Original Article
JOURNAL OF WOMEN’S HEALTH Volume 00, Number 0, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2015.5210
Diabetes Mellitus and the Risk of Depressive and Anxiety Disorders in Australian Women: A Longitudinal Study Syed Shahzad Hasan, PhD,1 Alexandra M Clavarino, PhD,1 Kaeleen Dingle, PhD,2 Abdullah A Mamun, PhD,3 and Therese Kairuz, PhD 4
Abstract
Background: Longitudinal studies examining the risk of depressive and anxiety disorders associated with diabetes are limited. This study examined the association between diabetes and the risk of depressive and anxiety disorders in Australian women using longitudinal data. Methods: Data were from a sample of women who were part of an Australian pregnancy and birth cohort study. Data comprised self-reported diabetes mellitus and the subsequent reporting of depressive and anxiety disorders. Mood disorders were assessed according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, obtained from participants using Composite International Diagnostic Interview (CIDI)-Auto (WHO WMH-CIDI CAPI, version 21.1.3). Multiple regression models with adjustment for important covariates were used. Results: Women with diabetes had a higher lifetime prevalence of any depressive and/or anxiety disorder than women without diabetes. About 3 in 10 women with diabetes experienced a lifetime event of any depressive disorder, while 1 in 2 women with diabetes experienced a lifetime event of any anxiety disorder. In prospective analyses, diabetes was only significantly associated with a 30-day episode of any anxiety disorder (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.09–2.15). In the case of lifetime disorders, diabetes was significantly associated with any depressive disorder (OR 1.37, 95% CI 1.03–1.84), major depressive disorder (OR 1.36, 95% CI 1.01–1.85), and posttraumatic stress disorder (OR 1.42, 95% CI 1.01–2.02). Conclusions: The findings suggest that the presence of diabetes is a significant risk factor for women experiencing current anxiety disorders. However, in the case of depression, the association with diabetes only held for women who had experienced past episodes, there was no association with current depression. This suggests that the evidence is not strong enough to support a direct effect of diabetes as a cause of mood disorders.
Studies among people with type 1 and type 2 diabetes mellitus (T1DM, T2DM) have shown a similar increase in the risk for developing depressive and anxiety disorders or symptoms;1,8,9 In the majority of cases, the initial onset of mood disorders seems to precede the diagnosis of T2DM, while in T1DM these disorders typically follow its diagnosis.10,11 Although both types of diabetes have dissimilar etiologies and progression of the disease, depression was found to increase the severity of complications, with a similar effect on both T1DM and T2DM.12 Regarding anxiety disorders and diabetes, there is evidence of increased complications,13 poor glycemic control,14 weight gain,15 and reduced quality of life;16 however, there
Introduction
P
eople with diabetes are at higher risk of developing depression and anxiety1,2 and women are almost 50 percent more likely to experience a mood disorder than men over their lifetime.3 Previous studies have demonstrated that a significant number of patients with diabetes have comorbid major depressive disorder (MDD) or generalized anxiety disorder (GAD) or experience depressive and anxiety symptoms.1,4 Globally, MDD is projected to be one of the three leading contributors to the burden of disease by 2030.5 In industrialized countries, MDD occurs twice as frequently in women,6 and the prevalence is significantly higher in women than in men with diabetes.7
1
School of Pharmacy, 3School of Population Health, The University of Queensland, Woolloongabba, Queensland, Australia. Queensland University of Technology, Queensland, Australia. 4 Department of Pharmacy, James Cook University, Townsville, Queensland, Australia 2
1
2
HASAN ET AL.
