Evidence from observational studies show that among people with physical LTCs the odds of psychological distress occurring is two to three times greater compared with people in which, LTCs are absent [37, 30, 23]. Thus the presence of a physical LTC appears to be a key driver for the development of distress. Conversely, studies exploring the reverse direction of effect show that among people with a diagnosed mood disorder, there is a 34–81 % increased risk of developing a physical LTC [38, 1, 39], relative to people without a mood disorder. In sum, the relationship between psychological distress and LTCs appears to be bi-directional.

However, the above studies have largely focussed exclusively on depression and overlooked anxiety and more general symptoms of distress. In addition, definitive causal conclusions cannot be made because of potential confounders that may better explain the relationship between LTC onset and the development of depression and vice versa, for example, personality traits or genetic factors. Nevertheless, quantitative findings complement those observed in the qualitative literature. Adults with diabetes and co-morbid depression described their causal beliefs about the aetiology of their conditions [40]. Some perceived their depression to be a causal consequence of their diabetes, others felt that their depressive disorder triggered the onset of their diabetes, and a third group felt that there was no connection between their physical and mental health. An understanding of both actual and patient perceived causes of their psychological distress will help to refine treatments further by offering individuals treatments that are consistent with their perceived causal triggers of their distressing symptoms.

Cognitive behavioural therapy (CBT) is a psychological talking therapy used to manage depression and anxiety [56]. Two meta-analyses exploring the effectiveness of psychological talking therapies (including CBT) for the management of depression in people with coronary heart disease [57] and diabetes [58] showed that these types of interventions improve depressive symptoms. However the size of improvements in depressive symptoms was small. This likely reflects the need to refine psychological treatments further to manage illness specific beliefs and challenging treatment demands and health consequences that present uniquely for each LTC. However, components of CBT can address the more generic mechanisms of action that perpetuate distressing symptoms and physical health outcomes in LTCs (See Fig. 22.1).

Activity scheduling can address sickness behaviour and its consequential effects on motivation. It encourages the planning of pleasurable activities into a person’s day to day routine to allow them to experience positive mood states. For example, a patient receiving dialysis may plan to go to the theatre with a friend. But also, activity scheduling encourages the explicit planning of necessary tasks (i.e. attending for dialysis treatments). It allows a person to gain a sense of achievement when necessary tasks are completed. By thoroughly planning pleasurable and necessary activities, a person can better incorporate LTC management challenges into their lives, whilst sustaining opportunities to experience pleasurable events. But caution is required to ensure that people’s pleasurable activities do not conflict with LTC management strategies. To elaborate, eating out with friends may generate challenges for people who are on restricted diets because of their condition; indeed it may trigger further distress because it reinforces the impact of the LTC on their day to day living.

Thought challenge techniques is another approach used in CBT. It encourages people to question the validity of their pessimistic thoughts. For example, a person may feel distressed because they perceive they have little control over their condition. Thought challenge techniques help people to identify situations where they have successfully managed their condition and encourage them to re-evaluate their initial pessimistic thoughts that are sustaining their distress. Skill building may also be used to encourage greater confidence in LTC management [59]. But not all pessimistic and distressing cognitions are amenable to thought challenge techniques. They are accurate perceptions about the seriousness of a LTC such as ESRD. Use of acceptance based approaches may be more appropriate for these types of beliefs [60] because it encourages people to distance themselves from their thoughts. But the efficacy of these approaches in people with LTCs has received little research attention to date. The interested reader should refer to Westbrook et al. [61] for a more thorough introduction to the principles of CBT and to McCracken [62] for examples of the application of acceptance based approaches in people with LTCs.

Pharmacotherapy can be used to treat clinically significant distress in LTCs [56]. According to the National Institute of Health and Care Excellence (NICE) depression [63] and generalised anxiety disorder guidelines [64], pharmacotherapy should only be used to treat patients who meet diagnostic criteria [14] for moderate to severe symptoms of distress. Currently, however there are no evidence-based guidelines with detailed pharmacotherapy algorithms for managing distress in the context of specific LTCs. Generating such algorithms is perhaps unfeasible given the heterogeneity of the patient population and high prevalence of multi-morbidity. Indeed, in England alone it is estimated that by 2018, 2.9 million people will have two or more LTCs [65].

When prescribing drug treatments to manage distress in people with physical LTCs the following factors need to be considered: (i) the potential for drug-drug interactions, (ii) the likely side effects of the medication, (iii) the patient’s previous history of pharmacotherapy treatments, (iv) patient preference, and (v) the toxicity of the drug and the risk of overdose among patients with suicidal ideation. NICE recommend selective serotonin reuptake inhibitors (SSRIs) as a first line treatment for depression and generalised anxiety disorders. However, SSRIs should be prescribed with particular caution among older patients because of increased risk of bleeding.

The US TEAMcare trial [66, 67] in primary care generated a medication treatment algorithm to manage depression in people with diabetes and/or coronary heart disease as part of a complex intervention (see website [68] for detailed treatment manual and medication algorithm). Consistent with NICE guidelines, patients were offered the SSRI citalopram. An initial dose of 10 mg per day was used, with doses gradually titrated upwards until a clinically meaningful improvement in depressive symptoms was observed. Citalopram was used as a first line treatment because of a decreased likelihood of drug-drug interactions with diabetes and/or coronary heart disease medications. If patients had tried SSRIs on two or more previous occasions and observed no improvements in their depressive status then they were offered the dopamine-noradrenaline reuptake inhibitor (DNRI) bupropion SR at a starting dose of 100 mg per day. Likewise to citalopram their dose was titrated upwards where necessary until a clinically meaningful response in their depressive symptoms was observed. Buproprion SR was chosen as an alternative first line drug treatment to citalopram because of: (i) its decreased potential for hepatic enzyme inhibition, (ii) fewer sexual functioning side effects, and (iii) evidence of weight loss when used in people with diabetes, which may indeed promote synergistic gains in physical and mental health.