Diabetes and depression: Two sides of the same coin?

There are many complications associated with diabetes; however, the significance of depression, anxiety or any mental health issue in people with diabetes is still not fully recognised. The reality is that there is a potential two-fold, or even three-fold, increased risk of depression in people with diabetes (Anderson et al, 2001). What is not known is whether diabetes causes depression or vice versa?

Until recent years, mental health and depression seemed to be the “Cinderella topic” of the diabetes world. However, we are now becoming more acutely aware of this very complex problem. 

Depression and anxiety are the most common mental health problems seen in people with diabetes and over 90% of people with depression and anxiety are treated in primary care (NICE, 2009). Sadly, however, many people still do not seek treatment or the support they so desperately need. We know the GP services work very hard in helping these people but I wonder if they are truly able to identify all individuals with mental health issues and are they realistically able to maintain the highest standards of care? 

Quality and Outcome Framework
Recent changes to the Quality and Outcome Framework (QOF) have downgraded the importance of asking about mental health issues in people with diabetes. Since April 2006, clinicians were encouraged to ask depression screening questions when speaking to people with diabetes and coronary heart disease (NHS Employers, 2010). These questions opened the conversation regarding this difficult subject, giving the individual the opportunity to discuss any concerns. Sadly, this year these questions were removed (NHS Employers, 2013.) 

Although common sense would suggest most primary care staff understand the need to ask about mental health issues, it seems likely that this area could now be neglected, especially now there is no cash incentive for GP practices.

The impact of stress
Depression rarely results from a single cause. Most of the time a combination of factors contributes to the illness. However, what is known is that depression can cause the body significant problems.

We know that with someone with diabetes (or risk of diabetes), the constant and/or prolonged release of the stress hormones, adrenaline and cortisol, can have a detrimental effect on blood glucose levels, as well as increased insulin resistance. We also know that depression is associated with lack of motivation or lethargy. People with depression will potentially have poorer food choices and/or poor activity levels, leaving them to the possibility of increased diabetes risk. Furthermore, depression is exhausting; it can take away your confidence, your happiness and your ability to function. Because of this, it is a condition that should never be underestimated. 

Interventions
Nurses should assist people promptly and have a good understanding of what evidence-based treatments are available. The role of psychological interventions for people with diabetes is important but unfortunately these services are lacking in the UK. However, their value should be acknowledged and we should be instrumental in persuading commissioners to employ such services for people with diabetes.

In this mental health section, Emma Britneff and Kirsty Winkley discuss the role of psychological interventions in people with diabetes and David Wasley and Matthew Moore report on a pilot study looking at anxiety and type 1 diabetes.