has been little focus on the possibility of diabetes as a risk factor for the onset of anxiety disorders. Unlike studies of depression, only a few longitudinal studies have examined the association between diabetes and the risk of anxiety symptoms or disorders.10,17–21 Most of the available studies have several methodology-related deficiencies, such as crosssectional study design and use of self-reported scales instead of Diagnostic and Statistical Manual of Mental Disorders (DSM)–based diagnoses.8,22 Despite the fact that literature suggests that anxiety is an important comorbid condition associated with diabetes, only one review published in 2013 examined the link between diabetes and the risk of developing anxiety.8 The current study bridges the gaps in the literature about depression, anxiety, and diabetes. The aim is to examine the prospective association between diabetes and the risk of developing depressive and anxiety disorders, diagnosed using DSM-based criteria. The study focuses on women because both depression and anxiety are reported to be higher in women than men.1,3,23 Methods Participants
We examined the association between diabetes mellitus, identified at 21-year follow-up, and the subsequent reporting of depressive and anxiety disorders, measured 6 years later at 27-year follow-up. The sample of women was part of an Australian pregnancy and birth cohort, the Mater-University of Queensland Study of Pregnancy (MUSP). This is a multidisciplinary study that represents Australia’s largest longitudinal
study of women’s reproductive life-course from pre-birth for 27 years postpartum. The longitudinal study began in 1978– 1979 with a number of pilot studies, and full data collection commenced in January, 1981. The recruited women gave birth at the Mater Misericordiae Mothers’ Hospital, which is one of two major obstetric units in Brisbane, Australia.24,25 The original study was approved by the Human Subjects Research Ethics Committees of the Mater Hospital and the University of Queensland. MUSP data were collected prospectively across the reproductive life course of a large group of women; 7861 women were originally enrolled in the study (8556 pregnancies), and 6753 of these women constitute the MUSP mothers’ cohort. To be enrolled in the cohort study, women had to deliver at least one live baby who neither died nor was adopted before leaving hospital, and had to have complete data from an initial interview (first clinic visit at approximately 18 weeks’ gestation) and an interview conducted shortly after the birth. These women were reinterviewed 3 to 5 days after delivery, and data from their medical records were collected. Additional interviews were conducted 6 months, 5 years, 14 years, 21 years, and 27 years after the index pregnancy. Table 1 presents the average age of the cohort at various stages, and the key outcome and exposure variables. The exposure variables in our analyses came from information regarding self-reported diabetes mellitus in the 21 years after the index pregnancy; data were collected using a self-administered questionnaire. Women were asked, ‘‘Have you EVER been told by a doctor that you have diabetes mellitus (high blood sugar)?’’ Only 32 women had reported diabetes at the time of the index pregnancy, and a positive
Table 1. Content of Measurements Stage
Average age in years
First clinic visit (1981–1983)
25.01
3–5 days after birth (1981–1984)
25.42
6-month follow-up (1981–1984)
26.10
5-year follow-up (1986–1988)
31.32
14-year follow-up (1995–1997)
39.72
21-year follow-up (2001–2004)
46.56
27-year follow-up (2008–2011)
53.26
Selected variables measured Sociodemographics (e.g., marital status), lifestyle factors (e.g., smoking), mental health (e.g., DSSI-depression, DSSI-anxiety), physical health (e.g., weight), clinical factors (e.g., pre-existing diabetes, hypertension) Sociodemographics (e.g., employment during pregnancy), lifestyle factors (e.g., smoking), mental health (e.g., DSSI-depression, DSSI-anxiety), physical health (e.g., problems during labor, obstetrical data) Sociodemographics (e.g., changes in marital status), lifestyle factors (e.g., breastfeeding duration), mental health (e.g., post-natal DSSI-depression, DSSI-anxiety), physical health (e.g., child development) Sociodemographics (e.g., children in household), lifestyle factors (e.g., patterns of child care), mental health (e.g., DSSI-depression, DSSI-anxiety, life events, CBCL), physical health (e.g., health problem inventory) Sociodemographics (e.g., family income), lifestyle factors (e.g., food frequency, physical activity), mental health (e.g., DSSI-depression, DSSI-anxiety, CBCL, violence in marital status), physical health (e.g., health problem inventory) Sociodemographics (e.g., number of children), lifestyle factors (e.g., food frequency, physical activity), mental health (e.g., DSSI-depression, DSSI-anxiety, medical service use, CES-D), physical health (e.g., weight, waist and hip circumference) clinical factors (e.g., diabetes, BP, respiratory function). Sociodemographics (e.g., marital status), lifestyle factors (e.g., smoking), mental health (e.g., DSSI-depression, DSSI-anxiety, CIDI), physical health (e.g., weight, waist and hip circumference) clinical factors (e.g., diabetes, BP).
BP, blood pressure; CBCL, Child Behavior Checklist; CES-D, Center for Epidemiologic Studies Depression; CIDI, Composite International Diagnostic Interview; DSSI, Delusions-Symptoms-States Inventory.
