THE COMPLICATED PATIENT
Based on estimates by the International Diabetes Federation, there are 451 million people with diabetes mellitus worldwide and the prevalence is projected to increase to 693 million by 2045. Worldwide, five million deaths were attributed to diabetes in 2017 and global health care expenditure incurred for diabetes in that year was 850 billion US dollars.1 The prevalence of diabetes mellitus in the US is variously estimated to be around 7% to 9%. Type 2 diabetes mellitus (T2DM) is the more common subtype of the disorder, accounting for 90% to 95% of the cases; the remaining are predominantly type 1 diabetes mellitus (T1DM).2,3
Anxiety disorders are also highly prevalent in the general population, particularly in those with medical illnesses such as diabetes. The umbrella term anxiety disorders includes a variety of psychiatric conditions characterized by excessive, impairing, and dysfunctional patterns of anxiety symptoms. Generalized anxiety disorder (GAD), social anxiety disorder, specific phobia, and panic disorder are all common anxiety disorders with varying rates of prevalence. PTSD and OCD used to be classified as anxiety disorders but are currently classified in DSM-5 in the Trauma and Stressor Related Disorders and Obsessive Compulsive and Related Disorders respectively.
Aside from specific anxiety disorders, anxiety symptoms not meeting criteria for a specific disorder, or subthreshold anxiety symptoms, are also common in the population and can nonetheless be distressing and impairing. In a study conducted across 15 primary care clinics in the US, 19.5% of 965 patients had at least one anxiety disorder, 7.6% had GAD, 6.8% had panic disorder, 6.2% had social anxiety disorder, and 8.6% had PTSD. Close to half (41%) of the patients with anxiety disorders were receiving no active treatment.4
Association between anxiety and diabetes
Comorbid anxiety disorders and diabetes mellitus is known to occur more than would be predicted by chance alone. In a meta-analysis of 12 studies including data from nearly 13,000 individuals with diabetes, diabetes was associated with an increased probability of anxiety disorders (odds ratio [OR] = 1.20) as well as anxiety symptoms (OR = 1.48).5
Analysis of data from the 2006 Behavioral Risk Factor Surveillance System (N = 201,575; 20,142 with diabetes) revealed that after adjusting for educational level, marital status, employment status, current smoking, leisure-time physical activity and body mass index, individuals with diabetes had a 20% higher prevalence of lifetime diagnosis of anxiety than those without (prevalence risk 1.20; 95% CI 1.12, 1.30). Young adults (aged 18-29 years) and Hispanics were noted to be at higher risk compared with other age and ethnic groups respectively.6
In a systematic review of 18 studies, prevalence of GAD was 14% in individuals with diabetes. The prevalence of anxiety disorder not otherwise specified (subsyndromal presentations) and of elevated anxiety symptoms were reported to be 27% and 40%, respectively. Anxiety symptoms were higher in diabetic women compared with men and similar in patients with T1DM versus T2DM.7
Dr Qadir is Second-Year Psychiatry Resident, Georgetown University Hospital, Washington, DC; Dr Abbas is Third-Year Psychiatry Resident, Howard University Hospital, Washington, DC; Dr Aftab is Geriatric Psychiatry Fellow, University of California San Diego, La Jolla, CA; he is also a member of the Psychiatric Times Advisory Board. The authors report no conflicts of interest concerning the subject matter of this article.
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