Anxiety and depression in juvenile diabetes: a critical review

Psychological characteristics of Korean children and adolescents with type 1 diabetes mellitus

PURPOSE

This study investigates the behavioral and emotional characteristics of Korean children and adolescents with type 1 diabetes mellitus (T1DM) as compared to healthy controls, and examines whether their psychological status is associated with glycemic control, insulin regimens, or disease duration.

METHODS

A total of 37 Korean children and adolescents with T1DM, aged 6-17 years, and 38 sex- and age-matched healthy controls were included in this study. Psychological distress was assessed using the Korean child behavior checklist (K-CBCL) and children's depression inventory (CDI) after the subjects and their parents were interviewed.

RESULTS

The CDI and K-CBCL scores were significantly higher in T1DM subjects compared to normal controls. The T1DM subjects with "poorly controlled" blood glucose (glycosylated hemoglobin ≥8%) and "old patients" (disease duration ≥1 year) had a tendency to show higher CDI and K-CBCL scores. There were no significant differences in CDI and K-CBCL scores between the intensive and conventional insulin therapy groups.

CONCLUSION

Children and adolescents with T1DM seem to have inferior psychological adjustment to their normal counterparts, which might be associated with glycemic control and disease duration. Psychological evaluation and intervention should be considered in the management of T1DM in children and adolescents.

Association of depression and anxiety with diabetes mellitus type 2 concerning some sociological factors

BACKGROUND

Diabetes is a metabolic disorder with a high worldwide prevalence. It has been reported that diabetic patients are more prone to depression and anxiety.

OBJECTIVES

This study aimed to evaluate the prevalence of depression and anxiety among diabetic patients with regards to some factors such as age, gender, level of education and occupational status.

MATERIALS AND METHODS

One hundred and eighty four diabetic patients have participated in this study. To assess the severity of depression and anxiety Beck depression inventory and Beck anxiety inventory questionnaire were used respectively. Binary logistic regressions were used to analyze the data.

RESULTS

The results of the present study have shown that 70.7% of the diabetic patients were suffered from depression. Besides, 69.6% of them were diagnosed with anxiety. According to the result, diabetes related depression is affected by sex (OR: 2.767), age (OR: 2.222), level of education (OR: 4.145) and job status (OR: 3.901). It has been also resulted that gender (OR: 2.274), age (OR: 2.706) and Job Status (OR: 2.441) are the effective factors leading to anxiety.

CONCLUSIONS

Depression and anxiety have higher prevalence among diabetic patients and some sociological factors such as age, gender, job and education are related to these psychological disorders.

What's distressing about having type 1 diabetes? A qualitative study of young adults' perspectives

BACKGROUND

Diabetes distress is a general term that refers to the emotional burdens, anxieties, frustrations, stressors and worries that stem from managing a severe, complex condition like Type 1 diabetes. To date there has been limited research on diabetes-related distress in younger people with Type 1 diabetes. This qualitative study aimed to identify causes of diabetes distress in a sample of young adults with Type 1 diabetes.

METHODS

Semi-structured interviews with 35 individuals with Type 1 diabetes (23-30 years of age).

RESULTS

This study found diabetes related-distress to be common in a sample of young adults with Type 1 diabetes in the second phase of young adulthood (23-30 years of age). Diabetes distress was triggered by multiple factors, the most common of which were: self-consciousness/stigma, day-to-day diabetes management difficulties, having to fight the healthcare system, concerns about the future and apprehension about pregnancy. A number of factors appeared to moderate distress in this group, including having opportunities to talk to healthcare professionals, attending diabetes education programmes and joining peer support groups. Young adults felt that having opportunities to talk to healthcare professionals about diabetes distress should be a component of standard diabetes care.

CONCLUSIONS

Some aspects of living with diabetes frequently distress young adults with Type 1 diabetes who are in their twenties. Clinicians should facilitate young adults' attendance at diabetes education programmes, provide them with opportunities to talk about their diabetes-related frustrations and difficulties and, where possible, assist in the development of peer-support networks for young adults with diabetes.

Family involvement with the diabetes regimen in young people: the role of adolescent depressive symptoms

AIMS

In young people with Type 1 diabetes, depressive symptoms and shared responsibility for management of diabetes impact upon diabetes management and control. However, the simultaneous effects of both depressive symptoms and parental involvement on diabetes self-care and glycaemic control have not been examined. Thus, the aim of the current study was to examine the relationships between parental involvement and adolescent depressive symptoms in predicting blood glucose monitoring and glycaemic control.

METHODS

One hundred and fifty young people with Type 1 diabetes (mean age 15.3 years) and their parents completed responsibility sharing and depressive symptom assessments, meter assessment of blood glucose monitoring and HbA(1c) at baseline and then 6, 12 and 18 months.

RESULTS

Parental involvement affected HbA1c through blood glucose monitoring only at low levels of adolescent depressive symptoms (score ≤ 6), which made up only 20% of the sample. In the presence of more depressive symptoms, parental involvement no longer was related to HbA1c through blood glucose monitoring. This was the relationship in the majority of the sample (80%).

CONCLUSIONS

While most young people in this sample are not showing evidence of high levels of depressive symptoms, even modest levels of distress interfere with parental involvement in diabetes management. By addressing adolescent depressive symptoms, interventions promoting parental involvement in these families may be more effective.

Adolescents with type 1 diabetes: parental perceptions of child health and family functioning and their relationship to adolescent metabolic control

Background

Adolescents with Type 1 diabetes (T1D) show less effective metabolic control than other age groups, partly because of biological changes beyond their control and partly because in this period of developmental transition, psychosocial factors can militate against young people upholding their lifestyle and medical regimens. Parents have an important role to play in supporting adolescents to self-manage their disease, but resultant family tensions can be high. In this study, we aimed to assess family functioning and adolescent behaviour/ adjustment and examine the relationships between these parent-reported variables and adolescent metabolic control (HbA1c), self-reported health and diabetes self-care.

Method

A sample of 76 parents of Australian adolescents with T1D completed the Child Health Questionnaire –Parent form. Their adolescent child with T1D provided their HbA1c level from their most recent clinic visit, their self-reported general health, and completed a measure of diabetes self-care.

