Running head: INTEGRATIVE LITERATURE REVIEW 1

Integrative Literature Review

Megan Pollock

Bon Secours Memorial College of Nursing

NUR 4122: Nursing Research

Christine Turner, PhD

March 30, 2018

“I pledge…”
Running head: INTEGRATIVE LITERATURE REVIEW 1

Abstract
Purpose: The purpose of this integrative review is to identify if patients with type 1 diabetes

mellitus (T1DM) are at an increased risk of developing mental health disorders compared to

patients without T1DM.

Background: T1DM is a very serious disease that requires a strict treatment plan which can take

a toll on the mental stability of anybody. Emotional stressors that contribute to mental illness can

affect glycemic control and put patients at risk for complications.

Method: This is an integrative review that was completed using articles found from online

databases. All articles discussed are quantitative studies chosen based on their relevance to the

purpose of this integrative review. These articles were then used to determine if there was a

relationship between having T1DM and developing a mental illness.

Results and Findings: Evidence gathered from these articles supports that patients with T1DM

may be at risk for developing a mental disorder. Eating disorders, anxiety, and depression were

found to be the most common mental disorders patients were at risk for developing.

Limitations: The main limitation is the author’s lack of experience in writing an integrative

review. Another limitation was finding articles that pertained to only T1DM.

Implications and Recommendations: Determining if T1DM can lead to mental illnesses would

highlight the importance of implementing more screening tools in order to detect mental illness

early. It is recommended that screening tools be implemented by clinicians for patients in order

to prevent serious mental illness and diabetic complications.

INTEGRATIVE LITERATURE REVIEW 2

Integrative Literature Review

The purpose of this integrative review is to identify if patients with type 1 diabetes

mellitus (T1DM) are at an increased risk of developing mental health disorders compared to

patients without T1DM. Type 1 Diabetes is a disease that is steadily growing and already affects

200,000 children and adolescents, just in the United States (Bernstein, Stockwell, Gallagher,

Rosenthal, & Soren, 2013). Just like many other chronic diseases, T1DM diagnosed patients can

be at risk for developing a psychiatric illness or can have a pre-existing comorbidity (Bernstein,

et al., 2013). Based off of national data, the general adolescent population of the United States

has a prevalence of “31.9% anxiety disorders, 19/1% of behavioral disorders, and 14.3% of

mood disorders” (Bernstein, et al, 2013, p. 10).

The importance of determining whether or not having T1DM can lead to mental illness is

to implement more screening tools at follow-up appointments. If clinicians and nurses can

implement the use of mental illness assessment tools and notice signs and symptoms of different

disorders, they may be able to reduce the prevalence of type 1 diabetics that develop psychiatric

disorders as a comorbidity (Dybdal, Tolstrup, Sildorf, Boisen, Svensson, Skovgaard, &

Teilmann, 2017). The aim of this review is to discuss published literature and information as it

relates to the author’s PICOT question: Are patients with type 1 diabetes at an increased risk for

developing mental health disorders compared to patients without type 1 diabetes?

Design and Methods

This integrative review is based off of five research articles. To begin the process, the

researcher used search engines including Google Scholar, Academic Search Complete, and

PubMed. Search words used to find the articles were type 1 diabetes, mental illness, psychiatric

disorders, prevalence, depression, children, and adolescents. Filters applied consisted of the year
INTEGRATIVE LITERATURE REVIEW 3

published, peer reviewed articles, English language and full text articles. These filters lowered

the number of items that were located. Narrowing down the years that each article was published

to 2012 through 2018 significantly decreased the number of compatible articles to 23 on

Academic Search Complete, 400 on Pubmed, and 23,000 on Google Scholar.

Articles were then chosen based off their relevance to the PICOT questions stated

previously. Requirements the researcher set for each article included: having a purpose statement

to discover the prevalence of mental illness as a result of having T1DM, being quantitative, and

having qualified authors. Qualifications the researcher looked for in the authors consisted of

experience in patients with diabetes mellitus, children and adolescents, and mental illness. A

brief critical appraisal was conducted for each article in order to evaluate relation to the PICOT

question and whether or not the article was a valuable, trustworthy source. After applying these

specific pieces of criteria, the research resulted in five quantitative research articles (Bernstein, et

al., 2013; Butwicka, et al., 2015; Dybdal, et al., 2017; Khandelwal, et al., 2016; Telo, et al.,

2018).

