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Factors Associated with Suicidal Ideation and Quality of Life in Adolescents from Puerto Rico with Type 1 Diabetes.

Type 1 diabetes (T1D) is an autoimmune disease characterized by the body's inability to produce insulin (1). By 2010, the odds of being diagnosed with diabetes among Puerto Ricans in the United States (US) were 94% higher than such odds were for non-Hispanic whites (2). In 2012, about 208,000 people under 20 years old (0.25%) in the US had diabetes (type 1 or type 2) (3). By then, the crude prevalence of diabetes among adults over 18 years of age in Puerto Rico was 16.4% (4). Puerto Rican children have one of the highest T1D incidences among minorities in US and the highest in Latin America (3, 5, 6).

Coping with T1D is an arduous process that requires adherence to a medical regimen that includes insulin administration, exercise, glucose monitoring, and following a meal plan to prevent further complications. Poor glycemic control (GC) may lead to microvascular complications such as neuropathy, retinopathy, and nephropathy (7, 8). Moreover, accepting T1D represents a challenge to most youths, considering the wish for independence characteristic of this developmental phase. This desire is compromised because of the level of dependence on others that is associated with being a youth with a chronic disease. Resistance to accept their illness could also lead to rebellion towards figures of authority, such as doctors, which can have serious implications in terms of treatment adherence (9, 10).

The difficulties related to having a chronic illness are linked to the prevalence of suicidal behaviors among T1D youth. Research suggests that adolescents with T1D have a higher probability of presenting depressive symptoms and suicidal ideation (SI) (7, 11). Suicidal behavior comprises the wish to die as well as intrusive thoughts about death and possible ways to bring it about. It has been suggested that youths who have had diabetes for a long time, who are highly noncompliant in terms of their treatment, who have 1 or more coexisting psychiatric disorders, and who live in single-parent families, have a higher risk for SI (7, 12). Professionals must be alert to this problem, as it can be related to the improper use of insulin. Little research has been done on somatic complaints and suicidality in this population, although in a past study conducted with adolescents, somatic symptoms were found to predict suicide attempts (13).

In several studies youth with diabetes have presented higher levels of SI than expected, but their suicide attempt rates have been similar to those of the general population (7, 12, 14). In fact, in a study by Goldston et al. (7), although adolescents with diabetes had more suicidal thoughts, they were somewhat less prone to attempt suicide compared to the general community. Yet, in another study, the control group presented more suicidal ideation and attempts. Interestingly, in this study, T1D was also found to be a protective factor for suicidal behavior, at least for males (14).

According to the World Health Organization (WHO), quality of life (QOL) refers to the perception that a person has about his/her life, specific to a particular context and in relation to his/ her expectations and worries (15). Adolescents with diabetes are vulnerable to having a poor health-related QOL (16). It is important to have a measure of QOL that is specifically aimed towards the perceptions that people with diabetes have about their condition, the impact it has on them, and the ways that they manage it (17). Such an instrument provides the tools for the promotion of treatment compliance and for the evaluation of the factors that affect their diabetes-related quality of life (DRQOL) (18). Those factors in adolescents may include the daily and strict tasks regarding self-care and the fear of health-related complications (10).

The presence of psychological symptoms such as depression and anxiety are related to poor QOL (19-22). Low self-esteem, low self-efficacy, and older age in adolescents have also been related to this construct (19). In contrast, it has been found that a high socioeconomic status (23, 24) and perceived family social support in diabetes management are associated with a good QOL (24). Although several studies have shown that GC is associated with this last variable (25-27), others have not found a significant relationship between them (11, 20, 28). Furthermore, it has been suggested that GC does not always accurately reflect an individual's QOL, as while a given individual's GC may be adequate, various stressors can affect his/her psychosocial state (29). These findings emphasize the importance of considering treatments aimed at targeting not only biological aspects but also psychosocial variables related to T1D youths' overall wellbeing (18).

