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Cited by 210Diabetes Management and ResearchDiabetes Management and EducationDiabetes and associated disorders

Risks of psychiatric disorders and suicide attempts in children and adolescents with type 1 diabetes: a population-based cohort study

Open access
Butwicka, Agnieszka, Frisén, Louise, Almqvist, Catarina, Zethelius, Björn, Lichtenstein, Paul·2015·Diabetes Care
DOI 10.2337/dc14-0262PMC PMC4338504
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Abstract

OBJECTIVE: To assess the risk of psychiatric disorders and suicide attempts in children with type 1 diabetes and their healthy siblings. RESEARCH DESIGN AND METHODS: We performed a population-based case-cohort study of individuals born in Sweden between 1973 and 2009. Children with type 1 diabetes (n = 17,122) and their healthy siblings (n = 18,847) were identified and followed until their 18th birthday. Their risk of psychiatric disorders was compared with that of matched control subjects. RESULTS: The risk of psychiatric morbidity in children with type 1 diabetes compared with the general population was tripled within 6 months after the onset of diabetes (hazard ratio [HR] 3.0 [95% CI 2.7-3.4]) and doubled within the total observation period (HR 2.1 [95% CI 2.0-2.2]). An increased risk was noted in suicide attempts (HR 1.7 [95% CI 1.4-2.0]) and in most categories of psychiatric disorders. The risk of psychiatric disorders in probands declined from HR 2.7 (95% CI 2.2-3.3) for those in the cohort born 1973-1986 to 1.9 (95% CI 1.8-2.0) in those born 1997-2009. The risk for any psychiatric disorders among siblings of patients with type 1 diabetes was estimated to be HR 1.1 (95% CI 1.0-1.1), and there was no increased risk in any of the specific category of disorders. CONCLUSIONS: Children with type 1 diabetes are at high risk of psychiatric disorders, which seems to be a consequence of the disease rather than due to a common familial etiology. The results support recommendations on comprehensive mental health surveillance in children with type 1 diabetes, especially in recently diagnosed children.

Integrity signals

Registry

Crossref · 10.2337/dc14-0262

Cites

30 of 30 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 28 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    The adjusted risk for suicide attempts among healthy full siblings of a patient with type 1 diabetes was HR 1.2 (95% CI 1.0-1.4; P = 0.12).

    “for suicide attempts, the HR was 1.2 (95% CI 1.0–1.4; P = 0.12).”
    Quote in the paperNot a substantial claim
  • Findingown data

    The risk of any psychiatric disorder among siblings of patients with type 1 diabetes was HR 1.1 (95% CI 1.0-1.1).

    “The risk for any psychiatric disorders among siblings of patients with type 1 diabetes was estimated to be HR 1.1 (95% CI 1.0–1.1)”
    • Also stated in: § Siblings of Patients With Type 1 Diabetes · hedged
      “The adjusted risk for childhood psychiatric disorders among healthy full siblings of a patient with type 1 diabetes was estimated at HR 1.1 (95% CI 1.0–1.1)”
    Quote in the paperNot a substantial claim
  • Findingown data

    When analyses were conducted separately for different categories of psychiatric disorders, none of the categories were statistically significant.

    “When analyses were conducted separately for different categories of psychiatric disorders, none of the categories were statistically significant (Table 4).”
    Quote in the paperNot a substantial claim
  • Findingown data

    The overall prevalence of psychiatric disorders in probands was 11.4% (95% CI 10.8-12.0) in the 10 years after onset of type 1 diabetes.

    “The overall prevalence of psychiatric disorders in probands was 11.4% (95% CI 10.8–12.0) in 10 years after the onset of type 1 diabetes in the entire sample.”
    Quote in the paperNot a substantial claim
  • Findingown data

    A similar increasing trend in 10-year prevalence of psychiatric disorders was observed in healthy control subjects: 1.5 (95% CI 1.5-1.6), 3.1 (95% CI 3.0-3.1), and 8.7 (95% CI 8.7-8.8) for ICD-8, ICD-9, and ICD-10, respectively.

    “A similar trend was observed in the healthy control subjects, where the 10-year prevalence of psychiatric disorders was 1.5 (95% CI 1.5–1.6), 3.1 (95% CI 3.0–3.1), and 8.7 (95% CI 8.7–8.8), respectively, for ICD-8, ICD-9, and ICD-10.”
    Quote in the paperSubstantial claim
  • May combine two claims. 14
  • The quote only partly states this claim. 1
  • Classified as probably not a substantial claim. 11

  • May combine two claims.