Findings

All five of the articles reviewed found that having T1DM can lead to developing a mental

illness after diagnosis (Bernstein, et al., 2013; Butwicka, et al., 2015; Dybdal, et al., 2017;

Khandelwal, et al., 2016; Telo, et al., 2018). Table 1 – Article Evaluation provides a summary of

the five articles used for this review. The following is a review of each of the articles’ findings.

In the study conducted by Bernstein, Stockwell, Gallagher, Rosenthal, and Soren (2013),

the authors sought to determine the prevalence and impact of mental health issues in children and

young adults with T1DM. The researchers conducted a cross-sectional study using 150

participants that were both male and female between the ages of 11-25 with T1DM. After
INTEGRATIVE LITERATURE REVIEW 4

informed consent and assent was gathered from each participant and their caregiver, he or she

completed a self-reported survey about their demographic information, duration of T1DM

diagnosis, average insulin usage, HbA1c levels and if they have been previously diagnosed with

depression, anxiety, or eating disorders. A researcher then performed Beck’s Depression

Inventory, an anxiety screening tool (SCARED-41), and an eating disorder evaluation (ESP) on

the participants. After data was collected, SAS version 9.2 was used to analyze all of the data and

average HbA1c levels. Pearson X2 was used to compare demographic variables and diabetic

control. The authors found that of the children and young adults studied, 11% were positive for

depression, 21% were positive for anxiety, and 21% were also found to have an eating disorder.

Those diagnosed with mental illnesses were also found more likely to have poor glycemic

control.

Butwicka, Frisén, Almqvist, Zethelius, and Lichtenstein (2015) conducted a study in

Sweden that focused on assessing the risk of psychiatric disorders and suicide attempts in

children with T1DM. In this quantitative, population-based cohort study, the researchers

gathered their sample from the Swedish pediatric diabetes, quality registry, Swedish national

diabetes register, and Swedish national patient register. Using the national registry, the

researchers were able to match one T1DM patient to 100 control subjects with the same sex, age,

and birth county. Siblings of the participants with diabetes were also studied in order to eliminate

mental illness that may be caused by genetics. There was no exact number given of the sample

size. Data was collected by following each participant through the national patient registries until

the study ended, death occurred, or they were diagnosed with a psychiatric disorder. Data

analysis was done using X2 and student t-tests to find mean values. Cox proportional hazards

model and Kaplan-Meier method were used to evaluate data of psychiatric disorders. The Cox
INTEGRATIVE LITERATURE REVIEW 5

proportional hazards model was also used to evaluate prevalence of siblings that were diagnosed

with psychiatric disorders. After eliminating contributing factors such as sociodemographic and

perinatal factors, children with T1DM were 2.1 times more likely to receive a psychiatric

diagnosis and 1.7 times more likely to attempt suicide compared to children without T1DM.

There was also found to be an increased risk for mood disorders, anxiety, eating disorders,

substance misuse, attention deficit hyperactivity disorder, and more. The researchers found that

most diagnoses of mental illness were made within the first six months of the child’s diabetic

diagnosis and if the child was older in age. There was no statistical significance comparing

siblings together.

In a population-based, matched cohort study conducted in Denmark by Dybdal, Tolstrup,

Sildorf, Boisen, Svensson, Skovgaard, and Teilmann (2017), the purpose was to investigate

psychiatric morbidity following childhood onset of T1DM. The researchers ended up with a

sample size of 5,084 children that were diagnosed with diabetes before the age of 18 and 35,588

participants as a control group. Participants were matched by sex and date of birth with a ratio of