The main objective of this study was to explore the factors related to SI and DRQOL in adolescents from Puerto Rico with T1D. We considered socio-demographics, family social support, depressive and anxiety symptoms, hopelessness, self-care behaviors, barriers to T1D adherence, self-efficacy for diabetes and for depression, helplessness, self-deprecation, cognitive alterations, and anhedonia, as well as interpersonal and activity alterations, as possible correlates of these 2 variables. We also explored whether there was any relation between SI and DRQOL. Based on our reading of the research literature, we hypothesized that SI would be most highly associated with depressive symptoms. Regarding DRQOL, its association with self-care, social support, depression, and anxiety has been well documented, which made us expect similar findings.



This study was part of a major research project whose principal investigator was the second author of this manuscript. The data analyzed proceed from baseline assessments for that main study, which aimed to explore the initial efficacy of cognitive-behavioral treatment for depressed T1D youth. The participants were 51 Latino adolescents (29 girls) from ages 12 to 17 ([bar.x] = 14.78), accompanied by 1 caregiver each. Most of the participating adolescents (98.04%) were Puerto Rican, 56.86% lived in an urban zone, 43.14% lived in the San Juan metropolitan area, and 66.67% attended public schools. They ranged in grade from 6 through 12 ([bar.x] = 9.51, SD = 1.70). Their mean HbA1c value (based on their last private laboratory test prior to enrollment) was 9.14 (range: 5.76-17.70), with 73.5% of their values being over the limit of the current standards (30). The time elapsed since their T1D diagnosis ranged from less than 1 year to 15 years, with most (86.27%) of the adolescents having been diagnosed no less than 2 years prior to their enrollment. Their mean Children's Depression Inventory (CDI) score was of 19.53, suggesting that most presented moderate or severe depressive symptoms. The potential participant had to have obtained a score of 13 or greater on the CDI or a score of 44 or greater on the clinician-rated measure (see Measures) to be included in the main study. Psychotic symptoms, a history of bipolar disorder, recent (in the previous year) substance abuse/dependence, and imminent suicide risk were among the exclusion criteria. A more detailed description of the inclusion and exclusion criteria for the main study is presented elsewhere (31).

Most of the participants (72.55%) were from households with medium-low or low socioeconomic statuses. The mean household size was 4 members (SD = .98; range from 2 to 7). The primary caregivers were mostly (86.27%) women, mainly the biological mothers of the participants. About 45.10% of the youths lived with 2 parents/primary caregivers, while 29.41% and 13.73%, respectively, lived at homes in which the parents/ caregivers were either divorced or separated. About 94.12% of the caregivers were Puerto Ricans. Their ages ranged from 32 to 58 years old ([bar.x] = 43.45, SD = 6.59). Around 52.94% had full-time employment, and 11.76% had part-time jobs.


Socio-Demographic Data Form

We collected data about each adolescent's biological sex, age, ethnicity, employment status, grade, and type (public, private, other) of school attended. The participants' primary caregivers provided much the same information (the first 4 items), as well as details regarding their specific job and their level of education; in addition, perceived socioeconomic status was determined.

Glycemic Control (GC)

Glycosylated hemoglobin levels (HbA1c) were obtained through the participants' laboratory results. In addition to acquiring each participant's most recent results from private laboratories, tests were conducted in laboratory facilities at the University of Puerto Rico Medical Sciences Campus.

Diabetes Quality of Life for Youth (DQOLY) questionnaire

This is a 51-item measure of DRQOL in youth. It includes 3 subscales: satisfaction with life, diabetes impact, and diabetes-related worries (32). With T1D youth from Puerto Rico, the internal reliability of its subscales ranged from .82 (impact) to .90 (satisfaction with life) (10). Higher DQOLY total scores are indicative of worse quality of life (more problems).

Suicidal Ideation Questionnaire-Junior (SIQ-Jr)

This is a 15-item self-report measure for the frequency of suicidal ideation in adolescents. It is rated using a 7-point (0 to 6) Likert-type format (33). In a sample of Puerto Rican youths, this scale had an internal consistency of .91 (34).