    Findingown data

    In total, psychiatric disorders were recognized in 1,428 (8.3%) probands, of whom 259 had more than one disorder.

    “In total, psychiatric disorders were recognized in 1,428 (8.3%) probands, of whom 259 had more than one disorder.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Psychiatric disorders were observed in 1,059 (5.6%) siblings of probands, and 191 of these children received two or more psychiatric diagnoses.

    “Psychiatric disorders were observed in 1,059 (5.6%) siblings of probands, and 191 of these children received two or more psychiatric diagnoses.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Probands had increased risk for mood, anxiety, eating, substance misuse, ADHD, behavioral, autism, and intellectual disability compared with healthy peers, with hazard ratios ranging from 1.5 to 2.6.

    “Probands had an increased risk for mood disorders (hazard ratio [HR] 2.0 [95% CI 1.8–2.3]), anxiety disorders (HR 1.6 [95% CI 1.4–2.0]), eating disorders (HR 2.2 [95% CI 1.8–2.6]), substance misuse (HR 2.6 [95% CI 2.4–2.9]), attention-deficit hyperactivity disorder (HR 1.5 [95% CI 1.3–2.7]), behavioral disorders (HR 2.2 [95% CI 2.0–2.4]), autism spectrum disorder (HR 1.7 [95% CI 1.4–2.0]), and int”
    Quote in the paperSubstantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    The highest risk of psychiatric disorder in all age groups was within the first 6 months after diagnosis and declined with time.

    “The highest risk of psychiatric disorder in all age-groups was noted within the first 6 months after diagnosis of type 1 diabetes and declined with time (Table 2).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Increased risk of suicide attempts was significant only for diagnoses from inpatient care (HR 1.8, 95% CI 1.5-2.2), not for outpatient care (HR 1.4, 95% CI 1.0-2.0; P = 0.07).

    “Increased risk of suicidal attempts was significant only for diagnoses from inpatient care (HR 1.8 [95% CI 1.5–2.2])—not for outpatient care (HR 1.4 [95% CI 1.0–2.0]; P = 0.07).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The 10-year prevalence of psychiatric disorders in probands was 4.6% (95% CI 3.7-5.7) in the 1973-1986 cohort, 8.4% (95% CI 7.5-9.4) in 1987-1996, and 15.3% (95% CI 14.4-16.3) in 1997-2009.

    “The prevalence was lowest in the cohort with onset of type 1 diabetes in 1973–1986 (4.6% [95% CI 3.7–5.7]), when psychiatric diagnoses were based on the ICD-8 classification. The prevalence of psychiatric disorders doubled in 1987–1996 with ICD-9 (8.4% [95% CI 7.5–9.4]). Introduction of ICD-10 resulted in further increase in prevalence of psychiatric disorders (15.3% [95% CI 14.4–16.3]) in 1997–”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Probands were more often born moderate to late preterm (32-36 gestational age), with high birth weight (>3,500 g), and large for gestational age.

    “Probands seemed to more often be born moderate to late preterm (32–36 gestational age), with high birth weight (>3,500 g) and large for gestational age.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Large epidemiological studies have shown increased risks of psychiatric disorders in other chronic pediatric diseases.

    “Also, large epidemiological studies have shown increased risks of psychiatric disorders in other chronic pediatric diseases (5,6)”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [5] Feldman, 2006, Comorbidity between asthma attacks and internalizing disorders among Puerto Rican children at one-year follow-up, Psychosomatics source

      Not checked in the free run.

    • cites [6] Hesdorffer, 2012, Epilepsy, suicidality, and psychiatric disorders: a bidirectional association, Ann Neurol source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Children with type 1 diabetes are at high risk of psychiatric disorders, and this association appears to be a consequence of the disease rather than due to a common familial etiology.

    “Children with type 1 diabetes are at high risk of psychiatric disorders, which seems to be a consequence of the disease rather than due to a common familial etiology.”
    • Also stated in: § Implications · hedged
      “These results suggest that associations between type 1 diabetes and psychiatric disorders are due to biological and/or psychological effects of diabetes (i.e., consistent with a causal effect) rather than common genetic risk factors or within family environmental factors.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: If shared familial or genetic factors caused the association between type 1 diabetes and psychiatric disorders, healthy siblings of patients with type 1 diabetes would have a higher risk of psychiatric disorders.

  • May combine two claims.

