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Chapter 6 - Depression

Key messages

  • Major depression is a psychological condition indicated by a persistent (minimum of two weeks) state of lowered mood and/or lack of interest and pleasure in usual activities. This is in addition to other symptoms, such as significant changes in weight and sleep,
  • a lack of energy, difficulty concentrating, irritability, feelings of worthlessness or guilt, or recurrent thoughts about death or suicide.
  • Moderate-to-severe depressive symptoms, an indicator of depression, affect one in three people with insulin-treated type 2 diabetes, one in four with non-insulin-treated type 2 diabetes and one in five with type 1 diabetes; this is two to three times more than the general population.
  • Depressive symptoms in people with diabetes are associated with sub-optimal diabetes self-management and HbA1c, increased diabetes distress, less satisfaction with treatment, and impaired quality of life, are highly recurrent and are different from, yet sometimes confused with, diabetes distress.
  • Some depressive symptoms overlap with symptoms of diabetes (e.g. fatigue, sleep disturbance, changes in weight and altered eating habits).
  • A brief questionnaire, such as the Patient Health Questionnaire Nine (PHQ-9), can be used for assessing the severity of depressive symptoms. A clinical interview is needed to confirm major depression.
  • Mild and major depression can be treated effectively (e.g. with psychological therapies and medications)

Practice points

  • Assess people with diabetes for depressive symptoms using a brief validated questionnaire; remember that major depression needs to be confirmed by a clinical interview.
  • Treatment of depression will depend on severity, context and the preferences of the individual. Helping people with major depression to access suitable treatment may require a collaborative care approach beginning with the person’s GP.
  • Remain mindful that depressive symptoms and mild depression also need attention, as they can develop into major depression.

How common are symptoms of depression?

One in five people with type 1 diabetes are affected by moderate to severe depression symptoms.
One in three people with type 2 diabetes who use insulin treatment are affected by moderate to severe depression symptoms.
One in four people with type 2 diabetes who don't sure insulin treatment are affected by moderate to severe depression symptoms.



What is depression?

Depression refers to a wide range of mental health problems characterised by the absence of positive affect (a loss of interest and enjoyment in ordinary things and experiences), low mood and a range of associated emotional, cognitive, physical and behavioural symptoms. In contrast to just ‘feeling down’ or having a low mood, depression is a serious mental health problem.

The diagnostic criteria for depression are described in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10). The ‘gold standard’ for diagnosing depression is a standardised clinical diagnostic interview, for example the Structured Clinical Interview for DSM Disorders (SCID;

Major depression (also known as major depressive disorder or clinical depression) is indicated by five or more of the following symptoms being present during a two-week period, representing a change from previous functioning.

  • At least one of the symptoms is either persistent depressed mood or loss of interest/pleasure in regular activities.
  • Other symptoms include significant weight loss or gain, insomnia or excessive sleeping, lack of energy, inability to concentrate, indecisiveness, feelings of worthlessness, excessive/inappropriate guilt, and recurrent thoughts of death or suicide.

Mild depression (also known as subthreshold or minor depression) is characterised by the presence of depressive symptoms that do not meet the full diagnostic criteria for major depression. Although mild depression is less severe than major depression, it still impacts significantly on the person and deserves attention in clinical practice. Furthermore, if not treated, mild depression can develop into major depression.

Depression in people with diabetes

There is evidence of a bi-directional association between depression and diabetes. People with depression are more likely to develop type 2 diabetes.
People with diabetes are two to three times more likely than the general population to be affected by symptoms of depression. As in the general population, depression is highly recurrent in people with diabetes.

The causes of depression in people with diabetes are not well understood, but proposed mechanisms include biological, behavioural, social, psychological, and environmental factors. Non-diabetes-specific contributors may include stressful life circumstances, substance use, and a personal or family history of depression. Diabetes-specific contributors may include the chronic nature of the condition and complex management regimens. As various factors can contribute, the exact cause will be different for every person

In people with diabetes, depression or depressive symptoms are associated with adverse medical and psychological outcomes, including:

  • sub-optimal self-management (e.g. reduced physical activity, less healthy eating, not taking medication as recommended, less frequent self-monitoring of blood glucose, smoking)
  • elevated HbA1c, hypoglycaemia and hyperglycaemia
  • increased prevalence, and earlier onset, of complications and disability
  • increased risk of diabetes distress, and elevated anxiety symptoms
  • impaired quality of life, and social role/ functioning
  • increased burden/costs to the individual and the healthcare system
  • greater risk of premature mortality.