Results

Parent-reported family conflict was high, as was disease impact on family dynamics and parental stress. Higher HbA1c (poorer metabolic control) and less adequate adolescent self-care were associated with lower levels of family functioning, more adolescent behavioural difficulties and poorer adolescent mental health.

Conclusions

The implication of these findings was discussed in relation to needs for information and support among Australian families with an adolescent with T1D, acknowledging the important dimension of family functioning and relationships in adolescent chronic disease management.

Prevalence of depression among young people with Type 1 diabetes: a systematic review

AIMS

  To determine: (1) prevalence of depression among young people with Type 1 diabetes compared with control groups or population norms; (2) implications of depression for HbA(1c) level; and (3) the relationship between history of depressive symptoms and future depressive symptoms.

BACKGROUND

  Among adults with Type 1 diabetes depression is higher than the general population, and has been associated with adverse implications for self-care and HbA(1c) level. The last published review of depression among young people with Type 1 diabetes only included studies up to 1999.

METHOD

  Systematic searches were conducted for articles published from January 1999 to December 2011 including young people (up to 25 years old) with Type 1 diabetes.

RESULTS

  Twenty-three articles met the inclusion criteria. Of five studies that reported prevalence of depression compared with control groups, three found no differences. Of the three studies that investigated prevalence of depression making reference to population norms, all three showed higher rates of depressive symptoms. Fourteen of 15 studies found associations between more depressive symptoms and higher HbA(1c) level either cross-sectionally or longitudinally. Past depressive symptoms were associated with later depressive symptoms.

CONCLUSIONS

  Current evidence is inconclusive about whether there is increased prevalence of depression among young adults with Type 1 diabetes, as established among adults, but those who are more depressed have higher HbA(1c) level. This review is limited by methodological problems and no identified work in the UK met the inclusion criteria. Given the adverse clinical outcomes, we conclude there is a case for routine mental health screening for young adults with Type 1 diabetes.

Mental health issues in adolescents and young adults with type 1 diabetes: prevalence and impact on glycemic control

Mental health comorbidities can negatively affect disease management in adolescents with chronic illnesses. This study sought to determine the prevalence and impact of mental health issues in a population of adolescents and young adults with type 1 diabetes. A cross-sectional study of 150 patients aged 11 to 25 years with type 1 diabetes from an urban, academic diabetes center was conducted. Participants completed 3 validated mental health disorder screening instruments: Beck's Depression Inventory, the Screen for Child Anxiety Related Emotional Disorders-41 anxiety screen, and the Eating Disorder Screen for Primary Care. More than a third screened positive: 11.3% for depression, 21.3% for anxiety, and 20.7% for disordered eating (14.7% had ≥2 positive screens). Patients with a positive screen had twice the odds of having poor glycemic control as those without, as measured by HgbA1c. This study supports screening for mental health issues in adolescents and young adults with type 1 diabetes.

Anxiety in the pediatric medical setting

The relationship between pediatric anxiety disorders and physical health is not well-understood, but appreciation of the importance of this relationship is growing. Significant functional impairment may accompany a chronic physical health condition such as asthma, diabetes, or epilepsy, and anxiety may complicate the course. In addition, physical disease can present with symptoms of anxiety, and anxiety disorders may present or be associated with physical symptoms such as functional abdominal pain, headache, and fatigue. This article describes anxiety and its association with physical disease, outlines assessment, and presents a treatment overview including psychotherapy and pharmacotherapy.

The risk of developing type 2 diabetes mellitus associated with psychotropic drug use in children and adolescents: a retrospective cohort analysis

OBJECTIVE

Type 2 diabetes mellitus in children and adolescents has become an important public health concern, in parallel with the "epidemic" of overweight/obesity in this age group and a sharp increase in children being prescribed antidepressant or antipsychotic medications. In children and adolescents, the prevalence of being prescribed antidepressant or antipsychotic medications was examined as well as the association of these medications with developing type 2 diabetes mellitus.

METHOD

A retrospective cohort design evaluating South Carolina Medicaid medical and pharmacy claims between January 1, 1996, and December 31, 2006, was employed to identify 4,070 children and adolescents diagnosed initially with type 2 diabetes mellitus, 39% of whom were later reclassified as type 1 (using ICD-9 criteria). The added risk of developing type 2 diabetes mellitus posed by the use of antidepressants or antipsychotics was investigated in this cohort, controlling for individual risk factors and comorbid cardiometabolic conditions.

RESULTS

Use of antidepressants or antipsychotics alone, or the 2 in combination, conferred an increased risk (1.3 to 2 times greater) of having diagnosed type 2 diabetes mellitus and several comorbid cardiometabolic conditions (obesity, dyslipidemia, and hypertension). However, psychiatric illnesses generally developed and were treated after the initial development of diabetes.

CONCLUSIONS

Depression was diagnosed and treated in 10% to 20% of this cohort. While antidepressants and antipsychotics, alone or in combination, are associated with a diagnosis of type 2 diabetes mellitus and its cardiometabolic comorbidities by adolescence, they do not appear to be an explanatory factor in the early onset of type 2 diabetes mellitus in this age group and do not appear to cloud the initial, overlapping clinical picture between type 1 and type 2 diabetes mellitus.

The utility and financial implications of obtaining routine laboratory screening upon admission for child and adolescent psychiatric inpatients

The authors retrospectively explored the utility and fiscal implications of obtaining routine laboratory screening upon admission for child and adolescent psychiatric inpatients. A chart review of 153 sequential admissions (142 unique patients, with 11 patients admitted twice) over a recent 4-month period was conducted. Overall, 97.2% of all subjects who received a screening laboratory test had at least one abnormal finding. However, only four test results (<0.5%) actually had an impact on the psychiatric treatment plan or required immediate medical attention. With an average cost per patient for the full screening battery of $33-$122 and an average yearly direct cost to the inpatient unit of almost $38,000, potential alternatives to routine admission screenings are discussed. Given the cost of this relatively low yield outcome, these findings have important implications for psychiatric practice and cost-benefit analyses, which need to be further evaluated to better determine the actual utility of routine laboratory examinations upon admission.

Behaviour and metabolic control in children with Type 1 diabetes mellitus on insulin pump therapy: 2-year follow-up

AIMS

This study investigated whether continuous subcutaneous insulin infusion is associated with sustained improvement in behaviour and metabolic control.

