Individuals with type 1 diabetes have higher rates of depression and suicidal ideation than the general population, and symptoms of depression are often associated with higher A1C levels and complications. This study evaluated mental health follow-up rates in youth and young adults with type 1 diabetes who screened positive for depressive symptoms or suicidal ideation and identified differences between those who obtained follow-up mental health care and those who did not. Specifically, males were less likely to obtain follow-up, and those who had mental health follow-up had decreasing A1C over the following year. These findings suggest increased assistance and monitoring are needed to ensure follow-up mental health care is obtained.

The management of type 1 diabetes in youth and young adults presents unique challenges (1). Individuals in this age-group with type 1 diabetes are at increased risk of psychosocial issues, including depression and suicidal ideation (SI) (29), which contribute to difficulty in achieving glycemic control (24,10). The prevalence of depression in people with type 1 diabetes is two to three times higher than in the general population (46). In the pediatric and young adult population, individuals with positive depression screens are more likely to be older (11) and female (4,12), to identify as a minority race/ethnicity (12), and to have public insurance (11). Depression is often associated with higher A1C levels, decreased adherence, and increased complications in type 1 diabetes (4,5,13,14). Elevated A1C levels are associated with increased risk of acute complications such as diabetic ketoacidosis (15), as well as chronic complications such as retinopathy, nephropathy, and cardiovascular disease (1620). Approximately 15% of people with type 1 diabetes report SI compared with 9% in the general population, and suicide attempts are three to four times more likely (69). The increased rates of depression and suicide in type 1 diabetes and their correlation with diabetes complications emphasizes the need for improved behavioral health care for youth and young adults with type 1 diabetes.

Recently, there has been an increased focus on screening for depressive symptoms and SI in youth with type 1 diabetes. Diabetes centers across the country have started to integrate depression screening into their clinics (11,12,21). National programs such as the Type 1 Diabetes Exchange Quality Improvement Collaborative have also focused on improving depression screening practices in diabetes clinics across the country (22). After initial positive screenings, immediate follow-up typically occurs in a clinic, and referrals are provided for patients to obtain further mental health care (11,12,21). Suicide risk assessments for those with SI have also been successfully implemented in our diabetes clinic, in addition to depression screening (8). However, despite increased screening and immediate clinical follow-up, there is not enough evidence to suggest that screening successfully leads to continued mental health care follow-up and treatment.

Literature is limited on the rates of outpatient mental health follow-up in subspecialty clinics. However, in primary care settings, studies show poor rates of follow-up mental health care in youth and adolescents (2326). One study in youth with epilepsy who had positive depression screens interviewed 28 caregivers who did not make a behavioral health appointment for their child after a positive screen. Reasons cited included stigma against a mental health diagnosis and that the child did not want to go (27). Iturralde et al. (28) found that, of 16 patients with diabetes, inflammatory bowel disease, or cystic fibrosis who had a positive depression screen using the Patient Health Questionnaire-9 (PHQ-9) (29,30), approximately half completed a behavioral health appointment shortly after screening.

In the diabetes population, literature on follow-up mental health care after screening is even more scarce. Vassilopoulos et al. (31) was the first study to look at mental health follow-up in patients with diabetes after depression screening and included 60 patients with type 1 diabetes, type 2 diabetes, or monogenic diabetes who were referred for mental health follow-up after screening positive for depressive symptoms. Those with a positive screen either obtained brief onsite outpatient psychotherapy or community mental health referrals if concerns were not related to diabetes or required longer-term therapy. Only 24% successfully followed up with an outpatient mental health provider (31). More recently, Shapira et al. (32) discovered that, in 29 youth with positive depressive symptoms, 14% were already in mental health treatment and only 28% even accepted a referral. Conversely, Watson et al. (33) noted that 59% of their 34 patients with positive depression or anxiety screening followed up with recommended counseling regardless of whether they were already in counseling.

Given the increased rates of depression and SI in youth and young adults with type 1 diabetes and their association with worse glycemic control and complications (4,5,10,13,14), an important next step is determining how best to address and improve mental health care for individuals with type 1 diabetes, as screening for depression may not be helpful to patients unless adequate follow-up mental health treatment is initiated. The objectives of this study were to evaluate mental health follow-up in youth and young adults with type 1 diabetes after initial endorsement of depressive symptoms and/or SI and to compare demographic and diabetes-related characteristics between those who obtained follow-up mental health care and those who did not.

