INVITED COMMENTARY

Diabetes and Depression

Cathy E. Lloyd, PhD

Address
The Open University, School of Health and Social Welfare,
Walton Hall, Milton Keynes, MK7 6AA, UK.
E-mail: C.E.Lloyd@open.ac.uk
Current Diabetes Reports 2002, 2:465466
Current Science Inc. ISSN 1534-4827
Copyright 2002 by Current Science Inc.

Clinical and research experience tell us that diabetes

has both a daily and long-term impact on individuals,
both physiologically and in terms of the psychosocial
effects of the disease. These can include effects on mental
health, for example, anxiety and depression, self-esteem,
self-health care, day-to-day living activities, and overall
quality of life [1].
Compared with the general population, individuals
with diabetes have a much greater risk of developing symptoms of depression, although the reasons for this remain
unclear. International studies have estimated that the
prevalence rate of depression may be at least twice the
rate in the general population [2]. Clinical depression
in individuals with diabetes may recur more frequently,
episodes may last longer, and the long-term recovery rate
may also be much lower. This increased risk for depression
is thought to be similar in individuals with type 1 and
in those with type 2 diabetes, although, like the general
(nondiabetic) population, women are more likely to
report symptoms of depression compared with men [2].
Depression may be linked to glycemic control, either
through hormonal dysregulation, or more likely via the
negative effect on diabetes self-care behavior, including
lower levels of physical activity, increased smoking, as
well as poorer blood glucose monitoring. In a recent metaanalysis, Lustman et al. [3] observed that depression was
associated with hyperglycemia in individuals with either
type 1 or type 2 diabetes, although the directional nature
of this relationship was still unclear. It is now well established that poor glycemic control is associated with an
increased risk for developing the complications of diabetes, including diabetic retinopathy, peripheral neuropathy,
and renal problems. Risk of heart disease and stroke is also
increased, but these and other diabetes complications may
be further affected by depressive symptomatology [4].
Whether psychological distress increases the risk
of developing diabetes or its complications, or whether
diabetes or diabetes complications increases the risk of
depression, or whether these two are merely coincidental,

they have important consequences for both the individual

with diabetes and the health care professionals involved in
their care. Despite its higher prevalence, depression in
diabetes seems poorly recognized. US studies estimate
that only one third of people with diabetes and major
depression are identified and treated [5]. There may be
both under-reporting and underdiagnosing of depressive
disorders in individuals with diabetes, because psychological problems are often seen as secondary to the
diabetes by both patient and physician.
Patients may not consider their depressed mood to be
of relevance to their diabetes treatment, have no knowledge or low expectations of therapy effectiveness, or may
be reluctant to discuss their mood disorder with their
doctor [5]. Anecdotally, we have observed that in the
United Kingdom it is often seen as inappropriate to report
any kind of emotional or psychological problem,
with these types of symptoms taking second place to the
physical symptoms of diabetes during clinical care. In one
study, many individuals reported that this was the first
time they had been able to describe how they were feeling
without fear of stigma or lack of understanding [1].
There may be a confounding of symptoms of diabetes
with symptoms of depression (eg, fatigue, changes in sleep,
weight, and appetite), which may lead to underdiagnosis
of depression. However, although there may be some
overlap between the symptoms of depression and some of
the physiologic symptoms of diabetes, these symptoms do
not significantly compromise the sensitivity or the validity
of the diagnosis of depression, either when using criteriabased diagnostic symptoms (ie, Diagnostic and Statistical
Manual IV diagnoses) or when using screening tools
such as the Beck Depression Inventory. Case-finding
instruments, such as the Center for Epidemiologic Studies
Depression scale, have also proven to be effective in
screening for depression in primary care settings, and to be
suitable for use in people with diabetes.
Research has shown that some screening tools
can easily be used in a clinical setting by health
care professionals and their patients [1]. In one study, a
short 14-item questionnaire was used and 96% of
patients who were approached agreed to complete the
form [1]. In the same study, one third of respondents
reported that they were interested in receiving counseling
or psychotherapy; these individuals were significantly
more likely to report symptoms of depression or anxiety
at the same time.

