Journal of Affective Disorders 142S1 (2012) S8–S21

Epidemiology of depression and diabetes: A systematic review

Tapash Roy a , Cathy E. Lloyd b, *
a
BRAC Health Programme, Dhaka, Bangladesh & The University of Nottingham, Nottingham, UK
b
The Open University, Milton Keynes, UK

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Research suggests that co-morbid diabetes and depression is common; however, the implica-
Diabetes tions for clinical practice remain unclear. This paper reviews the current epidemiological evidence on co-
Depression morbid diabetes and depression, in order to identify the key publications which could both inform practice
Epidemiology and identify gaps in knowledge and research.
Systematic review
Methods: A systematic review was conducted to identify published literature on the epidemiology of diabetes
and depression. In order to review evidence on up-to-date knowledge of recent research and innovations in
care literature searches for the last five years (August 2006–August 2011) were conducted. To identify rele-
vant literature, electronic databases MEDLINE, Psych-INFO and EMBASE were searched for English language
articles in peer-reviewed journals.
Results: High rates of co-morbidity of depression and diabetes have been reported.The prevalence rate of de-
pression is more than three-times higher in people with type 1 diabetes (12%, range 5.8–43.3% vs. 3.2%, range
2.7–11.4%) and nearly twice as high in people with type 2 diabetes (19.1%, range 6.5–33% vs. 10.7%, range
3.8–19.4%) compared to those without. Women with diabetes and also women without diabetes experience
a higher prevalence of depression than men. Reviewed studies provide support for a modest relationship
between diabetes and depressive symptoms, but the exact direction of this relationship remains unclear.
Limitations: Most studies reviewed were cross-sectional and this limits any conclusions about the causal na-
ture and direction of the relationship between diabetes and depression. Variation in measurement methods,
lack of longitudinal data and few studies outside Europe and America limit the generalizability of the findings
of this review.
Conclusions: Current research suggests that the risk of developing depression is increased in people with di-
abetes; however, further studies are required in order to establish the nature of the relationship between
depression, glycaemic control and the development of diabetes complications, and make appropriate recom-
mendations for treatment and to support self-management of diabetes.
© 2012 Elsevier B.V. All rights reserved.

1. Background Epidemiological evidence suggests that at least one third of

The association between depression and diabetes has been
recognized for many years (Anderson et al., 2001), but the nature
of this relationship remains uncertain. Diabetes and depression are
both serious chronic conditions that negatively affect quality of life,
increase functional disability, and reduce life expectancy (Goetzel
et al., 2003; O’Connor et al., 2009). People with diabetes have an
increased risk of developing depressive symptoms and people with
depression also have an increased risk of developing diabetes (Lloyd
et al., 2010). Recently there has been an increased interest in the
relationship between diabetes and depression, and how research in
this area might inform practice.
* Address for correspondence: Dr C.E. Lloyd, Faculty of Health & Social Care, The
Open University, Walton Hall, Milton Keynes, MK7 6AA, UK. Tel.: +44 (0) 1908
654283; fax +44 (0)1908 654 124.
E-mail address: C.E.Lloyd@open.ac.uk (C.E. Lloyd).
people with diabetes suffer from clinically relevant depressive
disorders (Anderson et al., 2001; Lloyd et al., 2010). Data from
a range of settings suggest that the prognosis of both diabetes
and depression – in terms of severity of disease, complications,
treatment resistance and mortality – is worse for either disease
when they are co-morbid than when they occur separately (King
et al., 1998; Lustman et al., 2000; Katon, 2003; Lloyd et al.,
2010). Further to its implications for physical, mental and social
well-being, co-morbid depression contributes to poor self-care
and adherence to medical treatment, diminished quality of life
and higher rates of medical morbidity and mortality, as well
as increased health-care costs (King et al., 1998; Katon, 2003;
Ciechanowski et al., 2003; Egede et al., 2005).
In spite of the huge impact of co-morbid depression and diabetes
on the individual and its importance as a public health problem, the
exact mechanisms through which these two long term conditions
affect each other remain unknown and there are few integrated
approaches to the problem.

0165-0327/$ – see front matter © 2012 Elsevier B.V. All rights reserved.
 T. Roy, C.E. Lloyd / Journal of Affective Disorders 142S1 (2012) S8–S21 S9

The Dialogue on Diabetes and Depression (DDD) was estab- subset, at one specific point in time; (iv) Longitudinal study –
lished in 2007 with a view to supporting research and innova- observational study that involves repeated observations of the same
tions in the field of co-morbid diabetes and depression (www. variables over long periods of time; and (v) Experimental study –
dialogueondiabetesanddepression.org) and, as part of its work, to test cause and effect relationships between variables – further
agreed to summarise the key features of research in this field. This categorised as either case control study or randomised control trial
should allow clinicians and researchers to maintain an up-to-date (RCT).
knowledge of research and innovations in care. The aim of this
review was to develop an annotated bibliography on diabetes and
depression to identify key publications which could both inform 3. Results
practice and identify gaps in knowledge and research. This is the
first such document to review the epidemiological evidence. Using the databases described above, we identified 1,015 papers
through the three search strategies (Fig. 1). Of these, 1,012 were
available in English. Screening of the title of each paper identified
2. Methods 193 potentially relevant citations for abstract review. After review-
ing abstracts 48 relevant papers were selected for full text review.
A systematic review was conducted to identify published liter- Based on full text review a total of 20 key papers were finally
ature on the epidemiology of diabetes and depression. In order to identified to be included for annotated bibliography (see online
review evidence on recent research and innovations in care, litera- appendices 1).
ture searches only for last five years (August 2006 to August 2011) Table 1 summarises the population characteristics and major
were conducted using MEDLINE, Psych-INFO and EMBASE. The findings of 20 key studies (Ali et al., 2006; Brown et al., 2006;
searches were performed in three steps for specific terms included Barnard et al., 2006; Knol et al., 2007; Engum, 2007; Fisher et al.,
under the MeSH terms and supplemented with a keywords or title 2008; Golden et al., 2008; Icks et al.,2008; Mezuk et al., 2008;
search. The three search steps and corresponding terms were: step Katon et al., 2008; Holt et al., 2009; Lin et al., 2009; Collins et al.,
I – “depression OR depressive disorders OR depression symptoms 2009; Gendelman et al., 2009; Nouwen et al., 2010; Pan et al., 2010;
OR anxiety OR mood disorders OR psychological distress”; step Campayo et al., 2010; Pouwer et al., 2010; Paddison et al., 2011;
II – “diabetes mellitus OR type 2 diabetes mellitus OR diabetes Renn et al., 2011). Of these, five were systematic reviews and/or
symptoms”; and step III – step I AND step II AND (epidemiologic
studies OR cohort studies OR cross-sectional studies OR prevalence
OR incidence OR occurrence OR frequency OR association OR rela-
tionships). Within each database, articles that appeared in step III
search were retained for further examination.
Only articles and abstracts published in English were consid-
ered. Based on titles and abstracts, potentially relevant studies
were identified and the full texts of these articles were examined
for final determination of relevance. We included studies com-
paring depression and diabetes co-morbidities with prevalence of
depression and associated risk factors for either type 1 diabetes
mellitus (T1DM) or type 2 diabetes mellitus (T2DM). As implicit in
the search strategy adopted, for a study to be included, at least
an adult sub-population within the study was required to have
either diagnosed or undiagnosed diabetes and be specifically ex-
amined with respect to depressive symptomatology. Studies were
excluded if there were no explicit definitions of depressive symp-
toms and no information was available for type of diabetes. In
addition to observational studies, we included systematic reviews
and meta-analyses, and randomized trials conducted in adults with
T1DM/T2DM and depression, that attempted either (i) to reduce
the degree of depressed mood through an intervention (e.g. in-
tervention in depressed individuals with diabetes or other chronic
illness or (ii) to improve diabetes care outcome activity through a
depression-specific intervention.
These studies were categorised according to whether they
reported: (1) The prevalence of depression in T1DM or T2DM
(either depression leading to diabetes or diabetes as risk factor
for depression); (2) Depression in people with diabetes within
particular groups, such as men vs. women, the elderly, the young;
(3) Risk factors for depression in people with diabetes; or (4) The
relationship between depression and glycaemic control
For the purpose of this paper, we classified study type according
to the study design reported: (i) Observational study – designed to
draw inferences about the possible effect of exposure on outcomes
without the investigator’s intervention, which is further categorised
either as longitudinal or cohort studies; (ii) Prevalence study –
among observational studies those reported only prevalence or
incidence of depression and or diabetes; (iii) Cross-sectional study –
that involves observation of all of a population, or a representative Fig. 1. Flow diagram: database search (August 2006 to August 2011).
 S10
Table 1
Population characteristics and major findings of studies reviewed (n = 21).

