Comorbid depression and glycemic instability in adolescent type 1 diabetes: Clinical insights into suicide risk

Table 1 Multidimensional assessment indicators for suicide and self-harm risk

Dimension	High-risk indicators	Clinical pathological significance & mechanism
Metabolic	HbA1c persistently > 9.0% (75 mmol/mol)	Indicates chronic diabetes burnout or covert insulin omission; sustained hyperglycemic environment induces central neuroinflammation, impairing emotional regulation circuits
	Recurrent DKA (> 1 episode in the past year)	After excluding device failure and infection, highly suspect behavioral expression of “emotional dysregulation” or implicit suicide attempts. Each DKA episode intensifies cerebral hypoxia and inflammatory damage
	Frequent severe iatrogenic hypoglycemia	Screen for self-harm via insulin overdose or confusion in diet/insulin matching due to severe depression and cognitive decline
Psychobehavioral	Diagnosed with MDD or anxiety disorder	Depression increases suicide risk 3-6-fold; core symptoms of depression (e.g., avolition, hopelessness) directly undermine the willpower required to maintain complex self-management
	Eating disorders (ED-DMT1/diabulimia)	Insulin omission is the core symptom, carrying an extremely high lethality rate. This is not just an eating disorder but a chronic, devastating form of self-destruction
	History of NSSI (cutting, burning, etc.)	The strongest single predictor of suicide attempts; indicates the patient is habituated to using somatic pain to relieve mental anguish and has increased pain tolerance (acquired capability for suicide)
Social environment	High diabetes-specific family conflict	Parental overcontrol deprives adolescents of autonomy, whereas neglect leads to a lack of support. Both destroy the adolescent’s self-efficacy
	Bullying and social exclusion	Peer rejection due to public device wearing or insulin injection intensifies “disease shame” and social isolation, reflecting “thwarted belongingness” in the interpersonal theory of suicide

The content is adapted from the International Society for Pediatric and Adolescent Diabetes 2022 Guidelines[3,26] and Interpersonal Theory of Suicide[10]. HbA1c: Glycated hemoglobin; DKA: Diabetic ketoacidosis; MDD: Major depressive disorder; NSSI: Non-suicidal self-injury.

Table 2 Differential diagnosis of diabetes stress and clinical depression

Feature	DD	MDD
Core trigger	Directly related to diabetes management, fear of complications, doctor-patient relationship	No specific trigger or related to broad life stress events or genetic susceptibility
Symptom scope	Confined to diabetes-related contexts; patient may function well in non-diabetes areas	Pervasive; affects all areas of life (academics, social, hobbies, sleep, appetite)
Core experience	Feeling overwhelmed by disease, powerlessness, anxiety/avoidance of glucose data, and treatment burnout	Anhedonia, low self-worth, pervasive sadness, guilt, and thoughts of death
Diagnostic tools	PAID-T, T1-DDS	PHQ-9, Children’s Depression Inventory, and Beck Depression Inventory
Relation to HbA1c	Strong independent correlation; higher DD usually correlates with worse HbA1c	Weaker correlation; often affects HbA1c indirectly via DD as a mediator or appetite changes
First-line intervention	Diabetes education, self-efficacy-enhancing behavioral intervention, peer support, and resolving specific management barriers	Psychotherapy (CBT/IPT), psychopharmacology (SSRIs)

The content is based on the American Diabetes Association Position Statement[8] and the International Society for Pediatric and Adolescent Diabetes Psychological Care Guidelines[26]. DD: Diabetes stress; MDD: Major depressive disorder; PAID-T: Problem Areas in Diabetes-Teen; T1-DDS: T1 Diabetes Distress Scale; PHQ-9: Patient Health Questionnaire 9; HbA1c: Glycated hemoglobin; CBT: Cognitive behavioural therapy; IPT: Interpersonal therapy; NSSI: Non-suicidal self-injury.

Table 3 Stepwise intervention protocol based on risk stratification

Risk level	Clinical features	Recommended intervention strategy
Level 1 (low risk)	Good glycemic control (HbA1c < 7.5%), PHQ-9 < 5, occasional mild diabetes distress, and good family support	Basic support & prevention: Provide routine diabetes education emphasizing mental health importance; encourage participation in diabetes camps or peer support groups to enhance belonging; maintain quarterly routine psychological screening
Level 2 (moderate risk)	HbA1c 7.5%-9.0%, moderate diabetes distress, PHQ-9 indicates mild depression, no suicidal ideation, fluctuating compliance	Targeted intervention: Introduce a psychology nurse specialist or social worker for brief intervention; focus on resolving specific diabetes distress sources (e.g., needle phobia, social embarrassment); consider introducing CGM to reduce management burden but monitor anxiety levels; family sessions to resolve minor conflicts
Level 3 (high risk)	HbA1c > 9.0%, diagnosed with MDD or anxiety disorder, presence of NSSI behavior or eating disorder tendency, and distinct family conflict	Multidisciplinary team intervention: Establish joint rounds with endocrinology + psychiatry + nutrition; initiate CBT (for depression) or DBT (for self-harm) psychotherapy; cautiously initiate SSRI pharmacotherapy; recommend parents partially take over glycemic management responsibility to relieve adolescent burden
Level 4 (extremely high risk)	Recent suicide attempt, recurrent DKA admissions, severe insulin omission, specific suicide plan, and extreme hopelessness	Crisis intervention & hospitalization: Immediate hospitalization (endocrinology ward with enhanced monitoring or psychiatry closed ward); complete takeover of glycemic management responsibility, depriving the patient of independent access to insulin; strict means restriction; initiate family-based therapy to rebuild the family support system and resolve core conflicts

Developed according to the International Society for Pediatric and Adolescent Diabetes Stepwise Care Framework[26,33]. HbA1c: Glycated hemoglobin; PHQ-9: Patient Health Questionnaire 9; CGM: Continuous glucose monitoring; MDD: Major depressive disorder; NSSI: Non-suicidal self-injury; CBT: Cognitive behavioural therapy; DBT: Dialectical behaviour therapy; SSRI: Selective serotonin reuptake inhibitor; DKA: Diabetic ketoacidosis.