the prevalence of depression in diabetes is well documented , with a raft of research over the past two decades focusing on links between the two conditions .
people with diabetes are between 1.4 and 3 times more likely to develop depression compared to the general population ( 3 ) , with depression affecting 1520% of diabetes patients overall ( 4 ) .
when subclinical depression is included , prevalence estimates are greater , with at least two - thirds of a large sample of type 2 diabetes patients experiencing depressive symptoms ( 5 ) .
comorbid depression in diabetes patients is associated with poorer metabolic control , an outcome that predicts hyperglycemia and an increased risk of diabetes - related complications and mortality ( 6 ) .
these complications are , in turn , thought to be at least partly mediated by depression s association with poor adherence to medication and lifestyle recommendations , both of which predict reduced quality of life and increased health care costs ( 7 ) .
if anything , these figures likely underestimate both the prevalence of affective disturbances in diabetes and the associated costs of disease management , suggesting that the problem of depression may be far larger than is currently accepted .
commensurately , the negative effects of these conditions on crucial self - care regimens  and the resulting consequences in terms of increased disability , health care utilization , and mortality  also may be far more widespread .
given the scale of the problem of depression in diabetes , evidence to support the effectiveness of current antidepressant therapies is surprisingly sparse , and overall outcomes are still unclear . a recent systematic review and meta - analysis ( 8) , including 14 randomized , controlled trials ( rcts ) evaluating psychotherapy , pharmacotherapy , and collaborative care in 1,724 diabetes patients with comorbid depression , showed moderate effects for treatment overall .
it should be noted , however , that four of the five rcts ( n = 310 ) involving a psychotherapeutic intervention such as cognitive behavioral therapy ( cbt ) also included other supportive treatment such as diabetes education alongside the psychotherapy , making it difficult to assess the merits of the psychological intervention in isolation . additionally , most studies were small ( 10 investigated samples ranging from 13 to 60 participants ) and mainly involved type 2 diabetes patients , meaning results may not be generalizable to insulin - dependent type 1 diabetes patients .
furthermore , although depression in diabetes patients is linked to glycemic indices , it is not yet clear if successfully treating low mood is associated with improved metabolic control .
one review ( 7 ) found that improvements in depression were linked to improvements in glycemic control and overall perceptions of well - being . contradicting these findings , however
, are results of a meta - analysis ( 11 studies in adults and 10 studies in children and adolescents ) showing that , although both cbt and antidepressant medications were associated with an improvement in blood glucose readings in some studies , overall , there was no significant effect of either of these treatments on glycemic control in adults and only weak evidence of an effect in children and adolescents ( 9 ) . successfully treating depression in diabetes
is further complicated by the difficulty of detecting the presence of low mood , with evidence that only a small fraction of depressed patients receive any form of treatment , likely because of an overlap between symptoms of both conditions , such as pain and fatigue ( 7,10,11 ) .
furthermore , patients with diabetes may find depression difficult to acknowledge because it represents another area for them to be dissatisfied with themselves , perhaps further evidence of personal failure beyond their daily struggle with self - management targets ( 12 ) , and a focus , therefore , for continued negative self - judgment . in summary ,
evidence for the treatment of depression in diabetes patients is limited , with existing studies suggesting modest effects in some groups , at best .
further investigation is essential in light of the devastating downstream effects of depression on glycemic control and overall quality of life .
emerging research into the construct of self - compassion , with its specific focus on reducing self - criticism and treating oneself kindly , suggests its potential utility for this population .
self - compassion is defined as the practice of treating oneself with kindness , care , and concern in the face of negative events ( 13,14 ) . for diabetes patients ,  negative events  may include receiving less - than - optimal blood glucose readings together with other self - management failures involving nonadherence to medication , diet , and exercise prescriptions ( 15 ) . in this context , self - criticism , a common consequence of self - care failure among diabetes patients ,
neff ( 13 ) conceptualizes self - compassion as being composed of three components , all of which may be relevant to the experience of living with diabetes and managing its daily demands .
first , self - kindness refers to the tendency to be caring and understanding of oneself rather than being harshly critical or judgmental .