Study Type of study/article N (case n)/ Sample characteristics Depression assessment Diabetes assessment Major findings
control, n) methods methods
T2DM only
Ali et al., 2006 Systematic review & 12 studies Multi-ethnic adults (aged Self-report assessment of Either through self-report, Prevalence of depression is significantly higher in patients with Type 2
meta-analysis of included in 18–65+; female 60%) with depressive symptoms or FPG, or review of medical diabetes compared with those without and in females with diabetes compared
cross sectional analysis T2DM Composite International records with males. Perceived health-related quality of life may moderate the
studies Diagnostic Interview (CIDI) relationship between depressive symptomatology and T2DM.
Brown et al., 2006 Retrospective cohort 31,635/57,141 Community cohorts of Medical record & prescriptions Self-report The incidence of new-onset depression was similar in both diabetic and
study Canadian adult (aged ≥ 20 non-diabetic cohorts. Increased risk of depression was not associated with
years, 48% female) with and Type 2 diabetes if comorbid diseases and the burden of diabetes complications
without T2DM were accounted for.
Fisher et al., 2008 Non-interventional 506 A multi-ethnic sample of DSMM-IV Not mentioned Type 2 diabetes patients displayed high rates of affective and anxiety disorders
longitudinal study American adults (female CIDI over time (60–123% higher), compared to community adults. Younger age,
57%; aged 21–75 years) from CED-S female gender and high comorbidities were related to persistence of all
community & diabetes DDS depressive conditions over time.
centre with T2DM
Golden et al., 2008 Longitudinal study 5201 Multi-ethnic American CES-D American Diabetes Elevated depressive symptoms were associated with an increased risk of
community sample aged Association criteria developing T2DM at follow-up (2–5 years after baseline). In the same cohort,
45–84 years (53.5% female) treated T2DM and non-elevated depressive symptoms at baseline were
with either normal FPG, associated with significantly higher odds of developing depressive symptoms
IFPG, or T2DM at follow-up.
Holt et al., 2009 Cross sectional 2995 Community adults (female HADS WHO Criteria There is a relationship between depression scores and diabetes, irrespective of
prevalence study 47.3%; aged 20–65+ years) whether this had been previously diagnosed or not. There is also an association
sample of UK with known between depression scores and blood glucose and insulin concentrations in
and unknown DM status men without a previous diagnosis of diabetes.
Icks et al., 2008 Prospective cohort 4595 German community adults CES-D Self report No significant association exists between known diabetes and depressive
study (female 50.2%; aged 45–75 symptoms in women, in particular after adjustment for co-morbidities. In
years) with diagnosed and subjects with undiagnosed diabetes, however, depressive symptoms were less
previously undetected frequent in men compare with those without diabetes. Co-morbidities and
T2DM psychosocial conditions are strongly associated with depressive symptoms.
Knol et al., 2007 Empirical study – 4747 Dutch adults (aged ≥18 Symptom Check List (SCL-90) WHO Criteria Mean depressive symptom score was highest among diagnosed T2DM, with
cross-sectional years; female55.3%) from depression subscale and/or use 29.7% of this group meeting criteria for depressive symptoms (compared to
design both primary and secondary of antidepressant medication 20.0% for undiagnosed T2DM, 17.5% for IFG, and 19.4% among normal controls).
care settings with diagnosed After adjusting for a number of chronic diseases, those with diagnosed T2DM
and undiagnosed T2DM, were no longer at increased risk of depressive symptoms.
IFPG, or normal FPG
Lin et al., 2009 Prospective cohort 4148 Multi-ethnic sample of PHQ-9 Medical record Patients with Type 2 diabetes and coexisting depression face substantially
T. Roy, C.E. Lloyd / Journal of Affective Disorders 142S1 (2012) S8–S21

study American adults (female elevated mortality risks. Depressed patients were more likely to be single
48.5%; aged ≥18 years) from women and slightly younger, but they had longer duration of diabetes,
primary care settings with less-healthful habits, worse glycemic control, and more medical comorbidities.
T2DM After adjusting for demographic and clinical characteristics, health risk
behaviors, and disease control measures, major depression was significantly
associated with all-cause mortality and noncardiovascular, non-cancer related
mortality. After adjustment for these same characteristics, minor depression
showed a non significant association with any mortality outcome.
Mezuk et al., 2008 Meta analysis of 18 studies Multi-ethnic Adults (aged Either a diagnostic psychiatric self-report, oral glucose Depression is associated with a 60% increased risk of T2DM; T2DM is
prospective studies included in ≥18 years; female 44–59%) interview, use of self-report tolerance test (OGTT), associated with a 15% (modest) increased risk in new onset depression.
analysis from a range of settings with assessment of depressive diabetes medication use,
T2DM or normal FPG symptoms, or a diagnosis by a and/or FPG levels
general practitioner
Nouwen et al., 2010 Systematic review & 11 studies Multi-ethnic adult people Either a diagnostic psychiatric Either through self-report, People with T2DM have a 24% increased risk of incident depression compared
meta analysis of included in (aged >18 years) with interview, use of self-report FPG, or review of medical to people without diabetes.
prospective studies analysis normal glucose levels or assessment of depressive records
T2DM symptoms, or a diagnosis by a
general practitioner
Table 1 (continued)
Study Type of study/article N (case n)/ Sample characteristics Depression assessment Diabetes assessment Major findings
control, n) methods methods
Paddison et al., Prospective cohort 3240 Adults (female 38.6%; aged HADS WHO Criteria Diabetes screening outcome (positive or negative for diabetes) at baseline was
2011 study ≥18 years) from UK primary not related to differences in anxiety or depression levels at 12-month
care settings with T2DM follow-up. Higher number of self-reported (diabetes) symptoms after first
attendance was associated with higher anxiety and depression at 12-month
follow-up, after controlling for anxiety and depression after first attendance.
Renn et al., 2011 Systematic review Reviewed 14 Multi-ethnic adults (aged Either a diagnostic psychiatric Either through self-report, The relationship between diabetes (specifically, T2DM) and depressive
empirical studies articles >18 years) from a range of interview, use of self-report FPG, or review of medical symptomatology is well documented in literature, but the exact direction of
settings with normal glucose assessment of depressive records this relationship remains unclear. It remains unclear, however, if it is the
levels, T1DM or T2DM symptoms, or a diagnosis by a diagnosis of a chronic illness or the actual disturbance to the
general practitioner glucose-regulatory system that precedes depressive symptomatology, or if
both factors contribute bi-directionally.
Pan et al., 2010 Longitudinal study 65,381 Community sample of A five-item subscale of the Self-reported confirmed The relative risk for type 2 diabetes in individuals with depressed mood was
American adult women Short-Form 36 called Mental using a supplementary higher compared with non-depressed T2DM individuals after adjustment for
(aged ≥62.1 ± 6.8 years) Health Index (MHI-5) questionnaire validated by all covariates (OR 1.17; 95% CI 1.05–1.30). Further, participants using
with or without type 2 medical record review antidepressants were at a particularly higher relative risk (OR 1.25; 95% CI
diabetes at baseline 1.10–1.41). Alternatively, compared with non-diabetic subjects, those with
diabetes had a relative risk of developing clinical depression after controlling
for all covariates of (OR1.29; 95% CI1.18–1.40). These associations remained
significant after adjustment for diabetes-related co-morbidities.
T2DM + T1DM
Campayo et al., Longitudinal study 4803 Community sample of Based on the Geriatric Mental Medical history At follow-up (2.5 and 5 years later), clinically significant depression was
2010 (379/3142) Spanish adults (female State Schedule associated with a 65% increased risk of T2DM.
45.6%: aged ≥55 years)
without diabetes at baseline
Collins et al., 2009 Cross-sectional 1456 Irish Adults (female HADS Medical records People with diabetes are at a higher risk for experiencing the two most
design 37.1–42.5%; aged 20–75 common forms of psychological distress, anxiety and depression. Diabetes
years) from mixed care complications, smoking, uncertainty about glycaemic control and being an
settings either with T1DM or ex-drinker or a heavy drinker were risk factors for both higher anxiety and
T2DM depression scores. Female gender and poor glycaemic control were risks
factors associated only with higher anxiety scores.
Engum, 2007 Prospective Baseline Norwegian community Anxiety & depression index Self-report Individuals reporting symptoms of depression and anxiety at baseline had
longitudinal study 8311/28,980 adults (female 56%; aged (ADI); HADS increased risk of onset of type 1 and Type 2 diabetes at 10-year follow-up. In
Follow up ≥20 years) either with contrast, baseline diagnosis of diabetes was not associated with subsequent
37,291 T1DM or T2DM symptoms of anxiety or depression among males or females.
Katon et al., 2008 Cross sectional 10,704 Multi-ethnic American ICD-9/PHQ-2/self reported WHO Criteria Comorbid depression was associated with an increase in all-cause mortality
survey of MediCare adults (aged 75.6 ±9.2 anti-depressive prescription over a two-year period of approximately 36% to 38%. No significant increase in
database years; female 43.7%) with rates of cause-specific mortality from macrovascular disease was found in
either T2DM or T1DM (???) depressed versus non-depressed participants. Depression is also a risk factor
T. Roy, C.E. Lloyd / Journal of Affective Disorders 142S1 (2012) S8–S21

for mortality in older fee-for-service Medicare beneficiaries with diabetes who

have high levels of diabetes complications and medical comorbidity.
Pouwer et al., 2010 Cross-sectional 772 Multi-ethnic Dutch adults WHO-5, CESD, CIDI self-report & diagnostic Depression was found as a common comorbid health problem in both T1DM
design (aged ≥20 years; female interview and T2DM out-patient sample, with about one-third of patients reporting
43.1%) from diabetes elevated depression scores, and 8–24% being diagnosed with a depressive
outpatient clinics with disorder. In particular, women with T2DM, non-Dutch T2DM patients, poorly
either T2DM or T1DM controlled T1DM patients, obese T2DM patients and those with coexisting
complications of diabetes appear to be at greater increased risk.
T1DM only
Barnard et al., 2006 Systematic review of 14 studies Multi-ethnic adults (aged Self-report assessment of Either through self-report, The prevalence of clinical depression in controlled studies was significantly
prospective studies included in 18–65+; female 52.2%) with depressive symptoms or FPG, or review of medical higher in people with T1DM compared with control subjects (12.0% vs. 3.2%). In
analysis T1DM Composite International records studies with no control group, the prevalence of clinical depression was 13.4%.
Diagnostic Interview (CIDI)
Gendelman et al., Observational cohort DM – 458 Multi-ethnic American BDI-II, antidepressants use Medical records The prevalence of depression (assessed either by BDI-II cut score or
2009 study Non DM – 546 adults from diabetes clinics antidepressant use) was significantly higher in participants with T1DM than in
and community with T1DM non-diabetic participants. The participants reporting diabetes complications
(aged 44 ± 9; female 47%) had higher mean BDI-II scores than those without complications.
and without T1DM (aged 47
S11

