Prevalence of mental disorders in diabetes populations is high, poorly defined and often misdiagnosed. “Depression”, diagnosed without diabetes context by questionnaire diagnosis alone, is hard to distinguish from diabetes distress. In our clinic, in type 1 and 2 diabetes, we reported an independent association between clinically confirmed depression, past and present, and diabetes distress. We also confirmed the reported relationship between diabetes distress and glycemic control (HbA1c).

Diabetes is not just “another chronic illness”. It has complex genetic causes, a diverse population, a bidirectional relationship with depression, and distress is common due to daily diabetes demands with guilt and blame for “non-compliance”.

Successful treatment studies should improve depression/distress, and preferably diabetic outcomes (HbA1c), compared to matched controls. To achieve this, the complex nature of the diabetes population needs to be addressed. Currently, recruitment to diabetes studies is difficult, with few invited people participating and dropout rates > 50%, making study populations unrepresentative.  

Drug, psychotherapy and collaborative care, effective in depression alone, must be tested in diabetes-representative populations. Some studies show HbA1c improvements but most do not. Most successful depression/distress and diabetes studies include contact with empathic practitioners, in accord with diabetes research suggesting educators who build empathic therapeutic relationships, avoid overt criticism, and praise positive behaviour may help avoid or limit depression and diabetes distress (even improving HbA1c).

The desire for “cost effective” management has encouraged self-help, phone apps, on-line and other “no-contact” treatment but for the majority of diabetic people with depression/distress we await scientific confirmation of long-term effectiveness

Clear diagnostic guidelines for depression and distress in diabetes are essential from therapeutic studies in representative diabetes populations. Future therapeutic possibilities include diabetes-specific depression medications, rapid action anti-depressant drugs, and better mental health support, training and referral pathways in primary and secondary care.