Journal of General Internal Medicine

, Volume 34, Issue 2, pp 320–324 | Cite as

The Importance of Addressing Depression and Diabetes Distress in Adults with Type 2 Diabetes

  • Michelle D. Owens-GaryEmail author
  • Xuanping Zhang
  • Shawn Jawanda
  • Kai McKeever Bullard
  • Pamela Allweiss
  • Bryce D. Smith


People with type 2 diabetes often experience two common mental health conditions: depression and diabetes distress. Both increase a patient’s risk for mortality, poor disease management, diabetes-related complications, and poor quality of life. The American Diabetes Association and the U.S. Preventive Services Task Force recommend routine evaluations for these conditions in adults for optimal disease management and prevention of life-threatening complications. However, barriers exist within primary care and specialty settings that make screening for depression and diabetes distress challenging. Depression and diabetes distress influence diabetes self-care and diabetes control and barriers in clinical care practice that can hinder detection and management of psychosocial issues in diabetes care. This paper highlights opportunities to increase mental health screenings and provides strategies to help providers address depression and diabetes distress in patients with type 2 diabetes.


diabetes depression diabetes distress primary care providers 



The authors are grateful for comments and suggestions from Clarice Conley on earlier drafts of this article.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.


The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.


  1. 1.
    CDC. National Diabetes Statistics Report, 2017: Estimates of diabetes and its burden in the United States. Atlanta, GA: CDC, 2017.Google Scholar
  2. 2.
    Stark Casagrande S, Fradkin JE, Saydah SH, Rust KF, Cowie CC. The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988-2010. Diabetes Care 2013;36(8):2271–2279. Scholar
  3. 3.
    Perrin NE, Davies MJ, Robertson N, Snoek FJ, Khunti K. The prevalence of diabetes-specific emotional distress in people with type 2 diabetes: a systematic review and meta-analysis. Diabet Med 2017;34(11):1508–20. Scholar
  4. 4.
    Ascher-Svanum H, Zagar A, Jiang D, et al. Associations between glycemic control, depressed mood, clinical depression, and diabetes distress before and after insulin initiation: an exploratory post hoc analysis. Diabetes Ther 2015;6(3):303–16. Scholar
  5. 5.
    Fisher L, Skaff MM, Mullan JT,Arean P, Glasgow R, Masharani U. A longitudinal study of affective and anxiety disorders, depressive affect and diabetes distress in adults with type 2 diabetes. Diabet Med 2008;25(9):1096–1101. Scholar
  6. 6.
    Albertorio-Diaz JR, Eberhardt MS, Oquendo M, et al. Depressive states among adults with diabetes: findings from the National Health and Nutrition Examination Survey, 2007-2012. Diabetes Res Clin Pract 2017;127:80–8. Scholar
  7. 7.
    American Diabetes Association. Depression. 2013. Available at: Accessed 22 May 2018.
  8. 8.
    Roy M, Sengupta N, Sahana PK, et al. Type 2 diabetes and influence of diabetes-specific distress on depression. Diabetes Res Clin Pract 2018;143:194–8. Scholar
  9. 9.
    Snoek J, Bremmer MA, Hermanns N. Constructs of depression and distress in diabetes: time for an appraisal. Lancet Diabetes Endocrinol 2015;3:450–60. Scholar
  10. 10.
    Zhang X, Norris SL, Gregg EW, Cheng YJ, Beckles G, Kahn HS. Depressive symptoms and mortality among persons with and without diabetes. Am J Epidemiol 2005;161(7):652–60. Scholar
  11. 11.
    Lin EHB, Rutter CM, Katon W, et al. Depression and advanced complications of diabetes: a prospective cohort study. Diabetes Care 2010;33(2):264–9. Scholar
  12. 12.
    VA/DoD clinical practice guideline for the management of major depressive disorder. Available at: Accessed 29 Aug 2018.
  13. 13.
    Adult and adolescent depression screening, diagnosis, and treatment guideline. Available at: Accessed 29 Aug 2018.
  14. 14.
    Barnacle M, Strand MA, Werremeyer A, Maack B, Petry N. Depression screening in diabetes care to improve outcomes: are we meeting the challenge? Diabetes Educ 2016;42:646–51. Scholar
  15. 15.
    American Diabetes Association. Lifestyle management. Diabetes Care 2017;40(suppl 1):S33–43. Scholar
  16. 16.
    Young-Hyman D, de Groot M, Hill-Briggs F,Gonzalez JS, Hood K, Peyrot M. Psychosocial care for people with diabetes: a position statement of the American Diabetes Association. Diabetes Care 2016;39(12):2126–40. Scholar
