depresja w cukrzycy I.pdf

Journal of Psychosomatic Research 53 (2002) 907–911

Depression in Type 1 diabetes in children

Natural history and correlates

Margaret Grey*, Robin Whittemore, William Tamborlane

Yale School of Nursing, 100 Church Street South, New Haven, CT 06519, USA

Abstract

The combination of diabetes and depression in children and

adolescents is largely unstudied. The purpose of this article is to

review the literature on the natural history and correlates of co-

morbid diabetes and depression in children and adolescents.

Children with diabetes have a two-fold greater prevalence of

depression, and adolescents up to three-fold greater, than youth

without diabetes. Correlates of depression and diabetes include

gender, poorer metabolic control, and family behaviors. Very little

is known about treatment in these youth, and more studies are

Keywords: Type 1 diabetes; Children; Adolescents; Depression

Introduction

image, peer group pressure, autonomy from the parents and

identity formation [7]. De Groot et al. [8] propose several

possible mechanisms for an association between depression

and poor glycemic control, including neuropsychological

impacts of depression on memory and diabetes self-care

knowledge, persistent subthreshold depression’s effect on

adherence and the effect of negative attitudes associated

with diabetes self-care. Depression may be associated with

attitudinal or personality variables such as low self-esteem,

pessimism, poor concentration and loss of interest in daily

activities. Thus, adults with diabetes and depression have

poorer daily functioning and quality of life [9], poorer

adherence to the diabetes regimen [3], poorer metabolic

control [10,11] and an increased risk for both micro- and

macrovascular complications than adults with diabetes but

not depression [12,13].

Adults tend to have the view that childhood is an idyllic

time, and that depression is not as common as it is in

adulthood. In general, this assumption would be correct.

Nonetheless, the combination of diabetes and depression in

children, and especially adolescents, is important because:

(1) it is associated with 10-fold increase in suicide and

suicidal ideation (and children and adolescents who take

insulin have a ready method of performing suicide if they

wish to) [14,15]; (2) recurrence and course may be more

severe than in adults, with some studies showing that

depression tends to be more severe, take longer to resolve

the initial episode and is more likely to recur than in youth

Depression is a serious health problem and one that

affects a large percentage of those individuals suffering with

a chronic illness. According to Connell et al. [1], several

factors contribute to the increased prevalence of depression

among those with a chronic illness, including the effect of

the disease on physical functioning and activity, social

relationships, quality of life and morale. Lifetime prevalence

rates of major depression among adults with Types 1 and 2

diabetes range between 14.4% and 32.5% [2,3]. Depression

has a profound adverse influence on quality of life and

overall functioning and has additional repercussions with

individuals with diabetes because of its association with

poor management [4]. This association is poorly understood

but has been hypothesized to operate through depression-

induced abnormalities in neuroendocrine and neurotrans-

mitter function [5], through decreased compliance with

diabetes management, or because of as-yet-unknown com-

plex behavioral –physiologic interaction [6]. If these hypo-

theses can be supported, then new approaches to

interventions, combining pharmacologic and cognitive–

behavioral approaches, may be helpful. For adolescents,

the challenge of diabetes is combined with the devel-

opmental tasks of adapting to puberty and a changing body

* Corresponding author.

0022-3999/02/$ – see front matter

PII: S0022-3999(02)00312-4

908

M. Grey et al. / Journal of Psychosomatic Research 53 (2002) 907–911

without diabetes [16]; (3) it may be associated with poorer

metabolic control in diabetes, which may lead to compli-

cations and other poorer outcomes [6]; and (4) several

studies have suggested that youth with diabetes and

depression may be likely to have other comorbid condi-

tions, such as eating disorders, adjustment disorders or

anxiety disorders [6,16,17].

Natural history

The prevalence of depression in children and adolescents

without diabetes ranges from 0.4% to 8.3%, and increases

markedly from childhood into adolescence [18–20]. A

number of risk factors have been identified that increase

the likelihood of depression during childhood, including

female gender, family dysfunction and stressful experiences.

