ReviewPrevalence of anxiety in adults with diabetes: A systematic review
Introduction
The anxiety disorders defined in the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [2] include panic disorder, obsessive–compulsive disorder (OCD), posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), and agoraphobia, specific phobia, and social phobia. The nosology also includes some variants of these diagnoses (e.g., panic disorder without agoraphobia) and a category for subclinical presentations (anxiety disorder not otherwise specified). Although these disorders differ from one another with respect to course and severity, their clinical presentations overlap and often include prominent anxiety, fear, and apprehension, as well as adrenergic symptoms.
The anxiety disorders include some of the most common and disabling of all psychiatric illnesses. GAD, the most prevalent of the anxiety disorders, is found in up to 3–4% of the US population [6], [29], [76] and is associated with significantly diminished functioning and a more severe course of comorbid psychiatric and medical conditions [52]. The level of impairment associated with GAD is equivalent to that associated with major depressive disorder [28] and similar to that seen in other Axis I psychiatric disorders. Other anxiety disorders, e.g., agoraphobia or OCD, although less common than GAD, can be even more debilitating.
Another significant segment of the population has elevated anxiety symptoms or a subclinical anxiety disorder. These presentations, although typically less severe, are also associated with decreased functioning [17], [52], [59], [64] and poor quality of life [46], [64]. In the primary care setting, patients with subclinical anxiety consume a disproportionately large share of health care resources [12], [26], [27], [57] and thus are sometimes referred to as the worried well [11], [13].
Chronic hyperglycemia significantly increases the risk for micro- and macrovascular complications of diabetes [20]. Consequently, maintenance of good glycemic control is the focus of diabetes therapy, and the importance of psychological and other factors is valued in relation to their effects on this endpoint. Furthermore, despite the availability of effective treatment for diabetes, very few patients sustain glucose levels in the range needed to avoid diabetes complications [1], [71], suggesting a need for additional management options. Anxiety is associated with poor glycemic control [5], [31], [36], [45], [48], [70], and treatment of anxiety is associated with improved glycemic control [41], [58], particularly in the subset of patients with more severe anxiety [33]. A more accurate estimate of anxiety prevalence than is currently available is needed to gauge the potential impact of anxiety management in diabetes. In this paper, we comprehensively review the scientific literature in order to estimate the prevalence of clinically significant anxiety in adults with Type 1 or Type 2 diabetes.
Section snippets
Inclusion/exclusion criteria
MEDLINE and PsycINFO databases engines were used to locate studies that reported the prevalence of anxiety in adults (≥18 years of age) with diabetes. The keyword terms anxiety or anxiety disorder were combined with diabetes or diabetes mellitus. Reference lists were reviewed to identify other relevant articles. Studies were included only if they (1) had a sample size ≥25, (2) were comprised of persons diagnosed with Type 1 or Type 2 diabetes, and (3) were published or available in English
Results
Twenty-seven studies were identified, nine of which were excluded because the data were reported in another included study by the same research group [7], [37], [39], [47], [63], [73] or because the diabetic sample was limited to a select group (eating disorders [67], pregnancy [34], hyperglycemia [41]) poorly suited to the aims of the review. Of the 18 studies that satisfied the inclusion criteria (N=4076; 2584 diabetic subjects, 1492 controls), 5 (27.8%) were controlled (Table 1) and 13
Discussion
We surveyed the scientific literature and estimated the prevalence of anxiety disorders and elevated symptoms of anxiety from 18 studies having a combined total of 4076 subjects. The rates of panic disorder, OCD, PTSD, and agoraphobia were within the range of those reported in community studies [23], [29], [49], [55]. GAD was the most prevalent of the clinical disorders and was found in 14% of the diabetic subjects, most of whom were drawn from clinic populations. This rate is substantially
Acknowledgements
This work was supported in part by grants from the National Institute of Diabetes, Digestive, and Kidney Disease of National Institutes of Health (DK36452, DK53060, DK59364, and DK20579).
