Symptoms of anxiety and depression in type 2 diabetes: Associations with clinical diabetes measures and self-management outcomes in the Norwegian HUNT study
Introduction
Type 2 diabetes represents an increasing global health challenge, due to its growing prevalence worldwide and the chronic complications and functional impairment associated with this condition. Patients with Type 2 diabetes frequently suffer from unipolar depression and anxiety, at rates at least double those observed in diabetes-free populations (Golden et al., 2017, Semenkovich et al., 2015). There is increasing evidence that psychosomatic processes contribute to a range of Type 2 diabetes outcomes, and unipolar depression has been shown to influence the management and prognosis of Type 2 diabetes through adverse effects on factors such as glycemic control (Cherrington et al., 2010), self-care behaviours (Safren et al., 2014), and body mass index (de Wit et al., 2009). In line with this, the presence of comorbid depression in diabetes patients often leads to increased health-care costs, higher risks of vascular complications (Black et al., 2003, Lin et al., 2010), and excess mortality rates (Lin et al., 2004).
Although anxiety disorders often co-occur with depression, anxiety is a far less well understood comorbidity of diabetes. One notable limitation of studies in this area is that they tend to focus on one disorder type at a time, while failing to account for the presence of the other (Demakakos et al., 2014, Demakakos et al., 2010, Gale et al., 2010, Nichols and Moler, 2011). This makes it particularly challenging to assess the scope of the impact of anxiety disorders (or indeed, depression) on diabetes-related outcomes. Both psychiatric disorders share a significant overlap of features (e.g., generalized distress and low serotonin levels (Baldwin and Rudge, 1995)), and over 40% of Type 2 diabetes patients presenting with major or minor depression in primary care settings are diagnosed with a concurrent anxiety disorder (Golden et al., 2017). However, depression and anxiety also display important phenotypic differences. Whereas depression is uniquely associated with anhedonia and physiological responses such as lethargy and fatigue, anxiety is marked by excessive worry and physiologic hyperarousal such as trembling, sweating, and muscle tension (Gelenberg, 2000, Zbozinek et al., 2012). Evidence suggests that, like depression, anxiety may have important associations with diabetes outcomes such as an increased risk of hypertension, inflammation, and glycemic control (Anderson et al., 2002, Vogelzangs et al., 2013). It is also evident that important sex differences may exist with respect to these associations; for example, depression has been linked to poor glycemic control in men, but not women (Cherrington et al., 2010). Similar results have been noted with respect to anxiety disorders and risks of heightened inflammation in men (Vogelzangs et al., 2013).
The experience of concurrent symptoms of anxiety and depression is also associated with worse treatment outcomes than either disorder alone, including poorer adherence to treatment, higher costs, and lower quality of life (Hofmeijer-Sevink et al., 2012). Recent research in patients with cancer demonstrated that concurrent anxiety-depression was present in over 60% of patients with depression, and that this phenotype was only associated with specific cancer subtypes (Brintzenhofe-Szoc et al., 2009). To our knowledge, no similar research has been conducted with respect to affective symptom phenotypes and diabetes outcomes. By failing to adequately differentiate between these phenotypes, existing studies may link complications related to the presence of anxiety or its correlates erroneously to depression, or vice versa. A proper understanding of these relationships may inform the development of more refined and integrated approaches to treatment in the future, as certain affective symptom phenotypes may be more relevant to specific Type 2 diabetes outcomes, and these associations could vary across patient populations.
The purpose of this study was to investigate the mutually exclusive associations between symptoms of depression and/or anxiety and several important clinical and behavioural outcomes in Type 2 diabetes, as well as to document any variations in patient outcomes by sex.
Section snippets
Data source and participants
This was a cross-sectional study which used data from the third wave of the Norwegian Nord-Trøndelag Health Study (HUNT). The HUNT study is a large population-based survey conducted over three waves, in 1984/86 (HUNT 1), 1995/97 (HUNT 2) and 2006/08 (HUNT 3). The survey was conducted using a simple non-stratified design that included every adult resident of the Nord-Trøndelag County. The initial HUNT study was primarily established to address arterial hypertension, diabetes, tuberculosis
Results
We included 2035 participants confirmed to have Type 2 diabetes and who completed the items on mental health (CONOR-MHI). With regards to the factor structure of these items, the superior model consisted of a two-factor structure representing latent anxiety and depression dimensions, which exhibited very strong model fit indices when compared to the competing models (Supplementary Table 1). Of our total study sample, 839 (41.2%) individuals were above the cut-off for affective symptoms (i.e.,
Discussion
This population-based study of Norwegian adults demonstrates that symptoms of depression and anxiety are differentially associated with behavioural and clinical outcomes in individuals with Type 2 diabetes. Overall, we confirmed the high prevalence of anxious and depressive symptoms previously documented in individuals with Type 2 diabetes (Anderson et al., 2001, Grigsby et al., 2002). We observed associations between these symptoms and diet adherence, the subjective diabetes experience,
Funding
This work was supported in part by funding from the Canada Research Chairs program for IC, and by an Ontario Mental Health Foundation doctoral award held by KN. JAJ holds a Senior Health Scholar award from Alberta Innovates Health Solutions. None of the authors of this article have any conflicts or duality or interest to declare.
Author contributions
KN is the guarantor of this manuscript. All authors contributed substantially to the synthesis of this manuscript (KN, IC, DM, SO and JAJ: study hypothesis and design; SO, BS, and JK: data access and statistical support; KN: data analysis and manuscript draft). All authors (KN, SO, JAJ, DM, JK, BS, and IC) contributed extensively to the interpretation of the results and manuscript revision.
Acknowledgements
We would like to acknowledge the Nord-Trøndelag residents who participated in the HUNT study. The Nord-Trøndelag Health Study (The HUNT Study) is a collaboration between HUNT Research Centre (Faculty of Medicine, Norwegian University of Science and Technology NTNU), Central Norway Regional Health Authority, Nord-Trøndelag County Council and The Norwegian Institute of Public Health.
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