± 9; female 51%)
S12 T. Roy, C.E. Lloyd / Journal of Affective Disorders 142S1 (2012) S8–S21
meta-analyses and the remaining 15 were either empirical studies
(either observational cohort studies [n = 6], longitudinal studies [n
= 5] or cross-sectional studies [n = 4]). Only five of the 15 empirical
studies were controlled, with the rest being uncontrolled studies.
In most of these studies (n = 15), diabetes was identified using
diagnostic criteria, self-report, diabetes medication use, physician
diagnosis, oral glucose tolerance test (OGTT), fasting plasma glucose
(FPG) levels or through reviewing patient medical records. None
of the studies were completed after the change in the diagnostic
criteria to include HbA1c . One study did not mention the methods
used to identify diabetes. Depression cases were identified either by
self-report questionnaire, using diagnostic psychiatric interviews,
combined self-report questionnaire and diagnostic interviews, an-
tidepressant medication use, or diagnosis by a general practitioner.
Four studies were conducted in mixed settings, with samples
drawn either from both primary and secondary-care settings (n
= 2) or from community and primary-care settings (n = 2). The
remaining studies were conducted in either population samples (n
= 7) or in primary-care settings (n = 3).
The majority (n = 6) of the empirical studies were conducted in
the USA; eight studies involved patients from Europe (UK = 2; the
Netherlands = 2; Norway = 1; Germany = 1; Ireland = 1 and Spain)
and one study was conducted in Canada.
3.1. Prevalence
The prevalence rates of depression in people with diabetes
are significantly increased (see Table 2) and are thought to be at
least double for those with diabetes compared to those without
any chronic disease (Ali et al., 2006). Most data pertain to study
populations with T2DM or populations where type of diabetes is
not differentiated, and to research conducted in the western world.
Thirteen of the 20 papers (65%) measured depression specifically in
populations with T2DM (Ali et al., 2006; Brown et al., 2006; Knol et
al., 2007; Fisher et al., 2008; Golden et al., 2008; Icks et al., 2008;
Mezuk et al., 2008; Lin et al., 2009; Nouwen et al., 2010; Pan et al.,
2010; Paddison et al., 2011; Renn et al., 2011); two papers (10%)
measured depression in patients with T1DM (Barnard et al., 2006;
Gendelman et al., 2009); three (15%) papers reported depression in
both T1DM and T2DM; and two (10%) reported depression where
type of diabetes was not differentiated. Table 2 illustrates the
prevalence of depression and diabetes reported by the studies.
It is unclear whether prevalence rates differ according to type
of diabetes. A few studies have reported that depression prevalence
does not differ with diabetes type (Engum, 2007). More recently, a
study in the Netherlands reported almost similar rates of depression
in individuals with T1DM or T2DM (using WHO-5: 33% vs. 37%;
using CED-S: 30 vs. 38) (Pouwer et al., 2010). Similar rates (32.1%)
were reported in a U.S. study of individuals with T1DM (Gendelman
et al., 2009). A further U.S. longitudinal study reported a prevalence
rate of 34.4% in individuals with T2DM at follow-up (Fisher et al.,
2008). In contrast Knol et al. (2007) reported a prevalence rate of
19.3 % in a population study of T2DM in the Netherlands.
Some studies have demonstrated that depression is not only
associated with an increased risk for the development of T2DM, it
is also an established risk factor for cardiovascular disease (Knol
et al., 2007), and features of the metabolic syndrome, stroke,
retinopathy and obesity (Brown et al., 2006; Icks et al.,2008; Holt et
al., 2009; Collins et al., 2009; Pouwer et al., 2010). Diabetes-specific
risk factors for depression include co-morbidity of diabetes-related
complications (Engum, 2007; Gendelman et al., 2009) and in
particular vascular complications (Brown et al., 2006; Knol et al.,
2007; Katon et al., 2008). Knowledge of type 2 diabetes (Katon
et al., 2008), higher number of co-morbidities (Fisher et al., 2008;
Icks et al., 2008), smoking (Collins et al., 2009), obesity (Pouwer et
al., 2010), and perceived burden of diabetes treatment (Golden et
al., 2008) have all been postulated as risk factors but little, if any,
epidemiological data are available.
3.1.1. Depression in Type 2 diabetes
The prevalence rates in uncontrolled studies (n = 12) are
between 17.8 and 39% for individuals with T2DM, with higher much
lower rates observed in controlled studies (n = 3; rates between 3.2
and 6.5%). A number of studies have reported prevalence rates of
depression which are markedly and consistently higher in people
with T2DM compared with those without T2DM (Ali et al., 2006;
Knol et al., 2007; Engum, 2007; Golden et al., 2008; Icks et al.,
2008; Holt et al., 2009). However, in contrast, a number of studies
in Europe (UK and Germany) and Canada have reported lower
prevalence rates of depression in people with T2DM (Brown et al.,
2006; Icks et al., 2008; Paddison et al., 2011). The study of Brown
and colleagues reported a lower incidence of new-onset depression
in both T2DM and non-T2DM cohorts (6.5% vs. 6.6%) (Brown et
al., 2006). These authors further highlighted that increased risk
of depression was not associated with T2DM in their sample
if co-morbid diseases and the burden of diabetes complications
were accounted for. In a recent study, Holt et al. (2009) reported
similar low rates in both people with and without T2DM (5.0% vs.
3.8%); but they found a statistically significant association between
depression and diabetes. Icks et al (2008) suggested that there is
no significant association between known diabetes and depressive
symptoms in women, after controlling for co-morbidities. Recently
Paddisson et al (2011) reported suggested that diabetes screening
outcome (either positive or negative for diabetes) at baseline had
no effects on anxiety or depression levels at 12-month follow-up in
their sample.
3.1.2. Depression in Type 1 diabetes
Barnard et al have suggested that there is as yet no clear
evidence to support the assertion that individuals with T1DM have
significantly increased rates of depression compared with healthy
controls (Barnard et al., 2006). However, their systematic review
points to the wide-ranging differences in methods used and size
of population studies, which makes any conclusions premature.
The prevalence of clinical depression in controlled studies was
12% (range 5.8–43.3%) for people with diabetes compared with
3.2% (2.7–11.4%) for control subjects; in studies with no control
group, the prevalence of clinical depression was 13.4% (range
5–33.3%) (Barnard et al., 2006). In contrast Gendelman et al.
(2009) reported significantly higher prevalence rates of depressive
symptoms in both men and women with T1DM compared to
individuals without diabetes (men: 25.5 vs. 11.6%; women: 37.9
vs. 20.5%). The prevalence rates were even higher if reports of
elevated symptoms were combined with the use of anti-depressant
medication, especially in women. Similarly high rates were also
reported by Collins et al. in their cross-sectional study among Irish
patients with diabetes (22.4%) (Collins et al., 2009). More recently,
in a cross sectional study involving out-patients with diabetes in
the Netherlands, Pouwer et al. (2010) observed that about one-third
of their sample reported elevated depression scores, and 8–24%
were diagnosed with a depressive disorder.
3.1.3. Ethnic differences
There may be geographical and cultural differences in the
prevalence of depression, however, this is difficult to establish
with available data. Most research has compared prevalence rates
generally, and none of these studies have addressed culture as a
specific factor within or across populations. Indeed only six studies
stated the ethnic background of the participants and reported a
mixed ethnicity of their sample.
Most studies considering race or ethnicity only analysed ethnic-
ity as an associated variable of depression and/or diabetes (either as
 T. Roy, C.E. Lloyd / Journal of Affective Disorders 142S1 (2012) S8–S21 S13

Table 2
Prevalence of depression or diabetes in adult populations.

Study Sample (n) Prevalence of depression (%) Prevalence of DM (%)

All (case vs. control) Men/Women With DM/ All Men/Women With depression/
Without DM Without depression
T2DM only
Ali et al., 2006 12 studies included in analysis 17.8% 12.8/23.8 17.6/9.8 – – –
Brown et al., 2006 31,635/57,141 6.5 vs. 6.6 (case vs. control) – 6.5/6.6 – – –
Fisher et al., 2008 506 CED-S – 22.6 vs. 34.4 (baseline – – – – –
vs. 18 months follow up)
DDS – 18.0% vs. 29.2% (baseline
vs. 18 months follow up)
CIDI – 10.7% vs. 18.8% (baseline
vs. 18 months follow up)
Golden et al., 2008 5201 17.5 5.2/12.3 11.7/9.5 – – 22/16.6
10.8
Holt et al., 2009 2995 5.0 4.8/5.4 5.0/3.8 – – 23.0/14.1

Icks et al., 2008 4595 27.6 10.6/17.0 30.4/27.9 13.3 9.2/17.0 –

Knol et al., 2007 4747 19.3 – 29.7/19.4 – –
Lin et al., 2009 4148 20.3 17.8/23.0 – – – –
Mezuk et al., 2008 18 studies included in analysis 15% increased risk – – 60% increased – –
risk
Nouwen et al., 2010 11 studies included in analysis 24% increased risk – – – – –
Paddison et al., 2011 3240 HADS-A 6.04 (base) – – – – –
HADS-D 4.24 (after 12 months)
HADS-A 5.81 (base)
HADS-D 4.25 (after 12 months)
Renn et al., 2011 Reviewed 14 articles – – – – – –
Pan et al., 2010 65,381 19.1 – – – – –
T2DM + T1DM
Campayo et al., 2010 4803 (379/3142) 6.6 – – – – 19.7/12.4
4.4
Collins et al., 2009 1456 T1 – 22.4 T1: – – – –
T2 – 32.0 30.9/44.6
T2:
27.6/30.3
Engum, 2007 Baseline 8311/28,980 22.3 – 33/10.2 – – T1 – 0.4; T2 – 2.5/
Follow up 37,291 33/10.2 T1 – 0.4; T2 – 1.6
Katon et al., 2008 10,704 15.5 11.8/20.2 – – – –
Pouwer et al., 2010 772 WHO-5: 33 (T1) 44.0/52.0 – – – –
WHO-5: 37-39 (T2) 37.0/43.0
CIDI 8% (T1) CIDI 8% (T1)
CIDI 2% (T2)
CESD 30 (T1)
CESD 38 (T2)
T1DM only
Barnard et al., 2006 14 studies included in analysis All – 13.4 – 12.0/3.2 – – –
Controlled studies – 3.2
Uncontrolled studies – 12.0
Gendelman et al., DM – 458 32.1 25.5/37.9 32.1/16.0 – – –
2009 Non DM – 546 16.0 11.6/20.5