METHODS

Children with Type 1 diabetes mellitus (n = 27, 8-18 years old) who had been assessed previously prior to commencing continuous subcutaneous insulin infusion, and 6-8 weeks later, were re-evaluated 2 years after commencing insulin pump therapy. Behaviour was reassessed using the Behavioral Assessment System for Children-2nd edition (BASC-2) and current HbA(1c) levels were recorded.

RESULTS

Two years after commencing continuous subcutaneous insulin infusion, parent-reported internalizing and externalizing symptoms were significantly lower than pre-insulin pump therapy commencement levels. Self reports of internalizing and externalizing problems did not differ significantly across the three assessment points. There was no significant difference between pre-insulin pump therapy HbA(1c) and HbA(1c) after 2 years on continuous subcutaneous insulin infusion, despite an initial improvement 6-8 weeks after commencing the therapy.

CONCLUSIONS

Children with Type 1 diabetes mellitus showed sustained improvements in parent-reported behaviour, but not in self reports of behaviour or in metabolic control 2 years after commencement of continuous subcutaneous insulin infusion.

Parenting behavior, child functioning, and health behaviors in preadolescents with type 1 diabetes

OBJECTIVE

To examine the association of critical parenting behaviors with preadolescent reported depressive symptoms, self-efficacy, and self-care behaviors in youth with type 1 diabetes (T1D).

METHOD

A total of 84 youth with T1D, ages 9-11 years, completed the Diabetes Family Behavior Checklist, Child Depression Inventory, Self-Efficacy for Diabetes scale, and Self-Care Inventory during a baseline assessment for a randomized controlled trial of an intervention to promote adherence.

RESULTS

Preadolescents who reported more critical parenting behaviors reported more depressive symptoms and lower self-efficacy. The relationship between critical parenting and self-efficacy was partially mediated by depressive symptoms. In a second model, depressive symptoms were associated with lower self-efficacy and fewer self-care behaviors. The relationship between depressive symptoms and self-care was fully mediated by self-efficacy.

CONCLUSIONS

Critical parenting behaviors are associated with preadolescents' psychological well-being, which has implications for self-care. Clinical implications include decreasing critical parenting behaviors and monitoring preadolescents with T1D for depressive symptoms.

Children with diabetes compared to peers: depressed? Distressed? A meta-analytic review

BACKGROUND

It is not clear from the literature whether children with diabetes have more psychological difficulties than their peers.

PURPOSE

This study aims to use meta-analysis to determine if children with diabetes differ from children without a chronic illness in a variety of domains reflecting psychological well-being.

METHOD

A meta-analysis was undertaken of 22 studies that compared children with diabetes to a comparison group. Outcomes included depression, anxiety, behavioral problems, and related constructs.

RESULTS

Children with diabetes were more likely than comparison groups to experience a variety of psychological difficulties. However, these effects were small to medium in magnitude and were typically smaller among more recent studies and studies with well-matched comparison groups.

CONCLUSIONS

This meta-analysis suggests that children with diabetes are at slightly elevated risk for psychological difficulties. Future work will need to help identify children at the highest risk, and to identify factors associated with resilience.

Depressive symptoms and unmet psychological needs of Dutch youth with type 1 diabetes: results of a web-survey

OBJECTIVE

To examine rates of depression and (un)met psychological needs in youth with type 1 diabetes.

METHODS

An open-access web-survey was conducted, collecting data on demographics, self-reported HbA1c, depressive symptoms [Child Depression Inventory (CDI)], wished and received psychological care in youth with type 1 diabetes (9-19 years).

RESULTS

The survey was completed by 233 youth; 17.2% reported elevated depressive symptoms on the CDI, girls more than boys (p = 0.003). Half of the youth did not talk about their feelings with their pediatrician or nurse. Of those youth with elevated depressive symptoms, 28% received psychological care, 25% wished to see a psychologist and 47% did not think it was necessary to receive psychological support.

DISCUSSION

This web-survey confirms the high prevalence of elevated depressive symptoms in youth with type 1 diabetes and the urgency to address their psychological needs. Screening for depressive symptoms in the context of periodic outpatient consultation could improve early detection and treatment of emotional problems.

Anxiety in medically ill children/adolescents

Anxiety disorders are thought to be one of the most common psychiatric diagnoses in children/adolescents. Chronic medical illness is a significant risk factor for the development of an anxiety disorder, and the prevalence rate of anxiety disorders among youths with chronic medical illnesses is higher compared to their healthy counterparts. Anxiety disorders may develop secondary to predisposing biological mechanisms related to a child's specific medical illness, as a response to being ill or in the hospital, a threatening environment, as a result of other genetic and psychological factors, or as a combination of all these factors. Additionally, exposure to physical pain early in one's life and/or frequent painful medical procedures are correlated with fear and anxiety during subsequent procedures and treatments, and may lead to medical nonadherence and other comorbidities. Anxiety disorders can have serious consequences in children/adolescents with chronic and/or life-limiting medical illnesses. Therefore, proper identification and treatment of anxiety disorders is necessary and may improve not only psychiatric symptoms but also physical symptoms. Behavioral and cognitive methods as well as psychotropic medications are used to treat anxiety disorders in pediatric patients. We will review current treatments for anxiety in children/adolescents with medical illnesses and propose future research directions.

Meeting the psychosocial needs of children with diabetes within routine clinical practice

AIMS

There is little guidance for paediatric diabetes teams on how best to meet their patients' psychosocial needs. The aims of conducting this survey of practitioners were to examine the challenges they face in delivering routine care, elicit their approaches to encouraging behaviour change and to inform the development of a training package to be evaluated in the Development and Evaluation of a Psychosocial Intervention with Children and Teenagers Experiencing Diabetes (DEPICTED) Study.

METHODS

A semi-structured telephone interview was completed with 44 doctors and seven paediatric diabetes specialist nurses and emergent themes identified.

RESULTS

The key challenges for practitioners were categorized as engagement and communication, meeting the needs of different ages and helping patients and their families integrate diabetes into their everyday life. Approaches to behaviour change were described in terms of education, advice and listening.

CONCLUSIONS

The survey demonstrates the complexities of communication with such a heterogeneous patient group and the range of approaches taken by practitioners in addressing behaviour change within routine care.