1 T1DM participant to seven control subjects. Subjects and data was gathered from the Danish

Civil Registration System and The National Patient Register and followed until the study ended,

death occurred, or the subject was diagnosed with a psychiatric illness. Variables studied

included many psychiatric disorders such as substance misuse, mood disorders, anxiety,

personality disorders, autism, and behavioral disorders. Eating disorders and mood disorders

were found to be diagnosed more frequently in the study subjects with T1DM. Diabetic patients

were found to have a 1.46 hazard rate of developing psychiatric illnesses while the control group

had a hazard rate of 1.38. Average onset of a mental illness was found to be 14 years of age and

having had diabetes for longer than five years. Statistical analysis was done using STATA/IC for
INTEGRATIVE LITERATURE REVIEW 6

Windows, risks were done by Cox proportional hazards model, and estimations of standard error

were done for both groups studied.

Khandelwal, Sengar, Sharma, Choudhary, and Nagaraj (2016) completed a study with a

sample size of 184 children, male and female, between the ages of 6 and 14. The study was a

cross-sectional, comparative study that aimed to assess prevalence, severity, pattern, and

variables affecting psychosocial illness in children with type 1 diabetes mellitus. Data was

collected by a survey given to the parents of children who came into a pediatric acute care unit of

a chosen hospital. The child’s history and socioeconomic status was collected, as well as, onset

and duration of diabetes diagnosis, diet, family dynamics, and HbA1c levels. A researcher then

evaluated the psychological stability of the child using the DSM5 assessment tool. Analysis was

done by completing a chi-squared test and comparing answers from surveys of diabetic patients

and the participants chosen for the control group. The authors found that 47 out of the 84 type 1

diabetic children being studied, had psychological disorders such as irritation, depression, and

anxiety. These results were significantly more than what was found with the control group.

Increased HbA1c was found to be a leading contributing factor to developing psychiatric

disorders.

In a quantitative study done by Telo, Cureau, Lopes, and Schaan (2018), the authors used

a sample of 73,624 participants that aged from 12 to 17 years old. 116 of these participants were

diagnosed with T1DM. Data for the control group was gathered from a cross-sectional study

previously completed to gather sociodemographic features, weight, and height. Other variables

studied were pubertal development, amount of physical activity, alcohol consumption, tobacco

use, and mental health. Data was collected from surveys completed by the participants including

the Tanner Stage to determine pubertal stage, a physical activity checklist, and a general health
INTEGRATIVE LITERATURE REVIEW 7

questionnaire to screen for non-psychotic mental health symptoms. Analysis of these variables

was done using STATA statistical software and mean and standard error values were completed

for descriptive data. Type 1 diabetics reported more feelings of not enjoying normal activities,

struggling to overcome difficulties, not feeling useful, losing confidence, and feeling more

depressed or stressed in comparison to the control group. Although T1DM participants were

more likely to have symptoms of mental health disorders, they did not have more medical

diagnoses.

Discussion and Implications

The articles used for this review indicated a positive correlation between having T1DM

and developing a mental illness. The researcher outlined this review into two categories: small

sample size and large sample size. This section is a discussion on how these articles relate to the

PICOT question, how nurses can implement the authors findings into medical practice, and what

future research may be needed.

Small Sample Size

The sample size of the study is important to this review because it allowed some studies

to explore more information regarding the participants. Two groups of researchers in this review

had a small sample size of less than 200 participants (Bernstein, et al., 2013; Kahndelwal, et al.,

2016). This allowed them to gather more in-depth data such as onset and duration of T1DM,

HbA1c levels, average amount of insulin used, and diet (Bernstein, et al., 2013; Kahndelwal, et

al., 2016). HbA1c is an important factor when evaluating glycemic control in diabetics because it

takes into account the patient’s blood sugar averages for the past three months. Including this

data was important because it was discovered that having an increased HbA1c level increased the

risk for developing a psychological illness (Khandelwal, et al., 2016). Having a smaller sample
INTEGRATIVE LITERATURE REVIEW 8

size also allowed the researchers to have an affiliation with only one medical center. In the study

done by Khandelwal (2016), a small sample size was collected from an acute care unit in a single

hospital. In a study performed by Bernstein (2013), patients were chosen from one single

diabetic treatment center. This single center approach allows for a face-to-face interaction with

each patient participating in the study.

