Suicide in diabetes: An important but under-recorded problem
The FDA has recently highlighted the elevated risk for suicide in people with diabetes, resulting in the creation of the REducing SuiCide rates amongst individUals with diabEtes (RESCUE) Collaborative Community to examine issues relating to the identification and management of increased suicide risk in people with diabetes.
In this brief overview, we look at the scale of the problem, why the scale can be difficult to accurately define, and where the focus of current and forthcoming research lies.
Is suicide an active area of research in diabetes?
Published research that provides insight into suicide deaths in people with diabetes goes back several decades. However, the majority of these studies looked more generally at mortality in people with diabetes, and the headline findings focused on factors such as acute complications like ketoacidosis or chronic complications or comorbidities such as cardiovascular disease or cancer, with suicide deaths being a secondary finding, or lumped together with accidents.
Also, many of the studies that looked specifically at suicide risk are published in psychiatry and psychology journals, making them less likely to come to the attention of healthcare professionals without a specific interest in psychosocial care.
However, the volume of papers dedicated specifically to the issue of suicide – ideation, attempts, and deaths – in people with diabetes has been increasing over recent years, indicating a growing awareness of the problem.
What’s the risk, and does it vary by diabetes subtype?
A 2017 meta-analysis, the first on the subject, drew these disparate studies together and reported a significantly increased relative risk for suicide of 2.25 associated with type 1 diabetes. The pooled suicide rate was 2.35 per 10,000 person–years and 7.7% of deaths in people with type 1 diabetes were attributed to suicide.
The results for type 2 diabetes were less clear. There was a trend toward an increased suicide risk, at a nonsignificant relative risk of 1.65, with a 95% confidence interval of 0.95–2.85 and p value of 0.07. The suicide rate was 2.56 per 10,000 person–years and 1.3% of deaths in people with type 2 diabetes were attributed to suicide.
Men and women with diabetes had a similar relative risk for suicide, although rates and the proportion of attributable deaths were higher in men than women.
Are the data reliable?
A problem common to many of the papers included in the meta-analysis is that of accurate coding of causes of death. A study in 2002, showed that while deaths of people with type 1 diabetes caused by cancer or vascular disease were reliably coded on death certificates, those due to hypoglycemia or ketoacidosis were often not described as such on death certificates nor identifiable by International Classification of Diseases (ICD) code. Just 41% of suicide deaths could be identified by ICD code.
Thus, the scale of the problem may be underestimated, and potentially also the size of the relative risk for suicide in people with diabetes.
What are the current areas of focus?
The authors of the aforementioned meta-analysis did not report any subgroups beyond sex and diabetes type. However, a number of studies since then have highlighted adolescence and young adulthood as a particularly high-risk time for suicide. One, for example, found that 9% of a sample of 550 youth and young adults with type 1 diabetes reported suicide/death ideation, with 16% having previously made an attempt, three of whom had used insulin to do so. This study also found a very high rate of depressive symptoms (83.4%), in line with another report that found an increased prevalence of both mood disorders and suicide attempts in adolescents with diabetes. In another study of 61 adolescents with type 1 diabetes, 21% were considered at increased risk for suicide with one admitted for acute psychiatric care as a result of the study.
Another study showed that the risk for suicide attempts in young adults with diabetes increased in the 12 months following hospitalization for diabetic ketoacidosis.
Creating standards of care and standardizing care pathways for people with severe hypoglycemia or ketoacidosis will be one priority area of focus for the RESCUE Collaborative Community. Others will cover coding suicide ideation and suicidal acts, use of machine learning to potentially identify self-mismanagement or suicide ideation, and measures to support tailored education on the subject of suicide for healthcare professionals working with people with diabetes.
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