding out about psychological and emotional wellbeing is yet another challenge. And it was great at the time because many of us wrote a report which was presented to the House of Lords on recommendations on how we could prioritise diabetes research for people from South Asian communities. Well, obtaining informed consent really isn't that difficult. A lot of studies, when we're gaining access to members of communities, regardless of whether they have literacy or language difficulties or not, quite often we just knock on the doors. We just find out what's going on at grassroots level. Or we do what's called snowballing. So we might recruit one person and then that person might know somebody else who might want to take part and so on and so forth. We were very lucky because we were accessing individuals who had already participated in a study at Birmingham Heartlands Hospital called the UK Asian Diabetes Study. Now, when that study was going on, one of the things that we were trying to find out about was knowledge of diabetes. So each participant was asked to complete a knowledge questionnaire. But what they were doing was, they were actually saying to the Asian link worker or whoever was helping them complete the questionnaire, oh, you fill it in, you know better, you know more about diabetes than me. So we weren't actually finding out how much knowledge they had. So that's really where I came in and started to work with Shanaaz. And we wanted to try and get more people who had literacy and language difficulties. We wanted to get them more into our research. So we started ringing these people up or grabbing hold of them in clinic and asking them if they'd like to take part. And to ensure that we actually provided them with the relevant information, we asked them about their literacy skills, what language they spoke at home and what would their preferred language be if they could choose any language to do there to take part in the research. And then we gave them audio recorded information to take away. And we also gave them the written sheet because we knew some people might go home and have a relative want to read the information as well. So we were giving them both. And then we took audio recorded consent before they participated. So once they said they were happy to take part, we pulled them in and we got them to sit and listen to that audio again with us and ask any questions. And then we recorded their consent by sitting them down and asking them to say their name and the date and that they were happy to participate. And then they took one copy of that recording away and we kept the other. And this quote shows how acceptable that way of doing things was. This person said, I did listen to your information audio and read the sheet in Bengali as well. I found the audio went excellent. It was simple. You use very simple Saleti terms. I can read Bengali but sometimes it's difficult to get the harder terms. You know, we feel comfortable in Saleti. So we knew that we were on the right track and what we were doing was really helping get those people on board that we knew hadn't had their voices heard up to that point. So once we'd got everybody in and signed up for the study, we wanted to start developing culturally applicable ways of collecting data. And there were two parts to this. There was the initial part, which is the EMIC part, where we wanted to understand culturally specific ways of thinking about or experiencing depression. And then we wanted to take that understanding to consider an existing depression tool so that we could adapt that so that we could ensure that it really did have the accurate meaning. So we set up focus groups and we asked them to describe their symptoms of depression, how they would describe depression or low mood. And these are some of the comments that we had. Bad mood, off mood. You're so down as if you cannot do anything. Joylessness. Now, I think joylessness is a really brilliant way of describing feeling low, feeling depressed. I just found that. I mean, I wish that was on our depression questionnaires, let alone ones we developed for other languages. But they also reported somatic symptoms or feelings of physical pain. So the feeling of pain or tiredness that you can't explain. You can feel pain, but it's difficult to explain to others. A feeling of heaviness in your heart, a lot of pressure in the head. And these were the things that we weren't actually asking. When we were asking anybody from different communities other than the white Caucasian population in the UK, these were just not being asked about. And I think this is great. This is something that really reminds me about what we're doing. This definition that they call, there's differences between posh and conversational language. You know our conversational language is different than that of written form. Specifically, our Cileti dialect is totally different. You're asking the question in Bengali and then explaining it in Cileti. And this was during the focus groups when we were looking at these questionnaires and we were saying, well, this is what it says in Bengali. Does that make sense to you? But then having to explain it and discuss it in Cileti so that we knew that we could really get to groups with how they were feeling. So the next step was after getting that understanding we wanted to use that to develop a culturally appropriate version of the PHQ-9, the Patient Health Questionnaire. Now this is something that's used in all general practices. There's two initial questions that are asked and if you say yes to either one of those then you're asked to complete the other questions. And those with high scores on this instrument are theoretically then referred to any psychological support that's available. So because this was used in all general practices so we knew that our participants would probably be coming across it whenever they met with their GP. This was the one we really wanted to get to groups with. So we started developing this using that the information already gained and it went back and forth and back and forth so we would develop an audio version we would record it and then we would take it back to the focus group and they'd say we really haven't got that quite right. This needs to change, this needs to change. It was a very extensive and quite a long process and then when they were happy with them we wanted to test them out. So for those who are able to read and write either Bengali or Urdu, we asked them to complete a standard self-complete paper and pencil version of the questionnaire although it was adapted with the different terms. I must say that. For those who weren't able to read or write to actually try out a partially assisted collection of the data. So we asked the specialist nurses and the researchers to actually sit with the participant and read out the questions and the participant had a colour coded response sheet and they were in green and the light of the shade with a lower level of symptoms was very dark, colour green which was the more severe symptoms so that they could indicate on this just how they were feeling. When I first tested this out I put it on really fancy paper really solid fancy paper and then I realised when I got there that actually the burrows weren't working on it because it was so fancy it just wouldn't, unless you really, really did it hard. So that was my first lesson. The final test was to look at an independent audio collection again using the colour coded response sheet but on a not so posh piece of paper. So they completed these and then they gave us feedback and they said which one they preferred and many of them really liked the independent audio collection. They were happy to put their headphones on and to do it on their own and they said it gave them a real sense of privacy. They didn't matter whether they felt tearful whether they felt like really couldn't get the words out it was done in a private