Comprehensive Insights into Anxiety, Depression, and Glycemic Control in Adolescents with Type 1 Diabetes and Their Parents: A First Look in Latvia and Implications for Multidisciplinary Care

Abstract

Background/Objectives: Chronic somatic diseases are significant risk factors for the development of mental disorders. Type 1 diabetes mellitus (T1D) is the most common chronic endocrine pathology in children. Treatment requires nutrition management, physical activity, lifelong insulin therapy, and proper self-monitoring of blood glucose. It is complicated and therefore may result in a variety of psychosocial problems for children, adolescents, and their families. Considering the rapidly growing incidence of type 1 diabetes in the pediatric population of Latvia, it is important to detect and prevent the risks of anxiety and depression in families with children suffering from type 1 diabetes. Methods: This was a quantitative interdisciplinary cross-sectional study to determine the prevalence of anxiety and depression in adolescents with T1D and their parents. Two tools were used to detect the presence of symptoms of anxiety and depression: the Generalized Anxiety Disorder Scale-7 (GAD-7) and the Patient Health Questionnaire 9 (PHQ-9) scale. Results: A total of 812 respondents were eligible for screening. Anxiety and depression symptoms were seen significantly more frequently in the study group than in the control group. The study found negative effects of anxiety and depression on the compensation of diabetes. Conclusions: Adolescents with type 1 diabetes and their parents are more predisposed to anxiety and depression symptoms than somatic healthy children and their parents, thus worsening disease control and prognosis.

1. Introduction

Type 1 diabetes (T1D) is one of the most common autoimmune disorders in children and adolescents. T1D is a chronic immune-mediated disease with a subclinical prodrome of variable duration. It is characterized by selective loss of insulin-producing β cells in the pancreatic islets in genetically susceptible subjects and results in the destruction of β cells by the immune system [1,2]. In 2019, an estimated 1,110,100 children and adolescents aged < 19 had T1D worldwide, and the global incidence of T1D has increased annually by 3% since the 1980s [3]. Data from a meta-analysis by Mobasseri et al. of 193 studies between 1990 and 2019 showed a global prevalence of the disease of 9.5 and an incidence of 15 per 100,000 people [4]. A systematic review with a meta-analysis of 126 studies in 55 countries between 2020 and 2022 showed a pediatric type 1 diabetes incidence rate of 14.07 (95% CI, 12.15–16.29) per 100,000 person-years, with variability between different countries and age groups [5]. In Latvia, the number of patients diagnosed with type 1 diabetes mellitus for the first time under the age of 18 has increased from 40 children in 1993 to 90 children in 2020 [6]. The dynamics of the incidence of type 1 diabetes in the child population in Latvia is shown in Figure 1.

During the study period, the Children’s Clinical University Hospital registered approximately 670 children with type 1 diabetes mellitus, including 465 children between the ages of 12 and 18 [6,7]. In 2021, when the research data were collected, the population of Latvia was 1,893,223, including 121,702 children ages 12 to 18 [8,9]. Individuals diagnosed with diabetes mellitus must undergo significant lifestyle adjustments, adhering to a strict regimen that involves frequent blood glucose monitoring, multiple daily insulin injections, and careful consideration of carbohydrate consumption and physical activity. The only available treatment is lifelong insulin therapy, which can be a considerable psychological burden not only for the patient but also for their family members, potentially contributing to the onset of mental health disorders such as anxiety and depression, as documented in previous research [10,11,12,13].

The relationship between anxiety, depression, and type 1 diabetes is multifactorial, involving biological, psychological, and social factors. It is impossible to strictly separate groups of factors; they overlap and mutually influence each other. Anxiety and depression, which belong to the group of diagnoses of mental disorders, have an integral biological background. Stress and depressed mood reduce an individual’s ability to perform daily duties, creating impairments in social, professional, and interpersonal functioning [14,15]. Type 1 diabetes, as a chronic and incurable disease that, once diagnosed, requires an immediate and drastic lifestyle change, is a risk factor for the development of anxiety and depression [16,17]. It is characterized by increased circulating cytokines in autoimmune diabetes, a lack of insulin affecting neurogenesis and neurotransmitter metabolism, as well as chronic hyperglycemia or iatrogenic hypoglycemia that activates the hypothalamic–pituitary–adrenal axis, thus increasing the risk of emotional lability and affective fluctuations [18]. On the other hand, the conditional stress of psychological factors against the background of genetic predisposition is considered one of the factors contributing to the development of type 1 diabetes. Increases in serum concentrations of glucocorticoids and catecholamines increase the need for insulin and insulin resistance. This approach is defined by the “β cell stress hypothesis” [19]. Pancreatic β cells provide regulation of glucose homeostasis in the body by secreting insulin. The high secretory activity of the cells is ensured by a functional and healthy endoplasmic reticulum. Disruption of endoplasmic reticulum homeostasis and the chronic need for intensive insulin secretion can lead to β cell dysfunction and death. Type 1 diabetes is defined as a chronic inflammatory disease caused by the autoimmune destruction of β cells. Although autoimmunity is an important part of the pathogenesis of the disease, there is a growing body of evidence that also shows the essential role of β cell endoplasmic reticulum stress and aberrant unfolded protein response in the initiation and progression of type 1 diabetes [20]. Sipetic et al. noted the possibility that psychological, biological, and social stressors that cause excessive catecholamine and cortisol release increase the need for insulin with subsequent β cell overload, contributing to the development of type 1 diabetes [21]. Studies show that depression increases the risk of micro- and macrovascular complications of diabetes and predicts earlier development of complications and higher mortality. Both diabetes and depression reduce an individual’s quality of life and mutually potentiate each other [18]. Daily management of diabetes and continuous glycemic control to minimize the risk of complications often leads to anxiety and/or depression, which in turn biologically contributes to hyperglycemia and worsens diabetes compensation rates. The “vicious circle” of pathogenesis is formed.

