Category: Mental Health

JDRF-CIHR Mental Health Grants

Mental health and psychosocial issues remain an under-researched yet frequent aspect of living with type 1 diabetes (T1D). As part of the JDRF-CIHR Partnership to Defeat Diabetes, JDRF is pleased to support four new Canadian grants focused on improving mental health and wellness in people with T1D. These grants are each worth $1 million over 4 years.

Having diabetes is associated with an increased risk of mental health conditions including anxiety, depression and eating disorders, as well as “diabetes distress”, which is a clinical condition that refers to the negative emotions that come with the burden of diabetes self-management. 

There is some evidence that behavioral health interventions can address mental health issues such as clinical depression and diabetes distress, as well as improve quality of life and diabetes self-management in people with T1D. However, more evidence is needed, including how to best implement these interventions into practice. The four grants are focused on the development, validation and clinical implementation of mental health interventions that will ideally offer long-lasting and scalable solutions for Canadians with T1D.

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Aiming for something sweeter: Supporting youth with type 1 diabetes during transition from pediatric to adult diabetes care

Dr. Sonia Butalia (University of Calgary)

Dr. Butalia and her team are researching the transition from pediatric to adult diabetes care in people with T1D. This transition leaves teenagers struggling to navigate the adult health care system while also juggling increased pressures and competing priorities, such as finishing high school, navigating future plans and potentially leaving the family home, increased responsibility for their diabetes management, managing social pressures and mental health issues, to name a few.  This is a crucial timepoint as inadequate transition has been found to impact psychosocial issues as well as leading to increased HbA1c values and risk of hospitalization. 

Dr. Butalia and her team have previously created a transition intervention that supports teens through texting, emails, phone calls, and social media groups via non-medical transition coordinators. A pilot study of this intervention was very successful, with clinic attendance increasing 4-fold and improved blood glucose levels amongst those involved in the program. Dr. Butalia will use the JDRF-CIHR grant to expand this program to 5 major sites in Alberta and evaluate the impact of the program on participants’ mental health, diabetes management and care transition, and cost effectiveness of the program. The team will also develop a free, online toolkit that can be used by all communities across Canada to implement transition programs so that teenagers with T1D across the country can benefit. 

Adaptation and pilot evaluation of a digital intervention targeting the psychosocial needs of individuals with pregestational diabetes

Dr. Deborah Da Costa (McGill University)

Pregnancy and the postpartum period are a critical life stage where persons living with diabetes may be especially vulnerable to diabetes distress, anxiety and depression because of the added physical, emotional, behavioural and social readjustments that occur, including the adjustments to a new role and new care tasks. Diabetes-specific distress and poor mental health during the preconception and pregnancy period can adversely impact maternal and offspring outcomes, yet research in this field has not been prioritized and limited interventions exist. Dr. Da Costa and her team are experts in maternal mental health and have previously developed a successful digital intervention for pregnant and postpartum women and birthing persons. They will now use the JDRF-CIHR grant to collaborate with diabetes experts – primarily those living with T1D and T2D – to adapt their platform for women and birthing persons with pregestational diabetes. 

Dr. Da Costa will use a community-based participatory research approach to adapt their existing platform (HealthyMoms) for the diabetes community. This research approach ensures that the intervention is created by the community, for the community. The new adaptation – HealthyMoms DM+ – will be evaluated to determine its impact on mental health outcomes in people with pregestational diabetes (i.e., T1D or T2D prior to becoming pregnant) who are planning to become pregnant, are currently pregnant, or are in the 1-year postpartum period. This intervention will fill an important gap in current healthcare and web-based resources targeting the prevention of maternal psychological difficulties for those with pregestational diabetes. Promoting maternal health through tailored, preventive action has the potential to have a positive impact on parental, infant, and family outcomes across Canada.

Type 1 Diabetes, Exercise and Mentoring (TEAM) Trial: Peer mentorship to increase physical activity and quality of life in adolescents with type 1 diabetes

Dr. Jonathan McGavock (University of Manitoba)

Dr. McGavock and his team are focused on improving empowerment, resiliency, and autonomy in adolescents with T1D through physical activity. Despite physical activity being a crucial component of T1D management, essential for optimal quality of life, and a significant factor in mental health, daily physical activity levels remain low in adolescents with T1D. Dr. McGavock and his team will harness the effectiveness of peer-to-peer support and mentorship to create a behavioural intervention for adolescents with T1D. This program will provide strategies to address the three biggest barriers to physical activity in adolescents with T1D: (1) the increased risk and fear of hypoglycemia, (2) the trial and error to finding appropriate physical activity levels to maintain stable diabetes control, and (3) the limited motivation to exercise due to diabetes distress and existing mental health issues. 

