Self-Injury and Suicide 'All Too Common' in Type 1 Diabetes

Depression, self-harm, and suicide among people with type 1 and type 2 diabetes are "underappreciated" among healthcare practitioners, according to Katharine Barnard-Kelly, PhD, who founded the Reducing Suicide Rates Among Individuals With Diabetes (RESCUE) advocacy group in 2021.

"We have the most advanced technology to achieve glycemic control, but the mental burden remains underappreciated," she said at a symposium with other speakers from RESCUE during the American Diabetes Association (ADA) 82nd Scientific Sessions in New Orleans.

Notably, suicide and self-harm are "all too common" among young adults with type 1 diabetes who are receiving insulin, said Barnard-Kelly, a psychologist and visiting professor at Southern Health NHS Foundation Trust, Southampton, United Kingdom. And insulin under- or overdosing is the most common method of self-harm.

However, "with a multipronged approach to awareness, education, and identification, we have the opportunity to intervene on the link between suicide and diabetes," she said, noting that the aim is to "raise awareness and arm [doctors and others] with messages that can ultimately save a young person's life if adopted in clinical practice and through mental health screenings."

The rationale behind the RESCUE initiative is also described in a brief report published in Diabetes Technology & Therapeutics.

Six Key Messages

RESCUE now has "approximately 30 members across academia, clinical practice, industry, advocacy, government, regulatory bodies [including the US Food and Drug Administration], and people with diabetes from several countries," Barnard-Kelly told Medscape Medical News.

She identified six key messages from the symposium:

"Suicide prevalence is considerably higher among people with diabetes than the general population.
Talking about suicide does not increase an individual's risk of suicide.
Current screening tools for depression and suicide are not sufficiently sensitive to be effective among people with diabetes.
Identification of suicidal acts among people with diabetes is extremely difficult.
For every suicide, the World Health Organization reports there are 20 suicide attempts.
Healthcare providers often underestimate the prevalence of suicidality among their patient population and feel ill-equipped to initiate conversations with their patients about suicide."

Barnard-Kelly also presented some sobering statistics that highlight the need for increased awareness.

A study reported that, of 160 cases of insulin overdose, 90% were suicides.

Adolescents and young adults with type 2 diabetes are 61% more likely to report suicidal thoughts than those without diabetes.

The risk of depression is two- to three-times higher in people with diabetes. And 7% of deaths in individuals with type 1 diabetes are estimated to be from suicide, according to another study.

Survey About Screening for Depression, Suicide Risk in Diabetes

During the symposium, Daniel R. Chernavvsky, MD, reported results from a small online survey of healthcare professionals who treat patients with type 1 or type 2 diabetes, which identified their concerns about screening for depression and assessing suicide risk in patients with diabetes.

Respondents were mainly from the United States (103), but were also from the United Kingdom (18), Slovenia, and the Netherlands (5), said Chernavvsky, who is senior director of medical affairs at Dexcom in Charlottesville, Virginia.

They included 59 doctors, 21 nurses,17 diabetes educators, 15 psychologists, seven dieticians, four social workers, and six "other" healthcare professionals, with a mean age of 46 (range, 25-72 years old) who had been working on average 14 years (range, 0.5-45 years).

Close to three quarters (72%) reported that at least one of their patients had attempted suicide. The most common self-harm behaviors in their patients were insulin omission or a too large insulin bolus, and less often, binge eating.

Almost all respondents (95%) believed that routine visits to the diabetes clinic were appropriate times to discuss depression, self-injury, and suicidal ideation — at every visit (42% of respondents) or some visits (52%).

Only 30% were comfortable asking patients about self-harm or suicide.

Psychologists and social workers were very comfortable, but others were less comfortable or not comfortable at all.

Many respondents expressed concerns such as, "What do I do?" "Would I make the problem worse?" "Would I give the patient the idea?" Some reported they had "limited resources" or it "feels invasive."

They identified a need for "a better understanding of what [they could] do to support and care for patients," and "more knowledge about how to deal with [patients'] answers" to screening questionnaires.

Screening for Psychological Morbidities in Diabetes

Guidelines from the ADA and the International Society for Pediatric and Adolescent Diabetes recommend routine screening of patients with diabetes for psychological morbidities, including depression, said Shideh Majidi, MD.

Depression is associated with higher A1c, noted Majidi, who is associate director, childhood and adolescent diabetes program at Children's National Hospital, Washington, DC.

She identified the following topics that need to be addressed when considering implementing a program for depression screening and suicide risk assessment in a diabetes clinic:

Conducting screening: Which screening questionnaire will you use? Who will do it? Where? How often?

Scoring screening questionnaires: Who will do it?
Depression screening discussion: Who will do it? How will the person be notified of the score?
Suicide risk assessment: Who will conduct it? What is the process to get someone to the emergency department?
Resources/referral: Who will initiate and follow-up?

Next Steps

The RESCUE advocacy group is preparing educational and support materials for healthcare professionals who treat patients with diabetes as well as other materials for patients themselves.

ADA 2022 Scientific Sessions. Presented on June 3, 2022.

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