People with co-existing depressive and anxiety symptoms are likely to experience greater emotional impairment and take longer to recover.

7 As model: Depression

This dynamic model describes a seven-step process that can be applied in clinical practice. The model consists of two phases:

  • How can I identify depressive symptoms?
  • How can I support a person with depression?

Apply the model flexibly as part of a person-centred approach to care.


How can I identify depressive symptoms?


Depression has physical, cognitive, behavioural, and emotional symptoms. Some common signs to look for include: lowered mood (e.g. sadness, hopelessness, teariness), loss of interest or pleasure in usual activities, irritability (e.g. exaggerated sense of frustration over minor matters, persistent anger), difficulties concentrating, lack of energy, weight loss or gain, reduced self-esteem/self-confidence, feelings of worthlessness or excessive/inappropriate guilt, psychomotor changes (agitation or retardation), social withdrawal, and recurrent thoughts about death or suicide. Also, look for signs that the person is not coping adaptively, such as disturbed sleep or substance abuse (e.g. alcohol, sedatives or other drugs). Each person will experience different symptoms of depression.

Two classification systems are commonly used for diagnosing depression: DSM-53 and ICD-10. Consult these for a full list of symptoms and specific diagnostic criteria.

Depressive symptoms can overlap with somatic symptoms of diabetes (see Box 6.1) or with symptoms of diabetes distress (see Box 6.2). As a result, depression may be overlooked in diabetes clinical practice.

Although depression does not always develop in direct response to diabetes, some common signs that people with diabetes may be experiencing depressive symptoms include: declining motivation to engage in diabetes self-care tasks, more frequent presentations to health professionals with the same symptoms, and missed appointments.

Box 6.1 Symptoms of depression or diabetes?

Depression and diabetes share some similar somatic and behavioural characteristics (e.g. fatigue, sleep disturbance and appetite change). This poses a challenge, as symptoms of depression can be overlooked or mistaken for symptoms of diabetes and vice versa.

Caution must be taken when assessing for depression using a questionnaire. It has been shown that these may falsely identify people with diabetes as having depression when they do not. These questionnaires do not have the capacity to distinguish the underlying cause of the symptoms. For example, a person may feel tired due to disturbed sleep because of depression or because they have had several night-time episodes of hypoglycaemia recently. Health professionals need to be mindful of these limitations.

This does not mean that depression questionnaires are not useful in clinical practice – it means that a clinical interview is needed to confirm a diagnosis of depression in people with diabetes. It is important to clarify the context and cause of the symptoms.

Box 6.2 Depression or diabetes distress?

Depression is often confused with diabetes distress – both in academic literature and clinical practice. While depression can influence how people feel about living with diabetes, it is broader, affecting how they feel about life in general. Conversely, diabetes distress is the emotional distress arising specifically from living with and managing diabetes, and does not necessarily affect how people feel about their life in general. Diabetes distress includes problems related to the relentlessness and frustrations of everyday diabetes self care, and worries about future complications (see Chapter 3).

While diabetes distress and depression are separate constructs, they are risk factors for each other. This means that people with depression are more likely to develop diabetes distress, and vice versa. In an Australian study, the co-occurrence for severe diabetes distress and moderate-to-severe depressive symptoms is approximately 13% (see diagram below).1 In practice, this means that both depressive symptoms and diabetes distress need to be assessed in clinical practice, to inform the type and intensity of intervention.



You may choose to ask about depressive symptoms:

  • in line with clinical practice guidelines (e.g. on a routine or annual basis; see Introduction)
  • when the person reports symptoms or you have noted signs (e.g. changes in mood/behaviours)
  • at times when the risk of developing depression is higher, such as during or after stressful life events (e.g. bereavement, traumatic experience, diagnosis of life-threatening or long-term illness) or periods of significant diabetes-related challenge or adjustment (e.g. following diagnosis of diabetes or complications, hospitalisation, or significant changes to the treatment regimen)
  • if the individual has a history of depression or other mental health problems.

Asking ‘How are you doing?’ or ‘How have you been feeling lately?’ may seem like rhetorical questions but the responses can be very revealing and are often the key to what you do next. Take the time to listen  to their answers and look for any sign that they may not be doing as well as usual. Create a supportive and safe environment so the person feels able to be open with you about how they are feeling. People will be more likely to share their innermost thoughts and feelings with you if they are emotionally engaged in the consultation and have confidence that you care and will support them.

There are various ways to ask about depressive symptoms. You may choose to use open-ended questions, a brief structured questionnaire, or a combination of both.