DIABETES AND RISK OF MOOD DISORDERS
response to this question indicated that the woman had developed incident diabetes mellitus at some stage during the 21 years after the index pregnancy.26 A total of 3486 women provided information regarding diabetes mellitus at 21-year follow-up. These women were followed prospectively, and 283 responded positively to the question about diabetes, of whom 32 had previously been diagnosed with T1DM or gestational diabetes. The remaining 251 did not specify the type of diabetes, although their age at the time the diabetes was reported suggested they would be predominantly participants with T2DM. Measurement of depressive and anxiety disorders
At the 27-year follow-up, data on disorders were extracted from a computerized structured interview of depressive and anxiety symptoms using the Composite International Diagnostic Interview (CIDI). This instrument assesses current and lifetime prevalence of mental health disorders according to the (DSM-IV) diagnoses. The CIDI was administered via the World Health Organization World Mental Health-Composite International Diagnostic Interview CAPI Modularization Program (WHO WMH-CIDI CAPI, version 21.1.3).27 Diagnostic concordance between the interviewer-administered CIDI and clinical checklists are satisfactory for depressive disorders, anxiety, and phobic disorders.28 The CIDI has been reported to have acceptable validity when compared with clinicians’ diagnoses, with overall agreement similar to comparisons between the paper-and-pencil CIDI and clinician diagnoses.28 The CIDI summary outcomes (any depressive or anxiety disorder) were calculated as a positive diagnosis across a range of DSM-IV diagnoses. The term ‘‘any depressive or anxiety disorder’’ indicates the presence of at least one disorder. For specific disorders, we focused on MDD, GAD, panic disorder, specific phobias (e.g., social phobia), and posttraumatic stress disorder (PTSD). Other disorders were excluded because we did not have enough numbers in each category to produce reliable results. We included three categories to define onset of (any) depressive or anxiety disorders: lifetime, 12-month, and 30-day periods. Lifetime disorders were included to estimate the prevalence of lifetime disorders in women with and without diabetes and to examine the association between lifetime disorders and diabetes irrespective of the onset of each condition. Depressive and anxiety symptoms, measured using the Delusions-Symptoms-States-Inventory /states of Anxiety and Depression at the 21-year follow-up, were used to identify cases of preexisting symptoms of anxiety and depression. Women who had symptoms of anxiety (n = 212), depression (n = 13), or comorbid depression and anxiety (n = 56) at the 21-year follow-up were excluded from analysis, and thus a total of 6472 women were included in the analysis.
3
Regarding income, women were asked to select, from a 7point scale, the (Australian) dollar range that best represented their total annual family income. In the current study, family annual income at the 21-year follow-up was categorized into either low (
JOURNAL OF WOMEN’S HEALTH Volume 00, Number 0, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/jwh.2015.5210
Diabetes Mellitus and the Risk of Depressive and Anxiety Disorders in Australian Women: A Longitudinal Study Syed Shahzad Hasan, PhD,1 Alexandra M Clavarino, PhD,1 Kaeleen Dingle, PhD,2 Abdullah A Mamun, PhD,3 and Therese Kairuz, PhD 4
Abstract
Background: Longitudinal studies examining the risk of depressive and anxiety disorders associated with diabetes are limited. This study examined the association between diabetes and the risk of depressive and anxiety disorders in Australian women using longitudinal data. Methods: Data were from a sample of women who were part of an Australian pregnancy and birth cohort study. Data comprised self-reported diabetes mellitus and the subsequent reporting of depressive and anxiety disorders. Mood disorders were assessed according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, obtained from participants using Composite International Diagnostic Interview (CIDI)-Auto (WHO WMH-CIDI CAPI, version 21.1.3). Multiple regression models with adjustment for important covariates were used. Results: Women with diabetes had a higher lifetime prevalence of any depressive and/or anxiety disorder than women without diabetes. About 3 in 10 women with diabetes experienced a lifetime event of any depressive disorder, while 1 in 2 women with diabetes experienced a lifetime event of any anxiety disorder. In prospective analyses, diabetes was only significantly associated with a 30-day episode of any anxiety disorder (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.09–2.15). In the case of lifetime disorders, diabetes was significantly associated with any depressive disorder (OR 1.37, 95% CI 1.03–1.84), major depressive disorder (OR 1.36, 95% CI 1.01–1.85), and posttraumatic stress disorder (OR 1.42, 95% CI 1.01–2.02). Conclusions: The findings suggest that the presence of diabetes is a significant risk factor for women experiencing current anxiety disorders. However, in the case of depression, the association with diabetes only held for women who had experienced past episodes, there was no association with current depression. This suggests that the evidence is not strong enough to support a direct effect of diabetes as a cause of mood disorders.