These articles are important to the PICOT question because they study whether or not

T1DM patients are more at risk for developing a mental health illness and what specific illnesses

might be more prevalent in this population. This face-to-face time is exactly how clinicians and

nurses can implement what these studies have found. More time with patients to assess whether

or not they show signs of mental health disorders can ensure that they are being properly referred

and receiving therapeutic help (Bernstein, et al., 2013; Khandelwal, et al., 2016). A

recommendation for further research would be to have a researcher assist in surveys rather than

having the parent present that could influence answers.

Large Sample Size

Having a larger sample size can be helpful in research because it gathers

information from a broader population. Articles written by Telo (2018), Dybdal (2017), and

Butwicka (2015), all have data collected from a nation whether it be by questionnaire or national

registries. Two of the studies were matched cohort studies that allowed them to have one

participant with T1DM paired up with multiple subjects from the control group that matched in

sex and age (Butwicka, et al., 2015); Dybdal, et al., 2017). This allowed for the data to not be

skewed one way or the other.

These articles related to the PICOT question because they compared the risk for

development of a psychosocial illness in type 1 diabetics and participants without T1DM. One
INTEGRATIVE LITERATURE REVIEW 9

way to implement the information found in these studies is to realize that diabetes is a disease

that can affect many nations. Nurses can raise awareness of this issue and the comorbidity of

mental illnesses that come along with it. A recommendation for future research could be to dive

deeper and find out why type 1 diabetic patients might have more feelings of uselessness or lack

of confidence (Telo, et al., 2018).

Limitations

Throughout this integrative review, the researcher came across many limitations that

could have affected the final product. The biggest limitation that was an issue was the lack of

experience the researcher had in conducting an integrative literature review. The conductor also

has limited experience working with diabetic or mental health patients, so the author can not

provide much insight into how the findings can relate to clinical practice.

The filters that were applied during the online literature search also proved to be a

limitation due to such specificity. Finding articles that were only related to type 1 diabetics and

not type 2 diabetics was also a challenge. Each article had its own limitations that also

contributed to the quality of this comprehensive review. Some limitations included subjective or

influenced answers on self-surveys, inclusion of other contributing factors that could be related

to mental illness, and possible inclusion of patients with mental illness before diagnosis of

T1DM (Bernstein, et al., 2013; Telo, et al., 2018). All articles also had resources that were

greater than ten years in the past which could lead to information that may not have great

reliability (Bernstein, et al., 2013; Butwicka, et al., 2015; Dybdal, et al., 2017; Khandelwal, et

al., 2016; Telo, et al., 2018).

Conclusion
INTEGRATIVE LITERATURE REVIEW 10

The evidence gathered from this integrative review of five articles, supports the claim

that having T1DM can increase the risk, or lead, to a mental illness diagnosis (Bernstein, et al.,

2013; Butwicka, et al., 2015; Dybdal, et al., 2017; Khandelwal, et al., 2016; Telo, et al., 2018).

Although self-surveys and questionnaires make it difficult to medically diagnose psychiatric

illnesses, it can be concluded that type 1 diabetics show more mental illness symptoms (Telo, et

al., 2018). The most common mental illnesses that were found in associated to patients with

T1DM were depression, anxiety, eating disorders, and behavioral disorders (Bernstein, et al.,

2013; Butwicka, et al., 2015; Dybdal, et al., 2017; Khandelwal, et al., 2016; Telo, et al., 2018).

Other contributing factors were poor glycemic control, age of diabetes onset, and length of time

since diabetes diagnosis (Bernstein, et al., 2013; Butwicka, et al., 2015; Dybdal, et al., 2017). In

relation to the PICOT question, the five articles have supportive evidence that patients with

T1DM may be at a higher risk to develop mental health illnesses compared to patients without

T1DM (Bernstein, et al., 2013; Butwicka, et al., 2015; Dybdal, et al., 2017; Khandelwal, et al.,

2016; Telo, et al., 2018). The information that these articles provided allows for health providers

to gain a better understanding of what symptoms and illnesses to be aware of when assessing

diabetic patients. It is important to incorporate more mental health assessment tools into practice

in order to catch mental health in T1DM patients sooner and prevent complications that can

impact their future.