Option 1: Ask open-ended questions

The following open-ended question can be integrated easily into a routine consultation:

  • ‘Have you noticed any change in how you have been feeling in the last couple of weeks? What have you noticed?’

If something during the conversation makes you think that the person may be experiencing depressive symptoms, ask more specific questions, such as:

  • ‘I know you as a [very active] person, but you’ve just told me that you haven’t felt motivated to [go running] lately. What has brought this about?’
  • ‘You mentioned you’ve been [drinking more alcohol than usual] lately, what has brought that about?’
  • ‘Have there been any changes in your [sleeping/ eating] patterns? What have you noticed?’

If the conversation suggests the person is experiencing depressive symptoms, further investigation is warranted (see ASSESS).

Option 2: Use a brief questionnaire

Alternatively, you can use a brief questionnaire to ask about depressive symptoms in a systematic way. Collectively, the following two questions are referred to as the Patient Health Questionnaire Two (PHQ-2). They are the core symptoms required for a diagnosis of depression.

You can find the PHQ-2 on the full PDF version of this guide (3MB)

Instead of administering this as a questionnaire, you could integrate these questions into your conversation.

Sum the responses to the two questions to form a total score. A total score of 3 or more indicates depressive symptoms, further assessment for depression is warranted.

At this stage, it is advisable to ask whether they have a current diagnosis of depression and, if so, whether and how it is being treated.

If the total score is 3 or more and the person is not currently receiving treatment for depression, you might say something like, ‘It seems like you are experiencing depressive symptoms, which can be a normal reaction to […]. There are several effective treatment options for depression, but first we need to find out more about your symptoms. So, I’d like to ask you some more questions if that’s okay with you’.

You may then decide to assess for depression using a more comprehensive questionnaire.

If the total score is less than 3 but you suspect a problem, consider whether the person may be experiencing diabetes distress, elevated anxiety symptoms, or another mental health problem.


Validated questionnaire

The nine-item Patient Health Questionnaire (PHQ-9) is widely used to assess depression. It mirrors the DSM-5 criteria for depression. It is quick to administer and freely available online ( Each item is measured on a four-point scale, from 0 (not at all) to 3 (nearly every day). Scores are summed to form a total score ranging 0-27. In the general population, PHQ-9 scores are interpreted as follows:

  • 0-4 indicates no depressive symptoms (or a minimal level)
  • 5-9 indicates mild depressive symptoms; these people will benefit from watchful waiting
  • 10-27 indicates moderate-to-severe depressive symptoms; these people will benefit from a more active method of intervention).

Asking the person to complete the PHQ-9 can be a useful way to start a dialogue about depressive symptoms and the effect they may have on the person’s life and/or diabetes management. It can also be useful for systematically monitoring depressive symptoms (e.g. whether the symptoms are constant or changing over a period of time).

A PHQ-9 total score of 10 or more must be followed by a clinical interview using DSM-53 or ICD-104 criteria to confirm depression.

You may have access to other validated questionnaires, such as the: Beck Depression Inventory; Hospital Anxiety and Depression Scale; Centre for Epidemiologic Studies Depression Scale; or Hamilton Depression Scale. While all of these tools are suitable for assessing depressive symptoms, they each have their own strengths and weaknesses.

Summaries of these questionnaires can be accessed elsewhere.

Additional considerations

Is this individual at risk of suicide? It is essential that you conduct a suicide risk assessment if you identify a person as having depressive symptoms or thoughts about self-harm or ending their life. Most depression questionnaires include an item about self-harm, suicidal ideation, or suicide (e.g. PHQ-9, item 9). If the person with diabetes endorses that item, further investigation and support is necessary (see Box 6.3), regardless of whether the total score indicates depressive symptoms.

What is the context of the depressive symptoms? Are there any (temporary or ongoing) life circumstances that may be underlying the depressive symptoms (e.g. a bereavement, chronic stress, changing/loss of employment, financial concerns, giving birth, or menopause)? What social support do they have? What role do diabetes-specific factors play (e.g. a lack of support for diabetes self care, severe hypoglycaemia, or burdensome complications)?

Are there any factors (physiological, psychological, or behavioural) that are co-existing or may be causing/contributing to the depressive symptoms? This may involve taking a detailed medical history, for example:

  • Do they have a history (or family history) of depression or another psychological problem? For example, an anxiety disorder, diabetes distress (see Box 6.2), personality disorder, post-traumatic stress disorder, dementia, or eating disorder. These conditions must also be considered and discussed where applicable (e.g. When and how was it treated? Whether they thought this treatment was effective? How long it took them to recover?).
  • Do they have any underlying medical conditions that may be contributing to the symptoms?
  • What medications (including any complementary therapies) are they currently using?
  • How frequently do they use alcohol and/or illicit drugs?

