Depressive Symptoms Undertreated in Youth With Diabetes

Veronica Hackethal, MD

October 19, 2015

Children and adolescents with type 1 and type 2 diabetes experience different rates of depression, but few receive help or treatment regardless of the type of diabetes, according to a new Pediatric Diabetes Consortium (PDC) study published online October 12 in Diabetes Care.

The results suggest the need for routine depression screening in youth with type 1 and 2 diabetes, say Janet Silverstein, MD, of the Jaeb Center for Health Research in Tampa, Florida, and colleagues in their article.

"[In our study], youth with type 2 diabetes had almost twice the prevalence of depressive symptoms as youth with type 1 diabetes," Dr Silverstein said.

Of youth with type 1 diabetes, 13% reported symptoms of depression, compared with 22% of those with type 2 diabetes, she pointed out.

Very few received treatment for their symptoms. Only 4% of those with type 1 diabetes who reported depressive symptoms had received treatment from a therapist in the last year, compared with 9% of youth with type 2 diabetes.

"It is important to routinely screen for depression at clinic visits as guidelines currently recommend," Dr Silverstein added. "Despite this recommendation, screening for depressive symptoms in both type 1 and type 2 diabetes is infrequently done, resulting in a lack of timely referral for psychological intervention."

Online screening tools that facilitate screening could improve the situation, she stressed.

Asked to comment, Jean Lawrence, ScD, MPH, a research scientist and epidemiologist at Kaiser Permanente Southern California, in Pasadena, who was not involved in the study, said, "The findings suggest that only a small proportion of youth with elevated [depression] scores have been diagnosed with mental-health issues," a result, she notes, that is "not surprising."

Dr Lawrence is a principal investigator for the SEARCH for Diabetes in Youth study, which is looking at socioeconomic and other factors that affect youth with diabetes.

"As noted by [the study authors], depression screening for youth with diabetes is not a standard part of routine care ... at present," Dr Lawrence explained. "In the absence of routine screening, it is likely only youth who showed significant signs of depression were screened and diagnosed with depression."

Depression Twice as Likely in Type 2 Diabetes

Youth with diabetes tend to have higher rates of major depressive disorder, subclinical depression, and depressive symptoms compared with similar-aged kids without diabetes.

Depressive symptoms, though, are not always clinically apparent. Moreover, some studies have linked depression to poor adherence to diabetes therapies and poor glycemic control, which makes screening a vitally important issue, according to Dr Silverstein.

The PDC consists of eight academic pediatric treatment centers in the US. For the study, participants were enrolled from their new-onset type 1 diabetes registry who had received care at a PDC center within 3 months of diagnosis. They also enrolled participants from the PDC type 2 diabetes registry, who had been diagnosed according to the American Diabetes Association criteria.

Researchers used the short 12-question version of the Children's Depression Inventory 2 (CDI 2) self-report questionnaire to screen 261 youth with type 1 diabetes and 339 youth with type 2 diabetes aged 10 to 17 years. The CDI 2 has been validated in youth up to age 17 years and is convenient because patients can complete it quickly and easily online using a tablet in the office, Dr Silverstein pointed out.

Results showed that significantly more youth with type 2 diabetes reported depressive symptoms compared with youth with type 1 diabetes (22% vs 13%; P = .007).

In both groups, depressive symptoms were not linked with age, diabetes duration, sex, race/ethnicity, or parent education.

In youth with type 1 diabetes, but not those with type 2 diabetes, lower family income (unadjusted P = .006) and being obese (unadjusted P =.002) were associated with depressive symptoms.

Therapy More Frequent in Those With Type 2 Diabetes

Of youth with depressive symptoms, just 4% with type 1 diabetes and 9% with type 2 diabetes had seen a therapist in the past year.

"It is difficult to explain why a higher percentage of patients with type 2 diabetes received therapy compared with type 1 diabetes," Dr Silverstein said, but it could be related to bullying, social stigmatism, and feelings of isolation that youth with type 2 diabetes often experience.

"Perhaps the combination of the social issues associated with obesity accompanied by the burden of dealing with a difficult chronic disease result in more overt depression and earlier referral," she suggested.

And though the study did not directly look at the issue of transition in adolescents — the period when they switch from pediatric to adult care and take on responsibility for managing their own disease — it can be fraught with difficulty and may exacerbate existing problems with depression, noted Dr Silverstein.

"In general, we don't do a very good job with transition in adolescents with diabetes. In many instances, the diabetes team provides a support system for youth, resulting in a feeling of abandonment when transition occurs," she explained.

"Transition to a new team can result in a real sense of loss and contribute to worsening of depressive symptoms, unless done in a way…[that] is gradual and done with pediatric and adult teams working together," she concluded.

One or more authors have reported consulting and/or grants from one or more of the following companies: Eli Lilly, Novo Nordisk, VeroScience, AstraZeneca, Boehringer Ingelheim, Takeda, and Janssen. Dr Lawrence has reported no relevant financial relationships.

Diabetes Care. Published online October 12, 2015. Abstract

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