Beck Anxiety Inventory (BAI)

This measure of anxiety symptoms consists of 21 items (35). It has adequate validity and reliability with Puerto Rican (alpha = .89) T1D youths (9).

Children's Depression Rating Scale-Revised (CDRS-R)

It consists of 17 clinician-rated items which measure diverse areas of depressive symptomatology in children and adolescents (36). Its internal reliability with Puerto Rican youth is .82 (37).

Self-Care Inventory (SCI)

This is a valid and reliable self-report measure that explores self-care in adolescents with diabetes during the past month. When administered to Puerto Rican youths with T1D, a preliminary internal consistency (alpha) value of .79 was obtained (38).

Diabetes Social Support Questionnaire-Family Version (DSSQ-Family)

This instrument measures the frequency with which family members engage in supportive behaviors and adolescents' perceptions of family support as it relates to 5 aspects of diabetes: insulin use, blood tests, meal plan, exercise, and emotions (39). Its validity and reliability with respect to Puerto Rican youths with T1D has been documented (40).

Youth Helplessness and Hopelessness Scale (EIDA, by its Spanish acronym)

This 17-item measure contains 2 subscales from the Depressive Symptoms Spectrum Assessment Inventory (DSSAI), an indigenous depression scale validated with Puerto Rican youths. The internal consistency values for its subscales is .87 (helplessness) and .89 (hopelessness) (41).

Escala de Autoeficacia para la Depresion en Adolescentes (Self-Efficacy for Depression Scale-Youth; EADA, by its Spanish acronym)

This 28-item scale assesses the perceptions of adolescents with regard to their confidence in their ability to confront situations related to depression. Developed for the Puerto Rican population, it has a high internal consistency and excellent concurrent validity (42, 43).

Self-Efficacy for Diabetes scale (SED)

This is a 35-item scale designed to measure the self-perception or expectations of competence, power, and resources for the successful self-management of diabetes (44). Its internal reliability with Puerto Rican T1D youth is .91 (45).

Undervaluing/Self-reproach and Cognitive Alterations scale (IVARAC, by its Spanish acronym)

This measure also contains 2 subscales from the DSSAI. Its internal consistency is .89 for undervaluing/self-reproach (self-deprecation) and .88 for cognitive alterations (41).

Anhedonia, Interpersonal and Activity Alterations scale (ANEDINA, by its Spanish acronym)

This measure contains parent-rated versions of 3 DSSAI subscales. It was validated for use in the main research study. We used the Activity Alterations subscale, which has an internal consistency of .82 (46).

Barriers to Adherence Questionnaire (BAQ)

It assesses the frequency of both environmental and cognitive events that may be obstacles to regimen adherence (self-care) in people with diabetes (47). We used a parent-rated Spanish version of the BAQ, whose internal consistency in this sample (.80) was similar to that of the original version (values of .84 to.86).

Child Behavior Checklist (CBCL)

This is a measure that is completed by parents and that has been widely used in Puerto Rico. In this study we used the Somatic Complaints subscale, whose internal reliability for rating young women (.68) and young men (.74) is adequate (48).


Information about the main study was disseminated in clinics for T1D, newspapers, and the radio and by distributing printed material at educational and recreational activities. Participants were recruited at summer camps and educational activities and through service providers' referrals and referrals from school personnel and other participants. Caregivers had to complete a participation application, which was evaluated by the project's personnel. This was followed by an appointment with the caregivers and adolescents for an eligibility evaluation. Informed consents were provided by the caregivers and assent was obtained from the adolescents. Finally, the participants and their caregivers completed various instruments through interviews and self-reports. The participants in this study met the full inclusion criteria during the eligibility assessments of the main research project. This study was approved by the IRB offices of both UPR, Rio Piedras (1112-005) and UPR, Medical Sciences Campus (A9530112).

