The contribution of illness perceptions and metacognitive beliefs to anxiety and depression in adults with diabetes
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.
References (43)
- et al.
Affective, substance use, and anxiety disorders in persons with arthritis, diabetes, heart disease, high blood pressure, or chronic lung conditions
Gen Hosp Psychiatry
(1989) - et al.
Depression, chronic diseases, and decrements in health: results from the World Health Surveys
Lancet
(2007) - et al.
Insulin-treated diabetes patients with fear of self-injecting or fear of self-testing: psychological comorbidity and general well-being
J Psychosom Res
(2001) - et al.
The bidirectional relationship of depression and diabetes: a systematic review
Clin Psychol Rev
(2011) - et al.
Psychiatric-medical comorbidity: effect of interventions for major depressive disorder and significant depressive symptoms in patients with diabetes mellitus: a systematic review and meta-analysis
Gen Hosp Psychiatry
(2010) - et al.
A systematic review of psychosocial outcomes following education, self-management and psychological interventions in diabetes mellitus
Patient Educ Counsell
(2003) - et al.
Metacognitions, anxiety and distress related to motor fluctuations in Parkinson’s disease
J Psychosom Res
(2015) - et al.
Research report: effectiveness of a stepped care intervention for anxiety and depression in people with diabetes, asthma or COPD in primary care: a randomized controlled trial
J Affect Disord
(2015) - et al.
A short form of the metacognitions questionnaire: properties of the MCQ-30
Behav Res Ther
(2004) - et al.
Measuring metacognitions associated with emotional distress: Factor structure and predictive validity of the metacognitions questionnaire 30
Personality Individ Differ
(2008)
Depression in diabetic patients: the relationship between mood and gylcemic control
Diabetes Complicat
Diabetes and anxiety in US adults: findings from the 2006 behavioural risk factor surveillance system
Diabetes Med
Epidemiology of depression and diabetes: a systematic review
J Affect Disord
Chronic medical conditions in a sample of the general population with anxiety, affective, and substance use disorders
Am J Psychiatry
The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R)
JAMA
Depression and quality of life in patients with diabetes: a systematic review from the European depression in diabetes (EDID) research consortium
Curr Diabetes Rev
Depression and diabetes: impact of depressive symptoms on adherence, function, and costs
Arch Intern Med
The summary of diabetes self-care activities measure: results from seven studies and a revised scale
Diabetes Care
Depression and diabetes treatment nonadherence: a meta-analysis
Diabetes Care
Is treatment of depression cost-effective in people with diabetes? A systematic review of the economic evidence
Int J Technol Assess Health Care
Economic aspects of the association between diabetes and depression: a systematic review
J Affect Disord
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2022, Saudi Pharmaceutical JournalCitation Excerpt :Other pathophysiological factors that might contribute to DM-associated cognitive decrements are oxidative stress, inflammation, the glycogen synthase kinase 3β (GSK3β) signaling mechanism, advanced glycation end-products (AGEs), protein misfolding and Aβ accumulation in the brain (Kong et al., 2020; Pugazhenthi et al., 2017). Furthermore, other concomitant psychological problems like, e.g. anxiety and depression also notably intensify the pressing problems in the daily lives of diabetics (Purewal and Fisher, 2018; Whitworth et al., 2016). DM is treated by employing a range of glucose-lowering drugs (alone or in combination).