Current Diabetes Reports

, Volume 13, Issue 6, pp 894–899 | Cite as

Psychological Care in a National Health Service: Challenges for People with Diabetes

  • Cathy E. LloydEmail author
  • Paramjit Gill
  • Margaret Stone
Psychosocial Aspects (KK Hood, Section Editor)


Recently, there has been a growing interest in psychological problems in people with diabetes and a concomitant increasing concern that these often go unreported and, thus, unidentified and treated. This has serious implications for both the self-management of diabetes and the individual’s quality of life. In this review article we consider the question of screening for depression in people with diabetes within a national health service in the UK. The inadequacies of psychological care for patients with diabetes are discussed, in particular with regard to the importance of distinguishing between depressive symptoms and emotional distress related to having diabetes. Criteria for assessing the validity of screening for depression are discussed, together with national and international recommendations, with particular emphasis on current practice. The screening strategy currently recommended for implementation in primary care in the UK is outlined. The need for rigorous evaluation of screening initiatives is highlighted and a key conclusion is that case-finding alone is unlikely to be effective in terms of improving patient outcomes unless considered and applied in the context of overall case management. This review highlights the barriers and challenges to optimizing care for patients with co-morbid diabetes and depression, and outlines the therapies currently available in the UK, which might be disseminated in other countries.


Diabetes mellitus Depression Diabetes-related emotional distress Primary care Screening Guidelines Psychological care National health service 



This article contains some material published in Lloyd CE and Roy T. Top Ten Screening Tools for Measuring Depression in People with Diabetes; and Stone MA and Gill PS. Screening for Depression in People with Diabetes in Primary Care, both in Lloyd CE, Hermanns N, and Pouwer F, editors, Screening for depression and other psychological problems, published by Springer-Verlag, London, 2013.