No depressive symptoms – what else might be going on? If the person’s responses to the questionnaire do not indicate the presence of depressive symptoms:

  • they may be reluctant to open up or may feel uncomfortable disclosing to you that they are feeling depressed
  • consider whether the person may be experiencing diabetes distress (see Box 6.2), elevated anxiety symptoms, or another psychological problem.

If any of these assessments are outside your expertise, you need to refer the person to another health professional.

Box 6.3: Suicide

Whenever you suspect that a person is experiencing depression, or they appear to be feeling despair, unbearable pain, hopeless, trapped, or like they are a burden on others or don’t belong, it is very important that you have a conversation about it
and assess their risk of suicide. Making direct enquiries about suicide does not prompt a person to start to think about harming themselves. Instead, addressing the issue is much more likely to enhance their safety and prevent an attempt.
Suicidality fluctuates and is influenced by such things as:

  • static risk factors, which are fixed and historical in nature (e.g. family history of depression, a history of self-harm or suicide attempts, or previous experience of abuse)
  • dynamic risk factors, which fluctuate in duration and intensity (e.g. substance use, psychosocial stress, or suicidal ideation/communication/intent)

Policies and procedures for conducting a suicide risk assessment vary between settings, but this is a general guide:

  1. Assess and ensure safety (the person with diabetes, yourself, and others).
  2. Establish rapport (non-judgemental, professionally empathetic, compassionate, open body language, and active listening).
  3. Assess the suicide risk, including factors such as:
  • any history of suicide attempts
  • any history of mental disorders
  • the existence of a suicide plan
  • access to the means to complete the plan
  • duration and intensity of the suicidal ideation
  • hopelessness or feeling trapped
  • lack of belonging, feeling alone or alienated
  • feeling like a burden on others
  • alcohol/substance use
  • intention/desire to die
  • family history of suicide
  • protective factors
  • recent help-seeking behaviours.

There are several questionnaires for assessing suicide risk. These can be useful for directing the conversation systematically but there is a lack of evidence for their diagnostic accuracy.

These questionnaires cannot replace clinical interview. Once you've established this:

  1. Collect and document relevant information (e.g. the person’s medical history, current physical and mental state, and evidence of a suicide risk assessment).
  2. Arrange additional psychological or psychiatric assessment
  3. Develop a safety plan with the person (i.e. a written list of coping strategies and support services to which the person can refer when they are having suicidal thoughts).
  4. Reassess as necessary and ensure that follow-up care is provided: for people who are at high risk, reassess within 24 hours; for moderate risk, reassess within one week; and low risk, reassess within one month.

If a person is actively suicidal: provide or arrange continuous supervision.

If a person is in immediate danger: follow your workplace’s emergency protocol. In the absence of a formal written procedure contact the nearest Mental Health Crisis Intervention Team and/or refer to the nearest Accident and Emergency Department.

Keep in mind that some individuals may decide not to share their suicide plans and deny they have suicidal thoughts.

How can I support a person with depression?


Now that you have identified that the person is experiencing depressive symptoms, you can advise them on the options for next steps and then, together, decide what to do next.

  • Explain that their responses to the PHQ-9 indicate they are experiencing depressive symptoms, and also that they may have major depression, which will need to be confirmed with a clinical interview, and that depressive symptoms fluctuate dependent  on life stressors and that it may be necessary to reassess later (e.g. once the stressor has passed or is less intense).
  • Elicit feedback from the person about their score (i.e. whether the score represents their current mood).
  • Explain what major depression is, and how it might impact on their life overall, as well as on their diabetes management.
  • Advise that depression is common and that help and support are available; depression is treatable and can be managed effectively.
  • Recognise that identification and advice alone are not enough; explain that treatment will be necessary and can help to improve their life overall, as well as their diabetes management.
  • Offer the person opportunities to ask questions.
  • Make a joint plan about the ‘next steps’ (e.g. what needs to be achieved to reduce depressive symptoms and the support they may need).

If the depression is clearly related to a particular stressor (e.g. financial or relationship problems), take into account the severity and likely duration of the problem, as this will help to inform the action plan.

Next Steps: ASSIST or ASSIGN?