One stressful experience that may increase risk for depres-

sion in the child or adolescent is diabetes.

There are few population-based studies of children and

adolescents with diabetes, but the prevalence of depression

in this population ranges from two- to threefold that of

peers without diabetes [21]. These rates are significantly

higher in youth with diabetes as indicated by a recent study

by Kokkonen and Kokkonen [22] in which the prevalence

of depression was reported to be 12% in Scandinavian

children aged 8–12 years and 18% in adolescents. How-

ever, these rates may vary according to the duration of

illness, in addition to geographic variations. Kovacs et al.

[23–26], in a series of studies, followed an onset cohort of

children, 8–13 years of age, for 6 years. The authors used

the Children’s Depression Inventory (CDI) [27] to measure

depressive symptoms. Although the sample size decreased

significantly over the 6 years of follow-up, they [26] found

that levels of depressive symptoms remained relatively

stable, but the presence of depressive symptoms at dia-

gnosis was associated with a higher prevalence of depres-

sion later. In contrast, Grey et al. [28] compared youth with

newly diagnosed diabetes with a cohort of age- and gender-

matched peers, and found that the youth with diabetes

reported significantly higher depressive symptomatology

than those without diabetes at the time of the diabetes

diagnosis and then again at the end of the second year.

They characterized this second period of depression as

being associated with the end of the physiologic hon-

eymoon period and the necessity of learning to live with

diabetes lifelong.

Jacobson et al. [29] also followed an onset cohort of

young adults (ages 19–26 years) for 10 years. Using the

depression subscale of the SCL-90, they found that depres-

sion was not significantly different among those with dia-

betes and a comparison group who had a moderately severe

acute illness. In addition, they found that males had signific-

antly more depression (and another psychiatric symptoms)

over time. While the finding that males had more depression

than females was unexpected, the authors suggest that in

Fig. 1. Point prevalence of CDI scores 13 and duration of diabetes in

102 adolescents with Type 1 diabetes (CDI scores 13 or greater indicate

clinical depression).

young adults, males may find the diabetes to have a more

profound effect on work and social life than females.

In a recent analysis conducted with a cohort of adoles-

cents in our clinic who were participating in a trial of

intensive management, we found that the overall prevalence

of depressive symptoms was 17%. Note that this was a

somewhat selected sample because it was a group recruited

for a study of intensive management; thus, the true preval-

ence may be higher or lower. Further, we found that

duration of diabetes was significantly correlated with

depressive symptoms in a U-shaped distribution, as shown

in Fig. 1. We found that depressive symptoms were more

common in the earlier years postdiagnosis, less common

between 4 and 9.9 years after diagnosis and rose again after

10 years.

Correlates

Researchers working in the area of childhood depression

have identified several correlates of depression in children

without diabetes [30]. As noted earlier, age is important,

since adolescents are significantly more prone to depression

than children at earlier ages. Gender is also important

[31,32]. Prior to adolescence, most studies suggest that

there are no gender differences in prevalence. In adoles-

cents, however, girls are consistently found to have more

depression than boys [31,32]. Maternal depression is also

associated with a higher incidence of depression in the

children [7]. Family stress or dysfunction appears to pre-

dispose children and adolescents to depression [7]. And,

finally, any stressor, such as health status, illness or injury,

can be associated with depression in children.

In children and adolescents with diabetes, some of the

same correlates have been found. For example, Jacobson

M. Grey et al. / Journal of Psychosomatic Research 53 (2002) 907–911

909

et al. [29] found that boys with diabetes were significantly

more likely to be depressed after 10 years than girls with

diabetes or a sample of youth who had a severe acute illness.

On the other hand, in the study of LaGreca et al. [32] of

42 adolescents with Type 1 diabetes, they found girls to be

significantly more depressed that boys.