Studies among people with type 1 and type 2 diabetes mellitus (T1DM, T2DM) have shown a similar increase in the risk for developing depressive and anxiety disorders or symptoms;1,8,9 In the majority of cases, the initial onset of mood disorders seems to precede the diagnosis of T2DM, while in T1DM these disorders typically follow its diagnosis.10,11 Although both types of diabetes have dissimilar etiologies and progression of the disease, depression was found to increase the severity of complications, with a similar effect on both T1DM and T2DM.12 Regarding anxiety disorders and diabetes, there is evidence of increased complications,13 poor glycemic control,14 weight gain,15 and reduced quality of life;16 however, there
Introduction
P
eople with diabetes are at higher risk of developing depression and anxiety1,2 and women are almost 50 percent more likely to experience a mood disorder than men over their lifetime.3 Previous studies have demonstrated that a significant number of patients with diabetes have comorbid major depressive disorder (MDD) or generalized anxiety disorder (GAD) or experience depressive and anxiety symptoms.1,4 Globally, MDD is projected to be one of the three leading contributors to the burden of disease by 2030.5 In industrialized countries, MDD occurs twice as frequently in women,6 and the prevalence is significantly higher in women than in men with diabetes.7
1
School of Pharmacy, 3School of Population Health, The University of Queensland, Woolloongabba, Queensland, Australia. Queensland University of Technology, Queensland, Australia. 4 Department of Pharmacy, James Cook University, Townsville, Queensland, Australia 2
1
2
HASAN ET AL.
has been little focus on the possibility of diabetes as a risk factor for the onset of anxiety disorders. Unlike studies of depression, only a few longitudinal studies have examined the association between diabetes and the risk of anxiety symptoms or disorders.10,17–21 Most of the available studies have several methodology-related deficiencies, such as crosssectional study design and use of self-reported scales instead of Diagnostic and Statistical Manual of Mental Disorders (DSM)–based diagnoses.8,22 Despite the fact that literature suggests that anxiety is an important comorbid condition associated with diabetes, only one review published in 2013 examined the link between diabetes and the risk of developing anxiety.8 The current study bridges the gaps in the literature about depression, anxiety, and diabetes. The aim is to examine the prospective association between diabetes and the risk of developing depressive and anxiety disorders, diagnosed using DSM-based criteria. The study focuses on women because both depression and anxiety are reported to be higher in women than men.1,3,23 Methods Participants
We examined the association between diabetes mellitus, identified at 21-year follow-up, and the subsequent reporting of depressive and anxiety disorders, measured 6 years later at 27-year follow-up. The sample of women was part of an Australian pregnancy and birth cohort, the Mater-University of Queensland Study of Pregnancy (MUSP). This is a multidisciplinary study that represents Australia’s largest longitudinal
study of women’s reproductive life-course from pre-birth for 27 years postpartum. The longitudinal study began in 1978– 1979 with a number of pilot studies, and full data collection commenced in January, 1981. The recruited women gave birth at the Mater Misericordiae Mothers’ Hospital, which is one of two major obstetric units in Brisbane, Australia.24,25 The original study was approved by the Human Subjects Research Ethics Committees of the Mater Hospital and the University of Queensland. MUSP data were collected prospectively across the reproductive life course of a large group of women; 7861 women were originally enrolled in the study (8556 pregnancies), and 6753 of these women constitute the MUSP mothers’ cohort. To be enrolled in the cohort study, women had to deliver at least one live baby who neither died nor was adopted before leaving hospital, and had to have complete data from an initial interview (first clinic visit at approximately 18 weeks’ gestation) and an interview conducted shortly after the birth. These women were reinterviewed 3 to 5 days after delivery, and data from their medical records were collected. Additional interviews were conducted 6 months, 5 years, 14 years, 21 years, and 27 years after the index pregnancy. Table 1 presents the average age of the cohort at various stages, and the key outcome and exposure variables. The exposure variables in our analyses came from information regarding self-reported diabetes mellitus in the 21 years after the index pregnancy; data were collected using a self-administered questionnaire. Women were asked, ‘‘Have you EVER been told by a doctor that you have diabetes mellitus (high blood sugar)?’’ Only 32 women had reported diabetes at the time of the index pregnancy, and a positive
Table 1. Content of Measurements Stage
Average age in years
First clinic visit (1981–1983)
25.01
3–5 days after birth (1981–1984)
25.42
6-month follow-up (1981–1984)
