Depression and Distress in Diabetes

Diabetes is associated with an increased risk for depression and distress

Written by Amy Hess-Fischl MS, RD, LDN, BC-ADM, CDE

Diabetes, like any chronic disease, is associated with an increased risk for depression and distress. In fact, people with diabetes have a twofold higher prevalence of depression compared with the general population.1,2 Researchers speculate that shared biological and behavioral mechanisms (eg, hypothalamic-pituitary-adrenal axis activation, inflammation, autonomic dysfunction, sleep disturbance, inactive lifestyle, poor dietary habits, and environmental and cultural risk factors) may underlie this relationship.1

Depression and diabetes distress have been linked to worsening outcomes, including poor glycemic control and self-management as well as increased health care costs and mortality.3-5 Thus, early recognition and treatment of depression and diabetes distress are essential to achieving optimal goals in the management of depression and in patients’ overall quality of life. It is important to differentiate between true depression and diabetes distress as these conditions require different management approaches.

Overview: Depression and Diabetes Distress
While “depression” is typically used as a catch-all term for mood symptoms in patients with diabetes, it is important to differentiate between depression and diabetes distress.

Depression is a condition in which patients meet at least five of the Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-5) criterion for major depressive disorder (MDD) nearly every day during the same 2-week period.6 These criterion include:6

Diabetes Distress
Symptoms of distress, or what is often referred to as diabetes burnout, are linked to diabetes and management of this disease. Symptoms may include feeling overwhelmed by the demands of living with diabetes; often failure in following a prescribed diabetes routine; feeling unsupported by friends and family; feeling angry, scared, and/or depressed about living with diabetes; and feeling that long-term complications of diabetes are inevitable.7

In some patients, high levels of diabetes distress can lead to poor self-management and medication adherence, while in others, poor diabetes control can lead to distress.8 In addition, studies suggest that diabetes distress (but not depression or depressive symptoms) is linked to poor hemoglobin A1C levels, illustrating the importance of early detection and intervention.9

Screening for Depression and Diabetes Distress
Tools for screening and diagnosing depression include the 9-item Patient Health Questionnaire,10 Composite International Diagnostic Interview,11 Beck Depression Inventory,12 and the Center for Epidemiological Studies-Depression Scale.13 Experts suggest asking patients about alcohol use, since many people who are depressed self-medicate with alcohol, which also can affect glycemic control.

Because these depression scales are symptom-based and do not link symptoms to a cause, experts believe that many people with diabetes who have depressive symptoms actually have emotional distress rather than clinical depression.9 Diabetes distress may be assessed using the Problem Areas in Diabetes Scale,14  Diabetes Distress Scale,7 and Questionnaire on Stress in Patients with Diabetes-Revised.15

Treating Depression and Diabetes Distress
If screening tools suggest that a patient has depression, a referral to a mental health professional is necessary. In contrast, interventions for diabetes distress can be implemented in an endocrinology practice or primary care setting by endocrinologists, primary care physicians, diabetes educators, or other qualified health care provider.

Psychological and pharmacologic treatments have shown efficacy in treating depression in people with diabetes, but have mixed findings in terms of effects on glycemic outcomes.1 Some studies suggest that the collaborative care model to treating depression in patients with diabetes significantly improves both depression and glucose control.16 Importantly, some treatments for depression (eg, aripiprazole, bupropion, desipramine, duloxetine, fluoxetine, nortriptyline, and venlafaxine) and other medications may affect blood glucose levels; thus, patients should be closely monitored after medication initiation and should be counseled to carefully monitor their glucose levels.17

Diabetes Distress
Psychoeducational interventions focused on improved diabetes self-management are effective for reducing diabetes distress, according to a recent meta-analysis.18 Interventions delivered on a one-on-one basis were significantly more effective than those delivered in a group setting in this study.18 In the REDEEM study, all three of the following interventions significantly relieved diabetes distress and improved self-management behaviors: online self-management program, online self-management program plus diabetes distress-specific problem solving, or a computer-administered minimal supportive intervention.19 Research also suggests that patients’ perceived control of diabetes is an important mediator of emotional distress in patients with diabetes, suggesting another factor to counsel for during interventions.20

(Physician) Healthcare Professional Resources


1.      Holt RI, de Groot M, Lucki I, Hunter CM, Sartorius N, Golden SH. NIDDK international conference report on diabetes and depression: current understanding and future directions. Diabetes Care. 2014;37(8):2067-2077.