The global prevalence of anxiety in the adult population is 3.9%, including 4.9% in Europe, 6.2% in the USA, and 6.4% in Latvia [22,23]. A worldwide prevalence of anxiety of 6.5% is reported in the pediatric population [24]. In Latvia, there have been no specific prevalence studies on anxiety among children and adolescents. The most common psychosocial factors associated with anxiety in the adolescent population are loneliness, bullying, physical violence, poor relationships with parents, and lack of peer support [25].

The prevalence of depression in Europe has an average of 6.9% [26]. Studies of the population of Latvia show a prevalence of depression from 6.4% [27] to 6.7% [28]. The prevalence of depressive disorders in Latvia is comparable to global and European data. A systematic review and meta-analysis by Lu et al. showed that depression is prevalent among children and adolescents worldwide, with prevalence estimates of mild-to-severe depression at 21.3%, moderate-to-severe depression at 18.9%, and major depression at 3.7% [29]. Until now, there have been no studies on the prevalence of depression in the general population of Latvian children and adolescents.

Depression plays an important role in the course and outcome of chronic diseases. Patients with diabetes have double the risk of developing depressive disorders compared to somatically healthy individuals. Depression is associated with the adaptation period after the diagnosis of diabetes, diabetes compensation, and the indicator of the development of diabetes complications—elevated glycated hemoglobin. Depression is recognized and treated in less than 25% of the diabetic population. Elevated rates of depression have consistently been associated with diabetes. The results of a meta-analysis indicate that depression is twice as prevalent among people with diabetes than it is among persons without diabetes [30]. Adolescents with type 1 diabetes are 2.3 times more likely to have mental health problems than somatically healthy young people. When diagnosed with type 1 diabetes for the first time, the family experiences an acute psychological crisis with subsequent phases of shock, reaction, processing, and acceptance. Necessary changes in habits and lifestyle can lead to mental disorders, most commonly anxiety, depression, and eating disorders [16,31,32]. Parents play a critical role in the care of children with T1D. Parental concern for diabetes control is determined by the child’s age. A child’s self-determination abilities increase with age. In the case of diabetes, parents’ concerns about the child’s autonomy are reasonably greater than for parents of healthy children. However, greater child autonomy results in better adherence and more productive management of diabetes [33,34,35]. Meanwhile greater child autonomy is ensured by constructive relationships with parents. Needle phobia can cause additional anxiety in both children and parents, which is associated with poorer diabetes control indicators. Moreover, concerns about diabetes control may differ between children and parents. In general, the family microclimate and relationships between relatives play a significant role in disease management and quality of life [36,37]. A parent’s ability to take responsibility for disease control depends on many factors, including the caregiver’s mental health. It has been proved that anxious, stressful, and depressed parents are less able to control diabetes [38,39,40]. Otherwise, the mental state of parents affects the child and potentiates the development of depressive symptoms in adolescents with T1D [41]. A meta-analysis by Buchberger et al. showed that depressive symptoms are prevalent in up to 30% and symptoms of anxiety are present in up to 32% of children and adolescents with type 1 diabetes. A correlation was observed between the symptom level and glycemic control. It was proved that anxiety and depression symptoms negatively affect glycemic control [17,42,43]. Similar results were obtained in a systematic review and meta-analysis by Akbarizadeh et al. They found that the prevalence of anxiety and depression among children with T1D was 17.7% and 22.2%, respectively. The prevalence of depression was higher in lower-middle-income countries, reaching 29.3%. The results of the present study indicate the importance of paying attention to extensive periodic screening and appropriate activities to reduce pediatric depression [44].

To date, no interdisciplinary studies have been conducted in Latvia to assess the prevalence of anxiety and depression among adolescents diagnosed with type 1 diabetes mellitus (T1D). The aim of this study is to determine the symptoms of anxiety and depression in adolescents with type 1 diabetes mellitus and their parents. The following tasks of the research were to identify symptoms of anxiety and depression in children with T1D and their parents, detect symptoms of anxiety and depression in somatic healthy children and their parents, and compare the results in the target and control groups. We predict that in Latvia, adolescents with type 1 diabetes mellitus ages 12 to 18 and their parents have anxiety and depression symptoms more often than the general population, and the frequency of symptoms depends on the duration of the disease, the level of diabetes compensation, and sociodemographic factors. Permission No 6-1/07/46 was obtained from Riga Stradins University Ethics Committee to conduct the study.

