The association of illness perception and coping resources with depression and glycemic control among adolescents with type 1 diabetes.

Type 1 Diabetes is a chronic disease, diagnosed in childhood or adolescence.  Patients must adhere to a rigorous and daily regimen, in order to avoid or delay short and long-term medical complications  (Helgeson et al., 2009). Although adolescents who follow treatment guidelines can live as  full a life as their healthy peers (Lukács et al., 2013), the disease adds to   the already difficult physiological, emotional, social and cognitive developmental changes of adolescence. Depressive symptoms are the most common emotional reaction (Winkley, 2008) and their reduction is a primary goal in treatment.

Aims of the study: Based on the cognitive model of Stress and Coping (Lazarus and Folkman, 1984), this study aimed to examine the association between illness perception and depressive symptoms in adolescents with Type1Diabetes and to explore whether personal and environmental resources (self-efficacy, family conflicts) and self-care behavior would mediate or moderate this association. Additionally, we aimed to examine which variables contributed to depressive symptoms. Finally, we explored the association between depressive symptoms and glycemic control. Method:  The study population included adolescents diagnosed with Type 1 Diabetes treated at the Department of Endocrinology and Diabetes, Safra Children's Hospital, Sheba Medical Center, and at the diabetes clinic of the Maccabi Health Services in Ra'anana . The sample included 98 adolescents between the ages of 12-19 (87% response rate). Procedure: A staff member at each clinic approached the adolescents and their parents (either by phone or at the clinic itself) in order to request their participation in the study. After the parents signed an informed consent form, the adolescents filled out the self-report questionnaire. Research Tools: The questionnaire included demographic background, medical variables. Illness perception measure with four sub-scales (Skinner et al., 2003), self-efficacy (Iannotti et al., 2006), family conflicts (Hood et al., 2007), self-care behavior (La Greca, Swales, Klemp, & Madigan, 1988), and depressive symptoms (Kovacs , 2001). Data were analyzed using statistical tests of bivariate associations and multivariate hierarchical linear regression models in order to examine the contribution of study variables to depressive symptoms and in order to test mediation and moderation. Main Findings: A significant association was found between three of the four measures of illness perception and depression: a positive association between illness perception – short-term consequences and long-term consequences – and depression, and a negative association between illness perception – short-term control – and depression. Examination of mediation effects revealed significant associations between two measures of illness perception –long-term consequences and short-term control – and self-efficacy, and a negative association between self-efficacy and depression. Using a hierarchical linear regression model showed a full mediation by self-efficacy of the association between illness perception and depressive symptoms, confirmed by a significant Sobel Test for mediation. No mediation was found for family conflicts. Examining whether self-care behavior mediates the association between illness perception and depressive symptoms, a significant association was found between two measures of illness perception – long-term consequences and short term control – and self-care behavior. A negative association was found between self-care behavior and depressive symptoms.  A hierarchical linear regression with a Sobel Test showed a significant full mediation.

There was no moderating effect of the self-efficacy variable on the association between illness perception and depressive symptoms. However, a moderation effect of family conflicts was found: a significant contribution of the interaction between illness perception – short term consequences and family conflicts – was found, indicating that when the level of family conflict was high or moderate, there was a strong positive relationship between illness perception – short-term consequences – and depressive symptoms; in low levels of family conflict this relationship was non-significant.

In addition, an examination of the contribution of all the variables to depression showed that illness perception – short-term consequences as well as self-care behavior were the only two variables that contributed significantly to depressive symptoms. Finally, there was no association between depressive symptoms and glycemic control. Limitations: The data are based on adolescents' subjective firsthand reports only.  Since the admission of difficulties is not easy for adolescents, this report may be biased. In addition, other family members' perspectives are not included. The cross-sectional design of the study does not allow drawing conclusions about causality.

Main Contribution: The study provides additional understanding of factors that contribute to depression among adolescents with diabetes. The findings indicate the importance of the dimensions of the adolescents' illness perceptions to depressive symptoms, particularly their perceptions of short-term consequences; that is, adolescents who perceive the disease as having negative implications for their day-to-day lives are at greater risk for depression than those who do not. In addition, the direct contribution of self-care behavior, the mediating effect of self-efficacy and the moderating influence of family conflicts add theoretical and empirical support to previous research findings on the contribution of these variables to depression.

The implications for practice suggest that early identification of these factors can help identify adolescents at high risk for depression. Intervention programs aimed at reducing these adolescents' depressive symptoms should focus on ways to reduce their cognitive appraisal of the negative consequences of the disease on their daily lives as well as on enhancing their self-care behavior. Further intervention aimed at strengthening self-efficacy and early identification of medium or high levels of family conflicts will also indirectly contribute to improving the mental health of adolescents.