Depression screening has been clinically performed annually in patients ≥10 years of age since January 2016 at the Barbara Davis Center for Diabetes via the PHQ-9 (29), a standardized screen for depressive symptoms and SI. A retrospective chart review was conducted of patients at the center who scored positive for depressive symptoms and/or endorsed SI between January 2016 and July 2018. The University of Colorado’s Multiple Institutional Review Board approved this study.

PHQ-9

The PHQ-9 is a validated self-administered depression screen that directly assesses the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, symptoms of depression (29,30). Respondents rate whether various symptoms have occurred in the previous 2 weeks, from 0 (not at all) to 3 (nearly every day). The severity level of each depressive symptom is categorized on a numerical scale as minimal (0–4), mild (59), moderate (5,1013), moderately severe (1418), or severe (1926). A PHQ-9 score ≥10 has 88% specificity and 88% sensitivity to detect major depression (29). The PHQ-9 includes one SI item, which asks whether the individual has had “thoughts that you would be better off dead or of hurting yourself in some way.” Any answer other than 0 (not at all) on this question suggests positivity for SI.

Depression Screening Procedures

Eligibility for screening was determined on a weekly basis for patients with scheduled appointments the following week. Eligibility criteria included individuals who are ≥10 years of age and English-speaking who had not had a depression screen in the previous year and were not developmentally delayed, resulting in the inability to understand the screening questions. Screening was only provided to patients who spoke and read English and who had a caregiver who spoke English if the patient was <18 years of age, as the clinic did not have a Spanish-speaking professional on the suicide risk assessment team.

For those eligible, the PHQ-9 was given to patients at their clinic visit by a patient navigator before they met with their provider. The PHQ-9 was scored by the patient navigator, and providers were notified if a patient scored positive for depressive symptoms and/or SI. When patients scored positive for SI, a member of the suicide risk assessment team was also notified.

Figure 1 provides details regarding the clinical flow for depression screening. Because of staffing constraints, clinic flow, and time limitations, not every eligible patient on a clinic day was able to have a depression screening conducted. For example, if a provider entered the room before the patient navigator could administer the PHQ-9, the patient was followed to receive a depression screening at a future diabetes appointment.

If the PHQ-9 score was clinically elevated (score ≥10) without SI, the provider reviewed depressive symptoms with the individual and provided a referral list of mental health providers in the community if the individual was not already actively seeing a mental health specialist. The mental health referral list included social workers, counselors, and psychologists in different cities and counties throughout the state. The referral list also contained information explaining how patients should contact their insurance company to find out which mental health providers in their area were covered by their insurance, as well as information about which providers offered payment via a sliding scale. If a mental health provider was known to have additional training in chronic illnesses such as diabetes, this was noted on the referral list as well.

If an individual endorsed SI on the PHQ-9 (with or without additional positive depressive symptoms), the provider would discuss the results with the individual, and a member of the suicide risk assessment team (comprising three social workers, a psychologist, and a physician) would also meet with the individual before the patient left clinic and conduct a suicide risk assessment. The mental health referral list was then provided after the suicide risk assessment if the individual was not already actively seeing a mental health specialist.

Suicide Risk Assessment

The suicide risk assessment team assessed individuals’ current risk of suicide using a standardized suicide risk assessment protocol recommended by Joiner et al. (34) and Chu et al. (35). Specifically, the risk assessment included questions pertaining to desire and ideations, plans and preparation, and other risk factors, which have been described elsewhere (8). Based on the information obtained from the risk assessment, patients were classified as being at either low, moderate, severe, or extreme risk for suicide, based on the decision tree described in Chu et al. (35). Recommendations provided were based on risk level and included creating a safety plan, providing a suicide hotline number, and providing the mental health referral list.

Mental Health Follow-Up Categorization

Individuals were categorized based on whether they had obtained any type of mental health follow-up (therapy and/or starting on psychiatric medication) within 1 year after the initial positive depression screen. Data on mental health follow-up were obtained via review of each participant’s chart, which included all encounters, medications administered, and notes at hospitals and clinics in Colorado that link or share with the Barbara Davis Center/Children’s Hospital Colorado electronic medical record (EMR) system. The following search terms were used: “psychiatric,” “psychiatry,” “psychology,” “psychologist,” “psychiatrist,” “mental health,” “behavioral health,” “counselor,” “counseling,” “therapy,” “therapist,” “depression” (which also populated any antidepressant medications), “suicide,” “suicidal,” “ideation,” and “psychotic” (which also populated any antipsychotic medications). Any medication lists, encounters, free-written text, or diagnoses in the EMR that contained any of these search terms were individually reviewed and recorded. Data on prior mental health care use was obtained by using the same search term methodology above and reviewing the visit notes from the day of screening. Those who had active (at the time of screening) or previous mental health treatment were combined in a group designated as having had previous mental health treatment.