a determinant or not). Studies with African American participants
have shown a mixed picture in terms of rates of diabetes and
depression (Knol et al., 2007; Katon et al., 2008; Fisher et al.,
2008; Golden et al., 2008), however, none have reported prevalence
rates separately by ethnic group. A review of the respective papers
has enabled us to extract prevalence rates according to ethnicity
for two U.S. studies. Katon et al. (2008) reported that depressed
individuals were less likely to be African-American and were more
likely to be Hispanic (African-American 13%; Asian-American 15.2%
White-American 15.5%; Hispanic 21.8%). However, Lin et al. (2009)
found no difference in rates between White-American and non-
White-Americans for either minor depression (7.9% vs. 10.8%) or
major depression (11.7% vs. 11.8%).
Two other U.S. studies have mentioned non-significant higher
rates in non-White Americans (with no further categorization)
compared to White-American individuals (although there was no
reference to actual prevalence rates) (Fisher et al., 2008; Golden
et al., 2008). The only European study by Pouwer et al. (2010)
reported higher levels of depressive symptoms or depressive effects
in non-Dutch patients with T2DM compared with Dutch patients.
However, they found no ethnic differences in depression in patients
with T1DM. A systematic review by Ali et al. (2006) has discussed
ethnic differences in people with diabetes in the UK and noted that
South Asians reported lower levels of diagnosed depressive disorder
than their White European counterparts.
3.1.4. Risk factors for depression in people with diabetes
Although most studies have been cross-sectional, evidence sug-
gests that there are a range of factors that may be associated with
the risk of developing depression. The prevalence of depression is
increased in the general population in people with the following
characteristics: female gender, younger and/or older age, individ-
S14 T. Roy, C.E. Lloyd / Journal of Affective Disorders 142S1 (2012) S8–S21
uals living alone, those with poor social support, and people with
low socioeconomic status. All these factors operating in the general
population have also been found to increase risk of depression in
people with diabetes. In addition, the following risk factors for de-
pression in people with diabetes have been found to be important:
occurrence of late or acute complications, persistent poor glycaemic
control, and insulin therapy in T2DM (Brown et al., 2006; Knol et
al., 2007; Golden et al., 2008; Collins et al., 2009; Pouwer et al.,
2010).
3.1.5. Gender differences
Nearly half of the studies (n = 9) examined differential rates of
depression in men and women with T1DM or T2DM (Barnard et
al., 2006; Knol et al., 2006; Knol et al., 2007; Fisher et al., 2008;
Icks et al.,2008; Katon et al., 2008; Lin et al., 2009; O’Connor et
al., 2009; Nouwen et al., 2010). With the exception of one study
(Holt et al., 2009) women have been found to have higher rates of
depression compared to men, with similar findings in T1DM and
T2DM (Barnard et al., 2006; Collins et al., 2009; Gendelman et al.,
2009).
3.1.6. Older people vs. the young
Most studies have reported age as a risk factor for depression,
however, depression has been found to be less common in older
cohorts (specifically lower in populations >60 years) (Fisher et al.,
2008; Katon et al., 2008). A number of community-based studies
in the U.S. have reported an increased prevalence of psychological
morbidity in younger adults with T2DM. Furthermore patients
with co-morbid depression and diabetes tend to be younger than
patients with diabetes but without depression (Fisher et al., 2008;
Katon et al., 2008; Lin et al., 2009). Collins et al. have reported lower
rates of depression in older individuals with T1DM, suggesting that
age might have a protective effect (Collins et al., 2009). Conversely,
Golden et al. (2008) reported older age as a risk factor for higher
prevalence of depression. However, the relationship between age
and risk for depression in people with diabetes remains complicated
and needs further exploration.
3.2. Depression as a risk factor for diabetes
Although there are no studies that demonstrate that depression
increases the risk of T1DM, a good number of studies support
the hypothesis that people with depression are more vulnerable
to developing T2DM (Knol et al., 2006; Knol et al., 2007; Mezuk
et al., 2008; O’Connor et al., 2009; Nouwen et al., 2010). It has
been hypothesised that behavioural factors associated with depres-
sion can ultimately lead to T2DM and poor self-care behaviour
in people with diabetes (Golden et al., 2008). This assumption
suggests that behaviours associated with depression can result in
obesity and insulin resistance, paving the way for development of
T2DM (Finkelstein and Finkelstein, 2000). Depressive symptoms are
associated with higher body mass index (BMI) and with unhealthy
behaviours such as consuming high calorie diets, which in turn are
risk factors for the development of T2DM (Golden et al., 2008; Cam-
payo et al., 2010). In addition the biochemical changes associated
with depression or its treatment may have a cascading effect that
results in diabetes (Finkelstein and Finkelstein, 2000).
Recently a follow-up meta-analysis conducted by Nouwen et
al. (2010) found a 24% increased risk of incident depression in
people with T2DM compared to people without diabetes. This latter
study speculated that this increased risk might result in part from
an increased awareness of both depression and diabetes, yielding
more diagnoses of depression in this population (Nouwen et al.,
2010). In support of this, it is known that people who are frequent
users of the medical system have higher rates of new depression
diagnoses; however, having diabetes may also mean an increased
likelihood of receiving such a diagnosis. In a recent study O’Connor
et al. (2009) compared the rate at which middle-aged and older
adults with and without T2DM received a new depression diagnosis
over two years in a primary care setting in the U.S. People with
T2DM were 46% more likely to receive a diagnosis of depression
compared to age and sex-matched non-diabetic counterparts. After
controlling for the number of primary care visits, patients with
T2DM were still at an elevated risk (32%) of being diagnosed
with depression. The authors argued that people with diabetes
may have more frequent contact with medical providers, and are
therefore more likely to receive a depression diagnosis (O’Connor
et al., 2009). In another large-scale study in the Netherlands,
Knol et al. (2007) investigated similar relationships in a sample
with either normal fasting glucose levels (absence of diabetes),
pre-diabetes (impaired fasting glucose), undiagnosed T2DM or
diagnosed T2DM. After controlling for lifestyle (e.g., tobacco and
alcohol consumption, physical activity) and demographic variables
(gender, age, and education), patients with diagnosed T2DM had
a 1.7 times increased risk of depressive symptoms compared to
individuals without a diagnosis (Knol et al., 2007). The results
indicate that prevalence of depression increased only in patients
with a known T2DM diagnosis, and not in participants with
undiagnosed T2DM.
3.3. A bidirectional relationship between depression and diabetes
Based on the existing evidence reviewed here, it is likely that
establishing a bidirectional relationship between depression and
diabetes is not as simple as establishing a unidirectional one, where
the evidence consistently suggests that people with either type of
diabetes are twice as likely as to be depressed compared to people
without diabetes (Ali et al., 2006; Barnard et al., 2006; Golden et al.,
2008; Mezuk et al., 2008). It has been argued by many researchers
that diabetes precedes depression and leads to depression either
through a direct effect of hyperglycaemia, possibly leading to
altered glucose transport, or as a result of the psychological stress
resulting from the knowledge of the diagnosis or from the rigours of
the treatment, both lifestyle and pharmacological (Anderson et al.,
2001; Engum, 2007; Renn et al., 2011). However, this assumption
has been challenged by several recent cohort studies that have
suggested that depression may be a risk factor for diabetes (Engum,
2007; Golden et al., 2008; Holt et al., 2009) while diabetes does not
necessarily predict depression or is associated with only a modest
risk of development of depression (Engum, 2007).
As very few studies have examined the bidirectional relationship
between depression and diabetes, it is difficult to provide a clear
picture. The key paper that provided evidence for a bidirectional
relationship is Mezuk et al.’s (2008) meta-analysis. This showed
that people with T2DM have a 15% increased risk of depression
compared to people without diabetes, and people with depression
have a 60% increased risk of developing T2DM. Pan et al (2010) have
also provided compelling evidence that the association between
diabetes and depression is bidirectional. In this latter study in
women over a 10 year period, the relative risk for type 2 diabetes
in those with depressed mood was higher compared with non-
depressed individuals after adjustment for all covariates (OR 1.17;
95% CI 1.05–1.30). In the same study, those with diabetes had
an increased relative risk of developing clinical depression after
controlling for all covariates of (OR1.29; 95% CI1.18–1.40) compared
to those without diabetes (Pan et al., 2010).
Further support for a bidirectional relationship between diabetes
and depression has been provided by Golden et al. (2006) and by
Renn et al. (2011). Based on their recent systematic review of the
literature, the latter authors demonstrated a robust and consistent
relationship between diabetes and depressive symptoms, but the
exact direction of this relationship remained unclear (Renn et al.,
 T. Roy, C.E. Lloyd / Journal of Affective Disorders 142S1 (2012) S8–S21
Table 3
The association between depression and sub-optimal glycaemic control.
Study Depression vs. glycaemic control
Fisher et al., 2008 CES-D scores and DDS scores were each significantly
associated with HbA1c at each wave. High depressive
affect and diabetes distress were consistently linked to
high HbA1c over time.
Golden et al., 2008 Developing elevated depressive symptoms were 0.79
times higher (95% CI, 0.63–0.99) for impaired fasting
glucose patient with T2DM
Holt et al., 2009 High value of fasting insulin, 2-h glucose concentrations
and insulin resistance were significantly associated with
high HAD-D scores. Glycaemic control was poor in
depressed people with T2DM
Knol et al., 2007 Impaired fasting glucose were not associated with
depression
Lin et al., 2009 No significant difference was observed in HbA1c level in
patients with no depression, minor depression or major
depression.
Engum, 2007 Non-fasting blood sugar was not associated with
depression
Collins et al., 2009 Uncertainty about or poor glycaemic control is associated
with depression and anxiety
Pouwer et al., 2010 Depressive affect was associated with poor glycaemic
control for T1DM but not for T2DM
Gendelman et al., A significant relationship between elevated mean HbA1c
2009 and a history of depression among participants with type
1 diabetes was observed.
2011). However, the mechanisms underlying depression and T2DM
co-morbidity may have reciprocal interactions, through which each