A few anecdotal reports suggested that poorer metabolic

control of diabetes was associated with depression in youth

with diabetes. Although this finding is not consistent,

studies appear to suggest that approximately 20% of the

variance in metabolic control is statistically explained by

depression in youth [21,26,32–35]. With the exception of

the work of LaGreca et al., gender differences were not

explored in these studies.

In our cohort of 102 adolescents with Type 1 diabetes,

we have begun to explore correlates of depression. First we

looked to see if depression was associated with age, gender

and socioeconomic status, and found no correlations. Then

we examined the data for relationships with acute compli-

cations, such as weight gain or severe hypoglycemia, and

again found no correlations. We also looked for correlations

with the presence of microvascular complications (as was

true in adults), and again found none. Finally, we examined

the data for correlations with family variables, using the

FACES II scale [36] and the Diabetes Family Behavior

Scale [37]. We found that those teens who reported lower

family adaptability (r = .41, P < .001), lower family cohe-

sion (r = .43, P < .001) and less warmth and caring dia-

betes family behaviors (r = .44, P < .001) were more likely

to have depressive symptoms than those with higher family

functioning. Interestingly, guidance and control in relation-

ship to diabetes family behaviors were not associated with

depression (r =.23, ns) in this group of teens. In addition, we

examined whether a history of psychosocial problems

(pervasive or persistent problems related to adjustment

disorders, family conflict/stress, rebellious or aggressive

behavior, mood disorders or compulsive behavior as

reported to the clinician at intake by the adolescent or their

parent) was associated with depression. As shown in Fig. 2,

youth who had a history of psychosocial problems were

significantly more likely to report depressive symptoms than

youth who did not report such a history.

We used multiple regression to examine factors that

were associated with depressive symptoms at baseline in

the adolescent study. Initially, the model included all of the

variables listed above, and stepwise regression yielded the

model shown in Table 1. The bestfitting model found that

reports of lower warm and caring family behaviors, lower

family adaptability and a history of psychosocial difficult-

ies remained significantly associated with depressive

symptoms, with about 24% of the variance explained. In

other words, youth who had a history of psychosocial

difficulties either individually or in the family and who

reported that they felt less warm and caring or adaptability

from their families in their diabetes management were

most likely to have higher depression scores.

Fig. 2. Comparison of CDI scores in youth with diabetes with positive

history of psychosocial problems or no history of psychosocial problems

(CDI scores 13 or greater indicate clinical depression).

Other outcomes that have been associated with depres-

sion in teens in at least one study include: Poorer quality of

life [35], poorer adherence to the diabetes regimen of

glucose monitoring, insulin injections and diet [6,32], lower

self-esteem [15], an increased incidence of disordered eating

[6] and suicide/suicidal ideation [14].

Even less is known about the mechanism responsible

for the relationship between depression and diabetes in

youth. The usual assumption has been that loss of self-

esteem and poor adjustment to the chronic illness were

responsible. Fear of diabetes-related complications and

helplessness to avoid them may lead to poorer self-care.

Our data suggest that preexisting family functioning may

be useful in understanding some of these phenomena. But

new hypotheses about the potential effects of immune

functioning and/or glutamic acid decarboxylase (GAD)

autoantibodies’ effects on the synthesis of the major

inhibitory neurotransmitter (gamma-aminobutyric acid,

GABA) in the beta cell and central nervous system are

beginning to emerge, leading some to conclude that the

mechanism may be physiological. Since disturbances in

GABAergic function are hypothesized to contribute to the

neurobiology of major depression [38,39], and approxi-

mately 70% of adolescents with Type 1 diabetes produce

GAD autoantibodies [40], these autoantibodies may play a

role in the development of both diabetes and depression. It

may also be that counterregulatory hormones, such as

cortisol released during times of stress, that impair glucose

tolerance also make diabetes control more difficult.