Relationship among psychopathological dimensions, coping mechanisms, and glycemic control in a Croatian sample of adolescents with diabetes mellitus type 1

Psychopathological factors associated with metabolic control in juvenile insulin-dependent diabetes mellitus (IDDM) deserve further investigation. This study assessed the relationship among specific psychopathological dimensions, coping mechanisms, and metabolic control in a Croatian clinical sample of adolescents with IDDM. One-hundred and one adolescents (aged 11-18) with IDDM filled out the youth self report (YSR) assessing psychopathological dimension and the scale of coping with stress (SCS). Glycemic control was estimated by the percentage of glycated hemoglobin (HbA1c). Subjects were divided into three groups according to HbA1C values: "optimal", "suboptimal control", and "at high risk". Subjects in optimal glycemic control presented with significantly lower scores in most of YSR scales compared to subjects at high risk. Moreover, they had significantly lower scores in avoidance and emotional reactivity and significantly higher scores in cognitive restructuring and problem solving SCS subscales. Regression models revealed that both internalizing and externalizing YSR scores, as well as emotional reactivity coping scores, independently contributed to explain variability of HbA1C values. Both internalizing and externalizing psychopathological dimensions, as well as emotion-oriented coping strategies, are independently associated with poor metabolic control in both boys and girls with IDDM, thus representing potential interest targets of psychotherapeutic interventions aimed at improving glycemic control in this population.

Predictors of metabolic control in children with Type 1 diabetes: the impact of Hurricane Katrina in a prospective study

AIMS

To prospectively examine the effects of fear of hypoglycemia (FH), adherence to blood glucose testing, and anxiety on metabolic control in youth with Type 1 diabetes. To examine the relationships among these variables in the context of a hurricane.

METHODS

Participants included 158 children completing measures at two times, with 58 participants completing measures pre- and post-Hurricane Katrina. Hierarchical regressions were run predicting indices of metabolic control.

RESULTS

HbA1c was a unique predictor of subsequent HbA1c although a significant interaction between children's FH and hurricane group was found for HbA1c. Percent of low blood glucose (BG) was the only unique predictor of subsequent low BG. Percent of high BG and demographic variables were predictors of subsequent high BG. There was also a significant interaction between children's FH and hurricane group for high BG.

CONCLUSIONS

Prior metabolic control is a strong predictor of subsequent metabolic control. Youth who exhibit FH are at risk for poor metabolic control, specifically demonstrating high BG levels and HbA1c if they have experienced a major stressor such as a natural disaster.

Follow-up results on monitoring and discussing health-related quality of life in adolescent diabetes care: benefits do not sustain in routine practice

OBJECTIVE

We previously demonstrated that adding monitoring and discussion of health-related quality of life (HRQoL) of adolescents with type 1 diabetes to routine periodic consultations positively impacts psychosocial well-being and satisfaction with care. The current study examines whether these positive effects are maintained 1 year after the intervention was terminated and patients received regular care again, with no formal HRQoL assessment.

PATIENTS AND METHODS

Forty-one adolescents with type 1 diabetes were followed for 1 year after the initial HRQoL intervention, in which their HRQoL had been assessed and discussed as part of period consultations using the PedsQL. Changes in physical and psychosocial well-being [Child Health Questionnaire-Child Form 87 (CHQ-CF87), diabetes family conflict scale (DFCS), Center for Epidemiological Studies scale for Depression (CES-D)], satisfaction with care [Patients' Evaluation of the Quality of Diabetes (PEQ-D) care], and glycemic control (HbA(1c)) were determined 12 months after the HRQoL intervention had ended.

RESULTS

One year after the HRQoL intervention, mean scores on CHQ subscales: behavior (p = 0.001), mental health (p = 0.004), and self-esteem (p < 0.001) had decreased, whereas the family activities subscale remained stable. Adolescents were less satisfied with their care (p = 0.012), and HbA(1c) values had increased significantly 12 months postintervention (p = 0.002).

CONCLUSIONS

The beneficial effects of an office-based HRQoL intervention in adolescents with diabetes largely disappear 1 year after withdrawing the HRQoL assessment procedure. This finding underscores the importance of integrating standardized evaluation and discussion of HRQoL in routine care for adolescents with diabetes.

Anxiety disorders in children and adolescents

Anxiety disorders are among the most common and functionally impairing mental health disorders to occur in childhood and adolescence. Primary care providers can expect to treat youth who have anxiety disorders frequently, and this article aims to provide the tools necessary to evaluate and manage patients who present with anxiety symptoms during childhood or adolescence. This article discusses the epidemiology of anxiety disorders, including the increased risk of future anxiety disorders and other mental health problems that are associated with having an anxiety disorder in childhood and adolescence. Next, the etiology of anxiety disorders is delineated, including discussion of genetic, cognitive-behavioral, physiological, and ecological explanatory models, and a summary of neurophysiological findings related to childhood and adolescent anxiety. Next, methods and tools are presented for assessment and treatment of anxiety disorders, with a focus on assessment and treatment that can be initiated in a primary care setting. Evidence-based therapy and medication interventions are reviewed. The article includes a focus on developmental differences in symptom presentation, assessment techniques, and treatment strategies, such that a primary care provider will have tools for working with the wide age range in their practices: preschool children through adolescents. We conclude that many effective intervention strategies exist, and their improving availability and ease of use makes it both critical and achievable for children and adolescents with anxiety disorders to be accurately diagnosed and treated with evidence-based medication and therapy.

Anxiety and depression in patients with chronic temporomandibular pain and in controls

OBJECTIVES

The purpose of this study was to assess the prevalence of anxiety and depression in temporomandibular disorders (TMD) patient subgroups and in controls with or without chronic facial pain (CFP).

METHODS

Our sample consisted of 61 men and 161 women. All TMD patients had suffered from pain for at least 6 months and were divided into two subgroups-an exclusively myofascial pain group and an exclusively joint pain group. Subjects without signs or symptoms of TMD but with and without CFP served as controls. All subjects were examined by calibrated examiners in accordance with the Research Diagnostic Criteria for Temporomandibular Disorders. The German version of the Hospital Anxiety and Depression Scale was used for assessment of anxiety and depression. Analysis of covariance was used to determine the effects of sex, age, and subgroup on anxiety and depression scores. Additional t-tests were performed and the subgroups were then compared with those from a general population sample.

RESULTS

Females from the exclusively myofascial pain group were significantly more depressed than those from the general population or from the exclusively joint pain group. Male controls with CFP were significantly more depressed than female CFP controls. For anxiety, no significant effect of sex or subgroup was found.