Data analyses

We computed descriptive statistics for the sample description. Using the Pearson correlation coefficient (one-tailed; p [less than or equal to] .05), we explored the relationship of potential correlates with SIQ-Jr and DQOLY total scores (the higher the score, the more severe the problems). To examine the ability of the independent variables to best explain the variance of youth SI or problems in DRQOL, we conducted multiple linear regression analyses (p [less than or equal to] .05).


The Pearson correlation between youth SI and DRQOL issues was .37 (p [less than or equal to] .01). These were the dependent variables in the subsequent regression analyses. Variables associated with youth SI were depressive symptomatology, somatic complaints, perceived family emotional support, anxiety symptoms, diabetes self-care, undervaluing/self-reproach, helplessness, hopelessness, self-efficacy for depression, depression-related cognitive alterations, and barriers to diabetes-treatment adherence (Table 1). Except for somatic complaints, all these, as well as activity alterations and self-efficacy for diabetes, were significantly associated with DRQOL scores, as reported by the participating adolescents. SI did not correlate with the socio-demographic variables evaluated, whereas a significant association was found between QOL and the adolescents' ages (r = .25; p [less than or equal to] .05). The QOL scores did not correlate with HbA1c values measured as a continuous variable, but were significantly associated with obtaining HbA1c values greater than or equal to 7.50 (r = .32; p [less than or equal to] .05). All the correlations that were significant went in the expected direction. The magnitude of the significant correlation coefficients for the variables in Table 1 ranged from .23 to .61 for SI and from .28 to .61 for QOL.

In a multiple regression analysis to explain SI, depressive symptoms, somatic complaints, and perceived family emotional support were the best and only independent predictors, explaining 46% of the variance (Table 2). Depression was the variable with the highest contribution, followed by somatic complaints. To avoid the inflation of the correlation between depressive symptoms and SI, the CDRS-R scores didn't include items about death or suicidal ideas. The best regression model to explain QOL scores reported by the youths in our sample accounted for 61% of the variance (Table 3). This model included independent contributions of variance from cognitive alterations, barriers to adherence, perceived family emotional support, and self-efficacy for diabetes scores. The scores from the Cognitive Alterations subscale were the ones with the most influence ([beta]) on variance.


In this study, we explored the factors associated with SI and DRQOL in T1D youth. Perceptions of poorer QOL and higher frequency of suicidal thoughts were significantly related. Specifically, adolescents' worries about diabetes and the impact the illness has on them can diminish their satisfaction with life and increase the frequency of morbid and suicidal thoughts. In addition, experiencing SI can exacerbate adolescents' difficulties with T1D self-care, leading not only to poorer health but also to more intense diabetes-related worries, thereby having a negative impact on their lives.

As suggested by our findings, suicidal thoughts in T1D youth are related to high anxiety and depressive symptoms and to negative views about themselves, the future, and their ability to cope with depression, as well as to poorer self-care behaviors. However, while some studies have found an association between socio-demographic factors and suicidality, none was found in this study. Results from the multiple regression analysis did, however, support the scientific literature, as they emphasize the predominant role of depressive symptoms as a predictor of suicidality. The fact that, in this sample, somatic complaints and perceived family emotional support contributed additional independent variance on SI shows that somatic and interpersonal factors aggravate this type of symptom in T1D youth. More research on this topic is needed, as the link between somatic complaints and SI has not been well studied in this population. On the other hand, the role of family emotional support is fundamental in the management of T1D due to the emotional baggage involved for adolescents. In depressed T1D youth, a poor perception of diabetes-specific family support could be particularly related to the negative view of others and the world that has been frequently found in patients with depression.

