Section 1 – Kathy

Kathy is a 45-year-old lady who was diagnosed with type 2 diabetes two years ago. She comes to the diabetes clinic for review, during which you notice that she appears rather subdued and less willing to interact than usual. When asked how she is feeling in herself, she becomes tearful and says she is feeling low.

Current medication: metformin, atorvastatin, losartan.

No diabetes complications.

Recent results: HbA_1c 65 mmol/mol (8.1%); U&E normal; LFT normal; lipid profile satisfactory; albumin:creatinine ratio < 3 mg/mmol.

Today’s measurements: Blood pressure 145/87 mmHg; BMI 28.7 kg/m².

What clinical condition do we need to consider here?

Section 2

We need to find out more about Kathy’s mood disturbance. This may reflect a recent upset but, if prolonged, might indicate depression.

Kathy says she has been feeling low for at least 3 months. She thinks this has been due to a combination of factors “dragging her down”. She has three teenage children – looking after them and managing household tasks has been demanding, although her husband is supportive and helpful. There have also been increasing pressures in her work as a laboratory technician.

In addition to these psychosocial factors that could predispose to depression, Kathy is concerned about “looking after her diabetes properly” and, in particular, her continuing weight gain.

Is diabetes a risk factor for depression?

Section 3

Yes. A systematic review and meta-analysis found that people with type 2 diabetes had a 24% increased risk of developing depression compared to those without diabetes (Nouwen et al, 2010). The prevalence of clinical depression is around twice as common in people with diabetes as in the general population (Beverley and Gonzales, 2025). A recent systematic review and meta-analysis found odds ratios for the prevalence of depression of 2.1 for type 1 diabetes and 1.76 for type 2 diabetes compared to people without diabetes (Farooqi et al, 2022).

—

It is also noted that Kathy did suffer from postnatal depression – another risk factor for subsequent depression.

What screening questions for clinical depression could you ask Kathy?

Section 4

The “depression identification questions” recommended by NICE (CKS, 2025) are those of the 2-item Patient Health Questionnaire (Kroenke et al, 2003):

• During the last month, have you often been bothered by feeling down, depressed or hopeless?
• During the last month, have you often been bothered by having little interest or pleasure in doing things?

Kathy answers “yes” to both these questions, pointing towards a possible diagnosis of depression. She is referred to her GP for further evaluation for depression.

What additional symptoms of depression in Kathy should you now look into?

Section 5

Ask Kathy about the following (CKS, 2025a):

• Disturbed sleep (either more or less).
• Change in appetite and/or weight (gain or loss).
• Fatigue, lack of energy.
• Poor concentration, unable to make decisions.
• Irritability.
• Feelings of worthlessness or guilt.
• Feeling agitated or slowness of thoughts/movements.

You should also determine whether Kathy has had recurrent thoughts or plans to self-harm or attempt suicide.

A formal depression questionnaire validated for use in primary care (e.g. the 9-item Patient Health Questionnaire) may be used to diagnose depression and assess its severity, although this is not a substitute for clinical assessment (CKS, 2025a).

Kathy reports insomnia, weight gain and fatigue, and admits to feeling indecisive and slow in her daily functioning. She feels she is letting herself down both at home and at work. Kathy denies thoughts of self-harm or suicidal ideation. Significantly, her symptoms have been both pervasive – present throughout the day – and persistent, lasting more than 2 weeks.

Kathy is diagnosed as having moderately severe depression.

How might Kathy’s depression impact on her diabetes care?

Section 6

The coexistence of depression with diabetes (whether type 1 or type 2 diabetes) is associated with poorer diabetes self-management, including the following (Gonzales et al, 2008):

• Unhealthy diet.
• Lack of physical activity.
• Reduced glucose monitoring.
• Non-adherence to medication regimens.
• Missed appointments.

People with type 2 diabetes who are depressed are more likely to have higher HbA_1c values, higher blood pressure and worse dyslipidaemia (Beverly and Gonzales, 2025). As a consequence, they are at higher risk of cardiovascular disease and premature mortality (Katon et al, 2015). They are also more likely to develop microvascular complications: retinopathy, nephropathy and neuropathy (Nouwen et al, 2010).

In people with type 1 diabetes, depression confers a similar picture of adverse metabolic parameters, increased diabetes complications, lower quality of life and increased mortality (Beverly and Gonzales, 2025).

—

Kathy tells you her diet has been “rubbish” and she isn’t finding the time or motivation to exercise. Her BMI and HbA_1c have risen significantly from her last measurements. She has continued taking her medications regularly, however, and has kept up with her diabetic eye and foot screening.

Can depression itself predispose to diabetes?

Section 7

Yes, it can. In the case of type 2 diabetes, the association with depression is bidirectional. Thus, in addition to an increased incidence of depression in people with diabetes, there is a 60% increased risk of developing type 2 diabetes in people who are depressed (Mezuk et al, 2008).

