Diabetes and Depression – Endotext

ABSTRACT

Depression is characterized by a disturbance of mood, affecting between 3–5% of the general population at any one time. The prevalence of depression is approximately doubled in people with diabetes compared to the general population, with similar rates between type 1 diabetes and type 2 diabetes. Although many cases of depression are coincidental to the presence of diabetes, certain diabetes factors including diabetes-related complications, diabetes treatments and obesity are associated with an increased risk of depression. There is a bi-directional relationship between diabetes and depression with specific disease and treatment factors explaining why diabetes pre-disposes to depression and vice versa. Genetics, early intra-uterine development, and social determinants of health may create a “common soil” for both conditions. The presence of depression in people with diabetes worsens both diabetes and depression outcomes. Mortality is increased, quality of life diminished, and healthcare costs are increased. Diabetes self-management is also impaired. It may be possible to reduce the incidence of depression in people with diabetes by considering the way in which the diagnosis of diabetes is conveyed and the psychosocial support that is given through an individual’s journey with diabetes. Several short screening questionnaires have been validated in people with diabetes. A diagnosis should be confirmed by a diagnostic interview. The main aims of treatment are to improve both diabetes and mental health outcomes with complete remission of depressive symptoms. Various psychological treatments, including cognitive behavioral therapy, problem-solving, and psychodynamic techniques have been used to treat depression in people with diabetes. Antidepressants reduce depressive symptoms in people with diabetes as well as the general population. All antidepressants appear to have similar effects on depressive symptoms as long as adequate doses are used. Treatment should be maintained for at least 4–6 months after remission of symptoms to reduce the risk of relapse and recurrence. The choice of antidepressant depends largely on the side-effect profile, individual preference, and response. Selective serotonin reuptake inhibitors are widely used as first-choice agents. A common model of care for depression is the Stepped Care Model which is designed to provide a rational approach to the treatment of depression, while reducing costs and side effects of antidepressants through more appropriate prescribing. A case management model known as collaborative care is a clinical- and cost-effective treatment of depression that also improves diabetes outcomes by involving a multidisciplinary team that works together to identify and treat depression within primary care settings. Although diabetes and depression remain a considerable clinical challenge, there are grounds for considerable optimism as the scientific knowledge that underpins clinical practices has expanded markedly in the last two decades. However, further research is needed to understand what can be done to prevent depression in people with diabetes and to identify the optimal treatment for an individual that improves both depressive symptoms and diabetes outcomes. For complete coverage of all related areas of Endocrinology, please visit our on-line FREE web-text, WWW.ENDOTEXT.ORG.

INTRODUCTION

The importance of considering the interaction between mind and body in the management and outcome of chronic diseases has been recognized for over 2,500 years but is particularly poignant for people with diabetes. Diabetes places high behavioral demands on those living with the condition whilst mental disorders, such as depression, may compromise an individual’s ability to perform the self-care needed to optimize health and prevent the long-term consequences of diabetes. Much of diabetes care is focused around the identification and treatment of long-term diabetes-related complications and diabetes healthcare professionals are adept in managing microvascular and macrovascular conditions. An appreciation, however, of the psychological consequences of diabetes has lagged behind, despite these being common and the morbidity, mortality, and health costs associated with the co-morbidity being disproportionately increased compared with the effects of either condition alone (1, 2).

Several factors contribute to the poorer health outcomes seen in people with diabetes and mental disorders. Despite the increased burden of disease, people with co-morbid mental disorders have often been disadvantaged by health services and have received sub-optimal medical care (3). They have been less likely to receive the necessary diabetes processes of care, self-management education, and cardiovascular preventative medication despite increased visits to their primary healthcare teams and despite similar interest in caring for their physical illness as the general population (4). Clinicians may fail to recognize that those with mental illness are more likely to develop physical illnesses and so physical complaints are either ignored or not taken seriously. Mental health symptoms often “over-shadow” other complaints leading healthcare professionals to focus on the mental illness to the detriment of any physical illness (5). Health services are often poorly configured with clinics focusing on either the treatment of physical illnesses or mental disorders rather than treating both conditions at the same time (3). The stigma associated with mental illness may prevent people and their families from seeking help for mental illness, thereby depriving them of effective treatments, which not only harms mental well-being but is detrimental to diabetes management (6).