QOL in T1D youth was significantly related to many mental health (e.g., anxiety and depressive symptoms, hopelessness, helplessness, undervaluing/self-reproach, activity alterations, self-efficacy for depression) and diabetes-related factors (e.g., self-care, barriers to adherence, self-efficacy for diabetes). However, as reflected in the multiple regression analysis, the cognitive alterations scores were superior to other possible predictors in explaining unique variance for QOL. This particular finding may be related to some of the individual components of this scale, which included items on rumination, mental fatigue, and difficulty in accepting changes and remembering things. Moreover, these specific cognitive problems may affect diabetes self-care and self-efficacy, resulting in further deterioration in youth QOL.

It is worth noting that perceived family emotional support was the only variable to contribute independently to the variance of both SI and QOL, highlighting its importance as a target in interventions for youth and their families. Such interventions should include not only promoting family behaviors intended to help their children but also working with teenagers to improve their recognition of family efforts to support them. Finally, as occurred in some other studies (11, 20, 28), we found no significant linear association between QOL and HbA1c continuous scores. However, HbA1c values of at least 7.50 and a higher age did correlate with poorer reports of QOL, which is similar to the findings of some other studies.

Because of its small sample size, the statistical power of our study is limited. Nevertheless, our findings stress the importance of emotional, cognitive, behavioral, somatic, and relational aspects in the quality of mental health and QOL of T1D youth in Puerto Rico. Health care providers should be aware of these factors, as they may influence this condition, considering the vast emotional strain it places on the youths who suffer from it. This study stresses the need for professionals and caregivers to be aware of the possibility of SI in adolescents with T1D and the consequences that its presence may bring to their treatment adherence and general well-being. Knowledge about the examined factors should also enhance communications between providers, caregivers, and adolescents as a means to improve the educational process about T1D management and its emotional impact. This study provides useful information for the development of psychosocial interventions aimed at the particular needs of this population, especially by suggesting that somatic and interpersonal aspects (not only cognitive, behavioral, and emotional ones) are important areas to consider when designing such interventions. Health professionals and relatives of T1D adolescents should keep in mind the fact that diabetes influences not only the physical but also the psychological health status of those individuals who have it and that the disease pervasively affects their sense of meaning and satisfaction with life. Further research is needed to assess the efficacy of the available psychosocial interventions in reducing SI and improving DRQOL in this population. We hope that findings from this study may inform about possible adjustments that health professional could make to those interventions to better serve the needs of adolescents with T1D and their families.


This study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases under award number R03DK092547, and by award number 2U54MD007587 from the National Institute on Minority Health and Health Disparities. We thank all the members of our research team and the personnel of the Puerto Rico Clinical and Translational Research Consortium (PRCTRC) for all their support in this project. We also thank the following for their collaboration: the Office of the President of the University of Puerto Rico, Diabetes Pediatric Foundation (FPD, by its Spanish acronym), Sugar Free Kids Foundation, Committee for the Education and Wellbeing of Children and Adolescents with Diabetes (CEBNAD, by its Spanish acronym), Puerto Rico Diabetes Center (CDPR, by its Spanish acronym), Puerto Rican Diabetes Association (APD, by its Spanish acronym), and Puerto Rican Association of Endocrinology and Diabetology (SPED, by its Spanish acronym). A preliminary version of this work was presented at the 35th Annual Research and Education Forum at the University of Puerto Rico, Medical Sciences Campus.


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Grace Guerrero-Ramirez, BA; Eduardo Cumba-Aviles, PhD

Institute for Psychological Research, University of Puerto Rico, Rio Piedras Campus, San Juan, PR

The author/s has/have no conflict/s of interest to disclose.

Address correspondence to: Eduardo Cumba-Aviles, PhD, University of Puerto Rico, Institute for Psychological Research (IPsi), PO Box 23174, San Juan, PR 00931- 3174. Email:
Table 1. Association of variables of interest with suicidal
ideation and quality of life

Variables                              SIQ-JR          DQOLY
                                       Total Score     Total Score