second , common humanity recognizes that all humans are imperfect , fail , and make mistakes , framing difficulties and painful experiences in light of the shared human experience .
finally , mindfulness , the third component of self - compassion , involves being aware of the present - moment experience so that one neither ignores nor ruminates on disliked aspects of oneself or one s behavior ( 17 ) . taken together , developing these capacities may not only enable individuals to reflect concern and compassion toward others , but
also may improve their capacity to direct this same concern and compassion toward themselves ( 13 ) . in doing so
, self - compassion may offer not only a gentler way of self - relating , but also one that may have the potential to reduce the depression and psychological suffering often associated with diabetes and its management . in the following section ,
the direct and indirect pathways by which both self - compassion and depression may relate to diabetes self - management are briefly reviewed , suggesting the utility of self - compassion for improving both mood and overall diabetes outcomes ( figure 1 ) .
interlocking cogs illustrate the hypothesized processes linking self - compassion to improved outcomes in diabetes patients
. increasing self - compassion may reduce depression , leading to improved outcomes via mechanisms including increased motivation and reduced self - criticism .
although the exact mechanisms by which depression is associated with markers of diabetes remain uncertain , there is evidence to suggest both direct ( physiological ) and indirect ( behavioral ) pathways .
interestingly , in terms of the current discussion , emerging evidence suggests that self - compassion may operate through similar processes .
early studies indicate that depression may complicate , or possibly contribute to , the cause of diabetes due to direct , reciprocal effects on endocrine and other physiological processes .
these effects include abnormalities of the hypothalamic - pituitary - adrenal axis , changes in sympathetic nervous system functioning as measured by decreased heart rate variability ( hrv ) , and increased release of inflammatory cytokines ( 11,18,19 ) .
support for a possible biological link between depression and diabetes was demonstrated in a recent meta - analysis ( 20 ) involving 24 studies that found patients with depression had significantly higher concentrations of tumor necrosis factor- and interleukin-6 ( il-6 ) levels compared to nondepressed subjects . in turn
, markers of inflammation such as il-6 have been proposed to be involved in diabetes disease onset ( 21 ) .
interestingly , emerging evidence suggests that self - compassion might be linked to improved mood through similar or related metabolic and autonomic processes , including inflammatory and sympathetic nervous system responses to stress .
cross - sectional reports show that self - compassion is associated with lower blood plasma levels of il-6 ( 22 ) , as well as improved autonomic nervous system responding to stress ( 23 ) , as measured by increased hrv ( 24 ) .
such data are consistent with the theoretical proposition that self - compassion may calm the threat system , which is associated with defensiveness and autonomic arousal , and activate the self - soothing system ( 14 ) .
a series of experimental studies suggests that quantifiable physiological and neurological processes underlie the experience of self - compassion .
( 25 ) used functional magnetic resonance imaging to demonstrate that the specific neuronal networks associated with love and affiliation were activated after the experimental stimulation of compassion .
participants also demonstrated an increase in positive affect ; compared with a memory control , participants who reacted with negative affect when witnessing others in distress before compassion training subsequently showed increased positive affective experiences after training .
( 26 ) also found that compassion training increased both altruistic behavior and neural responses to suffering , including activation of the inferior parietal cortex and dorsolateral prefrontal cortex .
taken together , these early fin - dings suggest that activation of attachment and affiliation circuitry through self - compassion may be linked to particular direct processes involving autonomic and metabolic pathways that may be common to both depression and diabetes .
although depression and self - compassion may be associated with processes directly linked to physical health , a number of cross - sectional and experimental studies in both patient and nonpatient populations suggest that compassion may alter psychological and behavioral processes leading to reductions in depressed affect and better self - regulation .
first , consistent evidence suggests that self - compassion is related to physical and psychological health as a result of reduced negative affect ( 17,2729 ) .
for example , in a study in patients with obesity and pain problems ( 30 ) , self - compassion predicted lower negative affect , higher positive affect , more adaptive pain coping , higher pain self - efficacy , and lower pain catastrophizing .
self - compassion also predicted more adaptive reactions to having hiv , including better adjustment and lower levels of stress , anxiety , and shame ( 31 ) .