Dr. McGavock and his team will conduct a 12-week program of group-based exercise led by mentors with T1D that are living healthy, active lifestyles. This program will seek to impart upon the participants a sense of mastery, relatedness and connection with peers, and a sense of autonomy to improve their quality of life through healthy, active lifestyles. The feasibility of this study, as well as the impact on mental health and diabetes outcomes, will help inform future physical activity guidelines for adolescents with T1D. 

Find Your CommuniT1D: Customized Virtual Peer Support for People Living with Type 1 Diabetes

Dr. Holly Witteman (Université Laval)

Using a unique approach, Dr. Witteman and her team will create a sustainable peer support program that is led by people with T1D, to improve the mental health and quality of life of people with T1D across Canada. CommuniT1D will be a virtual community led by people with T1D and supported by the research team who bring expertise in mental health, diabetes care, psychology, and social support. This program is intended to continuously adapt to the needs of the community, while the research will focus on the feasibility and acceptability of the program as well as its impact on diabetes distress, quality of life, well-being, diabetes management, and use of resources. 

CommuniT1D will be an ongoing virtual community that includes recurring small group meetings as well as large webinars. The small group meetings will foster relatedness while providing emotional and informational peer support. Peer leaders will be trained to moderate these meetings for people with T1D who share common characteristics or situations (for example, preferred language, ethnocultural group, stage of life, hobbies/interests, etc.). The large webinars will be planned for the community to deliver T1D-related information and hear from expert speaks on topics such as: depression and anxiety with T1D, better sleep with T1D, disordered eating in T1D, meditation and mindfulness tools, financial advice, caring for loved ones with T1D, etc. Stay tuned for more information on how you can be part of CommuniT1D. 

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JDRF has a fulsome mental health and diabetes strategy, and these grants are part of this overall aim to improve the mental health of Canadians living with T1D. 

Once in recruitment phase, we will post information on how to be part of these, and other, studies in our ‘Participate in Research’ page 

Mental Health and Diabetes – where JDRF is today

May is Mental Health Awareness month, a national movement to raise awareness of the importance of mental health, and the structural gaps that exist in accessing treatment and support.

There is no physical health without mental health, and this truth is beginning to be woven into a holistic approach to health care. JDRF has long recognized the need to accelerate that integration – particularly as it relates to our mission to improve the lives of people living with type 1 diabetes (T1D).  

T1D affects a person’s emotional, social, and behavioural wellbeing throughout their lifetime, known collectively as psychosocial health. Psychosocial health is directly related to physical health, and to health outcomes like glycemic control in T1D. JDRF’s Mental Health Strategy aims to etter support this critical need that has long been underappreciated and undertreated in people with T1D.

T1D is a lifelong disease that involves constant blood sugar monitoring, counting carbs, fear of complications, and taking insulin every day to stay alive. The stress around diabetes management can manifest in depression, anxiety, and “diabetes distress” – a term describing the powerlessness, stress, guilt, relentless worry and denial that accompanies living with diabetes and the burden of self-care.  

But for too long, healthcare practitioners focused exclusively on the physical manifestations of T1D without addressing mental health. Plus, T1D can be an isolating condition, and many living with it don’t have the social or community support that can help.

Gaps in mental health care for people with diabetes

Routine T1D appointments often do not address mental health

No standard mental health care referral pathway for people with T1D

Few mental health providers with T1D expertise in Canada

Insufficient funding for psychosocial research in T1D

Evidence from psychosocial research in T1D is not put into practice

It is for this reason that JDRF Canada developed a three-pronged approach to its mental health strategy: 

  • Funding research 
  • Training mental health providers 
  • Engaging, educating and supporting the diabetes community and healthcare providers 

Funding Research

Strategic partnerships help JDRF leverage your generous donations and expand their reach. When we launched our Mental Health Strategy, we committed to funding new research in this area, and to working with partners for maximum impact. JDRF Canada and Brain Canada partnered in 2021 to co-fund three clinical studies designed to develop and test the effectiveness of psychosocial interventions to improve mental health and diabetes outcomes. Together, we awarded three grants to investigators building pilot studies designed in consultation with and for youth and young adults living with T1D. 

