ReviewAssociation of diabetes with anxiety: A systematic review and meta-analysis
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.
References (60)
- et al.
Prevalence and incidence of chronic complications and mortality in a cohort of type 2 diabetic patients in Spain
Primary Care Diabetes
(2008) - et al.
Prevalence of anxiety in adults with diabetes: a systematic review
Journal of Psychosomatic Research
(2002) - et al.
Relationship of depression to diabetes types 1 and 2: epidemiology, biology, and treatment
Biological Psychiatry
(2003) - et al.
The association of depression and anxiety with medical symptom burden in patients with chronic medical illness
General Hospital Psychiatry
(2007) - et al.
Prevalence, characteristics and comorbidities of anxiety disorders in France: results from the “Mental Health in General Population” survey (MHGP)
European Psychiatry
(2011) - et al.
Epidemiology, patterns of comorbidity, and associated disabilities of social phobia
The Psychiatric Clinics of North America
(2001) - et al.
Detecting panic disorder in medical and psychosomatic outpatients: comparative validation of the Hospital Anxiety and Depression Scale, the Patient Health Questionnaire, a screening question, and physicians' diagnosis
Journal of Psychosomatic Research
(Dec 2003) - et al.
Panic episodes among patients with diabetes
General Hospital Psychiatry
(2006) - et al.
Pain severity in diabetic peripheral neuropathy is associated with patient functioning, symptom levels of anxiety and depression, and sleep
Journal of Pain and Symptom Management
(2005) - et al.
The relationship between generic and diabetes specific psychological factors and glycaemic control in adults with type 1 diabetes
Diabetes Research and Clinical Practice
(2009)
Self-reported diabetes and posttraumatic stress disorder among adults in the community
Preventive Medicine
Prevalence of distress, comorbid conditions and well being in the general population
Journal of Affective Disorders
Mental disorders among persons with diabetes—results from the World Mental Health Surveys
Journal of Psychosomatic Research
Gastrointestinal symptoms in diabetes mellitus, and their relation to anxiety and depression
Diabetes Research and Clinical Practice
Comorbid physical health conditions and anxiety disorders: a population-based exploration of prevalence and health outcomes among older adults
General Hospital Psychiatry
Injection related anxiety in insulin-treated diabetes
Diabetes Research and Clinical Practice
The role of depression and anxiety in onset of diabetes in a large population-based study
Journal of Psychosomatic Research
Impact of pain on the course of depressive and anxiety disorders
Pain
The epidemiology of generalized anxiety disorder
The Psychiatric Clinics of North America
The validity of the Hospital Anxiety and Depression Scale. An updated literature review
Journal of Psychosomatic Research
Latent structure of the Hospital Anxiety and Depression Scale: a 10-year systematic review
Journal of Psychosomatic Research
No further research needed: abandoning the Hospital and Anxiety Depression Scale (HADS)
Journal of Psychosomatic Research
Further research needed: a comment on Coyne and van Sonderen's call to abandon the Hospital Anxiety and Depression Scale
Journal of Psychosomatic Research
High agreement of self-report and physician-diagnosed somatic conditions yields limited bias in examining mental–physical comorbidity
Journal of Clinical Epidemiology
IDF Diabetes Atlas 5th Edition
Type 2 diabetes mellitus: a high-risk condition for cardiovascular disease irrespective of the different degrees of obesity
QJM
The prevalence of comorbid depression in adults with diabetes: a meta-analysis
Diabetes Care
A prospective study of depression and mortality in patients with type 2 diabetes: the Fremantle Diabetes Study
Diabetologia
Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication
Archives of General Psychiatry
Epidemiology of anxiety disorders in the Australian general population: findings of the 2007 Australian National Survey of Mental Health and Wellbeing
The Australian and New Zealand Journal of Psychiatry
Cited by (316)
Severe disability and self-reported depression and anxiety among persons living with Type 2 diabetes in Canada
2024, Journal of Affective Disorders ReportsRelationship between delay discounting, delay aversion and psychosocial domains of diabetes care
2024, Journal of Affective DisordersType 1 diabetes
2023, The Lancet