Jeffrey Gonzalez, PhD, is a co-author of the “Psychiatric and Psychosocial Issues among Individuals Living with Diabetes” chapter in the NIDDK publication Diabetes in America, 3rd Edition. Here, he discusses how depression and diabetes distress affect people living with diabetes and what health care professionals can do to help their patients.

Q: Why should health care professionals be concerned about depression in patients who have diabetes?

A: Health care professionals should be aware that depression is more common in people with diabetes, and, when it’s present, it’s associated with poor health outcomes in people who have diabetes.

A 2001 meta-analysis suggested that depression could be about twice as common in people with diabetes as in people without diabetes, and that's similar to what's been found in other chronic illnesses. In 2008, some colleagues and I did a meta-analysis of the literature that found depression was consistently associated with poor diabetes self-management. Other meta-analyses have found consistent associations between depression and hyperglycemia, increased risks of diabetes complications, and even early mortality.

Q: What is diabetes distress and how is it related to depression?

A: In the medical field and in many conversations around feeling down or blue, we often use the concept, “clinical depression.” That’s partly because the Diagnostic and Statistical Manual of Mental Health highlights depression as a mental health disorder that can be diagnosed based on certain symptoms. However, it’s hard to draw the line between clinical depression and emotional reactions to stressful situations. Big events, such as loss of a loved one or loss of employment, can cause emotional responses and symptoms that are very similar to those of depression, at least over the short term.

One way that depression and diabetes distress are different is that diabetes distress is not thought of as a mental illness. Diabetes distress is a construct proposed by researchers to describe the emotional response to living with diabetes, a life-threatening illness that requires chronic, demanding, self-management. However, tools used to screen for diabetes distress don’t ask only about emotions. They also ask about problems people have with their diabetes, such as a lack of social support, a poor relationship with their doctor, or difficulty accessing health care. Diabetes distress captures a person’s experience with the problems associated with diabetes.

Diabetes distress is much more common than clinical depression among patients with diabetes. Recent literature reviews suggest that between 30 and 40 percent of adults with diabetes are likely to report significant levels of diabetes distress over time.

Q: How is diabetes distress related to diabetes treatment adherence and self-management?

A: A body of research shows that people who report more diabetes distress are also more likely to report more problems with self-management and medication adherence and may also have higher blood glucose levels. Some evidence suggests they may also be more likely to experience hypoglycemia and fear of hypoglycemia, which can affect their ability and willingness to take their medications

Diabetes distress and everyday diabetes management are closely linked, and it’s probably a two-way street. People feel stressed and have emotional responses such as feeling down or hopeless. Then, they may avoid dealing with their diabetes and experience setbacks, such as hypoglycemia, hyperglycemia, or complications. Those setbacks further contribute to their distress, and it can become a vicious cycle.

Q: Among people with diabetes, do some people have a higher risk for depression or diabetes distress than others?

A: Yes, some people with diabetes appear to have a higher risk.

• Women report more depressive symptoms and more diabetes distress than men.
• People who report symptoms of depression are more likely to experience diabetes distress, and vice versa. That might have to do with difficulty drawing the line between clinical depression and feeling stressed.
• Younger middle-aged adults report more diabetes distress than older adults.
• Both diabetes distress and depression are associated with factors related to the severity of illness, such as hyperglycemia or complications. Distress or depression could lead to poor blood glucose management, but it could work the other way as well.
• People with type 2 diabetes who take insulin seem to have a higher risk for distress or depression than those who take oral medications. This probably isn’t just an effect of the insulin. People with severe illness and poor blood glucose control are more likely to take insulin.
• The prevalence of distress and depression may be higher among people with type 2 diabetes than among those with type 1, but more data are needed.

Q: How can health care professionals address depression or distress in patients who have diabetes?

A: Addressing the emotional side of living with diabetes should be part of comprehensive diabetes care. Emotional distress of some kind is going to be more common in patients living with diabetes and may be caused by some of the stresses related to diabetes.

Providers can ask questions about how people are doing, how they’re feeling, and what aspects of their diabetes are causing stress. Providers can also acknowledge and normalize the idea that diabetes distress is common and could occur sometime in the course of the illness, perhaps with the onset of complications or with life changes that make following a diabetes self-management routine more difficult.

Diabetes distress can cause people to feel stuck and to benefit less from their diabetes treatments. Providers should look out for people experiencing diabetes distress and offer support by talking with patients about distress and encouraging them to think about ways to better manage their distress. Providers may also be able to make the diabetes treatment regimen less burdensome for the patient.

It’s also important for providers to identify mental health professionals who can collaborate as part of the care team and provide more specialized help when it’s needed. Providers should think about how to help their patients find someone who can assist with depression or more significant problems with diabetes distress.

Q: Is there anything else that health care professionals should know about depression and diabetes distress in people with diabetes?

A: Depression and diabetes distress can be treated. We know about treatments for depression, from psychotherapy to pharmacological treatments. Diabetes distress seems to respond to many different kinds of interventions, including educational and supportive interventions.

A number of questionnaires are available to help providers screen for depression and diabetes distress in patients. As with any screening tool, the majority of people who screen positive won’t actually have the disorder. Providers need to talk with patients after the screening to further evaluate what's going on. At times, providers may feel they need input from a mental health specialist to make that differential diagnosis and to recommend the most appropriate treatment.

Providers can find more information about screening and monitoring patients for depression and diabetes distress in Psychosocial Care for People with Diabetes: A Position Statement of the American Diabetes Association.

Q: What research is being conducted on the relationship between depression and diabetes?

A: More research in this area is needed. One area of current research is the dissemination and implementation of treatment models that we already know can be helpful.

For example, I’m currently finishing a National Institutes of Health-supported trial that focuses on providing self-management support by telephone to adults with type 2 diabetes who are not at goal with their A1C. This program has been evaluated in a few previous trials, and we incorporated new components to train and support health educators in offering interventions that may be helpful for depression and diabetes distress.

Many studies are addressing how effective treatments can reach a wider number of people who need them, for example through interventions delivered by peers or community health workers. We have a mental health crisis in this country, where our mental health system does not meet the need among patients who are already identified. Screening programs that identify more people who need care will require a workforce and better reimbursements to meet that need. Over the next few years, we’ll see more research on translating expert recommendations into care for depression and diabetes distress that can be replicated in many settings and sustained over time.