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

Table 3 Stepwise intervention protocol based on risk stratification

Risk level	Clinical features	Recommended intervention strategy
Level 1 (low risk)	Good glycemic control (HbA1c < 7.5%), PHQ-9 < 5, occasional mild diabetes distress, and good family support	Basic support & prevention: Provide routine diabetes education emphasizing mental health importance; encourage participation in diabetes camps or peer support groups to enhance belonging; maintain quarterly routine psychological screening
Level 2 (moderate risk)	HbA1c 7.5%-9.0%, moderate diabetes distress, PHQ-9 indicates mild depression, no suicidal ideation, fluctuating compliance	Targeted intervention: Introduce a psychology nurse specialist or social worker for brief intervention; focus on resolving specific diabetes distress sources (e.g., needle phobia, social embarrassment); consider introducing CGM to reduce management burden but monitor anxiety levels; family sessions to resolve minor conflicts
Level 3 (high risk)	HbA1c > 9.0%, diagnosed with MDD or anxiety disorder, presence of NSSI behavior or eating disorder tendency, and distinct family conflict	Multidisciplinary team intervention: Establish joint rounds with endocrinology + psychiatry + nutrition; initiate CBT (for depression) or DBT (for self-harm) psychotherapy; cautiously initiate SSRI pharmacotherapy; recommend parents partially take over glycemic management responsibility to relieve adolescent burden
Level 4 (extremely high risk)	Recent suicide attempt, recurrent DKA admissions, severe insulin omission, specific suicide plan, and extreme hopelessness	Crisis intervention & hospitalization: Immediate hospitalization (endocrinology ward with enhanced monitoring or psychiatry closed ward); complete takeover of glycemic management responsibility, depriving the patient of independent access to insulin; strict means restriction; initiate family-based therapy to rebuild the family support system and resolve core conflicts

Developed according to the International Society for Pediatric and Adolescent Diabetes Stepwise Care Framework[26,33]. HbA1c: Glycated hemoglobin; PHQ-9: Patient Health Questionnaire 9; CGM: Continuous glucose monitoring; MDD: Major depressive disorder; NSSI: Non-suicidal self-injury; CBT: Cognitive behavioural therapy; DBT: Dialectical behaviour therapy; SSRI: Selective serotonin reuptake inhibitor; DKA: Diabetic ketoacidosis.