Despite the myriad causes, little is known about how to

treat these high-risk youth [41]. Indeed, optimal treatment

of depression in youth without diabetes remains contro-

versial. There have been very few well-controlled studies,

and there have been no longer-term studies of drug

treatment—most of the studies simply look at short-term

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M. Grey et al. / Journal of Psychosomatic Research 53 (2002) 907–911

Table 1

Multiple regression results for CDI scores at baseline

Variable b SE b t P R 2 change

DFBS—warmth/caring 0.38 0.02 3.81 .000 .15

FACES—adaptation 0.36 0.01 4.24 .005 .13

History of psychosocial

problems

0.20 0.30

2.02 .046 .06

characterize the nature of the depression in these youth

and begin to explicate why depression has a temporal

relationship with diabetes duration in youth. Few studies

include control or comparison groups, so it is difficult to

know if the correlates of depression in children without

diabetes are true in children with diabetes, except to

compare with psychiatric populations in the literature. We

need to understand the underlying mechanisms that explain

the relationship between depression and diabetes and

whether pharmacologic treatment can alter this mechanism.

We also need a better understanding of family characteristics

that support metabolic control and psychosocial health.

Many clinicians believe that it is all about ‘compliance’;

that when a patient is depressed, they just cannot take care

of themselves adequately. But it may be that, just as insulin

resistance explains a certain amount of the difficulties in

metabolic control in teens, there is a physiologic explanation

for the poorer metabolic control in these youth as well as for

the depression. Finally, controversy exists about the best

methods for measuring and studying depression. Better

definitions of depression and its symptoms and more

reliable methods to measure them need to be developed.

Interviews may be the most accurate for diagnosis of

depressive disorders, but they are not practical for large-

scale studies. Studies are needed that examine the optimal

timing of preventive interventions, such as coping skills

training provided at high-risk times such as diagnosis and

before 10 years of diabetes duration, and the impact of

interventions for diabetes on depression. In addition, inter-

vention studies examining the impact of treatment of

depression on metabolic control of youth with diabetes are

urgently needed.

DFBS—guidance/control 0.05 0.02

0.47 .65 –

R 2 =.28; adjusted R 2 =.24; F = 15.27; P < .001.

effects (6–8 weeks). Typically, such studies eliminate

youth with chronic conditions in the screening process.

Further, most studies of treatment examined drug treatment

compared to placebo, but comparisons of drug treatment

with and without family or behavioral treatment are also

needed. In addition, while there have been studies of the

impact of family interventions on youth with diabetes

[42,43], as well as on youth with depression, no studies

of the impact of family interventions on depression in

youth with diabetes were found. Insights into interventions

for families with difficulties may also be found in studying

resilient youth—those who face family conflict but who

escape depression and other psychosocial effects.

Summary

The comorbidity of diabetes and depression in children

and adolescents is a significant problem, affecting up to

20% of youth with diabetes compared to less than 7% of

youth without diabetes. Depression alone carries significant

potential for disability, but when combined with diabetes,

the comorbidity carries the potential for serious long-term

consequences; depression is associated with poorer meta-

bolic control, and thus, such youth may be more at risk for

long-term complications. Poor metabolic control in youth

with diabetes and depression may be associated with both

physiologic and behavioral factors, as depression may make

adherence to the diabetes care regimen more difficult and

hypersecretion of cortisol may impair response to insulin. It

is unclear whether diabetes may make adherence to inter-

ventions for depression more difficult. There is no question

that youth who are depressed have poorer psychosocial

outcomes and are more likely to have other psychiatric

disorders, such as adolescent adjustment disorders, eating

disorders and anxiety disorders. Finally, these youth may be

at high risk for suicide or suicidal ideation. Suicide and

severe eating disorders may lead to death. It is important to

note that family adjustment and support are critical corre-

lates of depression in youth with diabetes, suggesting that

family approaches, such as behavioral therapy for families,

may be effective in preventing or treating depression in

these youth.

On the basis of these few studies, we can conclude that

very little is known about depression in youth with diabetes.

More longitudinal studies are needed to more carefully

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