Demographics and Type 1 Diabetes–Specific Measures

Sex, age, race, ethnicity, and insurance status at the time of depression screening were collected from all individuals from the EMR. Diabetes-related characteristics, including diabetes duration, pump use, continuous glucose monitoring (CGM) use, and A1C at the time of screening, were also obtained from the EMR. All A1C measurements for visits between 13 months before and 13 months after the depression screening were also collected for each patient. One-year follow-up PHQ-9 scores were collected for those who had been rescreened by study end date (n = 27).

Analysis

Data analysis was performed using R, v. 4.0.4, statistical software (R Foundation for Statistical Computing, Vienna, Austria). Demographic and diabetes-related characteristics for those who obtained follow-up mental health care versus those who did not receive follow-up mental health care were compared using t tests for continuous variables or Pearson χ2 tests or Fisher exact tests for categorical variables. Logistic regression was used to examine predictors of obtaining follow-up mental health care. Piecewise linear mixed models were used to compare changes in A1C after screening in those who obtained mental health care versus those who did not. All A1C values were plotted, and a line of best fit was created for both groups (mental health follow-up vs. no mental health follow-up). The slope of A1C change over time before and after the positive screen was calculated for each group.

Depression screening was conducted in 1,376 youth and young adults (mean age 15.2 ± 3.2 years; 52.8% male; 64.1% identified race as Caucasian; 10.1% identified ethnicity as Hispanic; 68.3% privately insured). Two hundred patients (14.5%) were identified as having a positive depressive symptom (PHQ-9 score ≥10) and/or SI. Ninety-nine (49.5%) had positive depressive symptoms without SI, 70 (35.0%) had positive depressive symptoms and SI, and 31 (15.5%) had SI without positive depressive symptoms. Of those identified as positive for depressive symptoms and/or SI, 106 (53%) obtained mental health follow-up. Follow-up consisted of therapy (n = 62 [58.5%]), starting psychiatric medications (n = 10 [9.4%]), or both therapy and medication (n = 34 [32.1%]).

Sixteen (15%) of those with mental health follow-up after screening had a history of having had mental health care before the screening. It was not clear from chart review whether or when mental health treatment had stopped before the depression screening.

Those who had mental health follow-up after screening were more often female (67.0%, P <0.001) and had a higher initial PHQ-9 score (13.7 vs. 11.9, P = 0.005) (Table 1). The presence of SI at screening was not associated with obtaining mental health follow-up care (P = 0.47).

Type 1 Diabetes–Specific Characteristics and Outcomes

There were no differences between mental health follow-up groups in type 1 diabetes duration, insulin pump use, CGM use, or average A1C at time of screening (Table 1). Of the 200 individuals who screened positive, 10 (5%) did not have any subsequent diabetes visit after their screening visit and no follow-up A1C. Among those who had mental health follow-up, A1C post-screening decreased by an average of 0.25% per 3-month period, and by 1% per year (P = 0.008) when adjusting for the presence of mental health treatment before screening. Among those with no mental health follow-up, A1C post-screening increased by an average of 0.08% per 3-month period and 0.34% per year when adjusting for previous mental health treatment before screening, which was significantly different from those with evidence of mental health follow-up (P = 0.03) (Figure 2).

In models testing predictive factors for obtaining mental health follow-up, males were 64.8% less likely to do so (P = 0.003). Those with no documented previous mental health treatment were also 66.9% less likely (P = 0.002) to obtain mental health follow-up after a positive screen. For each 1-unit increase in PHQ-9 score, those who screened positive were on average 8.0% more likely to obtain follow-up mental health care (P = 0.039). Individuals of Hispanic ethnicity were 61.8% less likely to obtain mental health follow-up after screening positive, although this difference did not reach statistical significance (P = 0.068) (Table 2).