Diabetes and mental disorders are both common, and so a degree of co-occurrence would be expected purely by chance. The evidence suggests, however, that diabetes is more frequently associated with a range of mental and psychosocial disorders than expected (7, 8). Furthermore, several mental disorders, including depression, are associated with an increased risk of developing diabetes. An understanding of this complex interaction is crucial to the management and outcome of people with diabetes.

This chapter focuses on the co-morbidity of diabetes and depression; both are common, are relatively easy to diagnose, and have established effective treatments (8). They may also serve as an exemplar for other mental disorders and provide a model for the successful management of other co-morbid mental and physical health conditions. The chapter will describe the epidemiology of diabetes and depression and will discuss the mechanisms underlying the association between diabetes and depression. It will also highlight the clinical implications and consequences of co-occurring diabetes and depression. Diabetes healthcare professionals need to be aware of how to screen for depression and to provide “first response” management, while recognizing when to refer for specialist psychiatric care (9).

DEPRESSION

Depression belongs to a group of mental disorders where the primary abnormality is a disturbance of mood. The cardinal features of depression are low mood, and loss of interest or pleasure, lasting longer than two weeks. During a depressive episode, other symptoms may include poor concentration, feelings of excessive guilt or low self-worth, hopelessness about the future, thoughts about dying or suicide, disrupted sleep, changes in appetite or weight, and feeling especially tired or low in energy. People with depression are at an increased risk of suicide. Depressive symptoms exist on a continuum of severity, and it is important to recognize that depression is different from usual fluctuations in mood that occur with everyday life.

Major depressive disorder (also known as clinical depression, unipolar depression, or major depression) is defined by the diagnostic criteria of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-5), based on the number and duration of symptoms (Table 1) (10). The DSM-5 definition approximates a level of severity of symptoms that is associated with both disability and dysfunction. DSM-5 also recognizes several sub-types of depressive disorder where the symptoms are less severe but nevertheless may still compromise diabetes self-care and outcomes.

DIABETES AND DEPRESSION

The association between diabetes and depression has been recognized for many years. In the 17^th century, Thomas Willis, an English physician, described how “diabetes is a consequence of prolonged sorrow” (20). Until the last two decades, the focus of any discussion of mood and diabetes was on the increased likelihood of depression in people with diabetes, where the comorbidity was viewed as an understandable reaction to the difficulties and challenges of living with a demanding and life-limiting long-term physical illness. In this regard, it was treated no differently from other long-term physical conditions that are also associated with increased rates of depression. We now understand that the relationship between the two conditions is more complex and, at least for type 2 diabetes, is bidirectional (8).

Understanding the scale of the co-morbidity is challenging because the epidemiological studies examining the relationship have been hampered by considerable variation in measurement, study design, and use of terminology that have contributed to significant heterogeneity and inconsistency between studies (8). An example of this variability is illustrated by one meta-analysis that reported a range of prevalence rates of depression in people with diabetes from 1.8% to 88% (21).

The gold standard for the diagnosis of depression is a diagnostic interview, but many studies have relied on self-rating scales (22). These scales identify depressive symptoms rather than depression and do not differentiate between symptoms that could be caused by either diabetes or depression, for example, fatigue or weight change. This can lead to significant overestimates of the prevalence of depression in those with diabetes, as shown in an early meta-analysis where the prevalence of depression in people with diabetes identified by diagnostic interview was 11.4% compared to 31.0% in studies using self-rating questionnaire (23). However, a more recent meta-analysis argued that the symptom overlap does not affect prevalence (21). Nevertheless, the authors argue that depression measures that focus on the cardinal symptoms of depression rather than overlapping symptoms may most accurately diagnose depression.

Studies have often used mixed populations of people with type 1 diabetes and type 2 diabetes. This distinction is important because people with type 2 diabetes are generally older, and depression prevalence varies with age (16). There are differences in the prevalence of diabetes-related complications and other comorbid conditions such as obesity and heart disease, which independently affect the likelihood of developing depression (24). The pathogenesis and etiology of the two main types of diabetes differ, which may affect the risk of depression in different ways (25). Finally, the burden of management differs between type 1 diabetes and type 2 diabetes.

Many studies have not taken broad population approaches but have concentrated on convenience samples, usually drawn from specialist diabetes clinics, where the participants may not reflect the wider population of people living with diabetes. This bias is illustrated in the meta-analysis by Farooqi et al which reported that the prevalence of depression in people with diabetes was 36% in studies carried out in specialist care compared to 12% in community or primary care settings (26). Biases may also occur where there are low or unknown response rates, because the presence of depressive symptoms may affect the willingness of an individual to participate.