INTEGRATIVE LITERATURE REVIEW 11

References

Bernstein, C. M., Stockwell, M. S., Gallagher, M. P., Rosenthal, S. L., & Soren, K. (2013).

Mental health issues in adolescents and young adults with type 1 diabetes. Clinical

Pediatrics, 52(1), 10-15. doi:10.1177/0009922812459950

Butwicka, A., Frisén, L., Almqvist, C., Zethelius, B., & Lichtenstein, P. (2015). Erratum. Risks

of psychiatric disorders and suicide attempts in children and adolescents with type 1

diabetes: a population-based cohort study. Diabetes Care 2015;38:453–459. Diabetes

Care, 39(3). doi:10.2337/dc16-er03

Dybdal, D., Tolstrup, J. S., Sildorf, S. M., Boisen, K. A., Svensson, J., Skovgaard, A. M., &

Teilmann, G. K. (2017). Increasing risk of psychiatric morbidity after childhood onset

type 1 diabetes: A population-based cohort study. Diabetologia, 61, 831-838.

doi:10.1007/s00125-017-4517-7

Khandelwal, S., Sengar, G. S., Sharma, M., Choudhary, S., & Nagaraj, N. (2016). Psychosocial

illness in children with type 1 diabetes mellitus: Prevalence, pattern and risk

factors. Journal Of Clinical And Diagnostic Research, 10(9).

doi:10.7860/jcdr/2016/21666.8549

Telo, G. H., Cureau, F. V., Lopes, C. S., & Schaan, B. D. (2018). Common mental disorders in

adolescents with and without type 1 diabetes: Reported occurrence from a countrywide

survey. Diabetes Research and Clinical Practice, 135, 192-198.