such studies suggest that more self - compassionate people may treat themselves more kindly , recognize that their problems are common aspects of human experience , and , as a consequence , be less ruminative and self - judgmental when confronting negative or difficult feelings ( 32,33 ) . on the other hand ,
the opposites of self - compassion , including self - criticism , self - hate , self - judgment , and negative perfectionism , have been linked to greater psychological distress , including depression ( 16 ) .
one recent study in chronically ill patients found that self - criticism predicted depression , illness - related stress , and diminished quality of life ( 34 ) .
other nonpatient ( college student ) data likewise suggest a key role for self - criticism ; self - reported physical symptoms increased as self - judgment increased and self - kindness decreased ( 35 ) .
self - judgment may be particularly important to investigate in relation to diabetes patients given the daily demands of managing the illness and the difficulty in achieving  ideal  metabolic control , which seems a likely trigger for self - criticism ( 15 ) .
a second indirect pathway by which self - compassion may improve physical health among diabetes patients is as a consequence of greater self - care ( 36 ) .
evidence for this possibility can be seen in research , indicating that people reporting greater self - compassion may take greater responsibility for their problems and be less overwhelmed by difficulties , suggesting that they are more likely to take care of themselves when ill or injured ( 37 ) . for diabetes patients
, it may be that  taking care of oneself  includes seeking medical treatment , maintaining regular physical activity , maintaining appropriate dietary behavior , having regular foot checks , and self - monitoring blood glucose .
this suggestion is consistent with data from a study with type 2 diabetes patients showing that depression predicted a decline in the self - care routines that protect against poor glucose control and the development of complications ( 12 ) . provocatively ,
egede and osborn ( 12 ) suggest that the link between depression and poor self - care is mediated by a decline in the motivation to maintain self - care .
a series of experimental studies in nonpatient groups ( 38 ) adds weight to this suggestion , showing that self - compassion leads to increased self - improvement motivations , possibly because it provides a nonjudgmental context in which to appraise one s strengths and weaknesses and to strive to improve without the threat of unhelpful self - criticism . in the context of diabetes , enhancing self - compassion thus may enable patients to address evidence of less - than - ideal control without paralyzing self - criticism and help them reappraise and adjust their goals in support of good control .
the idea that self - compassionate individuals may be more motivated to take care of their health out of a desire to maximize well - being is also consistent with studies of several health behaviors that are directly related to outcomes among patients with diabetes .
for example , interventions to maintain diet ( 39 ) and exercise ( 40 ) and to quit smoking ( 41 ) have demonstrated the positive influence of self - compassion on affect and behavior .
( 41 ) found that smokers who were highly self - critical were helped to achieve their goals with an intervention that stimulated warmth and understanding while they attempted to quit .
these authors suggest that for highly self - critical people in particular , self - compassion might inhibit a reflex toward rumination and self - judgment when faced with setbacks , helping them tolerate the distress they experience while trying to quit and enabling self - regulation via the soothing system rather than the threat system ( 14 ) . a further intervention study ( 39 ) found that a self - compassion induction helped reduce negative self - evaluation , distress , and subsequent food consumption among highly restrictive eaters compared to dieters in a control condition .
participants in the self - compassion condition were able to hold eating goals in mind without ruminating or allowing negative evaluation to interfere with their eating goals .
alterations in self - management when confronting failures may be highly relevant to diabetes patients , who are generally required to monitor food intake as part of controlling blood glucose and can be assumed to experience setbacks as part of daily life .
finally , another study ( 40 ) found that self - compassion predicted superior exercise - related outcomes among women .
specifically , self - compassion was related to greater intrinsic motivation ( behaviors initiated and regulated through choice as an expression of oneself ) and lower external motivation ( behaviors pressured by environmental forces ) ( 42 ) . in sum , these initial studies are encouraging in that they illuminate the potential utility of self - compassion  based interventions in improving some of the health behaviors that routinely challenge diabetes patients .
finally , a theoretical model ( 43 ) suggests a third indirect pathway by which self - compassion may be linked to improved health as a consequence of broad improvements in motivational management and self - regulation ( 44 ) .