Comprehensive treatment of type 1 diabetes requires an interdisciplinary approach involving the collaboration of several specialists (an endocrinologist, a family doctor, a diabetes nurse, a social worker, a psychologist/child psychiatrist, and a nutritionist) [30,45].

2. Materials and Methods

2.1. Participants

This study was carried out at the Children’s Clinical University Hospital, specifically in the outpatient department, as well as in general practitioner (GP) practices. Participants were recruited based on availability during routine outpatient visits. Both adolescents and their parents received detailed information regarding the study’s objectives and methodology, after which they provided informed consent to participate. The study population was divided into 2 groups: the target group consisting of adolescents with T1D ages 12–18 and their parents (N = 502; 251 child–parent dyads) and the control group consisting of somatic healthy adolescents ages 12–18 and their parents (N = 310; 155 child–parent dyads). A total of 812 respondents were eligible for screening. The criteria for recruiting the research group were children ages 12–18 who were diagnosed with type 1 diabetes with an absence of other chronic diseases and diagnosed mental disorders. The children’s parents were people without chronic somatic illnesses and without diagnosed psychiatric disorders. Respondents were randomly selected during routine endocrinologist visits at the outpatient department of the Children’s Clinical University Hospital. The respondents represented all statistical regions of Latvia. Somatically healthy 12- to 18-year-old children and their parents without previously diagnosed psychiatric disorders were selected for the control group. The control group was recruited randomly in the practices of family doctors during preventive visits in different cities and rural areas of Latvia. The choice of the parent involved in the study—mother or father—was random and related to the parent who had visited a pediatric endocrinologist (in the research group) or a family doctor (in the control group).

2.2. Measurements

To assess symptoms of anxiety and depression, two validated instruments were employed: the Generalized Anxiety Disorder Scale-7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9). The GAD-7 is a self-reported questionnaire consisting of seven items designed for screening and severity assessment of generalized anxiety disorder. Its validity in Latvia was established by J. Vrublevska et al. [46]. Participants were required to indicate how much they had been affected by seven specific symptoms (e.g., nervousness, anxiety, or restlessness) over the past two weeks. Anxiety severity was determined on a scale from 0 to 21 based on responses categorized as “Not at all”, “Several days”, “More than half the days”, and “Nearly every day” [47]. The cut-off scores for mild, moderate, and severe anxiety were set at 5, 10, and 15, respectively [48]. A score of 10 or above was considered the threshold for generalized anxiety, with research indicating a sensitivity of up to 89% and a specificity of 82% [47].

Similarly, the PHQ-9 serves as a self-report tool to gauge the severity of depressive symptoms. Originally validated by Kroenke et al. in 2001, the instrument was later adapted and standardized for use in Latvia by J. Vrublevska et al. [49]. Participants were asked how frequently they had experienced various issues over the preceding two weeks, with nine symptoms explicitly listed [50]. The PHQ-9 scores range from 0 to 27, as each of the nine items is rated on a scale from 0 (“Not at all”) to 3 (“Nearly every day”) [51]. The severity levels of depression were classified based on score thresholds: 5 for mild, 10 for moderate, 15 for moderately severe, and 20 for severe depression [48]. The threshold value for clinically significant depression is 10 or more points, which is proven by the combined sensitivity of 85% and specificity of 85% obtained in studies [52]. Socio-demographic data—including age, gender, family size, household composition, marital status, parental education and employment, and income per family member per month (Appendix A,

Table A1. Distribution of respondents by sociodemographic data (N = 812).

Sociodemographic Characteristics		Study Group (N = 502)		Control Group (N = 310)
		Child (N = 251)	Parent (N = 251)	Child (N = 155)	Parent (N = 155)
Age (years)	12–15	165	-	111	-
	15.1–18	86	-	44	-
	30–40	-	55	-	69
	41–50	-	131	-	80
	51–60	-	67	-	6
Gender	female	140	218	89	150
	male	111	33	66	5
Number of children in family	1	-	63	-	40
	2	-	112	-	66
	3 or more	-	76	-	49
Number of persons in the household	2	25		21
	3	77		45
	4	90		54
	5 or more	59		35
Marital status	single parent	-	59	-	38
	married (incl. unregistered)	-	192	-	117
Parent education	primary	-	17	-	10
	secondary	-	92	-	47
	bachelor’s	-	77	-	36
	master’s		44	-	45
	other		21	-	17
Parents’ employment	paid work	-	186	-	110
	self-employed	-	19	-	15
	several places of work	-	7	-	8
	unemployed	-	23	-	17
	other	-	16	-	5
Income per family member per month (€)	less than 128.07	10		7
	128.07–300	44		29
	301–500	96		44
	501–700	50		31
	701 or more	51		44

)—as well as clinical information such as T1D duration, symptoms at diagnosis, diagnosis location, HbA1c levels, glycemic control methods, and insulin administration approaches, were collected via a questionnaire designed by the authors and supplemented with data from patients’ medical records.

