and atherosclerosis (Musselman et al, 1996), and altered autonomic tone leading to decreased heart rate variability (Carney et al, 1995).
Genetic and environmental interactions may also play a role - obesity, insulin resistance and hypertension tend to be grouped together (Stunkard et al, 2003). Common effects of depression are listed in Box 1.
Depression screening, management and support
Depression in people with diabetes was recognised by the NHS as a priority; depression screening was included in the UK diabetes review but has recently been removed from the Quality and Outcomes Framework assessment. NICE (2009) guidelines suggest GPs and practice nurses play an active role in assessment. Recommendations for treating mild depression include:
- Watchful waiting by the primary care health team;
- Guided self-help;
- Computerised cognitive behavioural therapy;
- Brief psychological interventions and exercise.
For moderate to severe depression, more complex psychological interventions and pharmacotherapy are recommended.
Many nurses will be familiar with the two-item screen for depression, which asks patients if they have low mood or have lost interest in everyday activities. If the patient answers “yes” to either question, the degree of depressive symptoms is then assessed with a validated questionnaire such as the Patient Health Questionnaire (Kroenke et al, 2001) or the Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983). A positive score on either does not mean the patient has depression but does indicate they should be assessed by an experienced clinician.
Some patients with diabetes may not realise they have depression; instead they may report having difficulty managing their diabetes, perhaps linked to increased symptoms, and are at the point of giving up on their self-management. Others may report anxiety or eating problems, which may be related to depression, such as emotional eating, binging or purging.
Now routine screening in primary care settings is no longer part of the QOF assessment, some patients with diabetes and depression will remain unidentified. Others with depression may not be detected because of stigma, language barriers, cognitive problems and disengagement with health services. Some patients deny having depressive symptoms as it is not thought culturally acceptable; these may report increased somatisation (physical symptoms) instead. Screening may be difficult due to language barriers and cognitive problems; many patients simply stop attending their regular appointments.
Management and support
Depression treatment for people with diabetes is largely successful, be it through psychological therapy, drugs or both.
In Lambeth and Southwark, in London, a new initiative in service delivery has targeted people with psychological problems who have persistent, poorly controlled diabetes, as well as social problems, that prevent them from managing their diabetes effectively. The 3 Dimensions of Care For Diabetes, led by Professor Khalida Ismail, fully integrates medical, psychological and social care, and works with the Intermediate Diabetes Team in the community. The aim is to improve diabetes control and quality of life. This service is new and it is not yet clear whether it will be cost effective in the long term but, if so, it may provide another referral route for patients.
Once detected or suspected, depression should be treated quickly. For many people with a mild depressive episode, guided self-help is recommended. Several websites and self-help guides are routinely recommended to patients; examples are Beating the Blues (www.beatingtheblues.co.uk), an online CBT course, and Mood Gym (www.moodgym.anu.edu.au), which is free. Exercise is also excellent for treating mild depression as it helps people regain a sense of control over their lives and has additional health benefits for those with diabetes. “Watchful waiting” can also be helpful; this means keeping in touch with the patient, offering regular phone calls and follow-up.
Patients who prefer one-to-one or brief psychological thera