Although depressive symptoms and SI are more common in the pediatric and young adult population with type 1 diabetes, only half of those who have a positive screen obtain follow-up mental health care. This finding is higher than that noted in the studies by Vassilopoulos et al. (31) and Shapira et al. (32) but similar to that in Watson et al. (33). The fact that our study accessed medical records that were outside of the diabetes clinic but integrated within or linked to the clinic’s EMR system may have contributed to the higher rate of mental health follow-up seen in our study and the one by Watson et al., who also accessed records outside of their clinic (33). Specifically, in those who had mental health follow-up, we found follow-up treatment via medication lists and encounters in 67% of the patients identified, and documentation of medication and/or therapy in clinic notes for the other 33%. The findings in all four studies indicate an important gap in care between individuals screening positive and then receiving follow-up mental health care.

This study also found that higher PHQ-9 scores were predictive of following up with mental health care after referral was provided in clinic, suggesting that those with greater depressive symptoms are more likely to seek follow-up care. Our study is consistent with others that have shown that males and those of Hispanic ethnicity are less likely to seek mental health care compared with females and individuals of non-Hispanic ethnicity (36,37). Studies have shown that there may be a greater stigma associated with seeking mental health care among males and individuals of Hispanic descent (3840), although it is not clear whether that is the reason for decreased follow-up in this study. Further studies to understand the roles of sex and race/ethnicity in adherence to mental health referral would be beneficial to improve rates of participation. Additionally, developing care coordination resources would be beneficial to ensure that patients with depression and/or SI and type 1 diabetes access behavioral care in a timely manner.

In this study, those found to be positive for SI had similar rates of mental health follow-up as those without SI. There is no other known study in the literature comparing mental health follow-up in those with versus without SI and diabetes. Matlock et al. (9) discussed mental health follow-up after SI, with 60% (23 of 38) seeing a mental health provider for follow-up after endorsing SI, whereas the rate of follow-up in this study was 50% (51 of 101). It is possible that the increased interaction in clinic between the suicide risk assessment team and those who endorsed SI played a role in the rate of mental health follow-up found, although whether this interaction led to an increased or decreased rate of follow-up is unclear. Further study is needed to determine why approximately half of those with SI did not obtain mental health follow-up care and to investigate how to overcome barriers to seeking mental health care in this group.

Previous studies have found that, often, depressive symptoms are associated with higher A1C levels and decreased adherence over time (4,10). The improvement in A1C trend slope seen in our study (A1C decrease by an average of 1% per year) in the group that used mental health resources compared with those who did not have mental health follow-up (increase in A1C by 0.34% per year) may suggest benefits in diabetes management for those who obtain mental health care. Given that this occurred in an age-group typically associated with increasing A1C, the improvement seen in those who obtained mental health follow-up care may indicate the importance of mental health integration into diabetes care, particularly in youth and young adults. Alternatively, those who are motivated to seek mental health follow-up care may also be motivated to improve diabetes management. Greater longitudinal studies are needed to further understand the long-term effects of mental health care on subsequent type 1 diabetes–related outcomes.

Some steps are currently underway to improve access to care, although further study and steps are needed to increase participation in mental health care after referral. The American Diabetes Association and American Psychological Association have started a diabetes education program for mental health professionals who are interested in providing care to people with diabetes (41), which could increase access to care. The results of our study underscore the benefits of having integrated mental health professionals in diabetes clinics, which has been successful in other studies (4244). Providing integrated mental health care within a diabetes center can decrease barriers for patients in accessing follow-up mental health care and normalize mental health care as part of routine diabetes care. In diabetes centers where behavioral health care specialists are not present, further investigation is needed to determine how best to ensure that follow-up mental health care is obtained.

Limitations

Although chart review was conducted in every individual and the EMR system pulls in clinical information from a variety of clinics and hospitals throughout the state, it is possible that this study underreported mental health utilization if it was not documented in the EMR or captured in facilities or practices that do not use a connecting record system. Additionally, the frequency of mental health follow-up visits, compliance, and length of psychiatric medication use was not always known in this study. Because of the differences in treatment for various forms of depression, type and duration of therapy may be important to note in future studies and be aware of in clinical practice. Although the PHQ-9 is an effective screening tool for depressive symptoms, it does not always indicate diagnosis, as it may overlap with diabetes distress, anxiety, and even emotions related to significant life events. This shortcoming might cause an overestimation of depression.

Documentation of patient refusal to complete a depression screening did not start until April 2017, so the refusal rates during the study period are not complete. However, the current overall clinical depression screening refusal rate is ∼3%. Although not all patients eligible for screening on a given clinic day were screened, we followed up with the missed patients at a later diabetes appointment to complete screening.