can contribute to and complicate the other (Renn et al., 2011). A
further possibility is that other risk factors pre-dispose individuals
to both diabetes and depression (Pan et al., 2010).
3.4. Association between depression and glycaemic control
A total of nine studies have examined the association of
depression with glycaemic control (Table 3), two of which were
longitudinal studies in T2DM and reported that depression was
associated with poorer glycaemic control (Fisher et al., 2008;
Golden et al., 2008). In a longitudinal study involving 3-waves of
follow-up of a community sample, both depression scores (using
CES-D) and diabetes distress scores were significantly associated
with level of glycaemic control (HbA1c ) over time (Fisher et
al., 2008). Holt et al. (2009) reported that high fasting insulin
values, 2-hour glucose concentrations and insulin resistance were
significantly associated with high depression (HAD-D) scores in a
cross-sectional study. In general, they found elevated glucose levels
in depressed people with T2DM. Another cross-sectional study by
Collins et al. was inconclusive regarding the relationship between
poor glycaemic control and depression/anxiety (Collins et al., 2009).
In contrast, other longitudinal studies have found no association
between depression and glycaemic control (Engum, 2007; Lin et al.,
2009). Knol et al’s (2007) cross-sectional study also demonstrated
that impaired fasting glucose was not associated with depression
in people with T2DM. Only one longitudinal study has examined
this relationship in people with T1DM, and observed a significant
relationship between elevated mean HbA1c values and a history of
depression among participants with T1DM (Gendelman et al., 2009).
In a more recent cross-sectional study involving outpatients with
either T1DM or T2DM, Pouwer et al. (2010) found that depressive
affect was associated with poor glycaemic control for T1DM but not
for T2DM.
S15
4. Summary
This systematic review has considered the recent epidemiologi-
cal evidence on diabetes and depression in terms of prevalence, risk
factors, and the possible association with glycaemic control. Whilst
there is a plethora of published data on depression and T2DM, there
is a significant shortage of data available on the prevalence and
characteristics of depression in people with T1DM. The evidence
suggests that the prevalence of depression is nearly twice as high
in people with diabetes compared to those without, with higher
rates in women than men. Depression may also increase the risk
of developing T2DM; however, the mechanisms via which this may
occur still require investigation. This review indicates that the link
between depression and the development of T1DM remains unclear
and it is not yet possible to conclude that the prevalence of clinical
depression is elevated in this group or that depression increases the
risk of developing T1DM. Although our review has demonstrated
that prevalence of depression is increased in people with diabetes,
the rates vary widely which may reflect differences in measurement
methods, or ‘real’ differences in terms of country, socio-economic
factors or other variables as yet not identified. These variations still
need to be fully examined in future studies.
This review has highlighted the range of potential risk factors
for depression in people with diabetes, some of which are shared
with those for people without diabetes. In addition to physiological
factors specific to diabetes there are other factors such as perceived
burden of treatment, which also impact on symptoms of depression.
Although a significant literature provides well documented
support for a modest relationship between diabetes (specifically,
T2DM) and depressive symptoms (Mezuk et al., 2008; Pan et al.,
2010; Renn et al., 2011), the exact direction of this relationship
remains unclear. The biochemical and physiological changes as-
sociated with diabetes, as well as the psychosocial burden of a
chronic disease, provides some evidence that depression may be a
consequence of diabetes. However, it is likely that the mechanisms
underlying this co-morbidity are not as simple as for a unidirec-
tional relationship. Instead, depression and T2DM may have pooled
interactions, through which each can contribute to and complicate
the other.
Longitudinal research may help quantify the independent effect
of depression as well as other modifiable risk factors on several
diabetes related outcomes, including glycated haemoglobin.
This literature review reports high rates of co-morbidity for
depression and diabetes. The need for clinicians to recognize this is
imperative, particularly in primary care settings where the majority
of people with diabetes receive their care. If depression is indeed a
risk factor for development of diabetes, early detection and timely
treatment planning could prevent the onset of the chronic disease.
At the very least, detection of depression could reduce medical
complications.
Diabetes demands high levels of self-care (e.g., frequent mon-
itoring of blood glucose, medication management, and strict nu-
tritional guidelines). The chronic nature of the disease requires
patients to develop their coping skills as the disease may result
in medical complications and decreased mobility. Also, biochemical
changes associated with diabetes, such as arousal of the nervous
system, could account for an increased risk of depression in indi-
viduals with diabetes (Knol et al., 2007). Additionally, the nature of
depression is such that patients are at risk for poor engagement in
self-care behaviours, resulting in poorer glucose control and more
complications once they develop.
S16 T. Roy, C.E. Lloyd / Journal of Affective Disorders 142S1 (2012) S8–S21
5. Limitations
Whilst there has been increased interest in diabetes and depres-
sion and the potential risk factors associated with co-morbidity,
many studies have been cross-sectional (Knol et al., 2007; Katon et
al., 2008; Holt et al., 2009; Collins et al., 2009) and are not able
to examine the temporal relationship between the two conditions.
This limits conclusions about the causal nature and direction of the
co-morbidity. Even where studies have used longitudinal research
designs (Brown et al., 2006; Engum, 2007; Fisher et al., 2008;
Golden et al., 2008; Icks et al., 2008; Lin et al., 2009; Collins et al.,
2009; Campayo et al., 2010; Pan et al., 2011; Paddison et al., 2011),
examining the direction of the relationship is difficult, as some
lifestyle and biological factors, or other common precursors of both
conditions, may be operating years before diagnosis (Brayne et al.,
2005). Furthermore, one cannot generalize from questionnaire-only
or screening studies because they may overestimate the prevalence
of depression. The majority of the studies only assessed depressive
symptoms and it is unclear whether the results would be different
if a clinical diagnosis of a depressive disorder had been used.
Where change in depressive symptoms has been reported, these
were in terms of statistical significance and not clinical significance.
For example, when changes in depression scores or depressive
symptoms were reported, it is unknown if these changes were
enough to change an individual’s clinical picture or diagnosis. This
implies that there is a lack of agreement of definition, operational
definitions, and measurement (Renn et al., 2011). For example, most
of the research investigated depressive symptomatology, not major
depression (with two exceptions: Fisher et al., 2008; Lin et al.,
2009). Future research should distinguish between both different
types of diabetes and methods of assessing depression.
A further limitation to this review is that studies have varied
widely in their methodologies, with differences in the measurement
of depression making comparisons difficult. Measurement of de-
pressive symptoms ranged from reviewing patient medical records
for anti-depressant prescriptions or physician diagnoses (Brown et
al., 2006; Katon et al., 2008) to self-report measures on a variety of
scales (e.g. CED-S, HADS, SCL-90, PHQ-9, WHO-5, BDI-II; see Knol
et al., 2007; Engum, 2007; Fisher et al., 2008; Golden et al., 2008;
Icks et al., 2008; Holt et al., 2009; Lin et al., 2009; Collins et al.,
2009; Gendelman et al., 2009; Pouwer et al., 2010; Paddison et
al., 2011). Among studies using self-report questionnaires to assess
depressive symptoms, different questionnaires and different cut-off
values were used to define symptoms of depression. Some studies
also included anti-depressant medication as a proxy measure of
depression (Brown et al., 2006: Knol et al., 2007; Katon et al., 2008;
Gendelman et al., 2009). However, this was not reported in other
studies and there is a possibility that this may act as a contributing
factor to the increased risk of diabetes among people with depres-
sion (Renn et al., 2011). This huge variation in the classification
and assessment of depression makes it difficult to compare the true
prevalence of depression across the studies and to draw conclusions
about the prevalence of depression and severity of symptoms.
The assessment of diabetes also varied, with some relying
on self-report, blood glucose measurements, oral glucose tolerance
tests, data from medical files or any combination. Another weakness
in previous studies has been that measurement of depressive
symptoms was taken at single points in time over a span of several
years. This is unlikely to produce reliable data on the incidence of
depression in diabetes; better designed and controlled studies are
clearly needed.
The majority of research in diabetes and depression has been
conducted on European and American samples. This limits the
generalizability of the findings presented in this review, although
it makes examination of the relationship between diabetes and
depression no less important for minority populations. There thus
now needs to be a greater focus on co-morbidity in regions of
greatest risk, including Asia, India, Pacific Regions (including Aus-
tralia and New Zealand) and the African nations. There may be
some overlap in risk and risk factors for co-morbidity between
marginalised cultural/ethnic groups within populations however,
this still requires investigation. Research should include full rep-
resentation of different race/ethnic groups, and should consider
vulnerable groups such as indigenous populations.
Despite doubts about the exact causal nature and directionality
of the relationship, future research into treatment for co-morbid
depression and T2DM is warranted. The reviewed research clearly
indicates that in co-morbid populations, the treatment of both dia-
betes and depressive symptoms should be undertaken to decrease
suffering and additional complications of the illness. Further studies
are required in order to find out the relative importance of different
psychological morbidities and their impact on glycaemic control,
the development of diabetes complications and the management of
diabetes.
Conflict of interest statement
TR received financial support from the Dialogue on Diabetes and Depression
(DDD) for conducting the systematic review and writing the paper. There are no
other conflicts of interest for either of the authors of this paper.
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and diabetes: A systematic review. Clin. Psychol. Rev. 31 (8), 1239–1246.
Appendix 1. Annotated bibliography: 20 key papers (last 5 years: August