The decision about whether you support the person yourself or involve other health professionals will depend on:

  • the needs and preferences of the person with diabetes
  • your qualifications, knowledge, skills and confidence to address depressive symptoms
  • the severity of the depressive symptoms, and the context of the problem(s)
  • whether other psychological problems are also present, such as diabetes distress or an anxiety disorder
  • your scope of practice, and whether you have the time and resources to offer an appropriate level of support.

If you believe referral to another health professional is needed:

  • explain your reasons (e.g. what the other health professional can offer that you cannot)
  • ask the person how they feel about your suggestion
  • discuss what they want to gain from the referral, as this will influence to whom the referral would be made.


Neither mild nor major depression is likely to improve spontaneously, so intervention is important. The stepped care approach provides guidance on how
to address depressive symptoms and depression in clinical practice.
Once depression has been confirmed by a clinical interview, and if you believe that you can assist the person:

  • Explain the appropriate treatment options (see Box 6.4), discussing the pros and cons for each option, and taking into account the context and severity of the depression, the most recent evidence about effective treatments (e.g. a collaborative and/or a stepped care approach) and the person’s knowledge about, motivation, and preferences for, each option.
  • Offer them opportunities to ask questions.
  • Agree on an action plan together and set achievable goals for managing their depression and their diabetes. This may include adapting the diabetes management plan if the depression has impeded their self-care.
  • Provide support and treatment appropriate to your qualifications, knowledge, skills and confidence. For example, you may be able to prescribe medication but not undertake psychological intervention or vice versa.
  • Make sure the person is comfortable with this approach.
  • At the end of the conversation, consider giving them some information to read at home. There are several resources that may be helpful for a person with diabetes who is experiencing depression or depressive symptoms at the bottom of this page. Select one or two of these that are most relevant for the person; it is best not to overwhelm them with too much information.

Some people will not want to proceed with treatment, at first. For these people, provide ongoing support and counselling about depression, to keep it on their agenda. This will reinforce the message that support is available and will allow them to make an informed decision to start treatment in their own time.

 Box 6.4: Treating depression

It is not within the remit of this guide to recommend specific pharmacological or psychological treatments for depression in people with diabetes. Here are some general considerations based upon the evidence available at the time these guidelines were published:

  • A combination of psychological intervention and pharmacological treatment is recommended for people with recurrent depression and major depression.
  • Psychological intervention and/or pharmacological treatment should be implemented through stepped care and/or collaborative care approaches.
  • Cognitive behavioural therapy (CBT) is the most effective psychological intervention.
  • Antidepressant medications are only effective for people with moderate-to-severe depression, not mild depression.
  • Selective serotonin re-uptake inhibitors (SSRIs) are the most effective pharmacological treatment for depression in people with diabetes.
  • When combines with diabetes self-management education, psychotherapy is most effective for reducing depressive symptoms and HbA1c.
  • Some antidepressant medications can have adverse side effects (e.g. weight gain, metabolic abnormalities) and are associated with insulin resistance. Consider the risks and benefits before prescribing these medications, as they may not be appropriate for some people with diabetes.


The vast majority of specialist diabetes services in the UK do not have an integrated mental health professional, such as a clinical psychologist, to refer to. Therefore, the majority of referrals will be made to professionals outside the diabetes service. These might include: 

  • A general practitioner to undertake a clinical interview and diagnose major depression, and/or a referral to an appropriate mental health professional, and prescribe and monitor medications. An extended appointment is recommended.
  • A psychologist to undertake a clinical interview and provide psychological therapy (e.g. cognitive behavioural therapy or interpersonal therapy).
  • A psychiatrist to undertake a clinical interview, and prescribe and monitor medications. A GP referral is usually required to access a psychiatrist. Referral to a psychiatrist is likely to be necessary for complex presentations (e.g. if you suspect severe psychiatric conditions, such as bipolar disorder or schizophrenia, or complex co-morbid medical conditions).
  • Community Mental Health Teams can help the person find ways to effectively manage situations that are contributing to their depression or inhibiting their treatment (e.g. trauma or life stresses), using psychologically-based therapies and skills training (e.g. problem solving and stress management).
  • Improving Access to Psychological Therapies – Long Term Conditions (IAPT-LTC) are accessible in some areas in England. These services focus on people with long term conditions, including diabetes. (Local contact details can be found online on the NHS website.