Dr. Marie-Eve Robinson, Children’s Hospital of Eastern Ontario (CHEO) 

Teaching adolescents with type 1 diabetes self-compassion (TADS) to reduce diabetes distress: A randomized controlled trial. 

Dr. Robinson and her team are testing the effectiveness of a mindful self-compassion program on improving the diabetes distress experienced by youth aged 12-17 years with T1D. The program focuses on teaching self-kindness, mindfulness, and the idea that negative experiences are not personal failures, but part of the common human experience. Learning to leverage a self-compassionate mindset has the potential to not only lead to better mental health outcomes, but better glucose control too. 

Accomplishments: Dr. Robinson and her team held two eight-week self-compassion courses in the fall of 2022 and two more in the spring of 2023. 

Future plans: The results of this research will inform future study designs to adapt and optimize the program and explore the integration of such an intervention at a diabetes camp. This program could also be adapted to younger children with T1D. 

Dr. Tricia Tang, University of British Columbia  

A randomized wait-list controlled trial of the REACHOUT intervention 

Dr. Tang and her team at the University of British Columbia are using a virtual care platform to deliver peer-led mental health support to adults with T1D in rural and remote communities in BC, through a mobile app called REACHOUT. 

Accomplishments: The team recruited peer supporters and began training them in 2023. They have also conducted focus groups with peer supporters and participants from the initial pilot study, funded with generous donor support in 2022. This feedback allowed the team to make upgrades and improvements to adapt the REACHOUT platform. 

Future plans: Dr. Tang and her team will continue to recruit participants and peer supporters, as well as update the intervention curriculum based on feedback from the focus groups. 

Dr. Peter Selby, Centre for Addiction and Mental Health (CAMH) 

Technology-enabled comprehensive care for young adults with type 1 diabetes and diabetes distress 

Dr. Selby and his team are bringing experts in mental health and T1D care together with those who have lived experience of T1D to co-develop a solution for diabetes distress for adults between the ages of 18 and 29, a group disproportionately vulnerable to diabetes distress. The project will focus on a digital-first platform that can be scaled and implemented more broadly to reach more individuals living with T1D. 

Accomplishments: The investigator team kicked off their research by defining key elements of the project and developing a prototype platform or the diabetes distress intervention. They established a partner advisory committee of six people with lived experience of T1D to consult on all activities. 

Future plans: The team will adjust the program as needed and are planning to a randomized control trial to confirm the efficacy of the model before scaling nationally or tailoring it to specific groups. 

JDRF is helping to facilitate recruitment for both Dr. Tang and Dr. Peter Selby’s studies through our Clinical Trials webpage  

An additional $4M research investment  

In partnership with the Canadian Institutes of Health Research (CIHR), JDRF will shortly be announcing 4 new grants in the area of mental health and T1D with a total investment of $4 million ($1 million per grant).

Training Mental Health Providers  

JDRF Canada and Diabetes Canada collaborated to launch the Mental Health + Diabetes Training Program in English and French in March 2023. The course consists of two streams: one for mental health providers in Canada – including registered psychologists, clinical counsellors, psychotherapists, social workers, psychiatrists, and mental health nurses – and one for the diabetes community and healthcare providers, caregivers, family members, friends, and anyone who wishes to take the general stream of the course.

Despite the large number of people living with the condition, only a handful of mental health providers in Canada have in depth knowledge of the unique psychosocial challenges that come with living with diabetes. The goal of the Mental Health + Diabetes Training Program is to increase knowledge about diabetes among mental health providers in Canada so as to prepare them with sufficient knowledge and skills to assess and treat their patients living with the condition. This program provides knowledge and tools to help these providers deliver the best support to their clients with type 1 or type 2 diabetes and expand the capacity of health systems to meet this need.

We are thrilled to collaborate with Diabetes Canada, which will allow us to expand our reach across the country to improve the quality of life of more Canadians with diabetes.

As of early April 2023, 176 mental health providers and 484 individuals in the general stream have registered for the Training Program.

“The Mental Health + Diabetes Training Program provided me with pertinent information about the physical and mental health effects of both type 1 and type 2 diabetes. After completing all areas of the training including the e-learning modules and the live session, I feel confident to incorporate the comprehensive material into my private practice.” – Monica Murray, Registered Psychotherapist, Ontario 

Mental health providers who complete the Training Program can join a new, publicly accessible Mental Health + Diabetes Directory, to be launched later in the year. The bilingual directory will allow healthcare providers and people living with diabetes to be referred or self-refer to trained providers who can offer specialized support specific to living with this chronic disease.  

