Depression and diabetes in children and adolescents Sunita M. Stewart a , Uma Rao a and Perrin White b Purpose of review Diabetes and depression are each public health concerns. They frequently co-occur, compounding complications of each disease. This review provides recent information regarding the mechanisms of association between the disorders and the availability and effectiveness of interventions for youth with diabetes who are depressed. Implications for primary care physicians are considered, particularly in relation to recognition of depression, and also to preventive strategies that increase the patient’s self-efficacy (evidence-based confidence in his/her ability to manage diabetes) and serve as protective factors in the development of depression. Recent findings Depressive symptoms are strongly associated with diabetes complications. To date, no studies have tested effectiveness of interventions with depressed youth with diabetes. Clinical trials with adults have shown the effectiveness of pharmacotherapy, but those with more complications show the least improvement, and health gains do not persist. In the absence of other data, these findings suggest that it would be prudent to identify and treat comorbid depression in children with diabetes early in the course of their illness, before medical complications develop. Summary Primary care physicians are in an important position to recognize early signs of depression in youth with diabetes and refer them for treatment. Furthermore, the literature provides numerous strategies that can be employed by primary care doctors that may enhance diabetes management as well as protect against depression. Keywords chronic illness, depression, diabetes, psychosocial function Curr Opin Pediatr 17:626—631. ª 2005 Lippincott Williams & Wilkins. a Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA; and b Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA Correspondence to Sunita M Stewart, PhD, Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-8589, USA Tel: 214 648 4304; fax: 214 648 4455; e-mail: sunita.stewart@utsouthwestern.edu Current Opinion in Pediatrics 2005, 17:626—631 Abbreviation HPA hypothalamic-pituitary-adrenal ª 2005 Lippincott Williams & Wilkins. 1040-8703 Introduction Diabetes and major depressive disorder are frequently comorbid, and in their combined condition, complications of each individual disease are exacerbated. This review fo- cuses on recent information regarding the association be- tween the disorders, and the availability and effectiveness of interventions for youth with diabetes who are de- pressed. Implications for primary care physicians, with regard to both detection and referral for treatment and preventive office-based interventions, is outlined. Diabetes and depression Diabetes mellitus and major depressive disorder are each associated with substantial morbidity, mortality, and health costs. Six percent of the population has diabetes, and over 200,000 of these patients are younger than 20 years [1]. Health care costs for both type 1 and type 2 diabetes and their complications are about $132 billion annually [1]. Depression also poses a significant public health problem. The World Health Organization has pre- dicted that by 2020, depression will be the second leading contributor to burden of disease, measured as disability adjusted life years (or the sum of years of potential life lost because of premature mortality and the years of produc- tive life lost because of disability), worldwide [2]. Twenty percent of people younger than 18 years in the United States have experienced at least one episode of depression [3]. Untreated pediatric depression is associated with substantial morbidity, including reduced academic per- formance, substance abuse, interpersonal problems, social withdrawal, poor quality of life, and increased risk of suicide [4]. Both types of diabetes are risk factors for the development of depression, and the presence of depression increases the likelihood of developing type 2 diabetes. Thus, these diseases are frequently comorbid. Recent reports [5,6] have shown an increased prevalence of eating disorders in youths with diabetes. Although there are factors related to diabetes, such as dietary focus, that may predispose to the development of eating disturbances [5], the increased incidence of eating disorders may also relate to the fact that depression is a risk factor for the development of eating pathology [7]. In children and adolescents with diabetes, the prevalence of depression is reported to be two-fold to three-fold higher than in nondiabetic youth [8], and additional psychiatric disorders are frequently present [9 • ]. The separate effects of diabetes and depression are exac- erbated in the comorbid state. Depressive episodes are 626