A further confounding factor is the concept of diabetes distress which describes the emotional response to living with diabetes, including the demands of self-management, the threat of complications, the social impact of stigma and discrimination, and the financial costs of treatment (27). Diabetes distress can fluctuate over time and may peak during challenging periods such as soon after diagnosis, during major treatment changes, or during the development or worsening of long-term complications (Table 3). Diabetes distress is distinct from depression in its association with self-management and glycemic levels, but the two conditions may co-exist in about 5-15% of people with diabetes. By contrast depression occurs without distress in 5-10% of people while distress alone affects 20-30% (28). The importance of diabetes distress was first proposed in 1995, and it is likely that early studies of diabetes and depression were capturing distress as well as depression, thereby contributing to an overestimate of the prevalence of depression.

Despite these caveats, several meta-analyses have indicated that the prevalence of depression is approximately doubled in people with diabetes compared to the background population (23, 26), with the prevalence of depression similar between type 1 diabetes (22%) and type 2 diabetes (19%) (26). Although most studies come from Western Europe or North America, the increased rates of depression or depressive symptoms have been found across the world (29, 30), with the prevalence being higher in low- and middle-income countries (26). A meta-analysis of 248 observational studies including over 8 million people with type 2 diabetes found a global prevalence of depression of 28%, with the highest rates observed in Asia and Australia whilst the lowest rates were found in studies from Europe (31). Cohort studies have shown an increase in incident depression in people with diabetes; one meta-analysis of 11 studies involving approximately 50,000 people with type 2 diabetes but without depression at baseline reported that the incidence of depression was 24% higher in people with diabetes (32), while another meta-analysis of 13 studies found incident depression was increased by 15% in people with diabetes (33).

An increased prevalence of depression has also been found in children with diabetes. A meta-analysis of 109 studies involving over 50,000 children with diabetes estimated that the prevalence of depression was 22.2% among children with type 1 diabetes and 22.7% in children with type 2 diabetes (34). Consistent with studies in adults, the prevalence of depression was higher among girls than boys (29.7% vs. 19.7%) and in low- to- middle-income countries.

Type 2 diabetes is a common comorbidity in people with mental disorders, with a reported prevalence ranging from 5% to 22% depending on the specific psychiatric disorder. Overall, the prevalence of diabetes in people with depression is 9% but there is considerable heterogeneity between studies (35). Consistent with this finding, the incidence of diabetes in people with depression is increased by 18-60% (33, 36, 37). People with depression, however, may receive more screening for diabetes than those without because of their increased contact with healthcare professionals and an awareness of the risk of diabetes by mental health practitioners, which may lead to an overestimate of the difference in diabetes risk between those with and without depression, particularly in studies that rely on routinely collected healthcare data.

MECHANISMS TO EXPLAIN THE LINK BETWEEN DIABETES AND DEPRESSION

No one mechanism explains the association between diabetes and depression, but specific disease and treatment factors may account for why diabetes pre-disposes to depression and vice versa (). These are, however, superimposed on other factors, such as genetics, early intra-uterine development, and social determinants of health, that create a “common soil” for both conditions.

Figure 1.

The possible mechanisms that lead to the co-morbidity of diabetes and depression.

CONSEQUENCES OF DIABETES AND DEPRESSION CO-MORBIDITY

The presence of depression in people with diabetes worsens both diabetes and depression outcomes ().

Figure 2.

The consequences of living with diabetes and depression.

MANAGEMENT OF DIABETES AND DEPRESSION

Treatment of Depression

The main aims of treatment are to improve both mental health and diabetes outcomes (Table 5). Ideally, any depression treatment for people with diabetes would simultaneously improve both sets of outcomes, but from a clinical perspective, the rapid improvement or remission of depression should be the first priority (138). This recommendation partly reflects the time course of treatment responses, which can be seen within 2–4 weeks for depression but also because treating the depression may aid optimal diabetes self-management.

Table 5.