    Study design and conductown data

    In 403 (2.4%) probands, psychiatric disorders were recognized before the onset of type 1 diabetes, significantly more often than among control subjects the same age (2.0%).

    “In 403 (2.4%) probands, psychiatric disorders were recognized before the onset of type 1 diabetes—significantly more often than among control subjects the same age (N = 33,928 [2.0%]).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Parents of probands were more likely to be over 35 years of age at the child's birth, have Scandinavian origin, and have an upper secondary level of education compared with parents of controls.

    “Parents of probands were more likely to be over 35 years of age at the time of child’s birth, have Scandinavian origin, and have an upper secondary level of education compared with the parents of their peers.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    For every patient with childhood-onset type 1 diabetes, 100 control subjects were randomly selected from the Total Population Register and matched by sex, year, and county of birth.

    “For every patient with childhood-onset type 1 diabetes, we randomly selected 100 control subjects (unexposed individuals) from the Total Population Register. Probands and unexposed individuals were matched by sex, year, and county of birth.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    A robust sandwich estimator was used to adjust for family clusters in the sibling analyses.

    “A robust sandwich estimator function was used to adjust for family clusters.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    Subsequent analyses were adjusted for sociodemographic and perinatal covariates because of baseline differences between groups not fully controlled by matching.

    “Because of baseline differences between groups, not fully controlled by matching, subsequent analyses were additionally adjusted for covariates.”
    • Also stated in: § Baseline Characteristics · plain
      “Subsequent analyses were adjusted to those discrepancies between groups.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductcitation

    The Swedish National Patient Register contains data on somatic and psychiatric inpatient care since 1973 and outpatient care since 2001.

    “The NPR contains data on somatic and psychiatric inpatient health care since 1973 and outpatient care since 2001 (15).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [15] Ludvigsson, 2011, External review and validation of the Swedish national inpatient register, BMC Public Health source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Noncompliance and persistent high level of glycated hemoglobin in type 1 diabetes is a risk factor for psychiatric comorbidity and neurodevelopmental problems.

    “Noncompliance and persistent high level of glycated hemoglobin in type 1 diabetes is a risk factor for psychiatric comorbidity and neurodevelopmental problems (28,30,31).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [28] Nylander, 2013, Children and adolescents with type 1 diabetes and high HbA1c -- a neurodevelopmental perspective, Acta Paediatr source

      Not checked in the free run.

    • cites [30] Butwicka, 2011, Sweet sins: frequency and psychiatric motivation for theft among adolescents with type 1 diabetes, Pediatr Diabetes source

      Not checked in the free run.

    • cites [31] Board of Health and Welfare. National guidelines for diabetes care [article online]. Available from http://www.socialstyrelsen.se/nationellariktlinjerfordiabetesvarden. Accessed 29 June 2013

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Changes in diabetes care such as more demanding insulin regimens and higher responsibility of youths and caregivers could theoretically explain increased psychological burden, but similar trends among control subjects suggest more general factors are responsible.

    “Changes in diabetes care such as more demanding insulin regimens and higher responsibility of youths and their caregivers for treatment decisions could theoretically be an explanation for the increased psychological burden in patients with type 1 diabetes in recent years. But similar trends among control subjects suggest that more general factors are responsible for the increased rates of psy”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A recent study by Cameron et al. demonstrated that impaired mental state in children with new-onset type 1 diabetes may be attributed to brain injury related to severe ketoacidosis.

    “A recent study by Cameron at al. (29) demonstrated that impaired mental state in children with new-onset type 1 diabetes may be attributed to the brain injury related to severe ketoacidosis.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] Cameron, 2014, Neurological consequences of diabetic ketoacidosis at initial presentation of type 1 diabetes in a prospective cohort study of children, Diabetes Care source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The study had strengths including large-scale population-based design, prospectively collected data from nationwide registries, control for several possible confounders, follow-up up to adulthood, definitions of outcome as diagnosed disorders justifying clinical intervention, and analysis of genetically informed sibling data.

    “Strengths of our study include a large-scale population-based design, prospectively collected data from nationwide registries, control for several possible confounders, follow-up period up to adulthood, definitions of outcome as diagnosed disorders justifying clinical intervention, and analysis of genetically informed data on siblings.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Kovacs et al. found that 47.6% from the cohort diagnosed with type 1 diabetes between 1981 and 1984 developed psychiatric disorders.