Depression screening in the study was also done only in English-speaking patients, as there were no Spanish-speaking members of the suicide risk assessment team to perform follow-up when there was a positive screen. Therefore, the results may not be generalizable to non-English–speaking patients and families. The lack of a Spanish-speaking team member excludes many of the most vulnerable patients facing barriers to care resulting from language and health literacy barriers, who may also be at high risk for depression and SI. For study participants of Hispanic/Latino ethnicity, English fluency was not recorded and may have influenced communication about mental health support to these families. It is essential that future studies include a Spanish-speaking member of the suicidal risk assessment team or a certified translator to avoid excluding this population from screening and research.

Although insurance status was not different between the groups, we could not determine whether socioeconomic status or affordability of mental health care played a role in low rates of accessing follow-up mental health care. It is important to investigate health disparities in mental health care to ensure that equitable care is being provided. Identifying specific barriers to obtaining follow-up mental health care in all patients is important to determine how best to connect patients with mental health care services. This study did not formally assess barriers such as cost and affordability, transportation, resource availability in rural communities, or stigma and preexisting beliefs pertaining to mental health problems. This is an important next step to create a more patient-centered approach to mental health referrals in the type 1 diabetes clinic and improve follow-up care.

Overall, this study found that almost 50% of those who screen positive for depressive symptoms and/or SI lack mental health care follow-up, particularly among males. This study highlights the need for further investigation into barriers to obtaining mental health care services both within and outside of the diabetes clinical setting to provide more complete diabetes care.

Acknowledgment

The authors thank Emma Mason, University of Denver, for help with preparing the manuscript.

Funding

This work was supported by National Institutes of Health (NIH)/National Center for Advancing Translational Sciences Colorado Clinical and Translational Sciences Institute grant UL1 TR002535. The authors are solely responsible for the contents of this article, which do not necessarily represent official NIH views.

Duality of Interest

No potential conflicts of interest relevant to this article were reported.

Author Contributions

K.R.S.W. and S.M. performed the research, wrote the manuscript, and reviewed/edited the manuscript. T.V. and L.P. conducted data analysis and reviewed/edited the manuscript. E.M.Y., E.F.-I., and J.T. performed the research and reviewed/edited the manuscript. J.K.R., J.S.-B., and A.S. reviewed/edited the manuscript. S.M. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