2006–August 2011)
Papers reported Depression and Type 2 diabetes (n = 13)
Author(s) Ali S, Stone MA, Peters JL, Davies MJ, Khunti K
Country/Setting United Kingdom
Title The prevalence of co-morbid depression in adults with Type 2
diabetes: a systematic review and meta-analysis
Source Diabet Med, 2006; 23: 1165–1173
Type of Study Systematic review & meta-analysis
Depression
Assessment – of depressive affect and distress was 60–737% higher than of
Summary This empirical research study estimated the prevalence and odds
ratio of clinically relevant depression in adults with Type 2 dia-
betes compared with those without. The authors/researchers in
the UK conducted a systematic search of MEDLINE, EMBASE, and
PSYCINFO databases and identified 10 studies potentially rele-
vant. They performed meta analysis to synthesize and analyse
the data. The authors reported a significantly higher prevalence
of depression in patients with Type 2 diabetes compared with
those without [17.6 vs. 9.8%, OR = 1.6, 95%, confidence interval
(CI) 1.2–2.0] and in females with diabetes (23.8%) compared
with males (12.8%). The authors also observer ethnic differences
in reporting depression symptoms in people with diabetes in
the UK; South Asians reported lower levels of diagnosed de-
pressive disorder compared with their Caucasian counterparts.
Further, patients with diabetes differed from those without on
variables known to be associated with an increased risk of de-
pression. They recommended the need for well-controlled and
S17
better-reported studies to inform the development of effective
treatments for depression in diabetes patients.
Author Keywords Adults, co-morbidity, depression, prevalence, Type 2 diabetes
mellitus
Author(s) Brown LC, Majumdar SR, Newman SC, Johnson JA
Country/Setting Canada/Community
Title Type 2 diabetes does not increase risk of depression
Source CMAJ, 2006; 175(1): 42–46
Type of Study Retrospective cohort study
Depression
Assessment Diagnostic codes from medical record & prescriptions for an-
tidepressants
Summary This article explains whether people with diabetes have a
greater incidence of depression than those without diabetes.
They authors conducted a population-based retrospective co-
hort study using the administrative databases of Saskatchewan
Health, Canada from 1989 to 2001. People older than 20 years
with newly diagnosed type 2 diabetes were identified (n= 31
635) and compared with a non-diabetic cohort (n=57,141).
The incidence of new-onset depression was similar in both
groups (6.5 vs.6.6 per 1000 person-years among people with
and without diabetes respectively). Similarity of risk persisted
after controlling for age, sex, number of physician visits and
presence of pre-specified co-morbidities (adjusted HR 1.04, 95%
CI 0.94–1.15). However, other chronic conditions such as arthri-
tis (HR 1.18) and stroke (HR 1.73) were associated with the
onset of depression. The main limitation of this study was that
Depression was ascertained via diagnostic codes from medical
record and prescriptions for antidepressants in the absence of
recommended diagnostic criteria or measurement. However, the
authors concluded that they found little evidence that type 2
diabetes increases the risk of depression once comorbid diseases
and the burden of diabetes complications were accounted for.
Author(s) Fisher L, Skaff MM, Mullan JT, Arean P, Glasgow R, Masharani U
Country/Setting USA/Community & diabetes outpatient
Title A longitudinal study of affective and anxiety disorders, depres-
sive affect and diabetes distress in adults with Type 2 diabetes
Source Diabet Med, 2008; 25(9): 1096–1101
Type of Study Non-interventional longitudinal study
Depression
Assessment Composite International Diagnostic Interview (CIDI), Centre for
Epidemiological Studies – Depression (CES-D), and Diabetes
Distress Scale (DDS)
Summary Fisher et al examined the prevalence and correlates of affective
and anxiety disorders, depressive affect and diabetes distress
over time. In this longitudinal study the authors assessed 506
patients with Type 2 diabetes for depressive disorders, general
anxiety and depressive affect three times over 18 months
period (9 months interval). They used Composite International
Diagnostic Interview (CIDI), Centre for Epidemiological Studies
– Depression (CES-D), and Diabetes Distress Scale (DDS) to
assess affective and anxiety disorders, depressive affect and
diabetes distress. The authors reported that diabetes patients
displayed high rates of affective and anxiety disorders over time
(60–123% higher), relative to community adults. The prevalence
affective and anxiety disorders. The increase for CES-D and
DDS scores was about 60% and persistence of CES-D and DDS
disorders over time was significantly greater than persistence of
affective and anxiety disorders. This article further highlighted
that younger age, female gender and high comorbidities were
related to persistence of all depressive conditions over time. The
main limitation in this study was that the short time interval
(only 9 months) between the waves may not have allowed
sufficient time to clarify potential confounding between the
length and frequency of episodes. Also, the authors compared
their diabetes sample with a historical reference group and
not with a contemporaneous control group. However, this
study reinforces the need for both repeated mental health and
diabetes distress screening at each patient contact, not just
periodically.
Author Keywords Affective and anxiety disorder; depressive affect; distress; preva-
lence
S18 T. Roy, C.E. Lloyd / Journal of Affective Disorders 142S1 (2012) S8–S21
Author(s) Golden SH, Lazo M, Carnethon M, Bertoni AG, Schreiner PJ, Diez
Roux AV, et al.
Country/Setting USA/Community
Title Examining a bidirectional association between depressive
symptoms and diabetes
Source JAMA, 2008; 299(23): 2751–2759
Type of Study Population-based longitudinal cohort study
Depression
Assessment Centre for Epidemiologic Studies Depression (CES-D) Scale
Summary This population-based study examined the bidirectional longi-
tudinal association between elevated depressive symptoms and
type-2 diabetes among ethnically diverse cohorts of US men
and women. The authors used Centre for Epidemiologic Stud-
ies Depression (CES-D) Scale for assessing elevated depressive
symptoms (score ≥16). The authors estimated the relative haz-
ard of incident type 2 diabetes in participants without type
2 diabetes at baseline (n=5201) over 3.2 years for those with
and without depressive symptoms. They further calculated the
relative odds of developing depressive symptoms in partici-
pants without depressive symptoms at baseline (n=4847) over
3.1 years for those with and without type 2 diabetes. The
findings of this study indicated that individuals with elevated
depressive symptoms at baseline have a modest increased risk
of developing type 2 diabetes during follow-up, independent
of sociodemographic, economic, and metabolic factors. Impaired
fasting glucose and untreated type 2 diabetes were inversely
associated with incident depressive symptoms, whereas treated
type 2 diabetes showed a positive association with depressive
symptoms. The main limitation of this study was that depressive
symptoms were only assessed at 1 follow-up time point over a
relatively short duration. Also, antidepressant use was included
in the definition of elevated depressive symptoms, which may
have misclassified participants who were taking antidepressants
for other reasons.
Author(s) Holt RIG, Phillips DIW, Jameson KA, Cooper C, Dennison EM and
Peveler RC, et al.
Country/Setting UK/Community
Title The relationship between depression and diabetes mellitus:
findings from the Hertfordshire Cohort Study
Source Diabet Med, 2009; 26: 641–648
Type of Study Cross-sectional population-based study
Depression
Assessment Hospital Anxiety and Depression Scale (HADS)
Summary The Hertfordshire Cohort Study Group in UK tested the hy-
pothesis that depression may increase the risk for diabetes.
They assessed the relationship between depression scores and
diabetes, glucose and insulin. In this cross-sectional population-
based study 1579 men and 1418 women from the Hertfordshire
Cohort Study were assessed for diabetes. Depressive and anxiety
symptoms were measured using the Hospital Anxiety and De-
pression Scale (HADS). The results of this study indicate there is
a relationship between depression scores and diabetes, irrespec-
tive of whether this had been previously diagnosed or not. The
authors have also shown that there is an association between
depression score and glucose and insulin concentrations in men
without a previous diagnosis of diabetes. This relationship may
help clinicians to consider screening for diabetes in those with
depression and vice versa. Although findings of this study pro-
vide convincing evidence that depression may predispose to
diabetes, these data, however, need to be interpreted in the
light of their potential imitations. The cross-sectional design
of this study limits the ability to determine whether a causal
relationship exists between diabetes and depression and it is
not possible to exclude an independent risk factor leading to
both conditions.
Author Keywords Depression, diabetes, diagnosis, epidemiology, population stud-
ies
Author(s) Icks A, Kruse J, Dragano N, Broecker-Preuss M, lomiany U, Mann
K, et al.
Country/Setting Germany/Community
Title Are symptoms of depression more common in diabetes? Re-
sults from the Heinz Nixdorf Recall study
Source Diabet Med, 2008; 25: 1330–1336
Type of Study Population-based prospective cohort study
Depression
Assessment Centre for Epidemiologic Studies Depression (CES-D) Scale
Summary This study estimated the association between depressive symp-
toms and Type 2 diabetes, as well as previously undetected
diabetes. The authors used baseline data of 4595 participants
from a population-based, prospective cohort study in Germany.
Depressive symptoms were assessed using the Center for Epi-
demiologic Studies Depression (CES-D) scale short form (cut-off
≥15 points). This study found no significant association be-
tween known diabetes and depressive symptoms in women, in
particular after adjustment for co-morbidities. In subjects with
undiagnosed diabetes, however, depressive symptoms were less
frequent in men compare with those without diabetes. Co-
morbidities and psychosocial conditions are strongly associated
with depressive symptoms. However, in this study the lower
prevalence of depressive symptoms in people with previously
undiagnosed diabetes may be in part as a result of a selection
bias as there is high possibility of under-reporting depressive
symptoms in the study assessment by these subjects.
Author Keywords Depressive symptoms, diagnosed and previously undetected
diabetes mellitus, population-based study
Author(s) Knol MJ, Heerdink ER, Egberts AC, Geerlings MI, Gorter KJ,
Numans ME, et al.
Country/Setting Netherlands/primary and secondary care
Title Depressive Symptoms in Subjects With Diagnosed and Undiag-
nosed Type 2 Diabetes
Source Psychosom Med, 2007; 69(4): 300–305
Type of Study Longitudinal study
Depression
Assessment Symptom Check List (SCL-90) or self-reported use of antidepres-
sants
Summary This study investigated if disturbed glucose homeostasis or
known diagnosis of diabetes was associated with depressive
symptoms. The authors classified 4747 subjects into four cat-