If possible, consider referring the person to health professionals who have knowledge about, or experience in, diabetes. For example, if their diabetes management is affected by their depression, they may need a new diabetes management plan that is better suited to their needs and circumstances at the time. This might require collaboration with a GP or diabetes specialist (e.g. an diabetologist, diabetes specialist nurse, and/or dietitian).

If you refer the person to another health professional, it is important:

  • that you continue to see them after they have been referred so they are assured that you remain interested in their ongoing care
  • to maintain ongoing communication with the health professional to ensure a coordinated approach.


Depending on the action plan and the need for additional support, it may be that more frequent follow-up visits or extended consultations are necessary until the person feels stronger emotionally. Encourage them to book a follow-up appointment with you within an agreed timeframe to monitor progress and address any issues arising. Telephone/ video conferencing, or text or email contact may be a practical and useful way to provide support in addition to face-to-face appointments.

Mental health is important in its own right but it is also likely to impact on the person’s diabetes self-management and their physical health. Therefore, it is important to follow up to check that they have engaged with the agreed treatment.

At the follow-up appointment, revisit the plan and discuss any progress that has been made. For example, you might say something like, 'When I saw you last, you were feeling depressed. We made a plan together to help you with that and agreed that you would make an appointment to see a psychologist, and I wrote a referral letter. How has this worked out for you?'

"A lot of the time people feel like they’re alone. Having someone say “that’s actually really common” is a really comforting thing to hear." - Person with type 1 diabetes


Case study

  • Julie
  • 65-year-old woman living alone
  • Type 2 diabetes, managed with diet and exercise; history of depression
  • Health professional: Dr Robert Stevens (GP)


When Julie arrives for her routine check-up, Robert notices signs that she isn’t her usual self:
she is not wearing make-up, has dark circles under her eyes, and she doesn’t greet him with her usual cheerfulness. He asks her how she has been, and she shrugs her shoulders replying, ‘You know how it is, just a bit tired, I need a holiday I think’. As the discussion moves on to her general physical health and diabetes management, Robert notes that Julie mentions again that she is tired, which has prevented her from exercising, and as a result her blood glucose has been a bit higher than usual and she has gained a couple of kilograms.


When Robert enquires further using open-ended questions, Julie confides that in the past she had enjoyed exercising with a friend, but over the past month she has found herself making excuses not to leave the house. ‘I just can’t get motivated to
exercise at the moment. I feel awful when I cancel my walks with Fran, but I’m just too tired these days – it feels like a chore. And I tell myself, “just do it, it’s not that hard, you’ll enjoy it once you’re outside”. But then I can’t bring myself to leave the house.’ Julie says she feels guilty for not exercising and has begun eating late at night, which she feels ashamed about. She worries about her weight but when she feels down, she eats more. She feels unsure about how to break herself out of this cycle. Robert is concerned about Julie’s struggles with motivation and about the impact her recent changes in behaviour and thought patterns will have on her diabetes if they continue in the longer term.


Robert knows that Julie has a history of depression and wonders whether her negative thoughts about herself, her low mood, the changes in her eating and exercise patterns, and her tiredness might be linked. He invites Julie to complete the PHQ-9. Julie’s score of 18 suggests she is experiencing moderately severe depressive symptoms. Because of her high PHQ-9 score, he also conducts a suicide risk assessment, and finds Julie to be at low risk of suicide.


Robert explains the PHQ-9 score to Julie and asks her if this fits with how she has been feeling lately. Julie says that she recognises the symptoms she has been experiencing from a couple of years ago when she was depressed after separating from her husband. Robert asks Julie whether she had sought help for the depression at the time and whether she had needed antidepressants. Julie says she had consulted a psychologist who had been able to help her without antidepressants. He asks Julie whether this would be a good option for her this time. They agree that it will be the best course of action for Julie to return to the same psychologist, as they have a previously established rapport. The psychologist will conduct a formal assessment and discuss a treatment plan with Julie.


With Julie’s permission, Robert makes contact with the psychologist to check that the referral was received and that an appointment can be made within an appropriate timeframe.


Robert encourages Julie to make another appointment to see him after she has met the psychologist to update him on her progress and assess whether there is a need for antidepressants at that stage. He also invites her to see him sooner if she needs to.