CONCLUSIONS

Depression may play an important role in women with chronic myofascial pain whereas anxiety does not seem to be relevant for either females or males. Further anxiety screening of patients with temporomandibular pain could not be justified.

The effects of parental depression and parenting practices on depressive symptoms and metabolic control in urban youth with insulin dependent diabetes

OBJECTIVE

Examine relationships between parental depressive symptoms, affective and instrumental parenting practices, youth depressive symptoms and glycemic control in a diverse, urban sample of adolescents with diabetes.

METHODS

Sixty-one parents and youth aged 10-17 completed self-report questionnaires. HbA1c assays were obtained to assess metabolic control. Path analysis was used to test a model where parenting variables mediated the relationship between parental and youth depressive symptoms and had effects on metabolic control.

RESULTS

Parental depressive symptoms had a significant indirect effect on youth depressive symptoms through parental involvement. Youth depressive symptoms were significantly related to metabolic control. While instrumental aspects of parenting such as monitoring or discipline were unrelated to youth depressive symptoms, parental depression had a significant indirect effect on metabolic control through parental monitoring.

CONCLUSIONS

The presence of parental depressive symptoms influences both youth depression and poor metabolic control through problematic parenting practices such as low involvement and monitoring.

Psychosocial problems in adolescents with type 1 diabetes mellitus

Adolescents with diabetes are at increased risk of developing psychiatric (10-20%) or eating disorders (8-30%), as well as substance abuse (25-50%), leading to non-compliance with treatment and deterioration of diabetic control. At high risk are female adolescents with family problems and other comorbid disorders. Impaired cognitive function has also been reported among children with diabetes, mainly in boys, and especially in those with early diabetes diagnosis (< 5 years), or with episodes of severe hypoglycaemia or prolonged hyperglycaemia. Type 1 diabetes mellitus contributes to the development of problems in parent-child relationships and employment difficulties, and negatively affects the quality of life. However, insulin pumps appear to improve patients' metabolic control and lifestyle. The contributions of family and friends to the quality of metabolic control and emotional support are also crucial. In addition, the role of the primary-care provider is important in identifying patients at high risk of developing psychosocial disorders and referring them on to health specialists. At high risk are patients in mid-adolescence with comorbid disorders, low socioeconomic status or parental health problems. Multisystem therapy, involving the medical team, school personnel, family and peer group, is also essential. The present review focuses on the prevalence of nutritional and psychosocial problems among adolescents with diabetes, and the risk factors for its development, and emphasizes specific goals in their management and prevention.

Peer relationships and diabetes: retrospective and ecological momentary assessment approaches

OBJECTIVE

To examine the association of positive and negative aspects of friendship to psychological well-being, self-care behavior, and blood glucose control and to determine whether these relations were moderated by gender.

DESIGN

Adolescents with Type 1 diabetes (n = 76) completed baseline measures of friendship quality, depressive symptoms, and self-care. A measure of metabolic control was obtained from medical records. Adolescents also tested blood glucose periodically over the course of 4 days and completed ecological momentary assessments of interpersonal interactions and mood using PDAs.

MAIN OUTCOME MEASURES

For between-groups analyses, primary outcomes were depressive symptoms, self-care behavior, and metabolic control. For within-groups analyses, primary outcomes were mood and blood glucose.

RESULTS

Results showed baseline reports of peer conflict but not support were associated with outcomes, particularly among girls. Conflict was more strongly related to poor metabolic control for girls than boys. Momentary interaction enjoyment and interaction upset were associated with mood, but were unrelated to blood glucose. Aggregate indices of enjoyable interactions were associated with fewer depressive symptoms and better self-care-especially among girls.

CONCLUSIONS

These results suggest that the positive and negative aspects of peer relationships are related to the psychological well-being and physical health of adolescents with diabetes.

Continuity and change in glycemic control trajectories from adolescence to emerging adulthood: relationships with family climate and self-concept in type 1 diabetes

OBJECTIVE

To determine developmental classes of glycemic control in young people with type 1 diabetes throughout adolescence and emerging adulthood and assess relationships with general family climate and self-concept.

RESEARCH DESIGN AND METHODS

In an eight-wave longitudinal study, 72 individuals (37 females) completed questionnaires assessing family climate (at times 1-4) and self-concept (at times 1-4 and 6). Times 1-4 covered adolescence (mean ages were 14-17 years, respectively); times 5-8 covered emerging adulthood (mean ages were 21-25 years, respectively). At each time point, patients visited their physicians to determine A1C values, and questionnaires were sent to the physicians to obtain these values. Latent class growth analysis was used to identify developmental classes of glycemic control.

RESULTS

Latent class growth analysis favored a three-class solution, consisting of optimal control (n = 10), moderate control (n = 51), and deteriorating control (n = 11). From time 3 on and especially during emerging adulthood, mean A1C levels were substantially different among the classes. Additional ANOVAs indicated that at times 1, 2, and 4, the optimal control class was characterized by the most optimal family climate, whereas at times 3, 4, and 6, the deteriorating control class was characterized by the lowest score on positive self-concept.

CONCLUSIONS

From late adolescence on, a multiformity of glycemic control trajectories emerged, which became more diversified throughout emerging adulthood. Family climate and self-concept in mid-to-late adolescence served as psychosocial markers of these developmental classes.

Association between emotional and behavioral problems and metabolic control in children and adolescents with Type 1 diabetes

OBJECTIVE

We aimed to investigate the differences in emotional and behavioral problems and to explore the association between the level of psychiatric problems and the metabolic control in Type 1 diabetes.

METHODS

The children with Type 1 diabetes (no.=42) and the "healthy" control group (no.=42), their parents and endocrinology specialist completed the forms prepared for the study. The parents completed the Child Behavioral Checklist (CBCL/4- 18).

RESULTS

The groups had significant differences in CBCL activities (p<0.001), social competence (p<0.001), total competences (p<0.001), withdrawal (p=0.036), anxiety/depression (p=0.033), social problems (p=0.009), and aggressive behavior (p=0.04) scores. We did not find significant differences in CBCL scores between the groups with good, moderate and bad metabolic control (p>0.05).