The causative factors here are likely to be poor diet, lack of exercise and lower socioeconomic status, which lead on to obesity and metabolic syndrome. Chronic stress can activate the hypothalamic–pituitary–adrenal axis, such that stress hormones (e.g. cortisol) are generated that have the potential to induce insulin resistance and drive hyperglycaemia (Bădescu et al, 2016).

What other mental health condition, commonly associated with and overlapping with depression, could you ask Kathy about?

Section 8

Anxiety frequently coexists with depression and is characterised by persistent and excessive worry that affects daily function. Fatigue, poor concentration and poor sleep are further psychological features of anxiety, whilst physical manifestations include sweats, tremor, palpitations, nausea, dizziness, and panic attacks (CKS, 2025b). Again, anxiety is more common in people with either type 1 or type 2 diabetes than in those without diabetes.

What screening questions for anxiety could you ask Kathy?

Section 9

The 2-questionnaire Generalized Anxiety Disorder (GAD-2) questionnaire is a useful screening tool that can be elaborated to GAD-7 to support clinical assessment (Kroenke, 2007):

Over the last two weeks, how often have you been bothered by the following problems?

• Feeling nervous, anxious or on edge.
• Not being able to stop or control worrying.

Kathy’s symptoms are more in line with apathy than anxiety. The priority is to treat her depression.

How would you go about helping Kathy’s depression?

Section 10

Firstly, explain the nature of depression and that it is amenable to treatment. Kathy is signposted to the MIND website (www.mind.org.uk) for more information about depression. She is encouraged to consider lifestyle change that could help with both her depression and diabetes: diet and exercise.

Kathy is keen to see a quick improvement in symptoms, and given her diagnosis of moderately severe depression, it is agreed to start an SSRI. The time course for improvement and possible side effects are explained to Kathy. A referral to the community mental health team to consider cognitive behavioural therapy is suggested, and Kathy is happy to engage with this (CKS, 2025a).

The offer of a fit note is made to support Kathy’s recovery, but she would rather continue at work. However, be aware that this option remains available.

Dapagliflozin is commenced to improve glycaemic control and facilitate weight loss.

Follow-up is arranged for 3 weeks’ time.

How might Kathy’s case influence your approach to identifying depression in people with diabetes?

Section 11

Given the increased prevalence of depression in individuals with type 1 and type 2 diabetes, it makes good sense to be on the lookout for this condition when consulting with people with diabetes. Indeed, the American Diabetes Association recommends annual screening for depressive symptoms in all people with diabetes, and more frequent screening where there is a history of depression (ADA Professional Practice Committee for Diabetes, 2026).

This ends Kathy’s case study.

Section 12 – Andy

Andy is a 43-year-old man with bipolar disorder, who was diagnosed with type 2 diabetes 6 months ago. He is under the care of psychiatrists and is treated with antipsychotic medication.

Current results: HbA_1c 71 mmol/mol (8.6%); non-HDL cholesterol 4.8 mmol/L; BMI 31.7 kg/m²; blood pressure 155/92 mmHg.

Current medication: metformin, quetiapine, citalopram.

Social history: lives alone, smokes, alcohol 12 units/week.

Are individuals with severe mental illness (SMI) like Andy more likely to develop type 2 diabetes than those without SMI?

Section 13

Yes. Around 10–15% of people with SMI, such as schizophrenia or bipolar disorder, suffer from type 2 diabetes, a prevalence 2–3-times higher than the population without SMI (Reilly et al, 2015).

So what factors might have led to Andy developing type 2 diabetes?

Section 14

Deteriorating self-care is common in people with psychosis. Poor diet, lack of exercise and weight gain may be important issues that need to be addressed in tackling Andy’s obesity and type 2 diabetes. Andy’s use of antipsychotics will exacerbate weight gain, further driving insulin resistance and metabolic syndrome (Holt, 2019).

How might Andy’s risk of cardiovascular disease and microvascular complications of diabetes be affected?

Section 15

Individuals with SMI who develop diabetes are predisposed to earlier onset of both microvascular and macrovascular complications compared to those without SMI, with higher mortality principally mediated by cardiovascular disease (Vinogradova et al, 2010).

Andy has an array of potential cardiovascular risk factors – hypertension, dyslipidaemia, smoking and type 2 diabetes – that need attention (Taylor and Shiers, 2017).

What steps could you take to help Andy?

Section 16

There are many! Here are some possibilities:

● Provide simple dietary advice, leaflets and websites.

● Offer referral to a local structured education programme for people with type 2 diabetes – Andy would be eligible for the Type 2 Diabetes Path to Remission Programme in England (Bakhai, 2023).

● Signpost to smoking cessation resources.

● Encourage exercise that Andy feels he could achieve and sustain.

● Confirm hypertension and treat appropriately.

● Consider statin therapy for dyslipidaemia.