Case Study

  • Luke
  • 24 year-old man living with his older brother
  • Type 1 diabetes (diagnosed 23 years ago)
  • Health professionals: Dr Glenn Jin (Consultant Diabetologist) and Thomas Mitchell (Diabetes Specialist Nurse)


Glenn is aware that people with diabetes are at a higher risk of emotional problems. He has decided to add a mental health questionnaire to the annual review process at his diabetes clinic. The questionnaire includes the Problem Areas in Diabetes (PAID) scale (to assess diabetes distress) and PHQ-2. Thomas is a diabetes nurse working at the clinic who assists with some of the physical health checks. He has been given the task of explaining the purpose of the questionnaire and encouraging people to complete it on a tablet computer in the waiting room while awaiting their appointment. The person’s questionnaire responses are automatically saved and summarised in their chart, for discussion during the appointment.


During Luke’s annual review, Thomas asks him some general questions about his health and well-being but Luke does not seem to be in the mood for talking. When it comes time for the questionnaire, Thomas tells Luke: ‘We’ve added something new to our annual assessments. We know that living with diabetes can be challenging and can, at times, feel like a burden for many people. So we’ve put together a brief set of questions about how living with diabetes affects your life and well-being. It will help us to know whether there are any specific issues you’re facing at the moment so that we can help you live well with diabetes. The questionnaire takes about 10 minutes, there’s no writing – you just have to tick the boxes. You can do it now while you’re waiting to see Glenn. Will you fill in the questionnaire?’ Luke agrees.


At the appointment, Glenn quickly looks over the questionnaire responses. Luke’s PAID score does not indicate a problem that needs immediate attention and he confirms this with Luke. However, Luke’s PHQ-2 score indicates that he is likely to be experiencing depression. Glenn asks Luke about how he felt completing the questionnaire, and Luke replies, ‘It was OK, y’know, a bit different, but OK’. Glenn says to Luke, ‘Looking at your responses, it looks like you’ve been feeling down over the past two weeks and not very interested in things. What’s going on Luke?’ Luke tells him that he lost his job about six months ago, and he couldn’t find work, which has affected his moods and relationships: ‘I can’t do anything right can’t find a job… then my girlfriend left  me… and I’m sleeping on my brother’s couch because I couldn’t pay the rent…, I’m such a loser, I feel completely worthless’.

Glenn acknowledges that Luke seems to have had a tough time lately, and that it is understandable that he has been feeling down. He explains to Luke that he may be experiencing depression and that help is available. Glenn asks Luke whether he has been diagnosed with depression before; Luke has not. Glenn then asks Luke to complete a few more questions to help him to be sure. Luke agrees, so Glenn gives him a copy of the PHQ-9. Luke’s PHQ-9 score is 23, indicating severe depressive symptoms. As Luke’s score on item 9, ‘Thoughts that you would be better off dead or of hurting yourself in some way’, was 2 (‘More than half the days’), Glenn also conducts a suicide risk assessment, and finds Luke to be at moderate risk.


Glenn explains the scores to Luke and gives him some information about depression, including the phone number for Samaritans. Glenn tells Luke that depression is treatable and explains the various options available. He advises Luke to visit his GP and the reasons for this – the GP will help him to access the most appropriate treatment (e.g. psychological intervention and/or medication). He invites Luke to ask questions.


Glenn checks whether Luke has a GP that he would be comfortable to speak with, and whether he is ok to do so. Luke agrees to both queries. Glenn also asks Luke if there is someone in his life (e.g. a friend or family member) that he can talk to, if he has thoughts about ending his life. Luke says that he has a good relationship with his brother who is very understanding and supportive. He will talk with him or call Samaritans about how he is feeling if things get too much. Glenn discusses other suicide risk mitigation strategies with Luke; together they develop a safety plan.


Glenn writes a letter of referral to Luke’s GP, and includes a copy of his PHQ-9 score and interpretation with the letter. He encourages Luke to make an extended appointment to see his GP as soon as possible, preferably in the next few days. With Luke’s permission, he contacts the GP to make sure that a timely appointment is made available to Luke.


Glenn asks Luke to come back to see him next month, so he can see how he is getting on with his GP. They will also continue with his annual diabetes review and consider whether any changes are needed to his diabetes management plan while Luke is receiving support for the depressive symptoms.

Questionnaire: Patient Health Questionnaire 9 (PHQ-9)

Find the PHQ-9 questionnaire, and information on how to use it on the full Diabetes and emotional health PDF (3MB)


For health professionals

Peer-reviewed literature

  • Depression and diabetes: treatment and health-care delivery

Description: This paper makes recommendations for clinical practice for addressing depression and diabetes.

Source: Petrak F, Baumeister H, et al. The Lancet Diabetes & Endocrinology. 2015;3:472-85.

  • The confusing tale of depression and distress in patients with diabetes

Description: A commentary on diabetes distress and depression, and recommendations for clinical practice.

