Anxiety and Depressive Symptoms as Predictors of All-Cause Mortality among People with Insulin-Naïve Type 2 Diabetes: 17-Year Follow-Up of the Second Nord-Trøndelag Health Survey (HUNT2), Norway.

Marjolein M. Iversen,Grethe S. Tell,Frans Pouwer,Kristian Midthjell,Giesje Nefs,Birgitte Espehaug,Marit Graue

doi:10.1371/journal.pone.0160861

Abstract

AimTo examine whether elevated anxiety and/or depressive symptoms are related to all-cause mortality in people with Type 2 diabetes, not using insulin.Methods948 participants in the community-wide Nord-Trøndelag Health Survey conducted during 1995–97 completed the Hospital Anxiety and Depression Scale with subscales of anxiety (HADS-A) and depression (HADS-D). Elevated symptoms were defined as HADS-A or HADS-D ≥8. Participants with type 2 diabetes, not using insulin, were followed until November 21, 2012 or death. Cox regression analyses were used to estimate associations between baseline elevated anxiety symptoms, elevated depressive symptoms and mortality, adjusting for sociodemographic factors, HbA1c, cardiovascular disease and microvascular complications.ResultsAt baseline, 8% (n = 77/948) reported elevated anxiety symptoms, 9% (n = 87/948) elevated depressive symptoms and 10% (n = 93/948) reported both. After a mean follow-up of 12 years (SD 5.1, range 0–17), 541 participants (57%) had died. Participants with elevated anxiety symptoms only had a decreased mortality risk (unadjusted HR 0.66, 95% CI 0.46–0.96). Adjustment for HbA1c attenuated this relation (HR 0.73, 95% CI 0.50–1.07). Those with elevated depression symptoms alone had an increased mortality risk (fully adjusted model HR 1.39, 95% CI 1.05–1.84). Having both elevated anxiety and depressive symptoms was not associated with increased mortality risk (adjusted HR 1.30, 95% CI 0.96–1.74).ConclusionsElevated depressive symptoms were associated with excess mortality risk in people with Type 2 diabetes not using insulin. No significant association with mortality was found among people with elevated anxiety symptoms. Having both elevated anxiety and depressive symptoms was not associated with mortality. The hypothesis that elevated levels of anxiety symptoms leads to behavior that counteracts the adverse health effects of Type 2 diabetes needs further investigation.

Highlights

People with Type 2 diabetes are more likely to experience elevated depression and/or anxiety symptoms or an anxiety disorder, than people without diabetes [1,2,3]
Elevated depressive symptoms were associated with excess mortality risk in people with Type 2 diabetes not using insulin
No significant association with mortality was found among people with elevated anxiety symptoms

Summary

Introduction

People with Type 2 diabetes are more likely to experience elevated depression and/or anxiety symptoms or an anxiety disorder, than people without diabetes [1,2,3]. While depression affects approximately one in five individuals with Type 2 diabetes [2], generalized anxiety disorder and elevated anxiety symptoms have been reported to be present in 14% and 40%, respectively [4]. Depression was found to be associated with a higher risk of adverse diabetes outcomes and higher mortality rates [5]. A meta-analysis including 11 cross-sectional studies found that anxiety disorders, but not elevated anxiety symptoms, were associated with hyperglycemia [9]. More recent cross-sectional studies examining the association between anxiety and the presence of diabetes complications have found mixed results [10,11,12]. Longitudinal studies focusing on the relation between anxiety and health outcomes are still lacking in people with Type 2 diabetes

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