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Invited Commentary

It is known that those patients with diabetes are more

likely to suffer from chronic depressive episodes or experience a relapse [6]. Depression in individuals with diabetes
may be especially severe due to their interaction at the
neuroendocrine level [6]. However, not all individuals
with diabetes suffer from clinically recognized levels of
depression; some may experience lower levels of mood
disturbance, or mild levels of depressive symptomatology
[1]. These levels of depressive symptomatology are
nonetheless important; a recent report from the Pittsburgh
Epidemiology of Diabetes Complications Study showed
that even relatively low levels of symptomatology
were associated with an increased risk of developing heart
disease [7]. Although literature on the treatment of
depression in people with diabetes is still scarce, there is
some evidence that cognitive behavior therapy and antidepressant medication are as effective in those with
diabetes as in those without diabetes, with additional
beneficial effects on glycemic control [6].
Given the high prevalence of depressive symptomatology in individuals with diabetes, further research is clearly
warranted to establish the reasons why this is the case and
the factors associated with this. International comparisons
are useful because they may highlight both similarities and
differences in the rates of psychological morbidity as well
as suggest possible differences in potential explanatory
variables. Important questions include the following:
1) Why is depression more common in individuals with
diabetes? 2) What factors are associated with this high
prevalence? 3) Why are some individuals diagnosed
whereas other are not, and what happens to those who are
diagnosed with depression? 4) What factors are associated
with its remission? Under the auspices of the Psychosocial
Aspects of Diabetes Study Group, a group of European
researchers have developed a protocol that aims to
investigate these important questions. Countries as diverse
as the United Kingdom, Holland, Germany, Croatia, and
Slovenia are currently involved in this research initiative,
aptly named the European Depression in Diabetes
Study Group.

In summary, depression and depressive symptomatology are both more common in those with diabetes
compared to those without, but can be treated effectively
in many cases. Depression may have a detrimental effect
on glycemic control; however, not all those who are
depressed have high blood sugar levels, and many diabetic
patients who are depressed manage their diabetes well. It is
important for the health professional working with the
diabetic patient to recognize that diabetes and depression
may go together but that they are separate conditions
both of which must be treated aggressively in order to
maximize the benefits to the person with diabetes.
Recently, there has been a surge of interest in psychological and psychosocial aspects of chronic disease, and
research in depression and diabetes has gained greater
recognition. This has been in light of the evidence that
does exist of the serious impact of psychological problems
on individuals with chronic conditions such as diabetes,
their impact on day-to-day living, and the high costs to
both the individual and society.

References
1.

2.

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4.

5.

6.
7.

Lloyd CE, Dyer PH, Barnett AH: Prevalence of symptoms of

depression and anxiety in a diabetes clinic population.
Diabet Med 2000, 17:198202.
Anderson RJ, Freedland KE, Clouse RE, Lustman PJ: The prevalence of comorbid depression in adults with diabetes.
Diabetes Care 2001, 24:10691078.
Lustman PJ, Anderson RJ, Freedland KE, et al.: Depression
and poor glycemic control: a meta-analytic review of the
literature. Diabetes Care 2000, 23:934942.
De Groot M, Anderson RJ, Freedland KE, et al.: Association of
depression and diabetes complications: a meta-analysis.
Psychosom Med 2001, 63:619630.
Lustman PJ, Clouse RE, Alrakawi A, et al.: Treatment of
major depression in adults with diabetes: a primary care
perspective. Clin Diabetes 1997, 15:122126.
Rubin RR, Peyrot M: Psychological issues and treatments for
people with diabetes. J Clin Psychol 2001, 57:457478.
Kinder LS, Kamarck TW, Baum A, Orchard TJ: Depressive
symptomatology and coronary heart disease in type 1
diabetes mellitus: a study of possible mechanisms.
Health Psychol 2002, in press.