DISCUSSION

The parents of children with Type 1 diabetes reported emotional and behavioral problems significantly more. We did not find any significant association between the level of metabolic control and the emotional and behavioral problems.

Identity development, coping, and adjustment in emerging adults with a chronic illness: the sample case of type 1 diabetes

PURPOSE

The present study focused on identity development in emerging adults (aged 18-30 years) with type 1 diabetes. The three study aims were to examine the following: (1) whether identity development was affected by having diabetes, as compared with development in a nondiabetic sample; (2) how identity development was related to depressive symptoms, coping with diabetes, and diabetes-related problems in the diabetic sample; and (3) whether the pathways from identity development to problems with diabetes and depressive symptoms were mediated through coping strategies in the diabetic sample.

METHODS

A total of 194 emerging adults with type 1 diabetes and 344 nondiabetic emerging adults participated.

RESULTS

First, using analyses of variance, some mean identity differences between the diabetic and comparison samples were found, with emerging adults with diabetes scoring lower on proactive identity exploration. Using cluster analysis, we found that the same identity types or statuses emerged in both the diabetic and nondiabetic samples. Second, in emerging adults with diabetes, these identity statuses were differentially related to diabetes-related problems, depressive symptoms, and illness coping, with the identity statuses representing a strong sense of identity being accompanied by less diabetes-related problems and depressive symptoms and more adequate coping strategies. Third, using structural equation modeling, the pathways from a strong sense of identity to diabetes-related problems and depressive symptoms were mediated through adaptive and maladaptive coping.

CONCLUSIONS

Clinicians should be sensitive to the normative task of identity development in emerging adults with diabetes because identity development can function as a resource in coping with and adjusting to diabetes.

Monitoring and discussing health-related quality of life in adolescents with type 1 diabetes improve psychosocial well-being: a randomized controlled trial

OBJECTIVE

To test the effects of monitoring and discussing of health-related quality of life (HRQoL) in adolescents with type 1 diabetes in a multicenter randomized controlled trial.

RESEARCH DESIGN AND METHODS

Four centers were randomly assigned to the HRQoL intervention (46 adolescents) or control (45 adolescents) group, with three regular visits scheduled within 12 months in both groups. In the HRQoL intervention group, HRQoL of adolescents was assessed using the Pediatric Quality of Life Inventory, and outcomes were discussed face-to-face during the consultation. The control group received care as usual. Mean differences between the groups at 12 months in physical and psychosocial well-being (Child Health Questionnaire [CHQ]-CF87/PF50, Diabetes-Specific Family Conflict Scale, and Center for Epidemiological Studies Scale for Depression), satisfaction with care (Patients' Evaluation of the Quality of Diabetes Care), and A1C were determined, controlling for baseline scores.

RESULTS

Mean scores on the CHQ subscales of psychosocial health (P < 0.001), behavior (P < 0.001), mental health (P < 0.001), and family activities (P < 0.001) improved in the HRQoL intervention group, except for adolescents with the highest A1C values. Adolescents in the HRQoL intervention group reported higher self-esteem (CHQ) at follow-up (P = 0.016), regardless of A1C, and were more satisfied with care (P = 0.009) than control subjects. No significant differences between the two groups over time were observed in A1C levels.

CONCLUSIONS

Periodic monitoring and discussion of HRQoL in adolescents with diabetes is appreciated and has positive effects on their psychosocial well-being, except for those in poorest control.

Predictors of metabolic control among adolescents with diabetes: a 4-year longitudinal study

OBJECTIVE

To employ a risk and resistance framework to examine changes in metabolic control over early to middle adolescence.

METHODS

We interviewed 70 girls and 62 boys (mean age 12 years) annually for 4 years. Risk and resistance factors, including demographics, disease-related variables, self-care behavior, and psychosocial variables were assessed. Hemoglobin A1c was obtained from medical records.

RESULTS

Multilevel modeling showed metabolic control deteriorated with age. Self-care behavior interacted with age to predict the decline, such that self-care was more strongly related to poor metabolic control for older adolescents. Eating disturbances, depression, and peer relations were related to poor metabolic control, whereas good family relations were related to better metabolic control for girls.

CONCLUSIONS

Independent risk factors for poor metabolic control included poor self-care, disturbed eating behavior, depression, and peer relations; parental support was an independent resistance factor for girls. Future research should examine mechanisms by which these relations emerge.

Improved glycemic control in adolescents with type 1 diabetes mellitus who attend diabetes camp

OBJECTIVE

Diabetes camp has become a common part of medical practice worldwide. Although patients' knowledge and self-management of diabetes may improve after camp, improved glycated hemoglobin A1c (HbA1c) levels have not been consistently demonstrated.

RESEARCH DESIGN AND METHODS

We performed a retrospective study of medical records at the Children's Medical Center Dallas Endocrinology Center for adolescents with type 1 diabetes aged 12-18 yr. We compared patients who did (n = 77) or did not (n = 106) attend Camp Sweeney, a regional 20-d diabetes camp. Some patients (n = 82) and their parents also completed measures of adherence, depression, and quality of life.

RESULTS

HbA1c decreased over time in patients who attended diabetes camp {mean [+/-standard deviation (SD)] at baseline, (T1) = 8.6% (+/-1.8%) and at follow-up, (T2) = 8.3% (+/-1.6%)}, whereas it increased in those who did not attend [mean (+/-SD) at T1 = 8.4% (+/-2.1%) and at T2 = 8.9% (+/-2.3%)] (p < 0.005). Seven months after camp (T3), there were still significant differences in HbA1c between the camp and control groups (p = 0.04), with the difference because of persistent improvement for girls but not for boys. Patients' adherence (p < 0.05) and adjustment (p < 0.05) improved by parental report in those who attended camp; parents of patients who did not attend did not report the change.

CONCLUSIONS

Attending Camp Sweeney is associated with improved glycemic control and parent-reported adherence and adjustment in adolescents with type 1 diabetes. Additional studies are needed to determine whether these findings can be generalized to other diabetes camps.

Prevalence and associations of psychological distress in young adults with Type 1 diabetes

AIMS

To determine the prevalence of psychological distress in young adults with Type 1 diabetes and to explore associated factors.