egories: normal fasting plasma glucose (FPG) (<5.6 mmol/l),
impaired FPG (≥5.6 and <7.0 mmol/l), undiagnosed type 2
diabetes (FPG ≥7.0 mmol/l), and diagnosed type 2 diabetes.
Presence of depressive symptoms was defined as a score of ≥25
on the depression subscale of the Symptom Check List (SCL-90)
or self-reported use of antidepressants. In this study the au-
thors demonstrated that diagnosed diabetes (but not impaired
fasting glucose and undiagnosed diabetes) was associated with
an increased risk of depressive symptoms after adjustment for
demographic and lifestyle. The findings suggest that disturbed
glucose homeostasis is not associated with depressive symp-
toms. The main limitation was that this study used self-reported
data to define diagnosis of Type 2 diabetes. Thus, it is possi-
ble that some misclassification occurred in that patients with
diagnosed diabetes misclassified themselves as not diagnosed.
Further self-reported use of antidepressants to assess depression
is also problematic – antidepressants are not solely prescribed
for depression but also for other psychiatric problems such
as anxiety and panic disorders; this prescription practice may
have confound the results of this study. The authors concluded
that the increased prevalence of depressive symptoms among
patients with diagnosed type 2 diabetes might be a consequence
of the burden of diabetes.
Author Keywords Depressive symptoms, diabetes, blood glucose, burden
Author(s) Lin EH, Heckbert SR, Rutter CM, Katon WJ, Ciechanowski P,
Ludman EJ, Oliver M, Young BA, McCulloch DK, Von Korff M
Country/Setting USA/Primary care
Title Depression and Increased Mortality in Diabetes: Unexpected
Causes of Death
Source Ann Fam Med, 2009; 7(5): 414–421
Type of Study Prospective cohort study
Depression
Assessment the Patient Health Questionnaire (PHQ-9)
Summary In this prospective cohort study of primary care patients with
type 2 diabetes (n=4,184) at Group Health Cooperative in
 T. Roy, C.E. Lloyd / Journal of Affective Disorders 142S1 (2012) S8–S21
Washington state Lin et al examines the association of de-
pression with all-cause and cause-specific mortality in diabetes.
The authors used the Patient Health Questionnaire (PHQ-9) to
assess depression at baseline and reviewed medical records
supplemented by the Washington state mortality registry to
ascertain the causes of death. This study demonstrated that
diabetes patients with coexisting depression differed signifi-
cantly from those with no depression. Depressed patients were
more likely to be single women and slightly younger, but they
had longer duration of diabetes, less-healthful habits, worse
glycemic control, and more medical comorbidities. After ad-
justment for demographic and clinical characteristics, health
risk behaviors, and disease control measures, major depression
was significantly associated with all-cause mortality and non-
cardiovascular, non-cancer related mortality. After adjustment
for these same characteristics, minor depression showed a non
significant association with any mortality outcome. Limitations
of this study are that depression was assessed at a single
point in time and there was no information available about the
history of depression before baseline measurements or interim
depression status before death. Lack of information on medi-
cation adherence is a limitation of these analyses. This study
concluded that patients with diabetes and coexisting depression
face substantially elevated mortality risks beyond cardiovascular
deaths.
Author(s) Mezuk B, Eaton WW, Albrecht S, Golden SH
Country/Setting USA
Title Depression and type 2 diabetes over the lifespan: a meta-
analysis
Source Diabetes Care, 2008; 31(12): 2383–2390
Type of Study Systematic review & meta-analysis
Depression
Assessment – higher number of self-reported (diabetes) symptoms after first
Summary This systematic review examines the bi-directional prospective
relationships between depression and type 2 diabetes. The au-
thors conducted a search using Medline for publications from
1950 through 2007. They included only comparative prospective
studies of depression and type 2 diabetes that excluded preva-
lent cases of depression (for diabetes predicting depression) or
diabetes (for depression predicting diabetes). The result of this
study demonstrated that depression is associated with a 60% in-
creased risk of type 2 diabetes and type 2 diabetes is associated
with only modest increased risk of depression (15%). The au-
thors further showed that pooled relative risk (RR) for incident
depression associated with baseline diabetes was 1.15 (95% CI
1.02–1.30). The RR for incident diabetes associated with baseline
depression was 1.60 (1.37–1.88). However, a potential limitation
of this meta-analysis is that most prospective studies focused
on incident depression and not on persistence of depression.
As a result, patients with a history of depression were often
excluded at baseline. Because depression is a highly recurrent
disease, this exclusion criterion may have contributed to a bias
towards “no difference”. The study in fact used a biased samples
of diabetes patients that are less vulnerable for depression.
Author Keywords –
Author(s) Nouwen A, Winkley K, Twisk J, Lloyd CE, Peyrot M, Ismail K, et
al.
Country/Setting – mains unclear. They call for future research into treatment for
Title Type 2 diabetes mellitus as a risk factor for the onset of depres-
sion: a systematic review and meta-analysis
Source Diabetologia, 2010; 53(12): 2480–2486 [Epub 2010 Aug 14]
Type of Study Systematic review and meta-analysis
Depression
Assessment –
Summary This empirical research examined the association of diabetes
and the onset of depression by reviewing the literature and
conducting a meta-analysis of longitudinal studies on this
topic. The authors searched EMBASE, MEDLINE and PsycInfo
for articles published up to September 2009. They included
all studies that examined the relationship between type 2
diabetes and the onset of depression. This study demonstrated
that compared with non-diabetic controls, people with type 2
diabetes have a 24% increased risk of developing depression.
S19
The authors further showed that this risk was significantly
higher for studies relying on diagnostic criteria of depression
than for studies using questionnaires. However, the mechanisms
underlying this relationship are still unclear and the authors
highlighted the need for further research.
Author Keywords Critical review, Depression, Incidence, Meta-analysis, Systematic
review, Type 2 diabetes
Author(s) Paddison CA, Eborall HC, French DP, Kinmonth AL, Prevost AT,
Griffin SJ, Sutton S
Country/Setting UK/primary care
Title Predictors of anxiety and depression among people attending
diabetes screening: A prospective cohort study embedded in
the ADDITION (Cambridge) randomized control trial
Source Br J Health Psychol, 2011; 16(Pt 1): 213–226
Type of Study A prospective cohort study embedded
Depression
Assessment Hospital Anxiety and Depression Scale (HADS)
Summary This study identified factors predicting anxiety and depression
among people who attend primary care-based diabetes screen-
ing. The authors designed a prospective cohort study nested
within a larger randomized control trial [the ADDITION (Cam-
bridge) RCT] and enrolled 3,240 participants who were at risk
of diabetes from 10 primary care practices. They screened the
individuals for diabetes at baseline and assessed for anxiety and
depression 12 months after diabetes screening using the Hos-
pital Anxiety and Depression Scale (HADS). This study reported
that screening outcome (positive or negative for diabetes) at
baseline was not related to differences in anxiety or depression
at 12 months. In fact participants in this research showed
low average scores on anxiety and depression scales after first
attendance and 1 year later. The authors further noted that
attendance was associated with higher anxiety and depression
at 12-month follow-up, after controlling for anxiety and de-
pression after first attendance. The authors acknowledged the
limitation of their study that as this research was nested within
a larger randomized control study, the research design itself
might influence the uptake of screening.
Author(s) Renn BN, Feliciano L, Segal DL
Country/Setting USA
Title The bidirectional relationship of depression and diabetes: A
systematic review
Source Clin Psychol Rev, 2011; 31: 1239–1246
Type of Study Systematic review
Depression
Assessment NA
Summary This systematic review examined the current literature on the
bidirectional relationship between diabetes (specifically, Type 2
diabetes) and depressive disorders. In this empirical research
study the authors have integrated all relevant aspects of re-
search findings that support depression both as a risk-factor
for and as a consequence of diabetes. The authors identified
although a significant literature provides well documented sup-
port for a relationship between Type 2 diabetes and depressive
symptomatology, the exact direction of this relationship re-
comorbid depression and Type 2 diabetes. The authors con-
cluded that despite uncertainties about the exact causal nature
the directionality, previous research clearly indicates that in
comorbid populations, the treatment of both diabetes and de-
pressive symptoms should be undertaken to decrease suffering
and additional complications of the illness.
Author Keywords Diabetes mellitus, Depression, Comorbidity
Author(s) Pan A, Lucas M, Sun Q, van Dam RM, Franco OH, Manson JE, et
al.
Country/Setting USA
Title Bidirectional association between depression and type 2 dia-
betes mellitus in women
Source Arch Intern Med, 2010; 170 (21):1884–1891
Type of Study Longitudinal study
S20 T. Roy, C.E. Lloyd / Journal of Affective Disorders 142S1 (2012) S8–S21
Depression
Assessment A five-item subscale of the Short-Form 36 called Mental Health
Index (MHI-5)
Summary In this large scale longitudinal study 65,381 women (aged 50 to
75) with type 2 diabetes were observed over a 10-year period.
Clinical depression or severe depressive symptoms were as-
sessed using a 5-item Mental Health Index (MHI-5) with cut-off
score of 52 or less. During 10 years of follow-up, the authors
showed that the relative risk for type 2 diabetes in individuals
with depressed mood was higher compared with non-depressed
T2DM individuals after adjustment for all covariates (OR 1.17;
95% CI 1.05–1.30). Further, participants using antidepressants
were at a particularly higher relative risk (OR 1.25; 95% CI
1.10–1.41). Alternatively, compared with non-diabetic subjects,
those with diabetes had a relative risk of developing clini-
cal depression after controlling for all covariates of (OR1.29;
95% CI1.18–1.40). These associations remained significant after
adjustment for diabetes-related co-morbidities. This study pro-
vides compelling evidence that the association between diabetes
and depression is bidirectional.
Author Keywords –
Author(s) Campayo A, de Jonge P, Roy JF, Saz P, de la Cámara C, Quintanilla
MA, et al.
Country/Setting Spain/Community
Title Depressive disorder and incident diabetes mellitus: the effect
of characteristics of depression
Source Am J Psychiatry, 2010; 167(5): 580–588
Type of Study Longitudinal three-wave epidemiological enquiry
Depression
Assessment Psychiatric interview and the Geriatric Mental State Schedule
Summary In this longitudinal three-wave epidemiological study Campayo