The directory will also help to address the system gap of a lack of a standard referral pathway for people living with diabetes to connect with a mental health provider trained specifically in the needs of people with diabetes. 

Engagement, Education and Support 

Our mental health strategy’s engagement, education and support activities will focus on health care providers as well as people who live with T1D and their families and caregivers.

JDRF’s new Mental Health Advisory Council, a diverse group of more than 100 volunteers from across Canada with lived experience of T1D, are collaborating with us to shape initiatives of the mental health strategy to ensure maximum impact and that they are driven by the T1D community, for the T1D community.

JDRF is currently developing new educational materials for healthcare providers – endocrinologists, nurses, GPs, and other healthcare professionals that cover some of the mental health aspects of T1D. We built a dedicated section on our website for healthcare providers and kicked off a virtual event about T1D and mental health in the fall of 2022. We are also encouraging healthcare providers and diabetes care teams to enroll in our Mental Health + Diabetes Training Program.

We will continue to collaborate with Diabetes Canada and other partners to expand and deepen healthcare provider engagement by delivering new educational resources such as electronic briefs, hosting webinars and educational events, and promoting the Mental Health + Diabetes Directory among healthcare providers, so they have a referral source for their patients. 

You can view past recordings on our YouTube channel. 
 
With our Mental Health Advisory Council’s input, we will continue to expand our mental health website content, build awareness of our Mental Health + Diabetes Directory so individuals feel empowered to self-refer, and develop new approaches to further educate and connect the community.

We are measuring success by evaluating the impact of each initiative, including with a research study to follow outcomes and impact of the Training Program and directory.

JDRF Canada extends our gratitude for the support of our Advisory Council, Cabinet Members and philanthropic partners, including charitable partners Brain Canada and Diabetes Canada. 

New funding investments and partnerships are still needed as we go forward. For more information, please email mentalhealthstrategy@jdrf.ca 

JDRF for Bell Let’s Talk Day

Bell annually runs its #BellLetsTalk campaign, raising awareness and helping to combat the stigma surrounding mental illness in Canada.

Living with type 1 diabetes (T1D), whether it’s you, your child, a friend or loved one, has an impact that extends far beyond physical health. The stress of managing a chronic condition, both from the time of diagnosis and even decades later brings with it challenges to overall wellbeing. Mental health challenges are common for people with T1D, at any age.

#BellLetsTalk day is January 26, 2022. We use this day across the country to amplify and recognize the importance of treatment for mental health issues, including for people with or affected by T1D.

Living with T1D

T1D is a chronic autoimmune disease that can be diagnosed at any age, but most commonly in childhood.

People living with T1D must follow a strict lifelong treatment plan that includes constant blood sugar monitoring, counting carbohydrates and taking insulin multiple times a day to stay alive. There is no treatment beyond insulin, and no cure.

T1D can impact mental, emotional, and psychosocial health

Mental health represents one of the most pervasive health issues affecting Canadians today. Combined with a chronic condition like T1D, feelings of anxiety, stress and depression are often intensified.

T1D frequently impacts a person’s emotional, social, and behavioural health, known as psychosocial health. One in five youth with T1D experiences anxiety and, compared to those without the condition, people with diabetes are more likely to experience depression or develop an eating disorder.

Diabetes can feel like a ‘hidden’ disease and isolating and lonely – particularly for kids and teens.

Traditionally, healthcare for T1D focuses primarily on managing glucose levels to help stave off potential diabetes-related complications. The mental health challenges that can accompany the condition are often overlooked, and this can affect overall health.

Many people with T1D suffer what is known as “diabetes distress” – a term describing the powerlessness, stress, guilt, relentless worry, and denial that comes with the constant self-management required to maintain balance with this disease.

We also know that under-served mental health issues can lead to higher HbA1c and an increased risk of complications, yet despite this – mental health care remains a gap in Canadian healthcare for people with T1D.

How JDRF Canada is addressing gaps in mental health care for people with T1D

In January 2021, JDRF Canada launched its $100 Million Campaign to Accelerate, which includes a six-pillar approach to funding research and other programs that accelerate towards cures and improving lives for people living with T1D today. One pillar of the campaign is dedicated to addressing mental health issues and expanding support to the T1D community.

In late September 2021 JDRF Canada’s mental health strategy was formally launched.

It is an ambitious plan that initially includes five areas of focus: funding research to test psychosocial interventions, providing education about psychosocial issues in diabetes to health care providers, supporting postdoctoral fellowships for clinical psychologists in training, providing support and resources for people living with T1D, and developing and launching a virtual training program about diabetes for registered mental health care providers.