METHODS

Ninety-two participants with Type 1 diabetes (46 male, 46 female) attending a young adult clinic completed two psychological self-report assessments; the Centre for Epidemiological Studies-Depression Scale (CES-D) and Adult Self-Report Scale (ASR). The mean age was 21.6 +/- 2.8 years (sd) and mean duration of diabetes was 9.3 +/- 5.4 years. A questionnaire identified the method of insulin delivery, the frequency of blood glucose monitoring and hypoglycaemia requiring third-party assistance. HbA(1c) was measured.

RESULTS

Of the participants, 35.2% reported depressive symptoms (CES-D > or = 16), 23.1% indicating severe depressive symptoms (CES-D > or = 24), and 32.2, 40.4 and 35.5% of participants reported significant distress (ASR > or = 60) on the ASR total problem scales, ASR internalizing and ASR externalizing scores, respectively. Mean HbA(1c) levels were higher in participants with depressive symptoms compared with those with normal scores (CES-D > or = 16, HbA(1c)= 9.4% vs. CES-D < 16, HbA(1c)= 8.4%, P = 0.01). Factors associated with psychological distress included use of continuous subcutaneous insulin infusion (CSII) (P = 0.02) and increased frequency of hypoglycaemic episodes (P = 0.03). CSII users had higher CES-D (21.3 vs. 11.9, P = 0.001) and ASR-Total (59.7 vs. 53.0, P = 0.02) scores than non-CSII users.

CONCLUSIONS

Approximately one-third of young adults with Type 1 diabetes experience psychological distress, which is associated with poorer glycaemic control. Psychological distress was related to frequency of hypoglycaemic episodes and method of insulin administration, with significantly greater distress being observed in those using CSII. These findings support inclusion of a psychologist in the diabetes team.

Agreement between parents and children regarding anxiety and depression diagnoses in children with asthma

This study examined parent-child agreement regarding anxiety and depressive disorders in youth with asthma and evaluated key demographic and health differences associated with parent-child agreement. Of 756 outpatient youth with asthma, 122 (16.0%) were diagnosed with a DSM-IV anxiety or depression disorder using the Diagnostic Interview Schedule for Children (C-DISC). Parents reported on internalizing symptoms using the Child Behavior Checklist (CBCL). Logistic regression analyses were used to examine factors related to parent- and child-reported symptom agreement. Low rates of agreement (48.9%) between youth and parents regarding diagnosis of a DSM-IV anxiety or depressive disorder were found among youth with asthma. Increased agreement was associated with higher externalizing behavior score on the CBCL and more anxiety and depressive symptoms on the C-DISC. Children without behavioral problems and with less severe anxiety and depression were recognized significantly less often by their parents.

Maternal Parenting Style and Adjustment in Adolescents with Type I Diabetes

OBJECTIVE

To investigate the cross-sectional relationship between maternal parenting style and indicators of well-being among adolescents with diabetes.

METHODS

Seventy-eight adolescents (ages 11.58-17.42 years, M = 14.21) with type 1 diabetes and their mothers separately reported perceptions of maternal parenting style. Adolescents reported their own depressed mood, self-efficacy for managing diabetes, and diabetes regimen adherence.

RESULTS

Adolescents' perceptions of maternal psychological control were associated with greater depressed mood regardless of age and gender. Firm control was strongly associated with greater depressed mood and poorer self-efficacy among older adolescents, less strongly among younger adolescents. Adolescents' perceptions of maternal acceptance were associated with less depressed mood, particularly for girls and with better self-efficacy for diabetes management, particularly for older adolescents and girls. Maternal reports of acceptance were associated only with adherence.

CONCLUSIONS

Maternal parenting style is associated with well-being in adolescents with diabetes, but this association is complex and moderated by age and gender.

Validation of the WHO-5 Well-Being Index in adolescents with type 1 diabetes

OBJECTIVE

It is recommended that the psychological status of adolescents with diabetes be assessed periodically as part of ongoing care. The World Health Organization-Five Well-Being Index (WHO-5) is a short self-report instrument that appears suitable for this purpose. This study is the first to assess the reliability and validity of the WHO-5 in adolescents with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Ninety-one adolescents with type 1 diabetes (aged 13-17 years) from four pediatric clinics completed the WHO-5, along with other psychological measures: the Center for Epidemiologic Studies Depression Scale (CES-D), the Diabetes Family Conflict Scale (DFCS), and the mental health and self-esteem subscales of the Child Health Questionnaire (CHQ-CF87). Confirmatory factor analysis (CFA) and exploratory factor analysis were conducted. Readability, homogeneity, and item-total and inter-item correlations were determined. Concurrent validity was examined by calculating correlation coefficients among all measures. Sensitivity and specificity of the WHO-5 were tested against those for the CES-D using receiver operating characteristic (ROC) curves.

RESULTS

CFA confirmed the one-factor structure; Cronbach's alpha of this 5-item scale was 0.82. The WHO-5 showed a moderate to strong correlation with the CES-D (r = -0.67), with the mental health (r = 0.60) and self-esteem (r = 0.43) subscales of the CHQ-CF87, and with the DFCS (r = -0.34), confirming concurrent validity. ROC curve analysis confirmed the WHO-5 cutoff point of <50 for identification of mild to severe depressive affect (sensitivity 89% and specificity 86%).

CONCLUSIONS

The WHO-5 is a brief, patient-friendly measure of positive well-being with good psychometric properties that appears suitable for routine use in adolescents with type 1 diabetes.

Mental health in adolescents with chronic physical illness versus controls in Northern Russia

AIM

To study the behaviour/emotional problems and depression in adolescents with and without physical illnesses; to compare the same psychological parameters in adolescents with different disorders.

METHODS

The sample consisted of 148 adolescents aged 13-16 years with one of the following physical chronic conditions: diabetes (n = 55), asthma (n = 59), or epilepsy (n = 59). Comparative data were obtained from a group of 301 schoolchildren. Test batteries (Child Behaviour Check-List, Youth Self Report, Beck Depression Inventory, socio-economic status questions) were individually completed by adolescents and their mothers.

RESULTS

Overall adolescents with physical illness had more behaviour/emotional problems and were more depressed compared to controls although results varied according to the informants and the disease severity. Two risk groups were revealed: girls with asthma and boys with epilepsy.

CONCLUSION

Our results suggest that mental health in adolescents with chronic physical illnesses is poorer than in controls and their mental health state is very much associated with the disease severity. The findings of the study can help to develop disease targeted and comprehensive interventions in outpatient clinics of Northern Russia in order to reduce behaviour and mood disorders in adolescents with chronic physical illnesses and therefore to smooth the transition through their teenage years.