successful self - regulation involves selecting goals , engaging in behaviors that support achievement of those goals , monitoring goal progress , and adjusting those goals when
sufficient progress is not being made  all of which are highly relevant to diabetes self - care .
it seems likely that more self - compassionate people may therefore attend to their own self - care out of a desire to treat themselves kindly and well by engaging in behaviors that support their ultimate good .
they may , for example , set more specific , achievable , and appropriate goals related to diet , exercise , and blood glucose targets ; prioritize attendance to these goals perhaps through regular medical appointments ; adhere to regular medication and testing regimens ; disengage from diet and exercise goals that are not working ; and establish new behavioral targets associated with better control .
evidence of this can be seen in a study ( 37 ) with a large sample of participants ( n = 241 ) with a range of serious medical conditions that found that self - compassionate people were more likely to take action with regard to their medical problems , including promptly visiting health care professionals when needed .
further analyses suggest that the benefits of self - compassion on outcomes results from the combined influence of benevolent self - talk , a motivation to treat oneself kindly , and a tendency to be proactive with regard to one s health .
early studies indicate that depression may complicate , or possibly contribute to , the cause of diabetes due to direct , reciprocal effects on endocrine and other physiological processes .
these effects include abnormalities of the hypothalamic - pituitary - adrenal axis , changes in sympathetic nervous system functioning as measured by decreased heart rate variability ( hrv ) , and increased release of inflammatory cytokines ( 11,18,19 ) .
support for a possible biological link between depression and diabetes was demonstrated in a recent meta - analysis ( 20 ) involving 24 studies that found patients with depression had significantly higher concentrations of tumor necrosis factor- and interleukin-6 ( il-6 ) levels compared to nondepressed subjects . in turn
, markers of inflammation such as il-6 have been proposed to be involved in diabetes disease onset ( 21 ) .
interestingly , emerging evidence suggests that self - compassion might be linked to improved mood through similar or related metabolic and autonomic processes , including inflammatory and sympathetic nervous system responses to stress .
cross - sectional reports show that self - compassion is associated with lower blood plasma levels of il-6 ( 22 ) , as well as improved autonomic nervous system responding to stress ( 23 ) , as measured by increased hrv ( 24 ) .
such data are consistent with the theoretical proposition that self - compassion may calm the threat system , which is associated with defensiveness and autonomic arousal , and activate the self - soothing system ( 14 ) .
a series of experimental studies suggests that quantifiable physiological and neurological processes underlie the experience of self - compassion .
( 25 ) used functional magnetic resonance imaging to demonstrate that the specific neuronal networks associated with love and affiliation were activated after the experimental stimulation of compassion .
participants also demonstrated an increase in positive affect ; compared with a memory control , participants who reacted with negative affect when witnessing others in distress before compassion training subsequently showed increased positive affective experiences after training .
( 26 ) also found that compassion training increased both altruistic behavior and neural responses to suffering , including activation of the inferior parietal cortex and dorsolateral prefrontal cortex .
taken together , these early fin - dings suggest that activation of attachment and affiliation circuitry through self - compassion may be linked to particular direct processes involving autonomic and metabolic pathways that may be common to both depression and diabetes .
although depression and self - compassion may be associated with processes directly linked to physical health , a number of cross - sectional and experimental studies in both patient and nonpatient populations suggest that compassion may alter psychological and behavioral processes leading to reductions in depressed affect and better self - regulation .
first , consistent evidence suggests that self - compassion is related to physical and psychological health as a result of reduced negative affect ( 17,2729 ) .
for example , in a study in patients with obesity and pain problems ( 30 ) , self - compassion predicted lower negative affect , higher positive affect , more adaptive pain coping , higher pain self - efficacy , and lower pain catastrophizing .
self - compassion also predicted more adaptive reactions to having hiv , including better adjustment and lower levels of stress , anxiety , and shame ( 31 ) .