doi:10.1016/j.diabres.2017.10.027
Running head: INTEGRATIVE LITERATURE REVIEW
First Author (Year)/Qualifications
Background/Problem Statement
Conceptual/theoretical Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and their
definition), if appropriate
Measurement Tool/Data Collection
Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
First Author (Year)/Qualifications
1
TABLE 1 - ARTICLE EVALUATION
Khandelwal – 3rd year resident in pediatrics
- Does type 1 diabetes influence psychosocial illness in children
- is severity effected
- type 1 diabetes is becoming very prevalent in our society
- takes a toll physically and mentally on children
- cross sectional, comparative study
- quantitative
- Survey given to parents of children that came into pediatric acute care unit of hospital
- 184 children, ages 6-14 years, male and female
- pediatric hospital
- children and parents told about the study and informed consent and assent was obtained
- children’s history, socioeconomic status, onset and duration of T1DM, diet, family
dynamics, HbA1c levels
- psychological stability evaluated
- DSM5 for psychological issues
- questionnaire taken by the parents of the children participating in study
- study and control group were compared
- chi-squared test completed
- 47/84 T1DM children have psychological disorders (irritation, depression, and anxiety) more
than control group
- Increased HbA1c lead to more psychological disorders
- contributes to additional care T1DM patients might need
- good article based on information gathered
- suggests additional experimenter with experience in mental illness
Bernstein – MD, MSc, pediatrics, Columbia University Medical Center
INTEGRATIVE LITERATURE REVIEW
Background/Problem Statement
Conceptual/theoretical Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and their
definition), if appropriate
Measurement Tool/Data Collection
Method
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
First Author (Year)/Qualifications
Background/Problem Statement
2
- prevalence and impact of mental health issues in children and young adolescents with T1DM
- patients with T1DM are more often referred for mental health help than the general
population of the same age
- cross sectional study
- Patients were chosen from an affiliated diabetes center
-survey and screening for symptoms of variables being researched
- 150 participants, male and female, 11-25 years, all having T1DM
- must speak/read English or Spanish
- informed consent/assent was obtained from each participant
- demographic information, duration of T1DM, usual about of insulin used or if not used at all,
HbA1c levels
- previously diagnosed depression, anxiety, and eating disorders
- self-report survey
- Beck’s depression inventory
-SCARED-41 – assessment tool for anxiety
-ESP – question tool to screen for eating disorders
- Univariate analyses using Pearson x2 statistic – demographic variables and diabetic control
- SAS version 9.2 – analysis of all data, HbA1c levels
- Predictors used to establish collinear relationships
- 11% positive for depression, 21% positive of anxiety and disorder
- Those diagnosed with psychosocial disorders were found to have poor glycemic control
- Important to review because it incorporates a broader and more diverse group of participants
Telo – Postgraduate program in Endocrinology, Univeridade Federal do Rio Grande do
Sul, Porto Alegre, Brazil
- evaluate the frequency of common mental disorders and their symptoms in adolescents with
and without type 1 diabetes
INTEGRATIVE LITERATURE REVIEW
Conceptual/theoretical Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and their
definition), if appropriate
Measurement Tool/Data Collection
Method
Data Analysis
Findings/Discussion
3
- Diabetes is a difficult disease to manage along with having to deal with adolescent changes,
poor mental health can negatively impact glycemic control
- Type 1 diabetes has been previously associated with depression, impaired executive
function, and reduced quality of life
- Although, previous studies were too small or poorly executed, current evidence inconclusive
- Compared youth with T1DM to youth without
- sample taken from previous study
- Quantitative
- Data taken from previous Brazilian study (ERICA, cross sectional study) to get obtain
sample that represents national and macro-regional levels
- institutional review board of each federative unit of brazil approved study
- parents/adolescents signed informed consent and assent before study began
- 12-17 years, 116 with T1DM, 73,508 without T1DM
- sociodemographic feathers, weight and height to determine BMI, pubertal development,
physical activity (frequency, time, and activities, <300 mins/week considered inactive),
parental education, alcohol consumption, tobacco use, mental health assessment
- Tanner stage (self-assessment used to classify pubertal stage
- self-administered physical activity checklist
- General health questionnaire – screening non-psychotic mental health symptoms
- Stata statistical software
- mean and standard error values or percentages for descriptive data
- T1DM youth reported not enjoying normal activities, struggling to overcome difficulties, not
feeling useful, losing confidence, feeling more depressed or stressed
- T1DM did not affect GHQ scores, no major differences in mental health diagnosis were
found between the two groups. T1DM were just more likely to have symptoms.
INTEGRATIVE LITERATURE REVIEW 4

