me 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 therapy may be able to access direct help via the Improving Access to Psychological Therapy service. Patients may be able to self-refer or access treatment through their GP. Now rolled out across England; the IAPT service offers an online training course to health professionals via the Royal College of General Practitioners website (www.tinyurl.com/RCGP-IAPT).
Moderate to severe depression
With moderate to severe depressive episodes, patients may need specialist psychological intervention or medication, the availability of which may depend on where they live. Patients may benefit most when services are provided by specialist diabetes mental health professionals. However, specialist psychological services are not widely available; a report commissioned by Diabetes UK (2008) found only 15% of diabetes services had access to these.
Antidepressants are readily available and successful but patients may not notice any improvement in their symptoms for at least two weeks; it may take longer than this for patients to receive a therapeutic dose.
Practical aspects of management
When patients are depressed it may seem the best and only thing to do is find treatment for their depression. However, good overall care is still necessary and nurses may be best placed to coordinate this. Practical tips are outlined in Box 2.
Depression is common for people with diabetes. However, screening for depression can detect most of these who are affected and treatment is usually successful. Nurses involved in the care of people with diabetes are well placed to screen for depression and coordinate subsequent treatment. Good overall care for both conditions will provide patients with the most benefit.
Anderson RJ et al (2001) The prevalence of co-morbid depression in adults with diabetes. Diabetes Care; 6, 1069-1078.
Black SA et al (2003) Depression predicts increased incidence of adverse health outcomes in older Mexican Americans with type 2 diabetes. Diabetes Care; 26, 2822-2828.
Brotman DJ et al (2007) The cardiovascular toll of stress. Lancet