Comorbid depression and glycemic instability in adolescent type 1 diabetes: Clinical insights into suicide risk

Table 1 Multidimensional assessment indicators for suicide and self-harm risk

Dimension	High-risk indicators	Clinical pathological significance & mechanism
Metabolic	HbA1c persistently > 9.0% (75 mmol/mol)	Indicates chronic diabetes burnout or covert insulin omission; sustained hyperglycemic environment induces central neuroinflammation, impairing emotional regulation circuits
	Recurrent DKA (> 1 episode in the past year)	After excluding device failure and infection, highly suspect behavioral expression of “emotional dysregulation” or implicit suicide attempts. Each DKA episode intensifies cerebral hypoxia and inflammatory damage
	Frequent severe iatrogenic hypoglycemia	Screen for self-harm via insulin overdose or confusion in diet/insulin matching due to severe depression and cognitive decline
Psychobehavioral	Diagnosed with MDD or anxiety disorder	Depression increases suicide risk 3-6-fold; core symptoms of depression (e.g., avolition, hopelessness) directly undermine the willpower required to maintain complex self-management
	Eating disorders (ED-DMT1/diabulimia)	Insulin omission is the core symptom, carrying an extremely high lethality rate. This is not just an eating disorder but a chronic, devastating form of self-destruction
	History of NSSI (cutting, burning, etc.)	The strongest single predictor of suicide attempts; indicates the patient is habituated to using somatic pain to relieve mental anguish and has increased pain tolerance (acquired capability for suicide)
Social environment	High diabetes-specific family conflict	Parental overcontrol deprives adolescents of autonomy, whereas neglect leads to a lack of support. Both destroy the adolescent’s self-efficacy
	Bullying and social exclusion	Peer rejection due to public device wearing or insulin injection intensifies “disease shame” and social isolation, reflecting “thwarted belongingness” in the interpersonal theory of suicide

The content is adapted from the International Society for Pediatric and Adolescent Diabetes 2022 Guidelines[3,26] and Interpersonal Theory of Suicide[10]. HbA1c: Glycated hemoglobin; DKA: Diabetic ketoacidosis; MDD: Major depressive disorder; NSSI: Non-suicidal self-injury.