2.3. Data Processing and Analysis

The quantitative data did not correspond to the normal distribution as assessed with the Q-Q plot and Shapiro–Wilk test; therefore, medians with interquartile ranges (IQRs) were used for continuous variables. Counts and percentages were given for categorical variables. Differences between the anxiety and depression levels of the study and control groups were determined using the Mann–Whitney U test. The Kruskal–Wallis H test was used to compare anxiety and depression between T1D duration time points. Correlational analyses (Spearman) examined the relationship between variables (anxiety and depression scores), sociodemographic data, and disease-specific parameters. The Chi-square goodness-of-fit test was conducted to evaluate the data distribution of severity of anxiety and depression symptoms. A p value < 0.05 was considered statistically significant. MS Excel 365 software and IBM SPSS Statistics 25.0 were used for statistical data processing. To examine potential mediating effects, general linear models (GLMs) were employed to assess the relationship between the dependent variable (glycated hemoglobin, HbA1c) and independent variables (child anxiety and depression). For data that did not follow a normal distribution, mediation effects (MEs) were evaluated using the bootstrap technique with 10,000 resampling iterations. A 95% confidence interval (CI) was determined by calculating the unstandardized MEs at the 2.5th and 97.5th percentiles. Statistical analyses were performed using Jamovi 2.5.5 statistical software and R software version 4.1.2.

3. Results

The study was conducted as a cross-sectional interdisciplinary study. A total of 812 respondents were eligible for screening. The study population was analyzed from two perspectives—the study and control group—as well as the subgroups of adolescents (Mage 14.49, age range 12–18 years, N = 406) and parents (Mage 44.67, age range 30–58 years, N = 406). The study group consisted of adolescents with T1D and their parents (N = 502; 251 child–parent dyads), and the control group consisted of somatic healthy adolescents and their parents (N = 310; 155 child–parent dyads). More than a half of the adolescent participants (56%) and most parent participants (92%) were female. Sociodemographic data included age, gender, level of education, employment, marital status, number of children in the family, and income per family member.

3.1. Characteristics of the Adolescents by Disease-Specific Factors

Clinical data were collected on 251 adolescents with T1D (

Table 1. Distribution of adolescents with T1D by disease-specific characteristics (N = 251).

Disease-Specific Characteristics of Adolescents with T1D		n	%
Duration of T1D	Less than a year	26	10.4
	1–3 years	65	25.9
	4–6 years	69	27.5
	7–10 years	48	19.1
	More than 10 years	43	17.1
Symptoms before T1D diagnosis	Few days	39	15.5
	One week to one month	149	59.4
	More than a month	63	25.1
Place of diagnosis	Outpatient	84	33.5
	Inpatient	78	31.0
	Inpatient—in the intensive care unit	89	35.5
HbA1c (%)	Optimal (HbA1C < 7%)	35	13.9
	Suboptimal (HbA1C = 7–9%)	129	51.4
	Poor (HbA1C > 9%)	87	34.7
Type of glycemic control	Symptomatically (by feelings)	6	2.4
	With a glucometer	131	52.2
	With continuous glucose monitoring and glucometer	114	45.4
Method of insulin administration	With insulin pen	173	68.9
	With insulin pump	78	31.1

). Duration of illness in 17.1% of the subjects exceeded 10 years. Diabetes-specific symptoms (weakness, thirst, frequent urination, weight loss, increased appetite) were present in all respondents prior to diagnosis. For more than half of the subjects, they lasted from one week to one month. Among the adolescents with T1D, 66.5% were diagnosed as inpatient, and 35.5% received intensive care. Insufficient compensation for diabetes (HbA1c > 7%) was found in most respondents. In 86.1% of cases, HbA1c level exceeded 7%. In Latvia, the guidelines of the International Society for Diabetes in Children and Adolescents are used for diabetes care, which set the HbA1c threshold value for optimal diabetes compensation at <7.0% (average glycemia 8.6 mmol/L) [53]. Blood sugar was controlled daily by most respondents. In 45.4% of cases, a continuous glucose monitoring system was used. Insulin was administered using an insulin pen (68.9% of cases) or an insulin pump (31.1% of cases).

3.2. Anxiety and Depression

Anxiety and depressive symptoms were present in both study groups. However, the intensity of symptoms varied. In the parental population, anxiety of varying severity (mild to severe) was observed in 86.5% of respondents in the study group and 62.6% of respondents in the control group. In the adolescent population, anxiety was reported at various levels in 85.7% of cases in the study group and 67.1% cases in the control group. Assessing the symptoms of anxiety and depression, in general, the rates were statistically significantly different in the study and control groups (p < 0.001) (

Table 2. Comparison of anxiety and depression scores between the study and control groups.