    “The 10-year prevalence was studied previously by Kovacs et al. (3), who found that 47.6% from the cohort diagnosed with type 1 diabetes between 1981 and 1984 developed psychiatric disorders.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [3] Kovacs, 1997, Psychiatric disorders in youths with IDDM: rates and risk factors, Diabetes Care source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Study design and conductreasoning

    Diagnostic bias from diabetologists noticing symptoms and initiating referral could account for higher rates of psychiatric disorders in children with type 1 diabetes.

    “Furthermore, one may argue that diabetologists could notice symptoms that otherwise would not have been recognized and initiated referral to mental health services, and this diagnostic bias could account for higher rates of psychiatric disorders in children with type 1 diabetes.”
    Quote in the paperNot a substantial claim
21 of 21

  • The authors state this as an assumption.

    Associations between other chronic pediatric diseases and psychiatric disorders may also be present for type 1 diabetes.

    “Also, large epidemiological studies have shown increased risks of psychiatric disorders in other chronic pediatric diseases (5,6), and it is reasonable to assume that such associations may also be present for type 1 diabetes.”

  • The authors state this as an assumption.

    If shared familial or genetic factors caused the association between type 1 diabetes and psychiatric disorders, healthy siblings of patients with type 1 diabetes would have a higher risk of psychiatric disorders.

    “This enabled us to test the hypothesis that the association between psychiatric disorders and type 1 diabetes is caused by familial factors, where high risk of psychiatric disorders among healthy siblings of children with type 1 diabetes would support a familial effect.”
2 of 2

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Different 10-year prevalence values for the same 1973-1986 cohort

    Major

    The paper gives two different 10-year prevalence figures for psychiatric disorders in the earliest birth cohort. One place says 4.6%, but later the same cohort is described as having 3.8% prevalence.

  • Reported prevalence increase is not threefold

    Minor

    An increase from 3.8% to 16.7% is approximately 4.4-fold, not threefold.

    Reported 3 · recomputed 4.394737

  • Cohorts are defined by both birth and diagnosis dates

    Minor

    The methods describe the year ranges as birth cohorts while saying they were assigned by diagnosis date. The results then describe the same year ranges as onset cohorts; these are different ways of grouping patients.

3 of 3

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Authors
Butwicka, A., Frisén, L., Almqvist, C., Zethelius, B., & Lichtenstein, P.
Affiliations
  • Medical University of Warsaw (PL)
  • Karolinska Institutet (SE)
  • Uppsala University (SE)
Corresponding author
Butwicka, Agnieszka
ORCID
Venue
Diabetes Care
Publisher
American Diabetes Association
Published
2015-02-03
Volume
38
Issue
3
Pages
453-459
ISSN
  • 0149-5992 (ISSN-L)
  • 1935-5548
DOI
10.2337/dc14-0262
PMC
PMC4338504
OpenAlex
W2165290457
Cited by
210
References
30
Citations by year
2026: 15 · 2025: 11 · 2024: 25 · 2023: 16 · 2022: 30 · 2021: 28 · 2020: 20 · 2019: 18 · 2018: 14 · 2017: 14 · 2016: 14 · 2015: 5
FWCI
13.58
Type
journal article
Language
en
Update notices
correction (2016-03-01)
Open access
Licence
www.diabetesjournals.org/site/license (vor, 210 d)
Locations
  • Diabetes Care (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Figshare (submittedVersion, cc-by)
  • Open Archive (Karolinska Institutet) (submittedVersion, cc-by)
Funders
  • The Polish Ministry of Science and Higher Education (903/MOB/2012/0, IP2012 006972)
  • The Swedish Research Council (523-2011-3807)
  • The Swedish Heart and Lung Foundation
  • The Strategic Research Program in Epidemiology at Karolinska Institutet
  • The Swedish Initiative for Research on Microdata in the Social and Medical Sciences (340-2013-5867)
  • The Regional Agreement On Medical Training And Clinical Research (ALF) between Stockholm County Council and Karolinska Institutet
  • The Swedish Association of Local Authorities and Regions funds the NDR
  • The Swedish Research Council for Health, Working Life and Welfare
  • National Institute of Child Health and Human Development (HD061817)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Diabetes and associated disorders
Keywords
type 1 diabetes, children and adolescents, mental illness, suicide attempts, siblings, mental health surveillance, familial risk
MeSH terms
Adolescent, Mental Disorders, Child, Child, Preschool, Diabetes Mellitus, Type 1, Epidemiologic Methods, Female, Humans, Male, Suicide, Attempted, Sweden, Siblings

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