Over the past few weeks, Children's National Medical Center has noted an increased frequency of new diagnoses of Type 2 Diabetes in children. In previous blogs, I quoted numerous dire statistics about the increasing frequency of this diagnosis. According to the latest statistics compiled by the American Diabetes Association in 2007, about 2 million adolescents aged 12 to 19 have pre-diabetes. Accordingly, most childhood diabetes programs are starting to see increasing numbers of both children and adolescents with new onset type 2 diabetes. The adult diabetes literature has noted that there is an increased association of depression and diabetes. Some authors have noted that the diagnosis of depression may even precede the diagnosis of diabetes. Thus, it is reasonable to assume that the depression also will be associated with childhood type 2 diabetes.
In our Diabetes Spectrum (Volume 23, Number 1, pages 25-31, 2010) paper, "Screening and Identification of Children and Adolescents at Risk for Depression During a Diabetes Clinic Visit," published by Monaghan, Singh, Streisand and Cogen, we discuss the importance of screening for depression in the outpatient setting. We note "that among patients with T1 and T2DM, depression is one of the most commonly occurring co-morbid conditions, with estimates suggesting that 12 to 18 percent of children and adolescents with diabetes report clinically significant symptoms of depression." In addition, only one-half of all adolescents with depression are identified and diagnosed before adulthood.
A recent paper published by Block, Putzer, and Jaramillo (Children with Type 2 Diabetes Mellitus and the Prevalence of Psychiatric Disorders) published in the December 2010 Southern Medical Medical Journal (Volume 103, Issue 12-pages 1214-1218), attempted to determine the frequency of psychiatric illnesses in a group of children and adolescents with type 2 diabetes. The other objective was to determine if there were any significant demographic differences in those children with psychiatric disorders and those without. The study was retrospective in that they reviewed charts from two children's hospitals located in the southeast.
What were the results?
26.2 percent (67/256) of children/adolescents with diabetes were diagnosed with neuropsychiatric disorders (particularly depression). A statistical difference (p value=0.009) noted that boys with type 2 diabetes were affected with neuropsychiatric disorders to a greater extent than in girls. The authors note that this is the first paper to demonstrate psychiatric illness (particularly depression) in children and adolescents with T2DM.
Our Diabetes Spectrum paper emphasizes the importance of assembling all variables including stability of the diabetes, associated diseases and psychosocial functioning in children and adolescents with possible symptoms of depression. Because of the potential for similarities of symptoms associated with depression and the subsequent impact of depression on diabetes self-care, diabetes team health care providers are in the unique position to identify physiological and psychological symptoms that may indicate and increased risk of depression. It is essential to rule out a physiological etiology before assuming a child/adolescent suffers from depression.
The most recent American Diabetes Association guidelines for care of children and adolescents with type 1 diabetes recommend an annual depression screening for children less than or equal to 10 years of age (and above) as part of routine best practices. It is imperative for our diabetes care teams to conduct as thorough evaluation as possible due to the overlap of symptoms of illness masquerading as depression or visa versa. Assuming that a patient has an underlying neuropsychiatric illness may lead to missing a medical diagnosis by ignoring significant signs and symptoms. On the other hand, after diagnosing a medical diagnosis, the healthcare team should not assume there that there is no requirement for supportive psychotherapy.
Now that the evidenced-based literature notes increasing incidence of neuropsychiatric illness in children/adolescents with T2DM, routine screening will need to be incorporated in pediatric diabetes centers.
Take home messages for families and healthcare providers:
- Identify and evaluate possible underlying causes of symptoms. Many symptoms typically denoting depression also may be suggestive of other illnesses.
- Be observant to the multiple spheres of the lives of children and adolescents. Our diabetes team only spends a fraction of time with your children on a daily basis. Functioning in the other aspects of children and adolescent's lives often opens a window to rule out different diagnoses.
- Diabetes healthcare teams should try to routinely incorporate psychosocial screening measures to help assess for depression. Based on clinical measures, quick referrals need to be provided. Developing a list of resources should be a priority to facilitate treatment.
We need to be proactive in preventing and treating underlying psychosocial problems in childhood and adolescence to avoid progression into adulthood.
Published On: January 04, 2011