Parameters	Study Group (Median (IQR))	Control Group (Median (IQR))	p Value	Value U
GAD-7 (parents)	15.00 (7.00–19.00)	5.00 (4.00–10.00)	<0.001	8863.000
PHQ-9 (parents)	14.00 (6.00–21.00)	6.00 (3.00–10.00)	<0.001	10,263.500
GAD-7 (child)	14.00 (6.00–19.00)	7.00 (4.00–12.00)	<0.001	11,910.500
PHQ-9 (child)	13.00 (6.00–20.00)	7.00 (3.00–14.00)	<0.001	13,126.500

).

GAD-7 and PHQ-9 scores were higher in the study group than in the control group, indicating a higher degree of anxiety and depression. The study group had a statistically significantly higher number of respondents with moderate to severe symptoms of anxiety and depression. Absence of symptoms of anxiety and depression prevailed in the control group (Figure 2 and Figure 3).

Severe, generalized anxiety was detected in 49% adolescents suffering from T1D and 52.6% of their parents. Severe depression was observed in 30.8% adolescents and 35.5% of their parents. In contrast, in the control group, 16.1% of adolescents and 7.8% of parents had severe anxiety symptoms. Severe depression was detected in 11.6% of adolescents and 4.5% of parents in the control group. Further, 17.9% of adolescents with T1D experienced symptoms of moderately severe depression vs. 11.6% of adolescents in the control group. The Chi-squared analysis indicated a non-random distribution of symptom severity. The target group demonstrated a significantly greater prevalence of severe anxiety and depression, while the control group showed a higher incidence of mild or no symptoms (

Table 3. Chi-squared goodness-of-fit: anxiety and depression symptom severity distribution between the study and control groups.

Severity of Symptoms	Target Group (N = 502)		Control Group (N = 310)
	Adolescents with T1D (N = 251)	Parents (N = 251)	Adolescents (N = 155)	Parents (N = 155)
Symptoms of anxiety, n (%)
Severe	123 (49.0)	132 (52.6)	25 (16.1)	12 (7.8)
Moderate	31 (12.4)	26 (10.4)	31 (20.0)	27 (17.4)
Mild	61 (24.3)	59 (23.5)	48 (31.0)	58 (37.4)
No symptoms	36 (14.3)	34 (13.5)	51 (32.9)	58 (37.4)
p-value	<0.001	<0.001	<0.001	<0.001
Symptoms of depression, n (%)
Severe	77 (30.8)	89 (35.5)	18 (11.6)	7 (4.5)
Moderately severe	45 (17.9)	36 (14.3)	18 (11.6)	10 (6.5)
Moderate	34 (13.5)	28 (11.2)	27 (17.4)	27 (17.4)
Mild	49 (19.5)	62 (24.7)	44 (28.4)	53 (34.2)
No symptoms	46 (18.3)	36 (14.3)	48 (31.0)	58 (37.4)
p-value	<0.001	<0.001	<0.001	<0.001

).

The Kruskal–Wallis H test demonstrated a significant difference in anxiety and depression between T1D duration time points (p < 0.001). Higher levels of anxiety and depression in the study population were in the subgroups that defined the duration of the disease as “less than 1 year” and “7–10 years”. In addition, the dynamics of the indicators were similar both in anxiety and depression scores as well as in subpopulations of parents and children (Figure 4 and Figure 5).

3.3. Diabetes Compensation

To evaluate the relationship between anxiety and depression levels of patients and the relationship with metabolic control of their diabetes, we assessed the last HbA1c levels. According to the guidelines of the International Society for Pediatric and Adolescent Diabetes, the threshold value that determines optimal diabetes compensation is a glycated hemoglobin (HbA1c) level below 7% [53]. Adolescents were divided into three subgroups according to their glycated hemoglobin level—optimal, suboptimal, and poor diabetes control (Table 1). There was a statistically significant difference between anxiety and depression level between the subgroups.

The results of the study showed an association between anxiety/depression rates and glycated hemoglobin in both the subgroups of parents and children (r > 0.5, p < 0.001). A strong positive correlation was observed between diabetes control (HbA1c) and stress-related mental health conditions (GAD-7 and PHQ-9) (

Table 4. Correlation between anxiety/depression and HbA1c.

		HbA1c	GAD-7 Child	PHQ-9 Child	GAD-7 Parents	PHQ-9 Parents
Spearman’s rho	HbA1c
	GAD-7 child	0.68 **
	PHQ-9 child	0.66 **	0.87 **
	GAD-7 parents	0.75 **	0.73 **	0.66 **
	PHQ-9 parents	0.71 **	0.70 **	0.68 **	0.85 **

N = 502; ** p < 0.001.

).

A Spearman rank correlation test showed significant positive associations (r > 0.5, p < 0.001) between diabetes control level (optimal, suboptimal, or poor) and severity of anxiety and depression (Figure 6 and Figure 7).