Aims of Depression Treatment in People with Diabetes

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Mental health outcomes	Diabetes outcomes
Decreased depressive symptoms	Optimal diabetes self-management
Remission of depression	Decreased HbA1c
Suicide prevention	Increased time in glucose range
Improved health-related quality of life	Less hypoglycemia
Restoration of psychosocial functioning	Reduced long-term complications
	Reduced mortality

Until relatively recently, people with diabetes have been under-represented in trials of depression treatment and so, there were few studies examining antidepressant and psychological treatment of depression. However, over the last two decades, the evidence base for treatment has grown substantially and has clearly indicated that treatment with either psychological therapies or antidepressant medication is effective (142) .

PSYCHOLOGICAL TREATMENT

Various psychological treatments, including cognitive behavioral therapy, problem-solving, and psychodynamic techniques have been used to treat depression in people with diabetes. Different members of the healthcare team have been utilized to deliver these interventions in primary and secondary care either in person or virtually through the internet or telephone (142, 143). The majority of trials have included people with type 2 diabetes with no trials conducted solely in people with type 1 diabetes.

A meta-analysis of psychological treatments, including group-based and online therapies, reported they were effective for the treatment of depression with large effect sizes (142). The follow-up ranged between 4 weeks and 1 year and thus, the longer-term effects are unknown. Cognitive behavioral therapy is the most studied intervention, with its core components being cognitive restructuring, behavioral activation, and problem solving. This intervention was judged to be moderately effective in two recent meta-analyses (144, 145). Mindfulness also has an moderate benefit in treating depression (146), but there is mixed evidence on the benefit of motivational interviewing in reducing depressive symptoms (147, 148). Although psychological treatments are better than no treatment, the rates of recovery are low post-psychological intervention (17% vs 9% in controls) (149), indicating that many people will need additional support if they are to recover fully from their depression.

There is more debate about the effect of psychological interventions on diabetes outcomes (138) with one systematic review reporting a reduction in HbA_1c of ~0.6% (6 mmol/mol) (150) while another only reporting a non-significant improvement in glycemic levels (151). A meta-analysis of cognitive behavioral therapy showed a statistically significant but clinically insignificant reduction in HbA_1c of 0.14% (1 mmol/mol). There was a greater effect on HbA_1c if the intervention was delivered in a group-based and face-to-face fashion and included psycho-education, behavioral, cognitive, goal-setting, and homework assignment strategies as central components (145).

One of the challenges in delivering psychological interventions is the lack of trained personnel, a situation which appears to be worsening, at least in the United Kingdom (152). To address this deficiency, interventions have been designed to be delivered online or using mobile technologies, a trend which has increased dramatically since the Covid-19 pandemic. This has the potential to increase accessibility to treatment while limiting costs (142). One meta-analysis reported large effect sizes on depressive symptoms for online therapy and a moderate effect for telephone interventions, although no change in diabetes outcomes was seen (142). The beneficial effect on depressive symptoms up to 12 months after the interventions was supported by another systematic review, albeit again without improvement in diabetes outcomes (153). However, this finding was contradicted by a recent meta-analysis of 24 randomized controlled trials, 14 non-randomized controlled trials and three observational studies which reported no significant effect on depression outcomes (154). The discrepancy may partly explained by drop-out rates which vary from 13% to 42%; for those who remain in treatment, the interventions appear effective (155) and so the challenge will be to deliver services that engage people with diabetes and depression.

In the United Kingdom in 2008, the National Health Service introduced the Improving Access to Psychological Therapies (now NHS Talking Therapies for anxiety and depression) program to improve the delivery of, and access to, psychological therapies for depression. By 2021/22, nearly 1.2 million people had accessed these services. Although the clinical workforce is appropriately trained and supervised, many practitioners do not have experience of the challenges of living with diabetes. To address this issue, the Southampton diabetes team has formed a partnership with the local NHS Talking Therapies service. A practitioner joins the multidisciplinary team in the young adult clinic once a fortnight, helping to engage the person with diabetes and facilitate referral and access to the service. There is also a wider benefit to the city as the NHS Talking Therapies team have become much more aware of the challenges of living with diabetes. Introducing this service led to reductions in depressive symptoms and diabetes distress and was well received by people with diabetes and staff alike (156).

