Comment on Gagnum et al. Long-term Mortality and End-Stage Renal Disease in a Type 1 Diabetes Population Diagnosed at Age 15–29 Years in Norway. Diabetes Care 2017;40:38–45

We read with interest the paper by Gagnum et al. (1) reporting on a well-organized prospective cohort study that assessed long-term mortality and end-stage renal disease in a type 1 diabetes (T1D) population diagnosed at age 15–29 years in Norway. The authors concluded that mortality in the cohort with T1D “was 4.4 times that of the general population, and more than 50% of all deaths were caused by acute or chronic complications. A relatively high proportion of deaths were related to alcohol” (1). We would like to offer further explanation and understanding of the impact of psychological disorders on mortality in patients with T1D.

In this study, high mortality related to alcohol abuse, violence, and suicide was observed. Of the 146 patient deaths, the underlying cause of death was alcohol related in 22 individuals (15.1%), violence in 21 individuals (14.4%), and suicide in 7 individuals (4.8%), with standardized mortality ratios of 6.8 (95% CI 4.5–10.3) for alcohol-related deaths, 3.6 (2.3–5.3) for violent deaths, and 2.8 (1.3–5.8) for suicide (1). Those factors were the leading causes of death when duration of diabetes was less than 10 years. Similar findings were reported by Harjutsalo et al. (2), who demonstrated that mortality from alcohol-related and drug-related causes in late-onset T1D (onset at 15–29 years of age) accounted for 39% of the deaths before a 20-year duration of diabetes. Harjutsalo et al. (2) also reported that suicides accounted for 10–20% of the total deaths in the early-onset cohort (onset of T1D at 0–14 years of age) and approximately 10% of deaths in the late-onset cohort. The aforementioned behavioral and mental aberrances could be due to psychological disorders that are secondary to T1D.

Patients with T1D often experience psychological disorders, including diabetes-specific distress, and they are at increased risk of depression, anxiety disorders, and eating disorders. Recently, a meta-analysis showed that the pooled prevalence was 30.04% for depressive symptoms and 32% for anxiety symptoms in young people with T1D (3). Individuals with these comorbidities are usually poorly compliant to drug therapy, have poor glycemic control, and are involved with alcohol and drug abuse, which can lead to increased risk of acute complications, chronic complications, and even death related to alcohol, drug abuse, and violence. A population-based cohort study also reported an increased risk of suicide attempts (hazard ratio 1.7 [95% CI 1.4–2.0]) and increased morbidity in most categories of psychiatric disorders in children and adolescents with T1D (4). If possible, the authors could provide more information on the psychological disorders at baseline and follow-up of the studied cohort (1), as it would help to better understand the association between psychiatric abnormalities and long-term mortality in a T1D population diagnosed during late adolescence or young adulthood.

In conclusion, the aforementioned articles highlight the contribution of psychological issues to mortality in T1D. We need to increase awareness not only of alcohol-related deaths but also of psychiatric-related deaths, and regular screening and treatment of psychological illness in patients with T1D ought to be encouraged.