way. So we knew that was a really good way of collecting that data and finding out about people's feelings. But other people said they liked sitting there with somebody. They liked sitting and talking about it and completing the questionnaire with somebody. So really as I've put here no one size fits all and perhaps you should be offering a choice of methods. Now that is really time consuming and I'd be very interested to hear how we can speed that up in future and how there might be better ways now of trying to do that so that people don't feel pressurised to ask those questions very quickly have a quick response and move on because sometimes that does require a lot of thought. And sometimes it's not really about questionnaires it's about sitting and listening. Okay well I'll confess it wasn't just about three cities. Well it was originally and then I thought I can't I just can't miss the opportunity to talk about this study and many of you have heard about this already. This study's been going on for a couple of years now. It's the international prevalence and treatment of diabetes and depression study. Thank goodness for acronyms it's the Interpret DD study. And this is a study that was set up under the auspices of the Dialogue on Diabetes and Depression. And this person here Professor Sartorius was the person who dragged me into this originally and Professor Nowan who's sitting here you got dragged in as well didn't you for our sins. And it's an international longitudinal study and we're looking at what happens to people who have both diabetes and depression. And we're looking at what their pathways to care are. And in each country where else we're inviting 200 adults with type 2 diabetes to participate. And each of these people undergo a clinical interview to measure depression and also complete different scoresheets, so depressive symptoms sheet, diabetes related distress questionnaire but we also ask them about where they live, if they're married and the number of children they have so we get some context from these people as well. And then we are following them up. So it does look like we're taking over the world really doesn't it we've got a lot here and a lot there. But we have not got sites in the US or Australia and this was deliberate. Most of the research up to now has taken place in those parts of the world so we wanted to go to places where there was very little data if any at all and find out what was happening there. And I must say that this study is nearly completely unfunded. Each country has a psychiatrist and a dipertologist as co-investigators and they are doing this work they're recruiting these people and interviewing them and editing, collecting the data entering the data with no funding at all. Which I just think is incredible and I don't think it would happen in the UK. So yeah, so there's 20 sites and there's about 4,000 participants at the moment. And we can see straight away from our work that there are some real challenges in terms of care. We asked all our sites whether they were any national guidelines for the care of people with both diabetes and depression because there are international guidelines there are American Diabetes Association guidelines in our country there are diabetes UK ones but in a third of the countries in our study they said there were no national guidelines and actually for those who had them it was just impossible almost to put them into practice they didn't have a standardized care pathway, different people were making the diagnosis and then following that on with different professionals intervening later on. Now in our study when we looked at this and when we did a clinical interview on everybody in our study we then went back and looked at their medical records their diabetes clinic medical records and actually apart from a handful of individuals there was no mention of any depression any other emotional or psychological problems in their notes so there was no there was no joined up care perhaps there was no identification or understanding of those problems and it may well have been that they just weren't reported as I said earlier of course some people don't like to admit that they have psychological problems they feel this is a stigma attached to having depression but the problem is is that if they're not identified and it's not recorded then they do go untreated so as we start to move through our study we're going to be looking at hopefully identifying best practice for care we've started looking at the baseline data and we know that those people who have major depressive disorders are clinically significant as it's called level of depression we know those are the people who are more likely to have high diabetes related distress but also to report a previous episode of depression so clearly those people are not being identified are not being followed up and are still coming back having those problems so we hope now we've got some follow up data I smile like this that we are going to be able to to start looking at that data and hopefully identifying best practice and that actually may be different depending on the context what we find is works best in Russia might be completely different for what's working in Argentina so it's really important to get that context and really understand what's going on at that grassroots level okay I'll be pleased to see that I'm going to summarise now and take questions so to summarise mental health problems including depression we're up to three times more common excuse me in people with diabetes sorry stress and depression we now can have a serious impact on diabetic control and if there is consistently poor diabetic control then that increases the risk of diabetes complications so they're more likely to have problems with their eyesight problems with their kidneys and so on so it's really important that we detect that so that we can do something about it but the problem is symptoms of depression are often unrecognised or unrecorded and are so untreated you also need to think about whether it is depression whether it is distress or whether there's an overlap between the two because that really does have implications for care as I've shown there are problems in identifying depressive symptoms in South Asian communities particularly the ones we've been working with which is the Pakistani community and the Bengali community but we know there are ways of overcoming this I think it's still in its infancy we know that there are problems but the ways of identifying those problems is still a bit of a challenge but we know if we recognise those symptoms of depression if we find out how people are feeling then we can offer more appropriate care we can improve their self-management and so overall health and quality of life now I'd just like to thank a few people not everybody is on here because I couldn't get all the stars on it took me ages to do this for those who know me I'm not very good on PowerPoint but these are some of the people that have been absolutely integral to my career some of them are here today as I said earlier Shanaz couldn't have done a lot of my research without you John and Tony people that absolutely just loved me from the minute I started at the OU like Moira who's here today people I work with now such as Arian Owen who was really inspiring and keeps me in line quite a lot so all these people Tom who isn't here today Julie I know is here today very inspiring wonderful colleague of mine and this person here Olya now I don't know where she is but Olya was the person that's put me on this track it's entirely her fault that I went to work with John Fuller and so on she pushed me into applying for a job with John and that was the beginning of the story so wherever you are Olya thank you very much and thank you all for coming and as you can see there are some refreshments after the question and answer session so thanks very much Thank you Thank you