● Consider adding an SGLT2 inhibitor or a GLP-1 receptor agonist to Andy’s metformin to improve glycaemic control, facilitate weight loss and provide cardiovascular protection

● Arrange follow-up. Bringing in these changes will require more than a single consultation. Ensure that the psychiatric team are aware of any interventions.

Be aware that there is clear evidence that people with SMI and type 2 diabetes are less likely to receive standard diabetes care (Whicher, 2019).

What would be your position on looking for diabetes and assessing cardiovascular risk in people with SMI?

Section 17

It is recommended that people with SMI are screened for diabetes (fasting or random blood glucose or HbA_1c) on an annual basis (CKS, 2025c). Other cardiovascular risk factors should also be assessed, including diet, smoking, alcohol consumption, BMI, blood pressure and lipid profile, with calculation of cardiovascular risk (e.g. QRISK3^® score).

The Lester intervention framework for assessing and managing cardiovascular risk in people with SMI is a useful resource (Perry et al, 2023; available at: https://bit.ly/4trWlfO).

This ends Andy’s case study.

Section 18 – Michelle

Michelle is a 21-year-old woman with type 1 diabetes diagnosed 5 years ago. She is established on basal–bolus insulin therapy. You have been notified that she has missed eye and foot screening appointments and defaulted on hospital diabetes clinic appointments.

Michelle comes to the surgery requesting a further prescription of her contraceptive pill. You take the opportunity to ask her about missed diabetes appointments.

What other areas of her diabetes care could you ask about?

Section 19

It appears Michelle is disengaging from her diabetes care. Establish whether or not she is continuing to take her insulin injections regularly. Is she still regularly monitoring blood glucose levels and, if so, what have they been? Do we have any recent HbA_1c and other diabetes blood test results?

Michelle says she has been taking her insulin doses regularly and you can see she has been requesting her insulin repeat prescriptions as expected. However, she states that she “can’t be bothered” with regular fingerprick glucose testing. Thus far, she has not taken up offers of continuous glucose monitoring despite recommendations from the Diabetes Specialist Team.

Michelle has experienced episodic hypoglycaemia, although the occasional glucose readings she has taken have often been between 10 and 20 mmol/L. Michelle has not had any recent diabetes blood tests, including HbA_1c measurement.

What might be your concerns for Michelle from a mental health point of view?

Section 20

You could explore the possibility of depression using screening questions.

Michelle says that generally she doesn’t feel “down” and is able to enjoy herself when she distances herself from her diabetes. However, she admits to being anxious about the risks of hypoglycaemia and diabetes complications, but to a significant degree feels helpless and unable to make decisions about her diabetes on a daily basis.

Overall, Michelle says she feels “stressed out” by her diabetes, finding the constant demands to be overwhelming, whilst at the same time feeling frustrated and guilty that she is not looking after her diabetes.

How might you classify Michelle’s problems with her diabetes?

Section 21

It does not appear that Michelle is suffering from depression. Rather, her emotional disturbance appears to be specifically about coping with her diabetes. When mental health symptoms are specifically associated with the persistent burden of living with and managing diabetes (rather than about life in general), this is termed diabetes distress (Gonzalez et al, 2011).

● Diabetes distress may exhibit similar symptoms to (and indeed co-exist with) anxiety and depression (Fisher et al, 2014).

● As many as 25% of people with type 1 diabetes are thought to suffer from diabetes distress, and this figure is nearly as high in people with type 2 diabetes, especially in those treated with insulin.

● Diabetes distress impacts adversely on diabetes self-care and is associated with higher HbA_1c levels, increased hypoglycaemia, reduced wellbeing and poorer quality of life.

In Michelle’s case, there are signs that this has progressed further, to diabetes burnout: a state of emotional exhaustion in which individuals feel helpless in the face of managing their diabetes (Polonsky, 2021). Under these circumstances, people may disengage with their diabetes care by not attending diabetes reviews and screening appointments, missing medications (including insulin), avoiding glucose monitoring or blood tests, and engaging in unhealthy lifestyles (poor diet, lack of exercise).

How can you help Michelle?

Section 22

Help needs to be individualised and in accordance with the person’s wishes. Some possibilities are outlined below:

● Supportive listening and explanation can be helpful.

● The practice diabetes nurse may be an accessible and acceptable person for Michelle to share her feelings with.

● Diabetes UK has resources to help those with diabetes distress and burnout, and peer support could be accessed via this route (Hendrieckx et al, 2019).

● Offer referral to the Diabetes Specialist Nurse service to review Michelle’s insulin use and to consider switching from fingerprick glucose checks to some form of continuous glucose monitoring.

● Offer referral to a structured education programme.

● Explain to Michelle the importance of screening appointments and encourage her to attend these.

● Discuss with Michelle whether she would like to access psychological support to help cope with life with diabetes. This might be from the local Improving Access to Psychological Therapies (IAPT) team.

This ends Michelle’s case study.