JDRF will also be developing and launching a directory to connect the diabetes community to providers that understand their unique mental health needs.

JDRF will partner with various diabetes and mental health organizations, including those that serve people living with type 2 diabetes

The virtual training program on diabetes and mental health for mental health care providers  will begin later this year. If you are a mental health provider interested in learning more, please contact: mentalhealthstrategy@jdrf.ca

Additional JDRF Resources

From diagnosis to daily life years after, having a community and connection to others affected by T1D offers critical support and lets them know they are not alone.

To help foster and grow the T1D community across Canada, JDRF has a strong community engagement team that works to offer the following sources of support:

  • Our virtual Let’s Talk T1D series, which includes a Connection Series moderated by volunteer with T1D and offers a space safe to share.
  • Talk T1D – a mentorship program that provides one-on-one support to families who are impacted by T1D from trained volunteers who have been there.
  • Our Youth Ambassador advocacy program for kids between 4 and 18 who want to share their T1D stories and inspire their communities, increase awareness of T1D, and join hundreds of kids across the country to help JDRF fundraise for a cure.
  • Our mental health resources section.

On #BellLetsTalk day, as we work to reduce the stigma around mental health issues, we recognize that psychosocial and mental health is a key component of overall health and should be integrated into a holistic healthcare plan for all Canadians affected by T1D.

JDRF launches new mental health strategy to support Canadians with type 1 diabetes

For the 300,000 Canadians living with type 1 diabetes (T1D), each day brings challenges – challenges that many others don’t understand. People living with T1D must follow a strict lifelong treatment plan that includes constant blood sugar monitoring, counting carbohydrates and taking insulin multiple times a day to stay alive. Due to this heavy burden of self-management and other factors such a social stigma, people living with type 1 diabetes are more likely to experience mental health challenges than their peers without T1D.

However, there are currently many gaps in knowledge, the healthcare system, and community support that mean this critical aspect of diabetes management is often overlooked. This is why JDRF Canada is pleased to announce that it has launched a $2 million fundraising campaign exclusively to support of the development of its first mental health strategy.

2021 marks the 100th anniversary of the discovery of insulin in Canada. Earlier this year, in honour of this anniversary, JDRF Canada, the largest charitable funder of T1D research in Canada, launched its $100M Campaign to Accelerate to build upon a long legacy of outstanding Canadian diabetes research, accelerating towards cures and improving the lives of those living with T1D. The Campaign takes a six pillar approach towards aggressively funding research into cures, while also helping people with T1D live healthier lives now – and given the importance of mental health in T1D, it is the focus of one of the Campaign’s pillars.

T1D never takes a day off, and constant and continual management coupled with worries about diabetes-related complications can take a toll on mental and emotional health. Compared to those without the condition, those with diabetes are more likely to experience depression or develop an eating disorder,1-3 and one in five youth with T1D suffer from anxiety.4

Why we are launching a Mental Health Strategy

“I’m okay, but I’m not happy. We’ve figured things out – mostly – after ten long years. Diabetes takes a lot out of me, emotionally and physically, and gets in my way every single day. I’ve cried a lot, and I’ve gotten frustrated, and sad, and angry. Diabetes takes up a lot of my emotional bandwidth and I’m tired of it…Diabetes makes me feel inadequate, but I’m doing my best.” 

Maryna Ell, a young adult who lives with T1D

Despite mental health being a crucial component of holistic diabetes management, it is often overlooked in diabetes care. Routine diabetes appointments frequently focus on the urgent aspects of diabetes care such as glucose-management and lack time to address emotional wellbeing and mental health. On top of this, there are only a handful of mental health care providers in Canada who specialize in the needs of the diabetes community.

There is currently no standard pathway for identification, screening and referral of mental health concerns for people with T1D. Finally, research in the area of mental health and T1D is woefully under-funded.

“Mental health challenges together represent one of the most pervasive health issues affecting Canadians today. When you add a chronic condition like T1D, feelings of anxiety, stress and depression are often amplified, which can negatively affect physical health. With a clear indication of the mental health strain this disease has on people living with T1D and the obvious gaps in care, it’s time to take action and that’s why we are raising $2M and launching our first mental health strategy.”

Dr. Sarah Linklater, Chief Scientific Officer of JDRF Canada

Our plans to address the need 

“Mental health needs to be a larger part of care, especially for teens with diabetes. There is so much pressure socially, academically and hormonally and it’s hard to find anyone who understands the difficulty of managing diabetes on top of all of that.”