During the study, a mediation analysis was performed. The results were published previously [54]. In the primary data analysis, the potential predictors of HbA1c level among individual and environmental (parental and socioeconomic) factors of the child were determined using the multivariate linear regression method. A strong positive association (r_s > 0.5) between HbA1C and the child’s anxiety and depression scores was detected by the semi-partial Spearman correlation method. Thus, the mediation analysis was performed with the aim of finding the indirect or mediated relationship between glycated hemoglobin and the mental state of the child, characterized by anxiety and depression indicators. The general linear models mediation analysis (GLM) assessed the mediating role of parental anxiety (GAD-7 score) and depression (PHQ-9 score) in the relationship between the independent variables (child’s GAD-7 and PHQ scores) and dependent variable (glycated hemoglobin) (Figure 8).

The results of the mediation analysis indicated that the effect of the child’s GAD-7 on HbA1c was significant (β = 0.479; z = 4.30; p < 0.001), but the effect of the child’s PHQ-9 on HbA1c was nonsignificant (β = 0.166; z = 1.49; p = 0.135). When the third variable (mediator) was included in the analysis, the influence of parents’ GAD-7, child’s GAD-7, and PHQ-9 on HbA1c became nonsignificant (respectively, β = 0.113; z = 0.98; p = 0.326 and β = 0.068; z = 0.74; p = 0.458). A significant indirect effect of child GAD-7 and PHQ-9 score (β = 0.366; z = 4.31; p < 0.001 and β = 0.098; z = 2.56; p = 0.010, respectively) on glycated hemoglobin was found through the mediator of parents’ anxiety. Thus, the mediation analysis revealed that the relationship between the dependent variable (HbA1c) and the independent variables (child GAD-7 and child PHQ-9) was fully mediated through parental anxiety (GAD-7).

There were no statistically significant differences in anxiety and depression rates observed in adolescents with T1D depending on the type of glycemic control and the form of insulin administration.

3.4. Sociodemographic Data

Anxiety and depression scores were analyzed in relation to the following sociodemographic data—age, gender, number of children in family, number of persons in the household, marital status, education, employment, and income. No statistically significant associations were found between respondents’ anxiety and depression symptoms and age, number of children and persons in the household, or income in either group.

Anxiety and depression symptom scores were statistically significantly different between both genders. Female respondents had higher anxiety and depression scores than male respondents (

Table 5. Comparison of anxiety and depression scores between genders.

Median (IQR)	Parents				Children
	Study group
	Female	Male	p	U	Female	Male	p	U
GAD–7	16.00 (7.00–20.00)	8.00 (5.00–17.00)	0.012	2621	15.00 (8.50–19.00)	10.00 (5.00–19.00)	0.019	6416
PHQ–9	16.00 (7.00–22.00)	7.00 (5.00–19.00)	0.016	2662	16.00 (8.00–21.00)	11.00 (4.00–20.00)	0.024	6466
	Control group
GAD–7	6.00 (4.00–10.00)	4.00 (3.00–7.00)	0.032	1093	9.00 (4.00–13.00)	6.00 (2.75–10.00)	0.005 *	2170
PHQ–9	7.00 (4.00–10.00)	4.00 (3.00–7.00)	0.107 *	1198	10.00 (4.50–16.50)	6.00 (2.00–9.25)	0.001	2017
	Study and control group together
GAD–7	10.00 (5.00–18.00)	7.00 (4.00–12.75)	0.002	7337	12.00 (6.00–18.00)	7.00 (4.00–17.00)	0.001	16,285
PHQ–9	10.00 (5.00–19.00)	6.00 (4.00–13.50)	0.007	7587	12.00 (6.00–20.00)	8.00 (4.00–16.75)	<0.001	15,892

* p ≥ 0.05 statistically significant differences were not found.

). The differences were analyzed both together and separately in the study and control groups, maintaining the division into children’s and parents’ populations. The level of statistically significant differences (p < 0.05) between both genders was not reached in children’s anxiety scores in the control group (p = 0.005) or parents’ depression scores in the control group (p = 0.107).

Statistically significant differences (p < 0.05) in depression scores were found between single and married parents in the study group. Single parents and their children had higher levels of depression: parents’ PHQ-9 median (IQR) 20.00 (8.00–22.00) and children’s PHQ-9 median (IQR) 18.00 (7.00–22.00)) vs. married parents’ PHQ-9 median (IQR) 11.00 (5.75–20.00) and children’s PHQ-9 median (IQR) 11.5 (5.00–20.00).

4. Discussion

This study was a quantitative interdisciplinary cross-sectional study to determine the prevalence of anxiety and depression in adolescents with T1D and their parents. A total of 812 respondents were eligible for screening.