References (79)
- et al.
Anxiety and depressive disorders in an adult insulin-dependent diabetic mellitus (IDDM) population: relationship with glycaemic control and somatic complications
Eur Psychiatry
(1998) - et al.
The treatment of emotional disorders in general practice: psychological methods versus medication
J Psychosom Res
(1986) - et al.
Distressed high utilizers of medical care: DSM-III-R diagnoses and treatment needs
Gen Hosp Psychiatry
(1990) - et al.
Utilization of medical specialists by anxiety disorder patients
Psychosomatics
(1997) - et al.
Effects of both the emotional behavior and feeding conditions on the circulating plasma volume and plasma glucose levels in cats
Auton Neurosci: Basic Clin
(2000) - et al.
Stress and immune function in diabetes mellitus
Clin Immunol Immunopathol
(1983) Anxiety disorders in adults with diabetes mellitus
Psychiatr Clin North Am
(1988)- et al.
Stress and diabetic control
Lancet
(1983) - et al.
Schedule for Affective Disorders and Schizophrenia—Lifetime Version Modified for the Study of Anxiety Disorders (SADS-LA): rationale and conceptual development
J Psychiatr Res
(1986) - et al.
Psychosocial correlates of hemoglobin A1c in young adults with type 1 diabetes
J Psychosom Res
(1990)
The functioning and well-being of patients with unrecognized anxiety disorders and major depressive disorder
J Affective Disord
Differences between bulimia and binge-eating disorder in females with type 1 diabetes: the important role of insulin omission
J Psychosom Res
Glycosylated hemoglobin levels in anxious and nonanxious diabetic patients
Psychosomatics
Affective, substance use, and anxiety disorders in persons with arthritis, diabetes, heart disease, high blood pressure, or chronic lung conditions
Gen Hosp Psychiatry
A rating instrument for anxiety disorders
Psychosomatics
Standards of medical care for patients with diabetes mellitus: position statement
Diabetes Care
Diagnostic and statistical manual of mental disorders
Diagnostic and statistical manual of mental disorders: DSM-II
The prevalence of comorbid depression in adults with diabetes: a meta-analysis
Diabetes Care
Phobic symptoms, particularly the fear of blood and injury, are associated with poor glycemic control in type 1 diabetic adults
Diabetes Care
Generalized anxiety disorder
Gastrointestinal symptoms in diabetic patients: lack of association with neuropathy
Am J Gastroenterol
Statistical power analysis for the behavioral sciences
Effects and correlates of blood glucose awareness training among patients with IDDM
Diabetes Care
Psychosocial sequelae of visual loss in diabetes
Diabetes Educ
The stigma of anxiety disorders
Int J Clin Pract
Consequences of anxiety in older persons: its effect on disability, well-being and use of health services
Psychol Med
Estimates of use and costs of behavioural health care: a comparison of standard and finite mixture models
Health Econ
The SCL-90-R administration, scoring and procedures manual I
A diagnostic interview: the Schedule for Affective Disorders
Arch Gen Psychiatry
Epidemiology of anxiety disorders in Florence
Acta Psychiatr Scand
Untreated anxiety among adult primary care patients in a health maintenance organization
Arch Gen Psychiatry
A case for blood glucose control
Adv Int Med
Diabetes in North American Indians and Alaska Natives
Glycated hemoglobin: methodologies and clinical applications
Clin Chem
Post-traumatic stress disorder in the general population: findings of the Epidemiologic Catchment Area Survey
N Engl J Med
Prevalence of anxiety and depressive symptoms in patients with type 1 and 2 diabetes
Rev Med Suisse Romande
Comorbidity as a fundamental feature of generalized anxiety disorders: results from the National Comorbidity Study (NCS)
Acta Psychiatr Scand
Impairment in pure and comorbid generalized anxiety disorder and major depression at 12 months in two national surveys
Am J Psychiatry
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