Review
Association of diabetes with anxiety: A systematic review and meta-analysis

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Abstract

Objectives

Anxiety has been shown to be associated with poor outcomes in people with diabetes. However, there has been little research which has specifically examined whether diabetes mellitus is associated with an increased likelihood of co-morbid anxiety. The aim of this systematic review and meta-analysis was to determine whether people with diabetes are more likely to have anxiety disorders or elevated anxiety symptoms than people who do not have diabetes.

Methods

A systematic review was performed by three independent reviewers who searched for articles that examined the association between anxiety and diabetes in adults 16 or older. Those studies that met eligibility criteria were put forward for meta-analysis using a random-effects model.

Results

A total of twelve studies with data for 12,626 people with diabetes were eligible for inclusion in the systematic review and meta-analysis. Significant and positive associations were found for diabetes with both anxiety disorders, 1.20 (1.10–1.31), and elevated anxiety symptoms, 1.48 (1.02–1.93). The pooled OR for all studies that assessed anxiety was 1.25 (1.10–1.39).

Conclusions

Results from this meta-analysis provide support that diabetes is associated with an increased likelihood of having anxiety disorders and elevated anxiety symptoms.

Introduction

The worldwide prevalence of diabetes mellitus is reaching epidemic proportions with recent estimates suggesting that 366 million people are currently affected [1]. Diabetes is associated with an increased risk of both physical [2], [3] and psychological [4], [5], [6] complications, both of which impact on mortality [7], [8].

The most investigated psychological disorder associated with diabetes is depression, with a meta-analysis indicating that people with diabetes are two-fold more likely to be diagnosed with depression as compared to people who do not have diabetes [4]. However, there has been little research conducted into the association of diabetes with anxiety. This is surprising given the high prevalence of anxiety disorders in the general population [9], [10], [11], [12], and the well documented association between various chronic diseases and obesity with anxiety [8], [13], [14].

Anxiety disorders are some of the most prevalent psychological disorders with an estimated general population prevalence ranging from 12% to 21% [9], [10], [11], [12]. Anxiety disorders typically present with core features of anxious cognitions, somatic symptoms and behavioral disturbance, with different subtypes of anxiety possessing distinct characteristics. Anxiety disorders typically have a chronic and recurrent life course, and occur early in adulthood [15]. The main anxiety disorders associated with medical illness are generalized anxiety disorder (GAD) and panic disorder [13], [16], [17].

Literature shows anxiety is an important co-morbidity to examine in diabetes. In people with diabetes co-morbid anxiety disorders and elevated anxiety symptoms have been shown to be associated with increased diabetes symptom burden [18], increased diabetes complications [19], [20], [21], increased pain [22], worsened blood glucose levels [21], [23], [24], [25], reduced quality of life [26], increased depression [27], increased body-mass index (BMI) [24] and greater disability [21].

Despite this, only one review has examined the prevalence of anxiety disorders and elevated anxiety in people with diabetes. Grigsby et al. [5] found that 40% of patients with diabetes have heightened anxiety symptoms and that the overall prevalence of anxiety disorders reported in this review lies at 14%. However, this figure is within the range of general population estimates of anxiety prevalence [9], [10], [11], [12], [15]. Thus, there is a need to determine if diabetes is associated with an increased likelihood of having an anxiety disorder or elevated anxiety symptoms compared to the general population without diabetes.

The aim of this systematic review and meta-analysis was to determine if adults with diabetes had an increased likelihood of having an anxiety disorder or elevated anxiety symptoms compared to people who do not have diabetes.

Section snippets

Materials and methods

A systematic literature search was undertaken between August 2011 and November 2011 with no limits set on publication date. An additional search to update results was undertaken in July 2012. Keywords focused on synonyms of diabetes and anxiety were developed for several major databases in collaboration with a librarian (see Appendix I for keywords). These databases included PubMed (United States National Library of Medicine, Bethesda, MD, USA), EMBASE (Elsevier, Amsterdam, Netherlands), ISI

Study selection

The initial search yielded a total of 10,124 studies excluding duplicates (see Fig. 1). Studies were assessed using broad screening criteria and 10,112 were rejected. The main reasons for rejection were assessment of an irrelevant study population, lack of reference population and incorrect outcome and/or explanatory variable. Four additional studies were identified through updating literature searches. This left 16 studies to be put forward for data extraction.

Following data extraction 4

Discussion

Results from this systematic review and meta-analysis provide evidence that there is a weak positive association between diabetes with both anxiety disorders and elevated anxiety symptoms. However, many of the studies included differ by anxiety assessment, diabetes assessment and confounder control.

Conclusions

Findings from the meta-analysis indicate that diabetes is associated with an increased likelihood of being diagnosed with an anxiety disorder and having elevated anxiety symptoms. However, results from the quality assessment and systematic review highlight the need for more studies that examine diabetes and anxiety, with thorough considerations for accuracy of measurements and confounder control. Future prospective studies are also needed in order to elucidate the direction of this association.

Funding

KS and NS are supported by Canadian Institutes of Health Research Funding.

Competing interest statement

The authors have no competing interests to report.

Acknowledgments

The authors would like to thank Lindsey Sikora for her help in developing the search terms used for this literature review, Dr. Jamie Bodenlos for providing a copy of her poster presentation and Karen Jameson from the Hertfordshire Cohort Study for providing the missing data from the Holt et al. (2009) article.

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