The association between anxiety, depression, and T1D has been demonstrated in many studies. Study results confirm the high prevalence of anxiety and depression symptoms in youth with T1D [12,17,30,42,44]. Our results have found that T1D patients and their parents are more prone to developing anxiety and depression than somatic healthy adolescents and their parents. The results of the study coincide with the data of the previously discussed studies. Studies reveal comorbidities of anxiety and depression. A. Galler et al. described the simultaneous symptoms of anxiety and depression in adolescents with T1D [42]. Our study found a very strong statistically significant positive correlation (r > 0.8) between anxiety and depression in both subgroups—parents and children. In accordance with the data and statistics of previous studies [55,56,57,58,59], in our study, female respondents had statistically significantly higher levels of anxiety and depression than male respondents. The results of many studies show that parents of children with type 1 diabetes have increased levels of anxiety and depression. This is determined by the complex management of diabetes, which is influenced by the parents’ belief in the ability to achieve the given goal. High parental self-efficacy predicts better diabetes monitoring and compensation [39]. Parental anxiety is associated with higher self-reported levels of anxiety and depression, conduct problems, and lower ratings of child quality of life [38]. One of the inclusion criteria for the study was that respondents had no previously diagnosed mental health disorders. Therefore, it can be presumed that the study population had not received professional psychological support. It is possible that if the respondents had received psychological assistance, anxiety and depression scores would have been lower in both the study and control groups. The psychological health of families is determined by such factors as the parents’ interrelation, their mental health, and the quality of their relationship with the child. Good and mutually supportive family relationships reduce stress and conflict related to diabetes [60]. Another important criterion for the healthy development of an adolescent with type 1 diabetes is the age-appropriate delegated responsibility of the parents for the control of the disease. Parent-supported adolescent autonomy promotes a child’s diabetes-related competence and psychological and physical well-being [34]. In Rawdon et al.’s study of parents’ perspectives on the self-management responsibilities of teenagers with type 1 diabetes, several areas that should be considered in the communication process were clarified. They are characterized by parental factors, quality of the parent–adolescent relationship, communication strategies, adolescent factors, communication triggers, and family or systemic factors. Improving mutual communication and relationships contributes to a better understanding of disease and its management among adolescents, promoting their autonomy [61].

The prognosis of diabetes is determined by diabetes control, one criteria of which is HbA1c—the reference method—which reflects glycemia over the preceding 4 to 12 weeks. The International Society for Pediatric and Adolescent Diabetes (ISPAD) recommends an HbA1c target level < 7%. The HbA1c value of 53 mmol/mol (7%) was chosen with the aim of avoiding long-term microvascular and macrovascular complications of diabetes [62]. The results of this study are consistent with previous studies showing that HbA1c levels do not meet the target value in most adolescents with T1D [17,42,45,62,63,64]. Better control and compensation of diabetes is considered a preventive factor for mental disorder development. Good mental health is a precondition for better self-management of diabetes. There is an inverse relationship between self-control and psychosocial complications [45]. The correlation between anxiety, depression, and poor glycemic control in children and adolescents with T1D has been repeatedly confirmed in different research studies. However, the results of previous studies are controversial. While some studies have found a positive relationship, others have not [63]. Like previous studies [17,43,65,66], ours also demonstrates the association of diabetes control with levels of anxiety and depression. We found a statistically significant association between HbA1c level and symptoms of anxiety and depression in both study group subpopulations—parents and children. Individual studies have analyzed the indirect effects of various factors on the metabolic compensation of diabetes. Mediation analyses prove that increased HbA1c is indirectly (via mediators) associated with anxiety and depression via diabetes-specific distress [67,68], reduced sleep duration via diabetes management [69], family income via nonadaptive parenting constructs [70], family conflict and parental monitoring via diabetes selfcare [64], and caregiver depression via diabetes-specific burden [71]. A mediation analysis conducted by the authors demonstrated that parental anxiety fully mediates the association between HbA1c levels and child anxiety (B = 0.366, z = 4.31, p < 0.001) [54].

Data from a meta-analysis of 32 studies by P. DeCosta et al. showed a high prevalence of stress and depression as transient in the first year and after two years of diagnosis of T1D [72]. In our study, the highest levels of anxiety and depression screening were found in the first year of the disease and 7–10 years after the diagnosis of T1D.

Sociodemographic factors such as age, number of children in the family, number of persons in the household, employment, education, and income did not show statistically significant associations with the level of anxiety and depression. Female gender and single-parent status (in the study group) were associated with higher anxiety and depression scores.

In Latvia, specially developed clinical pathways are used for the care of children with type 1 diabetes. These include outpatient and inpatient diagnosis, follow-up outpatient care, and information on options for children with type 1 diabetes and their families. Care for a child with type 1 diabetes is expected to include diabetes education, insulin therapy, diet plan, physical activity, glycemic control, monitoring for diabetic complications, and comorbidities. The child and his family should also receive psychological and social care. When diabetes is diagnosed, the training of patients and family members starts in the hospital. Diabetes training is continued on an outpatient basis according to individual needs [73].