such studies suggest that more self - compassionate people may treat themselves more kindly , recognize that their problems are common aspects of human experience , and , as a consequence , be less ruminative and self - judgmental when confronting negative or difficult feelings ( 32,33 ) . on the other hand ,
the opposites of self - compassion , including self - criticism , self - hate , self - judgment , and negative perfectionism , have been linked to greater psychological distress , including depression ( 16 ) .
one recent study in chronically ill patients found that self - criticism predicted depression , illness - related stress , and diminished quality of life ( 34 ) .
other nonpatient ( college student ) data likewise suggest a key role for self - criticism ; self - reported physical symptoms increased as self - judgment increased and self - kindness decreased ( 35 ) .
self - judgment may be particularly important to investigate in relation to diabetes patients given the daily demands of managing the illness and the difficulty in achieving 
ideal  metabolic control , which seems a likely trigger for self - criticism ( 15 ) . a second indirect pathway by which self - compassion may improve physical health among diabetes patients is as a consequence of greater self - care ( 36 ) .
evidence for this possibility can be seen in research , indicating that people reporting greater self - compassion may take greater responsibility for their problems and be less overwhelmed by difficulties , suggesting that they are more likely to take care of themselves when ill or injured ( 37 ) . for diabetes patients
, it may be that  taking care of oneself  includes seeking medical treatment , maintaining regular physical activity , maintaining appropriate dietary behavior , having regular foot checks , and self - monitoring blood glucose .
this suggestion is consistent with data from a study with type 2 diabetes patients showing that depression predicted a decline in the self - care routines that protect against poor glucose control and the development of complications ( 12 ) .
provocatively , egede and osborn ( 12 ) suggest that the link between depression and poor self - care is mediated by a decline in the motivation to maintain self - care .
a series of experimental studies in nonpatient groups ( 38 ) adds weight to this suggestion , showing that self - compassion leads to increased self - improvement motivations , possibly because it provides a nonjudgmental context in which to appraise one s strengths and weaknesses and to strive to improve without the threat of unhelpful self - criticism . in the context of diabetes , enhancing self - compassion thus may enable patients to address evidence of less - than - ideal control without paralyzing self - criticism and help them reappraise and adjust their goals in support of good control .
the idea that self - compassionate individuals may be more motivated to take care of their health out of a desire to maximize well - being is also consistent with studies of several health behaviors that are directly related to outcomes among patients with diabetes .
for example , interventions to maintain diet ( 39 ) and exercise ( 40 ) and to quit smoking ( 41 ) have demonstrated the positive influence of self - compassion on affect and behavior .
( 41 ) found that smokers who were highly self - critical were helped to achieve their goals with an intervention that stimulated warmth and understanding while they attempted to quit .
these authors suggest that for highly self - critical people in particular , self - compassion might inhibit a reflex toward rumination and self - judgment when faced with setbacks , helping them tolerate the distress they experience while trying to quit and enabling self - regulation via the soothing system rather than the threat system ( 14 ) . a further intervention study ( 39 ) found that a self - compassion induction helped reduce negative self - evaluation , distress , and subsequent food consumption among highly restrictive eaters compared to dieters in a control condition .
participants in the self - compassion condition were able to hold eating goals in mind without ruminating or allowing negative evaluation to interfere with their eating goals .
alterations in self - management when confronting failures may be highly relevant to diabetes patients , who are generally required to monitor food intake as part of controlling blood glucose and can be assumed to experience setbacks as part of daily life .
finally , another study ( 40 ) found that self - compassion predicted superior exercise - related outcomes among women .
specifically , self - compassion was related to greater intrinsic motivation ( behaviors initiated and regulated through choice as an expression of oneself ) and lower external motivation ( behaviors pressured by environmental forces ) ( 42 ) . in sum
, these initial studies are encouraging in that they illuminate the potential utility of self - compassion  based interventions in improving some of the health behaviors that routinely challenge diabetes patients .
finally , a theoretical model ( 43 ) suggests a third indirect pathway by which self - compassion may be linked to improved health as a consequence of broad improvements in motivational management and self - regulation ( 44 ) .
successful self - regulation involves selecting goals , engaging in behaviors that support achievement of those goals , monitoring goal progress , and adjusting those goals when sufficient progress is not being made  all of which are highly relevant to diabetes self - care .