1.
Silverstein
J
,
Klingensmith
G
,
Copeland
K
, et al.;
American Diabetes Association
.
Care of children and adolescents with type 1 diabetes: a statement of the American Diabetes Association
.
Diabetes Care
2005
;
28
:
186
212
2.
Young-Hyman
D
,
de Groot
M
,
Hill-Briggs
F
,
Gonzalez
JS
,
Hood
K
,
Peyrot
M
.
Psychosocial care for people with diabetes: a position statement of the American Diabetes Association
.
Diabetes Care
2016
;
39
:
2126
2140
3.
Foster
NC
,
Beck
RW
,
Miller
KM
, et al
.
State of type 1 diabetes management and outcomes from the T1D Exchange in 2016–2018
.
Diabetes Technol Ther
2019
;
21
:
66
72
4.
Hood
KK
,
Huestis
S
,
Maher
A
,
Butler
D
,
Volkening
L
,
Laffel
LMB
.
Depressive symptoms in children and adolescents with type 1 diabetes: association with diabetes-specific characteristics
.
Diabetes Care
2006
;
29
:
1389
1391
5.
Trief
PM
,
Foster
NC
,
Chaytor
N
, et al
.
Longitudinal changes in depression symptoms and glycemia in adults with type 1 diabetes
.
Diabetes Care
2019
;
42
:
1194
1201
6.
Pompili
M
,
Forte
A
,
Lester
D
, et al
.
Suicide risk in type 1 diabetes mellitus: a systematic review
.
J Psychosom Res
2014
;
76
:
352
360
7.
Fuller-Thomson
E
,
Sawyer
J-L
.
Lifetime prevalence of suicidal ideation in a representative sample of Canadians with type 1 diabetes
.
Diabetes Res Clin Pract
2009
;
83
:
e9
e11
8.
Majidi
S
,
O’Donnell
HK
,
Stanek
K
,
Youngkin
E
,
Gomer
T
,
Driscoll
KA
.
Suicide risk assessment in youth and young adults with type 1 diabetes
.
Diabetes Care
2020
;
43
:
343
348
9.
Matlock
KA
,
Yayah Jones
NH
,
Corathers
SD
,
Kichler
JC
.
Clinical and psychosocial factors associated with suicidal ideation in adolescents with type 1 diabetes
.
J Adolesc Health
2017
;
61
:
471
477
10.
McGrady
ME
,
Laffel
L
,
Drotar
D
,
Repaske
D
,
Hood
KK
.
Depressive symptoms and glycemic control in adolescents with type 1 diabetes: mediational role of blood glucose monitoring
.
Diabetes Care
2009
;
32
:
804
806
11.
Mulvaney
SA
,
Mara
CA
,
Kichler
JC
, et al
.
A retrospective multisite examination of depression screening practices, scores, and correlates in pediatric diabetes care
.
Transl Behav Med
2021
;
11
:
122
131
12.
Marker
AM
,
Patton
SR
,
McDonough
RJ
,
Feingold
H
,
Simon
L
,
Clements
MA
.
Implementing clinic-wide depression screening for pediatric diabetes: an initiative to improve healthcare processes
.
Pediatr Diabetes
2019
;
20
:
964
973
13.
Rewers
A
,
Chase
HP
,
Mackenzie
T
, et al
.
Predictors of acute complications in children with type 1 diabetes
.
JAMA
2002
;
287
:
2511
2518
14.
Roy
MS
,
Roy
A
,
Affouf
M
.
Depression is a risk factor for poor glycemic control and retinopathy in African-Americans with type 1 diabetes
.
Psychosom Med
2007
;
69
:
537
542
15.
Dunger
DB
,
Sperling
MA
,
Acerini
CL
, et al.;
European Society for Paediatric Endocrinology
;
Lawson Wilkins Pediatric Endocrine Society
.
European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents
.
Pediatrics
2004
;
113
:
e133
e140
16.
Rees
G
,
Xie
J
,
Fenwick
EK
, et al
.
Association between diabetes-related eye complications and symptoms of anxiety and depression
.
JAMA Ophthalmol
2016
;
134
:
1007
1014
17.
Wang
SY
,
Andrews
CA
,
Herman
WH
,
Gardner
TW
,
Stein
JD
.
Incidence and risk factors for developing diabetic retinopathy among youths with type 1 or type 2 diabetes throughout the United States
.
Ophthalmology
2017
;
124
:
424
430
18.
Obermannova
B
,
Petruzelkova
L
,
Sulakova
T
,
Sumnik
Z
.
HbA1c but not diabetes duration predicts increased arterial stiffness in adolescents with poorly controlled type 1 diabetes
.
Pediatr Diabetes
2017
;
18
:
304
310
19.
Daniels
M
,
DuBose
SN
,
Maahs
DM
, et al.;
T1D Exchange Clinic Network
.
Factors associated with microalbuminuria in 7,549 children and adolescents with type 1 diabetes in the T1D Exchange clinic registry
.
Diabetes Care
2013
;
36
:
2639
2645
20.
Demirel
F
,
Tepe
D
,
Kara
O
,
Esen
I
.
Microvascular complications in adolescents with type 1 diabetes mellitus
.
J Clin Res Pediatr Endocrinol
2013
;
5
:
145
149
21.
Corathers
SD
,
Kichler
J
,
Jones
NH
, et al
.
Improving depression screening for adolescents with type 1 diabetes
.
Pediatrics
2013
;
132
:
e1395
e1402
22.
Alonso