26.10
5-year follow-up (1986–1988)
31.32
14-year follow-up (1995–1997)
39.72
21-year follow-up (2001–2004)
46.56
27-year follow-up (2008–2011)
53.26
Selected variables measured Sociodemographics (e.g., marital status), lifestyle factors (e.g., smoking), mental health (e.g., DSSI-depression, DSSI-anxiety), physical health (e.g., weight), clinical factors (e.g., pre-existing diabetes, hypertension) Sociodemographics (e.g., employment during pregnancy), lifestyle factors (e.g., smoking), mental health (e.g., DSSI-depression, DSSI-anxiety), physical health (e.g., problems during labor, obstetrical data) Sociodemographics (e.g., changes in marital status), lifestyle factors (e.g., breastfeeding duration), mental health (e.g., post-natal DSSI-depression, DSSI-anxiety), physical health (e.g., child development) Sociodemographics (e.g., children in household), lifestyle factors (e.g., patterns of child care), mental health (e.g., DSSI-depression, DSSI-anxiety, life events, CBCL), physical health (e.g., health problem inventory) Sociodemographics (e.g., family income), lifestyle factors (e.g., food frequency, physical activity), mental health (e.g., DSSI-depression, DSSI-anxiety, CBCL, violence in marital status), physical health (e.g., health problem inventory) Sociodemographics (e.g., number of children), lifestyle factors (e.g., food frequency, physical activity), mental health (e.g., DSSI-depression, DSSI-anxiety, medical service use, CES-D), physical health (e.g., weight, waist and hip circumference) clinical factors (e.g., diabetes, BP, respiratory function). Sociodemographics (e.g., marital status), lifestyle factors (e.g., smoking), mental health (e.g., DSSI-depression, DSSI-anxiety, CIDI), physical health (e.g., weight, waist and hip circumference) clinical factors (e.g., diabetes, BP).
BP, blood pressure; CBCL, Child Behavior Checklist; CES-D, Center for Epidemiologic Studies Depression; CIDI, Composite International Diagnostic Interview; DSSI, Delusions-Symptoms-States Inventory.
DIABETES AND RISK OF MOOD DISORDERS
response to this question indicated that the woman had developed incident diabetes mellitus at some stage during the 21 years after the index pregnancy.26 A total of 3486 women provided information regarding diabetes mellitus at 21-year follow-up. These women were followed prospectively, and 283 responded positively to the question about diabetes, of whom 32 had previously been diagnosed with T1DM or gestational diabetes. The remaining 251 did not specify the type of diabetes, although their age at the time the diabetes was reported suggested they would be predominantly participants with T2DM. Measurement of depressive and anxiety disorders
At the 27-year follow-up, data on disorders were extracted from a computerized structured interview of depressive and anxiety symptoms using the Composite International Diagnostic Interview (CIDI). This instrument assesses current and lifetime prevalence of mental health disorders according to the (DSM-IV) diagnoses. The CIDI was administered via the World Health Organization World Mental Health-Composite International Diagnostic Interview CAPI Modularization Program (WHO WMH-CIDI CAPI, version 21.1.3).27 Diagnostic concordance between the interviewer-administered CIDI and clinical checklists are satisfactory for depressive disorders, anxiety, and phobic disorders.28 The CIDI has been reported to have acceptable validity when compared with clinicians’ diagnoses, with overall agreement similar to comparisons between the paper-and-pencil CIDI and clinician diagnoses.28 The CIDI summary outcomes (any depressive or anxiety disorder) were calculated as a positive diagnosis across a range of DSM-IV diagnoses. The term ‘‘any depressive or anxiety disorder’’ indicates the presence of at least one disorder. For specific disorders, we focused on MDD, GAD, panic disorder, specific phobias (e.g., social phobia), and posttraumatic stress disorder (PTSD). Other disorders were excluded because we did not have enough numbers in each category to produce reliable results. We included three categories to define onset of (any) depressive or anxiety disorders: lifetime, 12-month, and 30-day periods. Lifetime disorders were included to estimate the prevalence of lifetime disorders in women with and without diabetes and to examine the association between lifetime disorders and diabetes irrespective of the onset of each condition. Depressive and anxiety symptoms, measured using the Delusions-Symptoms-States-Inventory /states of Anxiety and Depression at the 21-year follow-up, were used to identify cases of preexisting symptoms of anxiety and depression. Women who had symptoms of anxiety (n = 212), depression (n = 13), or comorbid depression and anxiety (n = 56) at the 21-year follow-up were excluded from analysis, and thus a total of 6472 women were included in the analysis.
3
Regarding income, women were asked to select, from a 7point scale, the (Australian) dollar range that best represented their total annual family income. In the current study, family annual income at the 21-year follow-up was categorized into either low (