Jenna, JDRF Youth Ambassador, diagnosed with T1D at age 12

The vision of JDRF Canada’s Mental Health Strategy is to expand and create new avenues for children, youth, and adults with diabetes to access psychosocial health support and mental health services, ultimately improving quality of life and health outcomes.

The Strategy will involve multiple initiatives that focus in three main areas: funding research on mental health and T1D, informing and educating health care providers, and developing new programs to support the T1D community. Several initiatives, including research funding opportunities and development of a new virtual training program about diabetes for registered Canadian mental health providers, are already in progress.

“I started providing psychological services to those living with diabetes in 1985. At that time, I was amongst only a few Canadian mental health providers with an expertise in diabetes. Thirty-five years later almost nothing has changed. Most people living with diabetes experience psychosocial challenges that negatively impact their health and quality of life. Psychosocial issues are amongst the biggest care gap in diabetes management.”

Dr. Michael Vallis, registered psychologist and Associate Professor, Family Medicine, Dalhousie University, Halifax, NS

With the help of donors and our initial partners including Brain Canada, BD, iA Financial Group, Canucks for Kids and The Leona M. and Harry B. Helmsley Charitable Trust, JDRF is well-positioned to take the lead to address gaps in care and tackle one of the most significant health issues facing Canadians with diabetes.

With further support from donors and partners, JDRF can help to provide a unified approach to helping families across Canada overcome challenges and cope with T1D.

Facts and figures

People living with T1D are more likely to experience mental health disorders compared with their peers without T1D:

  • The prevalence of depression is 3 times higher in people with T1D than people without diabetes, with women experiencing higher rates than men.1
  • Teenage girls with T1D are 2.4 times more likely to develop an eating disorder, and over 30% of women with T1D have been reported to restrict insulin to control weight.2,3
  • One in five youth with T1D experience anxiety.4
  • Half of adults with T1D experience “diabetes distress”, a clinical term to describe the powerlessness, stress, guilt, relentless worry and denial that comes with living with diabetes and the burden of self-management.5
  • Mental health issues in people with diabetes are correlated with worse outcomes, including worse glycemic control,6-9 more frequent and severe hypoglycemia,10 and more frequent diabetic ketoacidosis (DKA),6 increased frequency of diabetes complications.11

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To learn more about partnering with JDRF Canada and get more details about our Mental Health Strategy, or to share your story about the impact of T1D on your psychosocial health and emotional wellbeing, please contact us at mentalhealthstrategy@jdrf.ca

References

1) Roy T and Lloyd CE. Epidemiology of depression and diabetes: a systematic review. Journal of Affective Disorders. 2012. 142 Suppl: S8-21.

2) Goebel-Fabbri, A. Diabetes and Eating Disorders. J Diabetes Sci Technol. 2008. May; 2: 530–532.

3) Hanlan ME et al. Eating Disorders and Disordered Eating in Type 1 Diabetes: Prevalence, Screening, and Treatment Options. Curr Diab Rep. 2013. Sep 12:10.1007/s11892-013-0418-4.

4) Herzer M and Hood KK. Anxiety Symptoms in Adolescents with Type 1 Diabetes: Association with Blood Glucose Monitoring and Glycemic Control. J Pediatric Psychol. 2010. May; 35: 415–425.

5) Vallis M et al. Diabetes Attitudes, Wishes and Needs Second Study (DAWN2): Understanding Diabetes-Related Psychosocial Outcomes for Canadians with Diabetes. Can J Diabetes. 2016. Jun; 40:bv234-41.

6) Plener PL et al. Depression, metabolic control, and antidepressant medication in young patients with type 1 diabetes. Pediatric Diabetes 2015; 16: 58–66.

7) Corathers SD et al. Improving depression screening for adolescents with type 1 diabetes. Pediatrics. 2013. 132:e1395-402.

8) Lustman PJ et al. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care 2000. 23:934–942.

9) Strandberg RB et al. Longitudinal relationship between diabetes-specific emotional distress and follow-up HbA1c in adults with Type 1 diabetes mellitus. Diabetic Medicine. 2015. 32: 1304-10.

10) Katon WJ et al. Association of depression with increased risk of severe hypoglycemic episodes in patients with diabetes. Annals of Family Medicine. 2013. 11: 245-50.

11) de Groot M et al. Association of depression and diabetes complications: a meta-analysis. Psychosomatic Medicine 2001. 63: 619–630.