Source: Fisher L, Gonzalez JS, et al. Diabetic Medicine. 2014;31:764-772.

  • Depression in diabetes mellitus: to screen or not to screen? A patient-centred approach

Description: A review article discussing methods for routinely screening for depression in people with diabetes.

Source: Van der Feltz-Cornelis CM. British Journal of Diabetes & Vascular Disease. 2011;11:276-281.

  • Safety planning intervention: a brief intervention to mitigate suicide risk

Description: This paper describes how to develop a safety plan to mitigate suicide risk.

Source: Stanley B, Brown GK. Cognitive and Behavioral Practice. 2012;19(2):256-64.

Additional information: Information about safety planning from the same authors can also be accessed at

Guidelines and recommendations

National Institute for Health and Clinical Excellence

(Guideline 91): Depression in adults with a chronic physical health problem: recognition and management. Published October 2009.

National Institute for Health and Clinical Excellence

(Guideline 90): Depression in adults: recognition and management. First published: October 2008. Last updated April 2018.


•    Screening for depression and other psychological problems in diabetes: a practical guide.  Lloyd CE, Pouwer F, et al., editors. London: Springer; 2013

•    Management of mental disorders (fifth edition)

Description: A book that provides practical guidance for clinicians in recognising and treating mental health problems, including depression. The book also includes worksheets and information pamphlets for people experiencing these problems and their families.

Source: Andrews G, Dean K, et al. CreateSpace. 2014.

Additional information: Sections of this book (e.g. treatment manuals and worksheets) are freely available to download from the ‘Support for clinicians’ section on the Clinical Research Unit for Anxiety and Depression (CRUfAD) website at

For people with diabetes

Select one or two resources that are most relevant and appropriate for the person.
Providing the full list is more likely to overwhelm than to help.

Support and Information

Books and Fact Sheets

•    Depressive Illness: The Curse of the Strong (3rd Edition). Tim Cantopher 2016, Sheldon Press, ISBN: 978-1847092359
Consultant Psychiatrist, Tim Cantopher guides the reader through the nature of depression, its history,symptoms, causes and treatments. He covers the latest information on medications, and new guidelines about how best to manage depression.

•    Diabetes & Wellbeing: Managing the Psychological and Emotional Challenges of Diabetes Types 1 and 2. Dr Jen Nash 2013, Wiley-Blackwell, ISBN: 978-1119967187. 
Written by a Clinical Psychologist who lives with type 1 diabetes, this book explores how to overcome the emotional and psychological challenges of living with diabetes. Includes Chapter 4 ‘Depression, Low Mood and Burnout’


•    Diabetes and Depression Fact Sheet
Description:  A fact sheet to accompany this guide with information and self-help ideas. You can download it here (PDF, 45KB) 

•    Depression and Low Mood:  An NHS Self-Help Guide:  

A booklet from the Northumberland Tyne and Wear NHS Trust containing information and practical ways to manage depression and low mood



•    Diabetes UK information on emotional wellbeing and support: 

A website page giving information and ideas of ways to access emotional support


• Rethink Mental Illness. 
Description:  An organization giving information and support to people with mental illness, including depression

Support and Peer Support

•    NHS ‘Moodzone’: dedicated pages on the NHS website for mental health, including anxiety, depression, self-help and how to get urgent mental health help when necessary.

•    Samaritans: 
Description: 24 hours a day national UK confidential emotional support for those in distress or despair, including those with depression. Trained volunteers are available on telephone, email, face to face and text
Tel: 116 123  Email:


•    MIND: 
Description: Mental health charity offering information and telephone and online support, including discussion forum Tel: 03001233393


•    Rethink Mental Illness Advice and Helplines and Support Groups

Description: Rethink provides a national and some local telephone Helplines for people living with mental illness including depression


•  Improving access to psychological therapies (IAPT) : 

IAPT is an NHS service providing treatment for depression. There is a search function to find local IAPT services on the NHS website: 


•    Peer Support Fact Sheet

Description:  A fact sheet to accompany this guide, giving information about ways to access peer support and its benefits. You can download it here (PDF, 39KB)

•    Diabetes UK Forum: 
An online discussion forum for people living with diabetes to access information and support, with many different topics being discussed.  The Welcome page explains more about it and where to find support for specific aspects of  diabetes, including depression 


See Diabetes and emotional health PDF (3MB) for our full list of references.


Disclaimer: Please note you may find this information of use but please note that these pages are not updated or maintained regularly and some of this information may be out of date.

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