ANTIDEPRESSANTS

Antidepressants have been used to treat depressive symptoms since the late 1950s. There are many different antidepressants, but these fall into five main categories:

• Selective Serotonin Reuptake Inhibitors (SSRI)

• Serotonin and Noradrenaline Reuptake Inhibitors (SNRI)

• Noradrenaline and Specific Serotoninergic Antidepressants (NASSA)

• Tricyclics (TCA)

• Monoamine Oxidase Inhibitors (MAOI)

The discovery of the first clinically useful antidepressants paved the way for an understanding of the underlying biological or neuroanatomical basis for depression. The first antidepressant was the tricyclic antidepressant (TCA), imipramine. It was first synthesized in 1951 as a potential antipsychotic and derived from work on chlorpromazine, which had pronounced sedative and antihistamine effects (157). Although imipramine has no antipsychotic effect, it was found to possess antidepressant effects. Other TCAs, such as amitriptyline, were subsequently synthesized by modifying the structure of imipramine. Iproniazid, a monoamine oxidase inhibitor (MAOI), was the next antidepressant to be discovered; again, this drug was initially developed for a different purpose, the treatment of tuberculosis, before its antidepressant effect was recognized. MAOIs prevent the breakdown of monoamine neurotransmitters (e.g. noradrenaline, dopamine and serotonin) while TCAs block the uptake of serotonin and noradrenaline resulting in an elevation of the synaptic concentrations of these transmitters. An understanding of the pharmacology led to the hypothesis that depression was caused by low catecholamine levels in the central nervous system (158). Both TCA and MAOI affect the serotonin system and in 1967, Coppen proposed that this was a more important neurotransmitter in depression than noradrenaline (159). Fluoxetine was the first in the class of selective serotonin re-uptake inhibitors (SSRI) and was developed by design following a search for molecules that could selectively block the re-uptake of serotonin. A major advantage of this approach was that it minimized adverse effects such as cardiovascular toxicity and anticholinergic effects. First synthesized in 1972 and launched in 1987, fluoxetine became the most widely prescribed drug in North America by 1990 (157). Although better tolerated than earlier antidepressants, SSRI still caused side effects, including sexual dysfunction, appetite change, nausea and vomiting, irritability, anxiety, insomnia, and headaches. In an attempt to reduce these adverse effects, other antidepressant classes were developed, including serotonin and noradrenaline reuptake inhibitors (SNRI, e.g. venlafaxine) and noradrenaline and specific serotoninergic antidepressants (NASSA, e.g. mirtazapine).

Antidepressants reduce depressive symptoms in people with diabetes as well as the general population; however, there have been relatively few formal efficacy trials in people with diabetes and even these have been are limited to a small group of antidepressants, including fluoxetine, sertraline, paroxetine, citalopram, escitalopram, agomelatine, nortriptyline, and vortioxetine (138, 160). Furthermore, most studies are short-term and so the medium- and long-term sustainability of pharmacological interventions after treatment cessation is uncertain. A systematic review and meta-analysis suggested that all antidepressants have similarly large effect size on depression outcomes as long as adequate doses are used (151). However, a more recent network meta-analysis of 12 randomized controlled trials involving 792 participants reported that there may be a greater reduction in depressive symptoms with escitalopram and agomelatine (160). Vortioxetine was associated with the greatest reduction in HbA_1c with escitalopram, agomelatine, sertraline and fluoxetine also associated with a fall in HbA_1c. No antidepressant was found to disrupt glucose levels (160). These differences should be viewed with caution as the number of trials and participants for each drug is small. Further head-to-head randomized controlled trials would help us understand more about the relative benefits and safety of different antidepressants on depression and glucose metabolism.

Given the similar efficacy between antidepressants, the treatment of choice depends largely on the side-effect profile, individual preference, and response. SSRI are widely used as first-choice agents because they are less cardiotoxic than TCA and are safer in overdose. Some antidepressants, notably mirtazapine, paroxetine and some TCA, may cause undesirable weight gain (91) and should be used with caution in people with type 2 diabetes. By contrast, buproprion, which is available in the USA, is associated with weight loss and, unlike SSRIs, does not appear to worsen sexual function (161).

The aim of treatment is complete remission of depressive symptoms. Treatment should be maintained at an adequate dose for at least 4–6 months after remission of symptoms to reduce the risk of relapse and recurrence. Recovery from depression may lead to a change in the individual’s behavior and routine which may have an effect on diabetes self-management. For example, if appetite improves, insulin requirements may increase, while on the other hand, if the person becomes more active, they may decrease. An individual approach is therefore needed to support the person’s glycemic management. There are important drug–drug interactions between antidepressants and oral anti-diabetes agents through inhibition of the cytochrome P450 3A4 and 2C9 isoenzyme. For example, the use of fluoxetine may potentiate the effect of sulfonylureas precipitating hypoglycemia (84).

