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PII: S0022-3999(02)00312-4
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
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
indicated. D 2002 Elsevier Science Inc. All rights reserved.
Keywords: Type 1 diabetes; Children; Adolescents; Depression
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
2002 Elsevier Science Inc. All rights reserved.
PII: S0022-3999(02)00312-4
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.
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
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
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
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.
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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