Compliance with Ethics Guidelines

Conflict of Interest

Cathy E. Lloyd is a member of the Dialogue on Diabetes and Depression. Paramjit Gill declares that he has no conflict of interest. Margaret Stone declares that she has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Lloyd CE, Underwood L, Winkley K, Nouwen A, Hermanns N, Pouwer F. The epidemiology of diabetes and depression. In: Katon W, Maj M, Sartorius N, editors. Depression and diabetes. Oxford: Wiley/Blackwell; 2010. ISBN 9780470688380.Google Scholar
  2. 2.
    Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of co-morbid depression in adults with diabetes. Diabetes Care. 2001;6:1069–78.CrossRefGoogle Scholar
  3. 3.
    Barnard K, Skinner T, Peveler R. The prevalence of co-morbid depression in adults with type 1 diabetes: systematic literature review. Diabet Med. 2006;23:445–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Beck AT, Garbin MG. Psychometric properties of the Beck Depression Inventory: 25 years of evaluation. Clin Psychol Rev. 1988;8:77–100.CrossRefGoogle Scholar
  5. 5.
    Radloff LS. A self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385–401.CrossRefGoogle Scholar
  6. 6.
    Spitzer RL, Kroenke K, Williams JB, the Patient Health Questionnaire Primary Care Study Group. Validation and utility of a self-report version of the PRIME-MD: the PHQ primary care study. JAMA. 1999;282:1737–44.PubMedCrossRefGoogle Scholar
  7. 7.
    • National Institute for Health and Care Excellence. Clinical Guideline 90. Depression. The treatment and management of depression in adults. London: National Institute for Health and Care Excellence; 2009. This is important because it lays out the standards for identifying and treating depression in the UK.Google Scholar
  8. 8.
    Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–13.Google Scholar
  9. 9.
    Lloyd CE, Pambianco G, Orchard TJ. Does diabetes-related distress explain the presence of depressive symptoms and/or poor self-care in individuals with type 1 diabetes? Diabet Med. 2010;27:234–7.PubMedCrossRefGoogle Scholar
  10. 10.
    • Esbitt SA, Tanenbaum ML, Gonzalez JS. Disentangling clinical depression from diabetes-specific distress: Making sense of the mess we’ve made. In: Lloyd CE, Hermanns N, Pouwer F, editors. Screening for depression and other psychological problems in diabetes. London: Springer; 2013. This chapter summarizes the evidence relating to the distinction between depression and diabetes-related emotional distress, offering ways of overcoming these challenges.Google Scholar
  11. 11.
    Polonsky WH, Anderson BJ, Lohrer PA, Welch G, Jacobson AM, Aponte JE, et al. Assessment of diabetes-related distress. Diabetes Care. 1995;18:754–60.PubMedCrossRefGoogle Scholar
  12. 12.
    Polonsky WH, Fisher L, Earles J, Dudl RJ, Lees J, Mullan J, et al. Assessing psychosocial stress in diabetes: development of the Diabetes Distress Scale. Diabetes Care. 2005;28:626–31.PubMedCrossRefGoogle Scholar
  13. 13.
    Pouwer F. Should we screen for emotional distress in type 2 diabetes mellitus? Nat Rev Endocrinol. 2009;5:665–71.PubMedCrossRefGoogle Scholar
  14. 14.
    Hood K, Naranjo DM, Barnard K. Measuring depression in children and young people. In: Lloyd CE, Hermanns N, Pouwer F, editors. Screening for depression and other psychological problems in diabetes. London: Springer; 2013.Google Scholar
  15. 15.
    Pouwer F, Beekman ATF, Lubach C, Snoek FJ. Nurses’ recognition and registration of depression, anxiety and diabetes-specific emotional problems in outpatients with diabetes mellitus. Patient Educ Couns. 2006;60:235–40.PubMedCrossRefGoogle Scholar
  16. 16.
    • Pouwer F, Geelhoed-Duijvestijn PHLM, Tack CJ, Bazelmans E, Beekman A-J, Heine RJ, et al. Prevalence of depression is high in out-patents with type 1 or type 2 diabetes mellitus. Results from 3 out-patient clinics in The Netherlands. Diabet Med. 2010;27:217–24. This study examined the prevalence of depression in both patients with type 1 and type 2 diabetes attending secondary care. The authors reported high rates of depression, which has important implications for the identification and management of psychological problems.PubMedCrossRefGoogle Scholar
  17. 17.
    American Diabetes Association. Standards of Medical Care in Diabetes-2011. Diabetes Care. 2011;34 Suppl 1:S11–61.CrossRefGoogle Scholar
  18. 18.
    International Diabetes Federation Clinical Guideline Task Force. Global guideline for type 2 diabetes. Brussels: International Diabetes Federation; 2005.Google Scholar
  19. 19.
    Lustman PJ, Freeland KE, Griffith LS, Clouse RE. Fluoxetine for depression in diabetes. A randomized double-blind placebo-controlled trial. Diabetes Care. 2000;23:618–23.PubMedCrossRefGoogle Scholar
  20. 20.
    Doran T, Fullwood C, Gravelle H. Pay for performance programs in family practices in the United Kingdom. N Engl J Med. 2006;335:375–84.CrossRefGoogle Scholar
  21. 21.
    National Institute for Health and Care Excellence. NICE Clinical Guideline 90 – Depression. Available at: Accessed April 2013.
  22. 22.
    • Improving Access to Psychological Therapies (IAPT). Available at: Accessed April 2013. This website provided cutting edge information on treatment strategies for individuals with psychological problems managed in primary care.
  23. 23.
    Lloyd CE, Hermanns N, Pouwer F, editors. Screening for depression and other psychological problems in diabetes. London: Springer; 2013.Google Scholar
  24. 24.
    National Institutes of Health and Clinical Excellence. Quality standards program. Cost impact and commissioning assessment: quality standard for depression in adults. March 2011. Available at: Accessed 4 June 2013.
  25. 25.
    Diabetes UK. 2013. Accessed 2 Sept 2013.

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Cathy E. Lloyd
    • 1
    Email author
  • Paramjit Gill
    • 2
  • Margaret Stone
    • 3
  1. 1.Faculty of Health and Social CareThe Open UniversityBuckinghamshireUK
  2. 2.Primary Care Clinical Sciences, School of Health and Population Sciences, College of Medical and Dental SciencesUniversity of BirminghamBirminghamUK
  3. 3.Diabetes Research UnitUniversity of Leicester, Leicester General HospitalLeicesterUK

Personalised recommendations