2.      Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24(6):1069-1078.

3.      Katon WJ, Rutter C, Simon G, et al. The association of comorbid depression with mortality in patients with type 2 diabetes. Diabetes Care. 2005;28:2668–2672.

4.      de Groot M, Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. Association of diabetes complications and depression in type 1 and type 2 diabetes: a meta-analysis (Abstract). Diabetes. 2000;49(Suppl 1):A63.

5.      Sumlin LL, Garcia TJ, Brown SA, et al. Depression and adherence to lifestyle changes in type 2 diabetes: a systematic review. Diabetes Educ. 2014 Jun 17. pii: 0145721714538925. [Epub ahead of print]

6.      American Psychiatric Association. Diagnostic ad Statistical Manual of Mental Disorders, Fifth Edition. 2013.

7.      Polonsky WH, Fisher L, Earles J, et al. Assessing psychological stress in diabetes: development of the diabetes distress scale. Diabetes Care. 2005;28:626-631.

8.      Gonzalez JS, Peyrot M, McCarl LA, et al. Depression and diabetes treatment nonadherence: a meta-analysis. Diabetes Care. 2008;31:2398-2403.

9.      Fisher L, Mullan JT, Arean P, Glasgow RE, Hessler D, Masharani U. Diabetes distress but not clinical depression or depressive symptoms is associated with glycemic control in both cross-sectional and longitudinal analyses. Diabetes Care. 2010;33(1):23-28.

10.  Kroenke, K, Spitzer, RL, Williams, JBW: The PHQ-9: Validity of a Brief Depression Severity Measure. Journal of General Internal Medicine. 2001;16:606-613.

11.  Wittchen HU. Reliability and validity studies of the WHO—Composite International Diagnostic Interview (CIDI): a critical review. J Psychiatr Res. 1994;28(1):57-84.

12.  Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J, et al. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:53-62.

13.  Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Appl Psychol Meas. 1977;3:385-401.

14.  Polonsky WH, Anderson BJ, Lohrer PA, et al. Assessment of diabetes-related distress. Diabetes Care. 1995;18:754-760.

15.  Herschbach P, Duran G, Waadt S, Zettler A, Amm C, Marten-Mittag B. Psychometric properties of the Questionnaire on Stress in Patients with Diabetes-Revised (QSD-R). Health Psychol. 1997;16:171–174.

16.  Atlantis E, Fahey P, Foster J. Collaborative care for comorbid depression and diabetes: a systematic review and meta-analysis. BMJ Open. 2014;4(4):e004706. doi: 10.1136/bmjopen-2013-004706.

17.  D’Arrigo T. Depression, distress, and diabetes. EndocrineNews. 2014;8:16-18.

18.  Sturt J, Dennick K, Hessler D, Fisher L. Are experimental interventions to reduce diabetes distress effective? Presented at: American Diabetes Association 74th Scientific Sessions; June 14, 2014; San Francisco, CA: 820-P.

19.  Fisher L, Hessler D, Glasgow RE, et al. REDEEM: a pragmatic trial to reduce diabetes distress. Diabetes Care. 2013;36(9):2551-2558.  

20.  Gonzalez JS, Shreck E, Psaros C, Safren SA. Distress and type 2 diabetes-treatment adherence: a mediating role for perceived control. Health Psychol. 2014 Aug 11. [Epub ahead of print]

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Depression, Distress, and Diabetes