The contribution of illness perceptions and metacognitive beliefs to anxiety and depression in adults with diabetes

https://doi.org/10.1016/j.diabres.2017.11.029Get rights and content

Highlights

  • Metacognitive beliefs are associated with anxiety and depression in diabetes.

  • Negative beliefs about the uncontrollability and danger most significant contributor.

  • Metacognitive beliefs explain anxiety and depression beyond illness perceptions.

  • Metacognitive model of emotional disorder has clinical utility in diabetes.

Abstract

Aims

Anxiety and depression are highly prevalent in people with diabetes (PwD). The most widely used psychological model to explain anxiety and depression in PwD is the Common-Sense Model, which gives a central role to illness perceptions. The Self-Regulatory Executive Function (S-REF) model proposes metacognitive beliefs are key to understanding the development and maintenance of emotional disorders. To test the potential utility of the S-REF model in PwD, the study explored if metacognitive beliefs explained additional variance in anxiety and depression after controlling for demographic and illness perceptions.

Methods

614 adults with either Type 1 (n = 335) or Type 2 (n = 279) diabetes participated in a cross sectional online survey. All participants completed questionnaires on anxiety, depression, illness perceptions and metacognitive beliefs.

Results

Regression analyses showed that metacognitive beliefs were associated with anxiety and depression in PwD and explained additional variance in both anxiety and depression after controlling for demographics and illness perceptions.

Conclusions

This is the first study to demonstrate that metacognitive beliefs are associated with anxiety and depression in PwD. The clinical implications of the study are illustrated.

Introduction

Anxiety and depression are common in people with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM). The lifetime prevalence for any anxiety disorder across all types of diabetes is 19.5% [1]. For depression, the lifetime prevalence is 12% in T1DM and 19.1% in T2DM [2]. Anxiety and depression frequently co-occur in people with diabetes (PwD) [3], [4], [5]. Anxiety and depression reduce quality of life [6], [7], [8], impair adherence to self-care regimes by interfering with exercise, diet and medication routines [9], [10], [11] and significantly increase health care use and costs [12], [13], [14].

Clearly, effective treatment of anxiety and depression in PwD is needed. Unfortunately, current pharmacological and psychological interventions achieve modest treatment effects [15], [16], [17]. Several psychological models have been developed to explain the development and maintenance of anxiety and depression in PWD. The predominant theoretical model is the Common-Sense Model (CSM) of self-regulation in health and illness [18] and underpins Cognitive Behavioural Therapy (CBT). The CSM proposes that appraisals or beliefs about the nature of the illness (illness perceptions) including the expected course, impact on life, and personal influence over the illness are fundamental to the persistence of emotional distress. Although, illness perceptions are independently associated with anxiety and depression in people with T1DM and T2DM [19], [20], [21] and with health-related quality of life and glycaemic control [17] they do not fully account for the variability in anxiety and depression. A theoretical model, which offers an alternative explanation is the Self-Regulatory Executive Function (S-REF) model [22] which suggests that anxiety and depression are not caused by the negative thoughts (illness perceptions) about diabetes, but are the product of a counterproductive style of responding and thinking to negative thoughts and feelings called the cognitive attentional syndrome (CAS). The CAS involves three processes: (i) perseverative thinking (e.g. worry, rumination, doubting); (ii) attentional strategies (e.g. focusing on symptoms, monitoring for negative thoughts and feelings); and (iii) unhelpful coping strategies (e.g. reduce activity, suppress unwanted thoughts and images). The S-REF model specifies that the CAS is activated and maintained by metacognitive beliefs. There are two main domains of metacognitive belief which can be categorised as positive and negative metacognitions. Positive metacognitive beliefs (e.g. “worrying about the future keeps me prepared”, “checking my mind for negative thoughts helps me cope”) promote the use of each aspect of the CAS. Negative metacognitive beliefs about the uncontrollability and danger of worry (e.g. worry is uncontrollable) perpetuate use of the CAS and reinforce unhelpful patterns of coping (e.g. thought suppression).

The S-REF model has clinical utility in understanding anxiety and depression in several physical health populations [22], [23], [24], [25], [26], but the model has yet to be tested in PwD. The S-REF model predicts that illness perceptions will be associated with anxiety and depression. However, the S-REF model also predicts that metacognitive beliefs will explain additional variance in anxiety and depression after accounting for the influence of illness perceptions. We test this prediction in the current study. In summary, the S-REF model specifies anxiety and depression are not caused by the content of thoughts or illness perceptions, instead it is metacognitive beliefs linked to the control and regulation of cognition which determine anxiety and depression.

Section snippets

Study design, participants and procedure

614 participants were recruited via adverts from the Help DiaBEATes NIHR Clinical Research Network or one of three online diabetes forums; diabetes-support.org.uk, diabetes.co.uk and Diabetes UK communications (Diabetes UK Balance magazine). PwD were invited to complete an online survey measuring metacognitive beliefs, illness perceptions, anxiety, and depression. Participants were included if they met the following criteria; (1) self-reported diagnosis of either TIDM or T2DM, (2) at least

Results

Sample characteristics by diabetes type are summarised in Table 1. People with T1DM were younger (U = 24,044, p < .001, r = −0.41)) and more anxious (U = 41,325, p = .013, r = 0.10) than people with T2DM. In addition, women with T1DM reported more anxiety (U = 10870.5, p = .025, r = −0.12) than men with T1DM. There were no other differences either within or across types of diabetes. A substantial proportion of the sample scored above the clinical cut off points for anxiety (49% of T1DM and 44%

Discussion

This is the first study to test the contribution of metacognitive beliefs to anxiety and depression in PwD. As predicted by the S-REF model [22] the relationship between metacognitive beliefs and anxiety and depression in both T1DM and T2DM remained significant when controlling for illness perceptions and age and gender.

In T1DM metacognitive beliefs explained 38% additional variance in anxiety and 29% additional variance in depression. In T2DM, metacognitive beliefs accounted for comparable

Conclusions

The S-REF model offers an alternative conceptualisation of the psychological mechanisms involved in anxiety and depression in people with T1DM or T2DM. The results support the prediction that metacognitive beliefs contribute to anxiety and depression beyond the contribution made by illness perceptions. Prospective studies are required to establish a causal role for metacognitive beliefs in anxiety and depression, coupled with a more complete test of the predictions made by the S-REF model.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

RP collected and analysed the data. PF conceived the study, and advised on data collection and analysis. Both authors contributed to drafting of the manuscript, and read and approved the final manuscript.

Acknowledgments

Many thanks to Katherine Grady and the Help DiaBEATes team (NIHR Clinical Research Network: Greater Manchester), Salford Royal NHS Foundation Trust for help with recruitment. A sincere thank you to the diabetes forums diabetes-support.org.uk and diabetes.co.uk and Diabetes UK communications (Diabetes UK Balance magazine) for allowing the advertisement of the study.

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