Commentary by Karen Soren, MD
Associate Professor of Pediatrics and Population and Family Health
Director, of Adolescent Medicine, Columbia University Medical Center
Management of type 1 diabetes is particularly challenging during adolescence, a time when teens are dealing with physical changes occurring with puberty, social pressures, and stress, among other issues. In addition, researchers from Columbia University have found that mental health issues including depression, anxiety, and disordered eating are common in teenagers and young adults with type 1 diabetes, and are linked to poorly controlled diabetes.
“I think it is critical for health care providers to screen all teens with chronic illnesses for anxiety and depression,” said senior author Karen Soren, MD, Associate Professor of Pediatrics and Population and Family Health, and Director, of Adolescent Medicine, at Columbia University Medical Center, in New York City. Teens “should be screened at least yearly—and probably also at times when their disease appears to be unexplainably out of control.
“The data reported in this relatively small pilot study mirror those in the literature, that youth and young adults with type 1 diabetes are at risk for mental health problems,” commented Margaret Grey, DrPH, RN, Dean & Annie Goodrich Professor, Yale University School of Nursing, New Haven, CT. “Several years ago, the American Diabetes Association recommended that all youth with type 1 diabetes be screened for depression once per year. [The study by Soren and colleagues] suggests that screening for anxiety and eating disorders should be considered, at least in the age group 11 years and older,” Dr. Grey said.
The cross-sectional study involved 150 patients age 11 to 25 years with type 1 diabetes from an urban, academic diabetes center. The participants completed the Beck’s Depression Inventory, the Screen for Child Anxiety Related Emotional Disorders-41, and the Eating Disorder Screen for Primary Care.
Mental health issues were common in this population with 11.3% of participants screening positive for depression, 21.3% for anxiety, and 20.7% for disordered eating. Nearly 15% had 2 or more positive screens.
The mean hemoglobin A1c (A1c) level in this group was 8.6, with 46% of participants having uncontrolled diabetes (ie, A1c level ≥8.5%). Other risk factors for uncontrolled diabetes included younger age at the time of the survey (odds ratio [OR], 0.90; P=0.017), younger age at the time of diabetes diagnosis (OR, 0.93; P=0.023), Latino/Hispanic ethnicity (OR, 2.96; P=0.002), Medicaid insurance (OR, 2.63; P=0.022), and taking less insulin than directed (OR, 8.50; P=0.001). After adjusting for age and insurance status, participants with at least 1 positive mental health screen had a twofold greater likelihood of poor diabetes control (OR, 2.16).
Tools for Depression Screening
“Any depression screen is useful,” said Dr. Soren. “We used the Columbia Depression Scale, but others use the Patient Health Questionnaire 9-item (PHQ-9). For anxiety, the Screen for Child Anxiety Related Emotional Disorders (SCARED) is available,” she said.
Next Steps For Teens With Depression and Type 1 Diabetes
“The first thing the physician should do is talk to the patient,” Dr. Soren said. “Sometimes, it is the diabetes physician who can understand the patient best and sympathize with the patient’s struggles. Referral to a mental health provider also is helpful and at times necessary,” she said.
When a depression screen is positive in this patient population, “the provider should first assess whether the adolescent or young adult is at serious risk for hurting themselves,” advised Dr. Grey. “If so, they should be taken to the psychiatric emergency department. If not, they should be referred to a qualified mental health professional who can assess the youth and determine if treatment is necessary,” Dr. Grey said.
For patients who report skipping doses, the next steps depend on how often they skip doses. “Almost all youth with diabetes take less insulin than they should once in a while,” Dr. Grey said. “If it is a rare occurrence, I would explore what leads to it and suggest alternative approaches. For example, girls will sometimes withhold insulin to lose weight. Helping them make healthier choices may be effective. If [skipped insulin doses] is a regular occurrence, the youth needs to see a mental health professional because of the risk of diabetes complications,” she said.
Counseling Patients on Disordered Eating
In patients with disordered eating or who skip insulin doses to lose weight, Dr. Soren advises health care providers to first sympathize with teens about the weight issue. “It is often very difficult for a teen who has gotten very thin when sick, to start putting on the pounds as the diabetes is treated. But thinness from untreated illness is a bad thinness, and it is important to point that out. Emphasize health and point out that teens feel much better when their sugars are normal. Also, have them work with a nutritionist in order to eat correctly, so that they do not gain unnecessary weight,” Dr. Soren said.
Bernstein CM, Stockwell MS, Gallagher MP, Rosenthal SL, Soren K. Mental health issues in adolescents and young adults with type 1 diabetes: prevalence and impact on glycemic control. Clin Pediatr. 2013;52(1):10-15.