et al. tested the hypothesis that clinically significant depression
detected in a population sample increases the risk of diabetes
mellitus. A large community sample (N=4,803) of adults aged
(≥55 years) was assessed for depression at baseline, and follow
up evaluations (2.5 years and 5 years later) were completed to
determine the incidence of diabetes. The research focused on
the effect of characteristics of depression frequently found in
the community on the risk of incident diabetes mellitus. The
risk of incident diabetes mellitus was reported to be higher
among subjects with depression when compared with non-
depressed subjects, and the association remained significant
after controlling for potential confounders, including diabetes
risk factors. The estimated rate of diabetes mellitus attributable
to depression was 6.9%. The authors noted that an increased
risk of diabetes mellitus is associated with Characteristics of
depression (e.g. non severe depression, persistent depression,
and untreated depression). The main limitation in this study was
that the incident diabetes was ascertained based on self-report
in the absence of laboratory measures. There is thus a possibility
of underestimation of the incidence rate of diabetes among both
depressed and non-depressed subjects. The authors concluded
that clinically significant depression is associated with a 65%
increased risk of diabetes mellitus. In view of the epidemic
nature of both diabetes and depression, the results of this study
have important public health as well as clinical implications.
Author(s) Collins MM, Corcoran P, Perry IJ
Country/Setting Ireland/mixed care: general practice and hospital
Title Anxiety and depression symptoms in patients with diabetes
Source Diabet Med, 2009; 26: 153–161
Type of Study Cross-sectional study
Depression
Assessment Hospital Anxiety and Depression Scale (HADS)
Summary This cross-sectional study of 2049 people with Types 1 and 2 di-
abetes in Ireland has identified the prevalence and determinants
of anxiety and depression symptoms in patients with diabetes.
The authors reported that high levels of anxiety and depression
symptoms in patients with diabetes; 32.0% exceeded the HADS
cut-off score of ‘mild to severe’ anxiety and 22.4% exceeded
the HADS cut-off score of ‘mild to severe’ depression. Diabetes
complications, smoking, uncertainty about glycaemic control
and being an ex-drinker or a heavy drinker were risk factors
for both higher anxiety and depression scores in multivariate
analysis. Female gender and poor glycaemic control were risks
factors associated only with higher anxiety scores. The cross-
sectional design of this study limits causal inference as a result
of uncertainty about the direction of the associations. However,
the results of this study support and strengthen the hypothesis
that people with diabetes are at a higher risk for experiencing
the two most common forms of psychological distress, anxiety
and depression.
Author Keywords Anxiety, Depression, Diabetes
Author(s) Engum A
Country/Setting Norway/Community
Title The role of depression and anxiety in onset of diabetes in a
large population-based study
Source J Psychosom Res, 2007; 62: 31–38
Type of Study Prospective population-based longitudinal study
Depression
Assessment Hospital Anxiety and Depression Scale (HADS)
Summary This study among a sample of Norwegian population (N=37,291)
investigated if symptoms of depression and anxiety precede the
onset of diabetes or vice versa. In this prospective population-
based longitudinal study the author observed that individuals
reporting symptoms of depression and anxiety at baseline had
increased risk of onset of type 1 and Type 2 diabetes at 10-year
follow-up. In contrast, baseline diagnosis of diabetes was not
associated with subsequent symptoms of anxiety or depression
among males or females. In this study, the information on dia-
betes was derived from either blood tests result obtained from
medical records or self reports, and mental symptoms were
self-reported. Thus, the information about exposure, outcome,
and potential confounders based on self-reported data may
lead to information bias and misclassifications. The analyses of
this study indicated that symptoms of depression and anxiety
were significant risk factors for the development of type 2
diabetes, exerting effects independent of previously established
risk factors for diabetes.
Author Keywords Anxiety; Depression; Diabetes; HADS; Metabolic syndrome
Author(s) Katon W, Fan MY, Unützer J, Taylor J, Pincus H, Schoenbaum M
Country/Setting USA/Community
Title Depression and Diabetes: A Potentially Lethal Combination
Source J Gen Intern Med, 2008; 23(10): 1571–1575
Type of Study Cross-sectional survey using MediCare database
Depression
Assessment Hospital Anxiety and Depression Scale (HADS)
Summary In this study Katon et al assessed whether Medicare fee-for-
service beneficiaries with depression and diabetes had a higher
mortality rate over a 2-year period compared with beneficiaries
with diabetes alone. The researches enrolled a total of 10,704
beneficiaries with diabetes and surveyed with a health assess-
ment questionnaire and followed over a two-year period. The
authors demonstrated that among their sample, comorbid de-
pression was associated with an increase in all-cause mortality
over a two-year period of approximately 36% to 38%. No signifi-
cant increase in rates of cause-specific mortality from macrovas-
cular disease were found in depressed versus non-depressed
beneficiaries. This study adds to the emerging evidence in pa-
tients with diabetes that depression is also a risk factor for
mortality in older fee-for-service Medicare beneficiaries with
diabetes who have high levels of diabetes complications and
medical comorbidity. The main limitation of this study is that
the author did not specify their sample according to the type of
diabetes, so it is difficult to assess diabetes-type-specific inter-
pretation of these results. Also, lack of generalizability given that
participants with diabetes were enrolled from one geographic
region of the United States. Also, the two-year follow-up pe-
riod was relatively short to estimate any long-term effects. The
authors highlighted the need for future research to determine
whether the increase in mortality associated with depression is
due to potential behavioural mediators (i.e., smoking, poor ad-
herence to diet) or physiologic abnormalities (i.e., hypothalamic-
pituitary axis dysregulation) associated with depression.
Author Keywords Depression; diabetes; mortality
 T. Roy, C.E. Lloyd / Journal of Affective Disorders 142S1 (2012) S8–S21
Author(s) Pouwer F, Geelhoed-Duijvestijn PH, Tack CJ, Bazelmans E, Beek-
man AJ, Heine RJ, et al.
Country/Setting Netherlands/Diabetic outpatients
Title Prevalence of comorbid depression is high in out-patients with
Type 1 or Type 2 diabetes mellitus. Results from three out-
patient clinics in the Netherlands
Source Diabet Med, 2010; 27(2): 217–224
Type of Study Cross-sectional study
Depression
Assessment WorldHealthOrganization-5Well Being Index (WHO-5), Centre
for Epidemiologic Studies Depression (CES-D) Scale, Composite
International Diagnostic Interview (CIDI)
Summary In this article Pouwer et al, reported the prevalence of de-
pression among adult outpatients with Type 1 (T1DM) or
Type 2 diabetes (T2DM) using both self-report measures and
a diagnostic interview, and to establish demographic and clin-
ical characteristics associated with depressive affect. The au-
thors enrolled 2055 diabetes out-patients from three diabetes
clinics in Netherlands. They assessed depressive affect using
theWorldHealthOrganization-5Well Being Index (WHO-5), the
Centre for Epidemiologic Studies Depression scale (CESD) with
predefined cut-off s cores, and depressive disorder with the
Composite International Diagnostic Interview (CIDI). The au-
thors demonstrated that depression is a common comorbid
health problem in both T1DM and T2DM out-patients in the
Netherlands, with about one-third of patients reporting elevated
depression scores, and 8–24% being diagnosed with a depressive
disorder. In particular, women with T2DM, non-Dutch T2DM
patients, poorly controlled T1DM patients, obese T2DM patients
and those with coexisting complications of diabetes appear to
be at even greater increased risk. The main limitation of this
study was that it is not possible to make any causal inferences
from this cross-sectional design – e.g. the temporal relationship
between the development of secondary complications and the
onset or recurrence of depression.
Author Keywords Ambulatory care, depression, diabetes, prevalence, risk factors
Author(s) Barnard KD, Skinner TC, Peveler R
Country/Setting United Kingdom
Title The prevalence of co-morbid depression in adults with Type 1
diabetes: systematic literature review
Source Diabet Med, 2006; 23: 445–448
Type of Study Systematic review
Depression
Assessment –
S21
Summary In this systematic review Barnared et al. estimated the cross-
sectional prevalence of clinical depression in adults with Type 1
diabetes. The authors/researchers conducted search using elec-
tronic databases to identify potentially relevant studies as per
their criteria. The authors identified five eligible studies between
January 2000 and June 2004 and added them with a previous
search result before 2000 (which identified 10 studies) in order
to report their findings. The authors reported that the preva-
lence of clinical depression in controlled studies was 12.0% for
people with type 1 diabetes compared with 3.2% for control sub-
jects. In studies with no control group, the prevalence of clinical
depression was 13.4%. The main limitation was that there was
wide range of differences reported in the various studies on the
prevalence of depression in Type 1 diabetes. Thus, a controlled
study using diagnostic interviewing techniques to determine
levels of depression was recommended to provide a clearer
picture of both the prevalence and characteristics of depression.
Author Keywords Adults, co-morbid depression, prevalence, Type 1 diabetes
Author(s) Gendelman N, Snell-Bergeon JK, McFann K, Kinney G, Paul
Wadwa R, Bishop F, Rewers M, Maahs DM
Country/Setting USA/Diabetes clinic and community
Title Prevalence and Correlates of Depression in Individuals With
and Without Type 1 Diabetes
Source Diabetes Care, 2009; 32(4): 575–579
Type of Study Observational cohort study
Depression
Assessment Beck Depression Inventory II (BDI-II)
Summary In this article Gendelman et al assessed the prevalence of de-
pression and antidepressant medication use among adults with
and without type 1 diabetes and the association between de-
pression and diabetes complications. This cohort study applied
the Beck Depression Inventory II (BDI-II) to 458 participants
with type 1 diabetes and 546 participants without diabetes.
The result of this study indicated that prevalence of depression
(assessed either by BDI-II cut score or antidepressant use) was
significantly higher in participants with type 1 diabetes than
in non-diabetic participants and the participants reporting dia-
betes complications had higher mean BDI-II scores than those
without complications. The authors used self-reported data for
antidepressant medication use and occurrence of diabetes com-
plications, which should be considered as a major limitation of
this study.
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