Diabetes and depression: a review of the literature

Depression affects millions of people in the United States. Drugs used to treat depression can lead to weight gain, which could predispose a person to type 2 diabetes. Also, certain medications that may be used to treat depression with psychotic features can lead to metabolic syndrome and new-onset diabetes. Diabetes is another chronic health care condition that affects millions of people in the United States. Diabetes is the leading cause of nontraumatic amputations and a leading cause of blindness. Both conditions can result in a lower quality of life. Clinicians face challenges in treating either condition, but can face greater ones when the conditions occur together. This article reviews the literature concerning depression and diabetes.

Self-report and parent-report of physical and psychosocial well-being in Dutch adolescents with type 1 diabetes in relation to glycemic control

Background

To determine physical and psychosocial well-being of adolescents with type 1 diabetes by self-report and parent report and to explore associations with glycemic control and other clinical and socio-demographic characteristics.

Methods

Demographic, medical and psychosocial data were gathered from 4 participating outpatient pediatric diabetes clinics in the Netherlands. Ninety-one patients completed the Child Health Questionnaire-CF87 (CHQ-CF87), Centre for Epidemiological Studies scale for Depression (CES-D), and the DFCS (Diabetes-specific Family Conflict Scale). Parents completed the CHQ-PF50, CES-D and the DFCS.

Results

Mean age was 14.9 years (± 1.1), mean HbA_1c 8.8% (± 1.7; 6.2–15.0%). Compared to healthy controls, patients scored lower on CHQ subscales role functioning-physical and general health. Parents reported less favorable scores on the behavior subscale than adolescents. Fewer diabetes-specific family conflicts were associated with better psychosocial well-being and less depressive symptoms. Living in a one-parent family, being member of an ethnic minority and reporting lower well-being were all associated with higher HbA_1c values.

Conclusion

Overall, adolescents with type 1 diabetes report optimal well-being and parent report is in accordance with these findings. Poor glycemic control is common, with single-parent families and ethnic minorities particularly at risk. High HbA_1c values are related to lower social and family functioning.

The role of socioeconomic status, depression, quality of life, and glycemic control in type 1 diabetes mellitus

OBJECTIVE

To test the hypothesis that poor glycemic control in type 1 diabetes mellitus (T1DM) is associated with depression and poor quality of life (QOL), with a higher prevalence in persons of lower socioeconomic status (SES).

STUDY DESIGN

Subjects with T1DM age 8 to 17 years (n = 222) were evaluated using the Childrens Depression Inventory, the Hollingshead Four-Factor Index to determine SES, and PedsQL questionnaires to ascertain QOL. HbAlC > 8% was considered indicative of poor glycemic control.

RESULTS

A total of 110 well-controlled subjects and 112 poorly controlled subjects (HbA1C 7.1% +/- 0.7% vs 9.9% +/- 1.6%) were recruited. It was found that 9.5% of poorly controlled subjects were depressed, compared with 3% of well-controlled subjects. Logistic regression revealed a 27% increase in probability of depression per unit rise in HbA1C (P < .03). Higher SES was associated with better glycemic control (P < .0005) and QOL (P < .0005); longer duration of illness was not associated with poorer glycemic control. Diabetes QOL deteriorated with poorer glycemic control (P < .002).

CONCLUSIONS

Poor glycemic control in peridatric T1DM is associated with lower SES and depression. The probability of depression increases as glycemic control worsens. Screening for depression should be routinely carried out in patients with T1DM, targeting patients with deteriorating glycemic control.

Predictors of metabolic control at one year in a population of pediatric patients with type 2 diabetes mellitus: a retrospective study

BACKGROUND/OBJECTIVES

The rising prevalence of pediatric type 2 diabetes mellitus (DM2) and non-adherence to diabetes regimens pose challenges to obtaining optimal control. This study evaluated factors that may impact glycemic control (HbA1c): age, Tanner stage, body mass index (BMI), total daily insulin (TDD), metformin dose (MET), activity level, frequency of clinic visits and adherence.

METHODS

One-year data from 72 patients (ages 8.6-17.8 years) were collected retrospectively. From that sample, 57 patients who continued to attend clinic for the entire year were assessed and divided into optimal and suboptimal HbA1c control groups.

RESULTS

All factors measured were similar in the two groups, except for lower initial and 1.0-year HbA1c, TDD, and rates of missing MET and insulin in the optimal HbA1c control group.

CONCLUSIONS

Initial glycemic status and adherence rate predicted metabolic control at one year. Early identification of DM2 may improve metabolic outcome, which may improve medical regimen adherence.

Prevalence and correlates of depressed mood among youth with diabetes: the SEARCH for Diabetes in Youth study

OBJECTIVE

The objective of this study was to determine if depressed mood among youth with diabetes was associated with type and duration of diabetes, mean glycosylated hemoglobin (HbA1c) level, and the frequency of diabetic ketoacidosis (DKA) and hypoglycemic episodes, hospitalizations, and emergency department (ED) visits.

METHODS

A total of 2672 youth (aged 10-21 years) who had diabetes for a mean duration of 5 years completed a SEARCH study visit, in which their HbA1c was measured and information about their demographic characteristics, diabetes type and duration, and episodes of DKA, hypoglycemia, hospitalizations, and ED visits over the previous 6 months was collected. Their level of depressed mood was measured using the Center for Epidemiologic Studies Depression Scale (CES-D).

RESULTS

Among these youth, 14% had mildly (CES-D 16-23) and 8.6% had moderately or severely (CES-D > or =24) depressed mood. Females had a higher mean CES-D score than males. After adjusting for demographic factors, and duration of diabetes, we found the prevalence of depressed mood to be higher among males with type 2 diabetes than those with type 1 diabetes and to be higher among females with comorbidities than those without comorbidities. Higher mean HbA1c and frequency of ED visits were associated with depressed mood. The prevalence of depressed mood among youth with diabetes was similar to that of published estimates of depressed mood among youth without diabetes.

CONCLUSIONS

Physicians and other health care professionals should consider screening youth with diabetes for depressed mood in clinical settings, particularly youth with poor glycemic control, those with a history of frequent ED visits, males with type 2 diabetes, and females with comorbidities.