GT
,
Corathers
S
,
Shah
A
, et al
.
Establishment of the T1D Exchange Quality Improvement Collaborative (T1DX-QI)
.
Clin Diabetes
2020
;
38
:
141
151
23.
Hacker
K
,
Arsenault
L
,
Franco
I
, et al
.
Referral and follow-up after mental health screening in commercially insured adolescents
.
J Adolesc Health
2014
;
55
:
17
23
24.
Wu
P
,
Hoven
CW
,
Cohen
P
, et al
.
Factors associated with use of mental health services for depression by children and adolescents
.
Psychiatr Serv
2001
;
52
:
189
195
25.
Merikangas
KR
,
He
JP
,
Burstein
M
, et al
.
Service utilization for lifetime mental disorders in U.S. adolescents: results of the National Comorbidity Survey-Adolescent Supplement (NCS-A)
.
J Am Acad Child Adolesc Psychiatry
2011
;
50
:
32
45
26.
Merikangas
KR
,
He
JP
,
Brody
D
,
Fisher
PW
,
Bourdon
K
,
Koretz
DS
.
Prevalence and treatment of mental disorders among US children in the 2001–2004 NHANES
.
Pediatrics
2010
;
125
:
75
81
27.
Wagner
JL
,
Ferguson
PL
,
Kellermann
T
,
Smith
G
,
Brooks
B
.
Behavioral health referrals in pediatric epilepsy
.
Epilepsy Res
2016
;
127
:
72
77
28.
Iturralde
E
,
Adams
RN
,
Barley
RC
, et al
.
Implementation of depression screening and global health assessment in pediatric subspeciality clinics
.
J Adolesc Health
2017
;
61
:
591
598
29.
Kroenke
K
,
Spitzer
RL
,
Williams
JB
.
The PHQ-9: validity of a brief depression severity measure
.
J Gen Intern Med
2001
;
16
:
606
613
30.
Richardson
LP
,
McCauley
E
,
Grossman
DC
, et al
.
Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents
.
Pediatrics
2010
;
126
:
1117
1123
31.
Vassilopoulos
A
,
Valenzuela
J
,
Tsikis
J
, et al
.
Pediatric diabetes patients infrequently access outpatient psychology services following screening and referral: implications for practice
.
Child Health Care
2020
;
49
:
202
217
32.
Shapira
A
,
Volkening
LK
,
Markowitz
JT
,
Butler
DA
,
Laffel
LM
.
Mental health providers’ assessment of parents’ reactions to their children’s elevated depressive symptoms
.
Pediatr Diabetes
2021
;
22
:
354
359
33.
Watson
SE
,
Spurling
SE
,
Fieldhouse
AM
,
Montgomery
VL
,
Wintergerst
KA
.
Depression and anxiety screening in adolescents with diabetes
.
Clin Pediatr (Phila)
2020
;
59
:
445
449
34.
Joiner
TE
,
Walker
RL
,
Rudd
MD
, et al
.
Scientizing and routinizing the assessment of suicidality in outpatient practice
.
Prof Psychol Res Pr
1999
;
30
:
447
453
35.
Chu
C
,
Klein
KM
,
Buchman-Schmitt
JM
,
Hom
MA
,
Hagan
CR
,
Joiner
TE
.
Routinized assessment of suicide risk in clinical practice: an empirically informed update
.
J Clin Psychol
2015
;
71
:
1186
1200
36.
Manuel
JI
.
Racial/ethnic and gender disparities in health care use and access
.
Health Serv Res
2018
;
53
:
1407
1429
37.
Broman
CL
.
Race differences in the receipt of mental health services among young adults
.
Psychol Serv
2012
;
9
:
38
48
38.
Latalova
K
,
Kamaradova
D
,
Prasko
J
.
Perspectives on perceived stigma and self-stigma in adult male patients with depression
.
Neuropsychiatr Dis Treat
2014
;
10
:
1399
1405
39.
Benuto
LT
,
Gonzalez
F
,
Reinosa-Segovia
F
,
Duckworth
M
.
Mental health literacy, stigma, and behavioral health service use: the case of Latinx and Non-Latinx Whites
.
J Racial Ethn Health Disparities
2019
;
6
:
1122
1130
40.
Collado
A
,
Zvolensky
M
,
Lejuez
C
,
MacPherson
L
.
Mental health stigma in depressed Latinos over the course of therapy: results from a randomized controlled trial
.
J Clin Psychol
2019
;
75
:
1179
1187
41.
American Diabetes Association
.
Mental health provider diabetes education program
.
42.
Andrews
AR
,
Gomez
D
,
Larey
A
, et al
.
Comparison of integrated behavioral health treatment for internalizing psychiatric disorders in patients with and without type 2 diabetes
.
Fam Syst Health
2016
;
34
:
367
377
43.
Stancin
T
,
Perrin
EC
.
Psychologists and pediatricians: opportunities for collaboration in primary care
.
Am Psychol
2014
;
69
:
332
343
44.
Nansel
TR
,
Iannotti
RJ
,
Liu
A
.
Clinic-integrated behavioral intervention for families of youth with type 1 diabetes: randomized clinical trial
.
Pediatrics
2012
;
129
:
e866
e873
Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at https://www.diabetesjournals.org/journals/pages/license.