Diabetes burdens the psyche.  Are children and adolescents with type 1 diabetes more often depressed than their peers? What effect does depression have, and how does one recognize it?

In recent years, many scientific articles have been published on the association between the incidence of type 2 diabetes and depression. Owners of the Diabetes Journal have certainly read about this several times.

Depression appears almost twice as much in adults with type 2 diabetes than in the general public. Those afflicted by both conditions are more likely to have poor metabolic control and to develop complications at an earlier stage. 

Depressive episodes in children with diabetes
What is the situation in children and adolescents with type 1 diabetes? Compared to those with type 2 diabetes, scientific data shows a more positive picture. The International Society for Paediatric Diabetes (ISPAD, www.ispad.org), as well as the recently published German Guidelines on Diagnosis, Therapy, and Management of Diabetes in Children and Adolescents (www.deutsche-diabetes-gesellschaft.de), have systematically examined the scientific data on depression in children and adolescents with type 1 diabetes.

According to these, severe (clinical) depression in children with diabetes does not occur more frequently than in children and adolescents generally. However, it has repeatedly been determined that mild depression and anxiety, especially in girls, does occur more often in those with diabetes.

On the other hand, there is insufficient representative data on the mental state of younger children with diabetes. Certain evaluations tend to show, however, no difference between younger children with or without diabetes. More conclusive studies need to be carried out before definite answers on the mental health of children with type 1 diabetes can be found.  

Manifestation of depression
Some typical signs of depression shortly after diagnosis in children and adolescents with diabetes, as well as their parents, can be observed. These are fully normal emotional reactions to a traumatic situation. Experts refer to this as an ‘adaptational phase’.

If this adaptational phase endures without improvement over several weeks, however, it can have an adverse effect on metabolic control, which can lead to acute complications such as severe ketoacidosis. Without proper treatment, this adaptational phase can turn into chronic depression and affect the whole family. 

Mental state of the mother
Several American long-term studies have shown that repeated depressive episodes in the mother have a detrimental effect on the metabolic control of their children with type 1 diabetes.

The experts are in general agreement that the mental state and psychological health of children with type 1 diabetes (and their parents) have a profound effect on their metabolic control.

Poor quality-of-life, subclinical or clinical depression or anxiety tends to correlate with a high HbA1c, a higher incidence of complications, and more frequent hospital admissions. This is why, in recent paediatric diabetic guidelines, it is recommended not only to monitor metabolic values, but also the mental condition of the children in question and their families. The earlier depression is recognized, the earlier and more effectively it can be treated.

Depression is more common than originally thought
Depression represents one of those conditions that appear quite often in children and adolescents. It is estimated that, in Western countries, one in every twenty youths up to the age of 18 experience at least one episode of clinical depression. Even very young children can suffer from depression, albeit rarely. The condition, however, tends to start at a later age. By the time the child becomes an adolescent, this figure rises quite drastically.

Until puberty, depression occurs at an equal rate between girls and boys. After puberty, girls seem to be afflicted by depression much more frequently. This has been shown in the KiGGS (Kinder- und Jugendgesunheits-Survey) with over 14 000 representatively selected children and adolescents across Germany. This survey showed considerable emotional problems in 11% of 11–13-year-olds.

Depression often goes unrecognized
Although the main symptoms are clear –  dark mood, apathy, lack of interest, lack of concentration, and sleep disorders –  it is not always easy to diagnose depression, even in adults. Reliable tests, obvious physical symptoms, or laboratory readings that clearly point to depression are not available. Diagnosis must result from a thorough anamnesis (dialogue with the doctor) about the symptoms and the course of the illness. In such cases, mild indications can easily be overlooked and the condition left untreated.

On the other hand, the severity of this condition must never be underestimated. Severe cases can lead to suicide attempts. Suicide is the commonest form of death, besides accidents, in young people. Many of these cases suffered from prior depression.

Symptoms vary according to age
It is more difficult to recognize depression in children than in adults. Typical indications are sadness, lethargy, listlessness, withdrawal, as well as feelings of anxiety, irritability, learning difficulties, aggression, or physical complaints such as headache and stomach ache. Many children have a sense of inferiority, worthlessness, and suffer from guilt feelings. Others sulk or develop fears from real or imaginary dangers.

Typical indications are the loss of friends, and a withdrawal into the virtual world of media, internet, and computer games. Other depressed youths, especially girls, become restless, cannot concentrate, and have sleep disorders. Also, a loss of appetite or addiction to sweets can indicate the presence of depression. Whichever the indication, it tends to depend on the developmental stage of the child. 

Signs and symptoms in the kindergarten
In many cases, kindergarten children tend to be more fearful and dread the parting from their parents more than normal. Their fears prevent them from exploring the world around them and asserting their independence, as is crucial at that age.

Depressed children of this age often have eating and sleeping disorders, and complain of stomach or headache. These children can sometimes recede in their development and start sucking their thumbs or to use pacifiers. Even already acquired speech, motoric, or cognitive skills can suddenly disappear.

Signs and symptoms in school children
Depressed school children tend to be down and listless, fearful and have a low self-esteem. Difficulties in concentration and lack of interest can have a detrimental effect on their marks. They find it hard to integrate with others their own age, which can lead to aggressive behaviour.

On the other hand, some kids are very restless and try to hide their depression by playing the clown. Such cases are more often accompanied by erratic eating disorders.

As children become older, their thoughts can turn to matters such as the meaning of life, sometimes resulting in suicidal thoughts.

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Professor Karin Lange, MD, Dip Psych
Director
Department of Clinical Psychology
Medical Institute
Hanover
E-Mail: Lange.Karin(at)MH-Hannover(dot)de