  17. 17.
    Katon W, Unutzer J, Fan MY, et al. Cost-effectiveness and net benefit of enhanced treatment of depression for older adults with diabetes and depression. Diabetes Care 2006;29(2):265–70. Scholar
  18. 18.
    Katon W, Russo J, Lin EH, et al. Diabetes and poor disease control: is comorbid depression associated with poor medication adherence or lack of treatment intensification? Psychosom Med 2009;71(9):965–72. Scholar
  19. 19.
    Walker RJ, Gebregziabher M, Martin-Harris B, Egede LE. Understanding the influence of psychological and socioeconomic factors on diabetes self-care using structured equation modeling. Patient Educ Couns 2015;98(1):34–40. Scholar
  20. 20.
    Brown SA, Garcia AA, Brown A, et al. Biobehavioral determinants of glycemic control in type 2 diabetes: a systematic review and meta-analysis. Patient Educ Couns 2016;99(10):1558–67. Scholar
  21. 21.
    U.S. Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med 2002;136:760–4. Scholar
  22. 22.
    Siu AL, and the U.S. Preventive Services Task Force. Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA 2016;315(4):380–7. Scholar
  23. 23.
    Fisher L, Gonzalez JS, Polonsky WH. The confusing tale of depression and distress in patients with diabetes: a call for greater clarity and precision. Diabet Med 2014;31(7):764–72. Scholar
  24. 24.
    Johansen C, Torenholt R, Hommel E, Wittrup M, Cleal B, Willaing I. Barriers to addressing psychological problems in diabetes: perspectives of diabetologists on routine diabetes consultations in Denmark. J Psychol Psychother 2014;4(2):1–6. Scholar
  25. 25.
    Egede LE. Failure to recognize depression in primary care: issues and challenges. J Gen Intern Med 2007;22(5):701–3. Scholar
  26. 26.
    Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta analysis. Lancet2009;374:609–19. Scholar
  27. 27.
    Hermanns N, Caputo S, Dzida G, Khunti K, Meneghini LF, Snoek F. Screening, evaluation and management of depression in people with diabetes in primary care. Prim Care Diabetes 2013;7:1–10. Scholar
  28. 28.
    Osborn CY, Kozak C, Wagner J. Theory in practice: helping providers address depression in diabetes care. J Contin Educ Heal Prof 2010;30(3):172–9. Scholar
  29. 29.
    Barley EA, Murray J, Walters P, Tylee A. Managing depression in primary care: a meta-synthesis of qualitative and quantitative research from the UK to identify barriers and facilitators. BMC Fam Pract 2011;12:47.
  30. 30.
    Kroenke K, Spitzer RL, Williams JBW. The PHQ-9. J Gen Intern Med 2001;16(9):606–13. Scholar
  31. 31.
    Janssen EP, Kohler S, Stehouwer CD, et al. The Patient Health Questionnaire-9 as a screening tool for depression in individuals with type 2 diabetes mellitus: the Maastricht study. J Am Geriatr Soc 2016;64(11):e201–6. Scholar
  32. 32.
    Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001.16:606–13. Scholar
  33. 33.
    Schmitt A, Reimer B, Kulzer B, Haak T, Ehrmann D, Hermanns N. How to assess diabetes distress: comparison of the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS). Diabet Med 2015; 33:835–43. Scholar
  34. 34.
    Katon WJ, von Korff M, Lin EHB, et al. The pathways study: a randomized trial of collaborative care in patients with diabetes and depression. Arch Gen Psychiatry 2004;61:1042–9. Scholar
  35. 35.
    Zagarins SE, Allen NA, Garb JL, Welch G. Improvement in glycemic control following a diabetes education intervention is associated with change in diabetes distress but not change in depressive symptoms. J Behav Med 2012;35(3):299–304. Scholar
  36. 36.
    Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med 2006;166(21):2314–21. Scholar
  37. 37.
    Powers MA, Bardsley J, Cypress M, et al. Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Care 2015; 38(7):1372–82. Scholar

Copyright information

© Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply)  2018

Authors and Affiliations

  • Michelle D. Owens-Gary
    • 1
    Email author
  • Xuanping Zhang
    • 1
  • Shawn Jawanda
    • 2
  • Kai McKeever Bullard
    • 1
  • Pamela Allweiss
    • 1
  • Bryce D. Smith
    • 1
  1. 1.Division of Diabetes Translation Centers for Disease Control and PreventionAtlantaUSA
  2. 2.Oak Ridge Institute for Science and EducationOak RidgeUSA

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