Part one of this series was dedicated to general disturbances and symptoms in children with diabetes. Part two focuses on adolescents in whom depression, caused by transitional processes in the brain, occurs frequently. Psychotherapy or medication, among other things, can be of help. 

Many of the typical symptoms of depression such as mood swings, irritability, withdrawal, apathy, and dejection, will present themselves in nearly all people at some time or other during adolescence.

Brain Undergoes Transition
‘Emotional fragility’ is caused by typical transitional processes that occur in the brain during puberty. Mood swings are caused by chemical changes in neurotransmission. Imbalances in cerebral metabolism are also recognized as causing the high incidence of depressive disturbances in puberty. As adolescents tend to withdraw from their parents and, for fear of appearing weak, show unwillingness to accept any help, depression is too often overlooked and left untreated.

Some youths attempt self-help by turning to psychoactive substances such as nicotine (calms and enhances concentration). Sometimes alcohol and illegal drugs such as amphetamines, cannabis and cocaine are used to improve mood, leading very quickly to addiction.

Physical symptoms in adolescence include headaches, eating disorders, and insomnia. As the lifestyle of many teenagers tends to be spontaneous and irregular, symptoms of depression are often difficult to separate from symptoms of other mental disturbances. The dominant psychological symptoms in adolescents are low self-esteem, dejection, and feelings of hopelessness.   

Be Careful in the Case of Diabetes
If an adolescent neglects his/her diabetes management to the point of experiencing severe ketoacidosis, parents need to sensitively judge whether the youth is genuinely over-challenged, or is tending to suicide.
Depressive adolescents with diabetes are particularly vulnerable when caregivers only focus on the success of insulin therapy.

Causes of Depression
Whether mild or severe, the cause of depression has not yet been conclusively agreed upon. Current scientific opinion, such as the Stress Diathesis Model of Nemeroff (1998), proposes that depression may result from the interplay between genetic predisposition and early adverse life events.

Adverse life events  
Family life and experiences have a profound effect of children. Pressure to perform, neglect, experiences of helplessness and vulnerability, violence, divorce or death of a parent, being bullied at school, poverty, and sexual abuse are all potential triggers for depressive illnesses. These things alone are not necessarily decisive, but how the child can learn to cope with these sorts of crises or seek help. 

Some researchers are convinced that the stress a child experiences as a result of neglect, violence or other traumas can trigger an over-reactions in those areas of the brain later in life, setting the stage for depression.

Children with diabetes who connect their disease with, for instance, rejection or parental disappointment or who, despite much effort, fail to achieve their therapeutic goals, or even feel responsible for the break up of their parents’ marriage, are particularly at risk.  

The burden of diabetes
Many adolescents with type 1 diabetes feel overwhelmed by the therapeutical expectations and, therefore, experience many downfalls. Hence, they often refuse to carry out blood sugar protocols—not because of the work it involves but fear of failure and the need to justify every negative reading that may appear. This feeling of inadequacy is coined by the psychologists as ‘learned helplessness’. Learned helplessness not only applies to young people but also parents with too high expectations. This, combined with lack of sleep due to nightly blood sugar checking, paves the way towards depression.

Seeking Help when Symptoms Appear
If parents should suspect depression in their youngster, the diabetes team should be consulted. Competent help can be sought at family counselling, or from a paediatric psychiatrist or psychotherapist. Many diabetes teams include a paediatric psychiatrist. Depression is a serious condition that should be treated early on. This also applies to mothers who carry much of the psychological and physical burden of having a child with diabetes.

Parents with depression are no longer adequately able to cater to the emotional needs of their children, putting them also at risk, if left untreated. If treated promptly, negative effects on the psychological and academic development can be minimized. Do not trivialize the condition. Take the feelings of your child seriously, and seek help.

N.B: Don’t ever feel that depression in your child is a reflection on you as a parent. It is simply a condition that requires treatment.

Tailored Therapy
As for diabetes, therapy for depression must be tailored to the individual. Each treatment has a different effect on different people. However, nearly all children and adolescents can be treated at the doctor’s. Only in severe cases, whereby the child is at risk of harming himself, may hospital admission be necessary.

Therapy takes age, developmental stage, family situation, and school environment into consideration. Parents usually take part in the treatment. Basically, there are two therapeutical approaches: 1) psychotherapy and 2) medication. Whichever approach is taken depends on the severity of the illness. A combination of the two is also possible.   

Psychotherapy
Scientific studies have shown psychotherapy to be very effective in adults, especially cognitive behavioural therapy (CBT). Similar methods are also used for children and adolescents. Family counselling and psychodynamic psychotherapy are also available. Medical insurance covers the costs of these sessions when carried out by a qualified practitioner or paediatric psychiatrist.

What psychotherapy may include

• Age-based information for both children and their parents on depression and its causes
• Help in easing relations between parents and child
• Physical activity for animation
• Reinforcement of positive experiences
• New ways of thinking and problem solving strategies
• Ways to overcoming anxiety
• Building up confidence
• Re-evaluation of failure, accentuation of the positive, raising self-esteem, and improving self-image.

Diabetes-specific topics:

• Effect of chronically high or low readings on mood and ability to concentrate
• Fear reduction for hypoglycaemia and complications
• Coping with therapeutical disappointments
• Putting therapeutical targets into perspective
• Managing blood sugar monitoring within the family
• Maintenance of self-confidence when blood sugar swings

Medication
Depending on severity, depression can also be treated with medication. However, not many studies have been done on its effectiveness in children and adolescents.

Medications from the so-called selective serotonin re-uptake inhibitor (SSRI) group are preferred due to their high efficacy and few side effects. SSRIs are also the preferred choice for adults with diabetes, as they don’t seem to adversely influence metabolism or insulin effect. Studies to this effect in children and adolescents are still pending.

SSRIs inhibit the re-uptake of the compound serotonin, helping to maintain a better mood. It takes, however, a couple of weeks until the effect kicks in. They are not ‘happy’ pills, that is, they don’t trigger euphoria but, rather, represent a solid, long-term therapeutical option.

Similarly, psychotherapy does not offer a ‘quick remedy’ either. Depression, which has often evolved over a long period of time, has no ‘instant’ cure. Over time, however, it can succeed in overcoming this illness, enabling the sufferer to live a normal and balanced life. 

Summary
During puberty, the brain undergoes many changes which can adversely affect mood. Hence, nearly all adolescents experience ups and downs and withdraw from the world at some time or other. Nevertheless, parents should be aware that diabetes can enhance the risk of the child sliding into depression.
Whoever suffers from depression needs to undergo tailored therapy. Psychotherapy and medication have proven themselves to be the two best approaches.

Parents of children with diabetes are also susceptible to succumbing to depression. 

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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