it seems likely that more self - compassionate people may therefore attend to their own self - care out of a desire to treat themselves kindly and well by engaging in behaviors that support their ultimate good .
they may , for example , set more specific , achievable , and appropriate goals related to diet , exercise , and blood glucose targets ; prioritize attendance to these goals perhaps through regular medical appointments ; adhere to regular medication and testing regimens ; disengage from diet and exercise goals that are not working ; and establish new behavioral targets associated with better control .
evidence of this can be seen in a study ( 37 ) with a large sample of participants ( n = 241 ) with a range of serious medical conditions that found that self - compassionate people were more likely to take action with regard to their medical problems , including promptly visiting health care professionals when needed .
further analyses suggest that the benefits of self - compassion on outcomes results from the combined influence of benevolent self - talk , a motivation to treat oneself kindly , and a tendency to be proactive with regard to one s health .
although research to date on self - compassion has not specifically examined its possible utility in diabetes patients , several considerations suggest that findings linking self - compassion to improved psychological and physical health , through both direct and indirect processes , could be of particular relevance to this group .
first , the daily struggle of diabetes patients to maintain adequate control is frequently characterized by negative feelings of stress , anxiety , guilt , and shame ( 15 ) , particularly when patients are continually reminded that their long - term health is dependent on their ability to self - manage .
second , maintaining good control involves ongoing adherence to a relentless daily self - management regimen to maintain optimal health and reduce the risk of long - term complications .
self - compassion may support adherence by reducing distressing and demotivating cognitive and emotional responses to medical problems such as self - blame , nonacceptance , and anger ( 43,45 ) .
negative emotions often accompany a diagnosis of a chronic , incurable illness such as diabetes ( 15 ) , and these emotions in themselves may be linked to self - regulatory failure ( 31 ) .
third , self - compassion may be linked to improved adherence through increased conscientiousness ( 32 ) .
it may be that the emotional stability provided by self - compassion helps engender more responsible behavior , even though taking care of one s health by maintaining a good diet and exercising frequently might initially involve a certain amount of displeasure .
overall , the relationships between diabetes , psychological distress , depression , and self - care are complex , and the pathways by which they are related are not yet fully understood .
what is clear , however , is that depression and distress play an important role in increasing the suffering and complications associated with managing this chronic condition ( 10,18 ) and that current approaches are having mixed success . given the links between self - compassion and improved psychological and physical health , self - compassion  based interventions may be a supplementary approach with the potential to reduce suffering and its negative effects on physical health outcomes among diabetes patients .
nascent research suggests that intervening to increase self - compassion , a construct that appears to tap into brain structures adapted for self - soothing and calming , may have quantifiable physiological , psychological , and behavioral effects that may help diabetes patients cope better with their condition and enjoy improved quality of life .
in particular , the bulk of research to date suggests that processes involving a reduction in negative self - evaluation and improved motivations for self - care may underpin the beneficial effects of self - compassion on physical and psychological health .
thus , the utility of self - compassion as an intervention to reduce self - criticism , improve mood , and increase motivation to maintain self - care among diabetes patients may be worthy of substantial further investigation .
 depression and severe psychological distress are frequently comorbid with diabetes and are associated with reduced adherence to medication and healthy lifestyle regimens , poorer glycemic control , and increased complications 
 . the mixed success of existing treatments for depression in diabetes patients suggests a need for supplementary approaches to this common problem . 
 this article reviews recent evidence for the benefits of self - compassion in chronically ill patients , suggesting its utility as a clinical tool for improving self - care , depression , and glycemic control in diabetes . 
 possible physical and psychological pathways by which self - compassion may promote better outcomes in diabetes patients are considered , with particular attention given to reductions in negative self - judgment and improved motivation to undertake self - care . 
Depression in Diabetes: The Status Quo
Current Treatment Approaches
Self-Compassion: Does Kindness Matter?
Depression and Self-Compassion: Common Pathways?
Direct Pathways
Indirect Pathways
Self-Compassion and Hypothesized Effects in Diabetes Self-Management
Summary