Review
Prevalence of anxiety in adults with diabetes: A systematic review

https://doi.org/10.1016/S0022-3999(02)00417-8Get rights and content

Abstract

Background: Anxiety is associated with decreased functioning and quality of life. It may have added importance in diabetes for its potential adverse effects on regimen adherence and glycemic control. Objective: To estimate the prevalence of clinically significant anxiety in adults with diabetes. Research Design and Methods: MEDLINE and PsycINFO databases and published reference lists were searched to identify studies that determined the prevalence of anxiety in diabetes from threshold scores on self-report measures or from diagnostic interviews. Prevalence was calculated as an aggregate mean weighted by the combined number of subjects in the included studies. Results: Eighteen studies having a combined population (N) of 4076 (2584 diabetic subjects, 1492 controls) satisfied the inclusion criteria. Most did not adjust for the effects of moderator variables such as gender, and only one was community-based. Generalized anxiety disorder (GAD) was present in 14% of patients with diabetes. The subsyndromal presentation of anxiety disorder not otherwise specified and of elevated anxiety symptoms were found in 27% and 40%, respectively, of patients with diabetes. The prevalence of elevated symptoms was significantly higher in women compared to men (55.3% vs. 32.9%, P<.0001) and similar in patients with Type 1 vs. Type 2 diabetes (41.3% vs. 42.2%, P=.80). Conclusion: GAD is present in 14% and elevated symptoms of anxiety in 40% of patients with diabetes who participate in clinical studies. Additional epidemiological studies are needed to determine the prevalence of anxiety in the broader population of persons with diabetes.

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).

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