EXERCISE

Many depression guidelines recommend exercise and other aspects of a healthy lifestyle as an integral component of management. Coupled with the importance of exercise in glycemic management, interventions to increase physical activity have been trialed and shown to be effective in reducing depressive symptoms and improving glycemic measures (162).

PREVENTING SUICIDE

A detailed description of the many effective interventions to prevent suicide is beyond the scope of this article (163), however, it is important for diabetes healthcare professionals to understand how to identify those at risk, particularly given the high prevalence of suicidal ideation and acts and immediate availability of a means of suicide. It is crucial that suicide can be discussed with people with diabetes in a safe and non-judgmental way. Talking about suicide remains highly stigmatized and choosing to reveal suicidal ideation can be difficult. The isolation that suicidal people feel can be reinforced by a critical response from the healthcare team. A recent survey of diabetes healthcare professionals found that the vast majority of respondents believed it is their professional responsibility to ask about suicide and self-harm, with nearly half reporting that this should be addressed every visit (164). Around three-quarters reported feeling comfortable discussing these issues, but those who were more reluctant to do so were concerned about their lack of training and uncertainty about what to do if someone reported self-harming behavior. Once an individual has discussed suicidal intention, it is important that the person is supported and has access to mental healthcare and suicide prevention interventions.

ORGANIZATION OF CARE

A common model of care of depression is the Stepped Care Model which provides a framework in which service delivery is organized to help those with depression, their caregivers, and healthcare professionals identify and access the most effective interventions () (131). The model utilizes a sequenced treatment process depending on the severity of depressive symptoms and response to previous treatments. The model allows a rational approach to the treatment of depression, while reducing costs and side effects of antidepressant through more appropriate prescribing.

Figure 3.

Stepped Care Model for management of depression (131).

The first step involves the recognition of depression through screening and diagnostic interview and is reserved for those with suspected depression. For those with mild depression, step 2 involves the use of guided self-help, computerized CBT, and brief psychological interventions which can be delivered by the primary healthcare team or psychologist. The third step, which is also delivered in primary care settings, is indicated for those who do not respond to step 2 interventions, or for those with moderate and severe depression. Treatments include medication, high-intensity psychological interventions, or combined treatment. Step 4 corresponds to severe or treatment-resistant depression; the interventions are similar to those used in step 3 but now involve the mental health team. The final step is for those with life-threatening depression and/or severe self-neglect. In addition to medication and high-intensity psychological interventions, electroconvulsive therapy may be required under the supervision of a mental health crisis services and involve hospitalization.

A meta-analysis of 18 randomized controlled trial of stepped care showed improvements in depressive symptoms and better remission rates (165). A significant benefit on quality of life was also observed. More people in the stepped care model were prescribed antidepressants.

The increasing fragmentation of medical services and super-specialization in modern medicine has resulted in clinicians focusing on the conditions with which they are most familiar and being unable or unwilling to recognize and treat comorbid illnesses when they occur (166). The need for integrated holistic healthcare has never been greater but many diabetes healthcare professionals feel ill-equipped to manage depression. To address this, a case management model known as collaborative care was developed in the U.S., that involves a multidisciplinary team working together to identify and treat depression within primary care settings. The prototype intervention led to improvements in depression symptoms but without change in glycemia (167). Subsequently, greater attention was paid to intervention strategies for diabetes, resulting in simultaneous improvements in glycemic and blood pressure management and improved depressive symptoms (140). In a meta-analysis of five studies from the U.S., collaborative care was shown to be a clinical- and cost-effective treatment of depression, with a moderate effect size for depression outcomes and a small effect size for glycemic levels (142, 168).

CONCLUSION

Diabetes and depression remain a considerable clinical challenge. While an awareness of this co-morbidity has increased in recent years, this has not necessarily translated into better care or outcomes. Effective treatments are available and these need to be made available to those with diabetes and depression in clear treatment pathways. There are grounds for considerable optimism as the scientific knowledge that underpins clinical practices has expanded markedly in the last two decades. However, further research is needed to understand what can be done to prevent depression in people with diabetes and to identify the optimal treatment for an individual that improves both depressive symptoms and diabetes outcomes.

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