The advantage of the research is its novelty in the Latvian context. Despite the widely performed screenings for anxiety and depression of children with type 1 diabetes and their parents in world science, this study is being conducted for the first time in Latvia. Until now, no interdisciplinary research has been undertaken in Latvia to investigate the prevalence of anxiety and depression among adolescents with chronic somatic conditions, including T1D. Determining the prevalence of anxiety and depression in adolescents with T1D and their parents would give an idea of the objective situation in Latvia to detect and treat anxiety and depression symptoms in a timely manner as well as to establish interdisciplinary cooperation among diabetes care professionals. The importance of the study in the context of Latvia as a northern European country is highlighted by the increasing incidence of type 1 diabetes in the pediatric population. Studies have shown that the highest incidence of type 1 diabetes is related to geographical region, and the highest rates are in northern countries. A scoping review by Gomber et al. reported that the highest incidence rates of type 1 diabetes in the age group from 0–14 years was reported in Northern Europe (23.96 per 100,000) [74]. The European region has reported the fastest growing incidence of type 1 diabetes in the population of young people and adolescents (from 11.8 to 18.8 cases per 100,000 inhabitants) in the period from 1990 to 2019 [75]. A rapid increase in incidence in the European region was also shown by a systematic review and meta-analysis by Ruiz-Grao et al. The incidence of type 1 diabetes increased in both sexes in the age group of 0 to 14 years from 10.85 per 100,000 person-years from 1994 to 2003 to 20.96 (95% CI, 19.26–22.66) per 100,000 person-years from 2013 to 2022 [76]. Therefore, in Latvia, as a country at risk, interdisciplinary studies of this type are particularly important. Among the strengths of the study is the relatively high coverage of the studied group. In 2021, 670 children (335 girls and 335 boys) with type 1 diabetes were registered in the Latvian Health Statistics database [77]. Of them, 465 children (229 girls and 236 boys) were between the ages of 12 and 18 [78]. The children’s population of the study group consisted of 251 children ages 12 to 18, so the scope of the study exceeded 50%, which allows us to draw conclusions about a wider population of adolescents with type 1 diabetes of the relevant age. This study supplements the global interdisciplinary research base with Latvian data on mental health challenges for children with type 1 diabetes and their parents.

There were several limitations to the study. Firstly, the study design corresponded to a quantitative cross-sectional study. This means that the interpretation of the data provides a picture of associations rather than causality between factors. Secondly, the research instruments—GAD-7 and PHQ-9 questionnaires—are screening methods that allow for determining only the presence of symptoms and not a diagnosis. They do not allow us to differentiate the nosological affiliation of the symptoms. Surveys are self-assessment scales that do not exclude the subjectivity of the respondents, the emotional background of the given moment, or other factors that could influence the answers at a specific point in time. The reference point of survey data was two weeks, which did not allow us to draw conclusions for a long period. The emotional and affective background of the respondents could be different after some time. Thirdly, the range of adapted and validated methods in anxiety and depression research is limited in Latvia. There are other tools widely used in the world for the detection of mental disorders in the pediatric population (e.g., Children’s Depression Inventory (CDI), Strengths & Difficulties Questionnaire (SDQ), Screen for Child Anxiety-Related Emotional Disorders (SCARED), and others), but these are unfortunately not yet validated in Latvia. Finally, the timing of the study coincided with the period of emergency and restrictions due to the COVID-19 pandemic, which may explain the high rates of anxiety and depression in both the study and control groups.

5. Conclusions

The hypothesis put forward in the study, that in Latvia, adolescents with type 1 diabetes mellitus ages 12 to 18 and their parents have anxiety and depression symptoms more often than the general population, and the frequency of symptoms depends on the duration of the disease, the level of diabetes compensation, and sociodemographic factors, has been confirmed. Anxiety and depression symptoms were seen significantly more frequently in the study group than in the control group. It can therefore be concluded that adolescents with Type 1 diabetes and their parents are more predisposed to anxiety and depression symptoms than somatic healthy children and their parents. Control of diabetes is closely related to levels of anxiety and depression in both parents and children. Higher rates of anxiety and depression are associated with poorer control of the disease.

Further work is needed on the translation, adaptation, and validation of diabetes-related mental health screening tools recognized in global practice to be more specific and more comprehensive in Latvia. Primary prevention and risk management of psychiatric disorders are critical to reducing both the healthcare and socioeconomic burdens associated with diabetes. Type 1 diabetes is just one of the chronic and incurable diseases in children. Screening for anxiety and depression at the primary health care or specialist level should also be indicated for other chronic childhood illnesses. An important direction could be public education on diabetes-related issues. This would make it possible to work on the prevention of risk factors for type 2 diabetes, which affects more and more young people, as well as to reduce the myths and stigmas associated with type 1 diabetes.

Considering the ever-increasing population of adolescents with T1D in Latvia and the significant relationship of the illness with anxiety and depression, further studies need to be carried out for multi-disciplinary care of T1D patients. Screening for anxiety and depression could be integrated into endocrinology and primary healthcare settings as a preventive measure to mitigate adolescent anxiety and depression. This approach could enhance diabetes management and metabolic control, ultimately reducing complications and alleviating the economic burden on both the healthcare system and the social care sector.