Appraisal/Worth to practice
- Mental health can affect glycemic control so it is important for providers to take the time to
screen for different disorders or those at high risk for developing mental illnesses in order to
maintain optimal glycemic control
- Good article because it uses a bigger sample size from a larger area than most studies
- Gathers sample from schools rather than just acute care settings where mental illness might
be more prevalent but due to other illnesses other than T1DM
INTEGRATIVE LITERATURE REVIEW
First Author (Year)/Qualifications
Background/Problem Statement
Conceptual/theoretical Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and their
definition), if appropriate
Measurement Tool/Data Collection
Method
Data Analysis
5
Daniel Dybdal – Department of Pediatrics and adolescent medicine in Denmark,
National institute of public health, university of southern Denmark
- Investigate psychiatric morbidity following childhood onset of T1DM
- Long-term consequences of psychiatric disorders and T1DM has such a high impact in
adolescents that awareness and screening should be increased
- Study done because previous studies have limited information based on small sample sizes
- Population-based, matched cohort study
- sample gathered from Danish Civil Registration System – contains age, sex, and vital status
of everyone living in Denmark
- Code taken from The National Patient Register to determine T1DM children
- Children diagnosed before age 18 from 1996-2013, size = 5,084, 48% female
- Excluded – youth diagnosed with psychiatric disorder prior to T1Dm diagnosis and children
who were not living in Denmark when diagnosed
- Control was chosen randomly from population that matched sex and date of birth, 7 control
children: 1 T1DM child, size of control = 35,588, 48% female
- psychoactive substance misuse, psychotic disorders, mood disorders, anxiety, dissociative,
stress-related and somatoform disorders, eating disorders, personality disorders, intellectual
disability, specific developmental disorders, autism spectrum disorders, unspecified
developmental disorders, hyperkinetic disorder, behavioral disorders, suicide attempts
- Study continued until the child was diagnosed with a psychiatric disorder, emigrated from
Denmark, died, or reached the end of the study period (December 31, 2013)
- Gathered date of diagnosis of disorder from The National Patient Register
- STATA/IC for Windows for statistical analysis
- Risk estimates by Cox proportional hazards model
- Estimations of standard error to allow for correlations and T1DM youth with corresponding
control children
INTEGRATIVE LITERATURE REVIEW
Findings/Discussion
Appraisal/Worth to practice
6
- Eating disorders, mood disorders most frequently, T1DM youth had IR of 1.46 of developing
psychiatric illness while control group was 1.38
- 14 years old was average onset of disorders, greater than 5 years of T1DM increased risk of
psychiatric illness onset
- Registries allowed for easier, more accurately gathered data
- Children with T1DM were less likely to be referred for mental health help
- private specialists and general practitioners were not counted in the patient registry because
not part of hospital
- Really good study because of how the sample size was gathered. The national registry
accounts for all individuals and the patient registry ensures that all diagnoses were made by
medical doctors
- if mental health is screening in T1DM patients early, we can prevent further complications of
diabetes and mental health
- Clinicians should be aware of symptoms
INTEGRATIVE LITERATURE REVIEW
First Author (Year)/Qualifications
Background/Problem Statement
Conceptual/theoretical Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and their
definition), if appropriate
Measurement Tool/Data Collection
Method
7
Agnieszka Butwicka – Department of medical epidemiology and biostatistics, Karolinska
Institute, Stockholm, Sweden and Department of child psychiatry, medical university of
Warsaw, Warsaw, Poland
- assess the risk of psychiatric disorders and suicide attempts in children with T1Dm and their
healthy siblings
- the threat of serious complications and strict treatment regimens can increase risk
- psychiatric disorders among T1DM children have not been properly tested with large
samples
- testing siblings will test whether family is a factor that other studies are not including
- population-based case-cohort study, quantitative
- sample gathers from Swedish pediatric diabetes quality registry, Swedish national diabetes
register, and Swedish national patient register (psychiatric)
- 1 T1DM patient: 100 subjects of control group, matched by sex, age, and county of birth
- individuals taken from registry born in Sweden from 1964 with onset before age 18
- divided into cohorts based on years diagnosed with T1DM
- Siblings of T1DM patients were also studied and confirmed biological relationship through
Multi-generation register
- any psychiatric disorder that was recorded in national patient register, suicide attempts,
psychotic disorders, mood disorders, anxiety, dissociative, stress-related and somatoform
disorders, eating disorders, psychoactive substance misuse, attention-deficit hyperactivity
disorder, autism spectrum disorder, intellectual disability, and behavioral disorders
- sociodemographic characteristics, parental psychiatric morbidity (psychiatric diagnosis,
suicide attempt, death by suicide),
- Study continued until the child was diagnosed with a psychiatric disorder, emigrated from
Sweden, died, or reached the end of the study period (January 31, 2010)
- gathered data by watching registers
INTEGRATIVE LITERATURE REVIEW
Data Analysis
Findings/Discussion
Appraisal/Worth to practice
8
- X2 and student t tests performed for mean values
- Cox proportional hazards model to estimate risk of psychiatric disorders
- Kaplan-Meier method to calculate prevalence of psychiatric disorders
- sibling data – Cox model to determine psychiatric disorders
- After eliminating contributing factors such as sociodemographic and perinatal factors, T1DM
children were 2.1 more times likely to receive a psychiatric diagnosis and 1.7 times more like
to attempt suicide
- increased risk for mood disorders, anxiety, eating disorders, substance misuse, ADHD,
behavioral disorders, autism, and intellectual disability
- psychiatric disorders risk increase with age of onset; most disorders were diagnosed within
the first 6 months of T1DM diagnosis
- the children with diabetes compared to their siblings were not statistically significant
- Comparing siblings validated that these children with T1DM are more at risk to develop
psychiatric disorders without the risk factors from genetics