Youth anxiety symptoms                  .28 *           .43 ***
Youth depressive symptoms               .61 ***         .28 *
Perceived family emotional             -.23 *          -.32 **
support (feelings)
Helplessness                            .34 **          .49 ***
Hopelessness                            .34 **          .43 ***
Self-efficacy for depression           -.33 **         -.57 ***
Diabetes self-care behaviors           -.36 **         -.36 **
Self-efficacy for diabetes             -.14            -.43
Somatic complaints                      .33 **          .12
Activity alterations                    .17             .39 **
Undervaluing/Self-reproach              .36 **          .61 ***
Cognitive alterations                   .28 *           .58 ***
Barriers to adherence                   .23 *           .46 ***
Inadequate glycemic control             .16             .32 **
(HbA1c [less than or equal to] 7.50)

Note: SIQ-Jr = Suicidal Ideation Questionnaire-Junior; DQOLY
= Diabetes Quality of Life for Youth; HbA1c = Glycosylated
hemoglobin; * p [less than or equal to] .05;
** p [less than or equal to] .01;
*** p [less than or equal to] .001 (one-tailed).

Table 2. Hierarchical multiple regression to explain
suicidal ideation associated with T1D

Variables                 B           SE     [beta]

First step
  Depressive symptoms     98 ***      .26    .48 ***
Second step
  Depressive symptoms     1.00 ***    .24    .49 ***
  Somatic complaints      2.02 **     .69    .34 **
Final step
  Depressive symptoms     1 03 ***    .22    .51 ***
  Somatic complaints      2 51 ***    .65    .42 ***
  Perceived family
    emotional support     -1.13 **    .36    -.35 **

Variables                 [R.sup.2]     [R.sup.2]
                          Change        Total
First step
  Depressive symptoms     --            .232
Second step
  Depressive symptoms     .117          --
  Somatic complaints      --            .349
Final step
  Depressive symptoms
  Somatic complaints      .112          --
  Perceived family
    emotional support     --            .461

Note: T1D = Type 1 diabetes; B = Regression Coefficient; SE
= Standard Error; [beta] = Standardized Regression
Coefficient; [R.sup.2] = Variance explained; F (3, 47) =
13.47, p [less than or equal to] .001; Adjusted [R.sup.2] =
.43; ** p [less than or equal] .01; *** p [less than or
equal] .001.

Table 3. Hierarchical multiple regression to explain quality of life
problems associated with T1D

Variables                       B           SE      [beta]

First step
  Cognitive alterations         2 41 ***    .48     .58 ***
Second step
  Cognitive alterations         2.06 ***    .46     .50 ***
  Barriers to adherence         .41 **      .14     .33 **
Third step
  Cognitive alterations         2.00 ***    .44     .48 ***
  Barriers to adherence         39 **       .13     .32 **
  Perceived family
  emotional support             -1.41 **    .53     -.27
Final step
  Cognitive alterations         1.80 ***    .40     .43 ***
  Barriers to adherence         .38 **      .12     .31 ***
  Perceived family
  emotional support             -1.32 **    .48     -.26 ***
  Self-efficacy for diabetes    - 35 ***    .10     -.32 ***

Variables                       [R.sup.2]   [R.sup.2]
                                Change      Total

First step
  Cognitive alterations         --          .335
Second step
  Cognitive alterations         .105        --
  Barriers to adherence                     .440
Third step
  Cognitive alterations
  Barriers to adherence         .075        --
  Perceived family
  emotional support                         .515
Final step
  Cognitive alterations
  Barriers to adherence         .097        --
  Perceived family
  emotional support                         --
  Self-efficacy for diabetes                .612

Note: T1D = Type 1 diabetes; B = Regression coefficient; SE
= Standard error; [beta] = Standardized regression
coefficient; [R.sup.2] = Variance explained; F (4, 46) =
18.17, p [less than or equal to] .001; Adjusted [R.sup.2] =
.58; ** p [less than or equal to] .01; *** p [less than or
equal to] .001.
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Author:Guerrero-Ramirez, Grace; Cumba-Aviles, Eduardo
Publication:Puerto Rico Health Sciences Journal
Date:Mar 1, 2018
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