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Association of depression and anxiety symptoms with functional disability and disability days in a community sample with type 2 diabetes Kimberley J. Smith PhD, Norbert Schmitz PhD

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Psychosomatics

Cite this article as: Kimberley J. Smith PhD, Norbert Schmitz PhD, Association of depression and anxiety symptoms with functional disability and disability days in a community sample with type 2 diabetes, Psychosomatics, http://dx.doi.org/10.1016/j. psym.2014.05.015 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Association of depression and anxiety symptoms with functional disability and disability days in a community sample with type 2 diabetes Running title: Depression, anxiety and disability in diabetes

Kimberley J Smith, PhD1,2; Norbert Schmitz, PhD1,2,3,4 1

Department of Psychiatry, McGill University, Montreal, Quebec, Canada.

2

Douglas Mental Health University Institute, Montreal, Quebec, Canada.

3

Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec,

Canada. 4

Montréal Diabetes Research Centre, Montreal, Quebec, Canada

Address for reprint requests: Kimberley J Smith, Douglas Mental Health University Institute, McGill University, 6875 LaSalle Boulevard, Montreal, Quebec, Canada. H4H 1R3. Telephone : 01-514-761-6131, ext. 3334 Fax: 01-514-888-4064 E-mail: [email protected] Word count : 2,927 (including abstract, excluding tables and references)

Keywords: Disability; Functioning; anxiety; depression; diabetes 1   

Abstract Objective: There is a well-documented association between depression and disability in people with diabetes. However less is known about the possible association of cooccurring anxiety on these associations. The objective of this study was to assess the association of elevated anxiety and/or depression symptoms with functional disability and frequent disability days in a community sample with type 2 diabetes. Methods : Participants were 1,999 people with diabetes who completed the baseline portion of the Evaluation of Diabetes Treatment study. Functional disability was assessed using the World Health Organisation Disability Assessment Schedule II. Frequent disability days were assessed using a cutoff of ≥ 14 on a question assessing past month functional disability from the Healthy Days Core Module. Depression and Anxiety were assessed with the Patient Health Questionnaire and General Anxiety Questionnaire with cutoffs of ≥ 10 applied to create groups. Additional questions examined diabetes complications, chronic conditions and sociodemographic characteristics. Results : Fully-adjusted logistic regression analyses demonstrated an increased likelihood of reporting functional disability for all groups with high anxiety and/or depressive symptoms. Groups with high depressive symptoms with and without high anxiety symptoms were also more likely to report frequent disability days. Conclusions: Results indicate that elevated anxiety and depression symptoms are important factors associated with increased functional disability and frequent disability days in people with diabetes.

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Introduction Type 2 diabetes is a chronic physical illness associated with problems maintaining optimal blood glucose levels and an increased risk of developing micro- and macrovascular complications (1). In addition to an increased risk of developing physical complications diabetes is also one of the leading causes of disability adjusted lifetime years worldwide (2). Research also consistently shows that people with diabetes are at an increased risk of physical disability and poorer functioning (3). Another factor which shares strong independent associations with diabetes and disability is mental health. Two of the most commonly studied mental health conditions in people with diabetes are depression and anxiety. Both depression (4, 5) and anxiety (6) have been shown to be more common in people who have diabetes than people who do not have diabetes. In addition both depression and anxiety are among the leading mental and behavioural causes of years lived with disability worldwide (7). There is a well-documented association between depression and disability in people with diabetes. People who have both diabetes and depression show increased problems with work performance (8), increased functional disability (9), lower social functioning (9), more problems with activities of daily living (10) and report more disability days (11). However, there is less information available for the association of anxiety with disability in people with diabetes. Results from the general population indicate that anxiety is also an important mental health factor associated with disability (12). Depression and anxiety disorders are also frequently co-morbid both in the general population (13) and people with chronic noncommunicable illnesses such as coronary 3   

heart disease (14). Despite this frequently observed co-morbidity there is little research which explicitly looks at both anxiety and depression in people with diabetes. It is important for researchers to be cognizant of both depression and anxiety when examining disability as in general population studies the co-morbidity of depression and anxiety has been shown to be associated with impaired functioning both crossectionally (15, 16) and longitudinally (17). Despite these observations there is, to our knowledge, no study that has looked at the association of depression and anxiety with disability in people with diabetes. It is important to examine these associations in a population with diabetes due to the high frequency of disability, depression and anxiety in this population. The aim of this study was to ascertain if there was an association between having elevated anxiety symptoms alone, elevated depressive symptoms alone or co-occurring elevated anxiety and depressive symptoms with two indicators of disability in a community sample with type 2 diabetes. Methods Sampling and participants Data for this analysis was taken from the 2011 baseline portion of the Evaluation of Diabetes Treatment (EDIT) study. The EDIT study is a longitudinal community-based study of Quebec residents with type 2 diabetes (2011-2014). Inclusion criteria included being aged 40-75, diagnosed with diabetes for less than 10 years and being insulin-naïve. The long-term goal of the EDIT study is to investigate the transition from oral hypoglycemic medication to insulin medication. Participants were sampled using random digit-dialing and letters of invitation. All participants who were eligible and provided 4   

informed consent (n=2028) completed a telephone survey which consisted of questions about physical health, lifestyle and psychological status (for characteristics of the sample see Table 1). The study protocol and sampling procedures gained full ethical approval from the Ethics Board of the Douglas Hospital Research Centre. Questionnaires Functional disability Functional disability was assessed with the 12-item version of the World Health Organisation Disability Assessment Schedule II (WHO DAS II) (18). This scale assesses functional disability within cognition, mobility, self-care, life activities, participation and interpersonal interaction. Summary scores were transformed to a percent score with high scores indicating higher levels of disability. A cutoff of 21 percent was taken to indicate moderate functional disability as has been done before in this population (19). Disability days Disability days were assessed using a single-item question from the Healthy Days Core Module (20). Participants were asked on how many of the last 30 days that poor physical or mental health had kept them from doing their normal activities (such as self-care, work or recreation).

A cut-off of 14 was taken to indicate substantial activity limitation

(hereafter referred to as frequent disability days) as has been done in previous studies (21, 22).

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Anxiety and depression symptoms Anxiety symptoms were assessed using the 7-item Generalized Anxiety Disorder Questionnaire (GAD-7: (23) which screens for symptoms of general anxiety. A score of ≥ 10 was used as a validated cut-off to indicate clinically elevated anxiety symptoms (23). Depression symptoms were assessed using the 9-item Patient Health Questionnaire (PHQ-9: (24). A score of ≥ 10 was used as the validated cut-off for clinically significant depressive symptoms (25). Participants were placed into one of four categories based on whether they met the cut-off for clinically significant anxiety and/or depression symptoms. Stratification was chosen due to the high correlation between depressive and anxiety symptoms; Below threshold anxiety and depressive symptoms: Score < 10 for both GAD-7 and PHQ-9. Elevated anxiety symptoms: Score ≥ 10 for GAD-7 and < 10 for PHQ-9. Elevated depressive symptoms: Score ≥ 10 for PHQ-9 and < 10 for GAD-7. Co-occurring elevated anxiety and depressive symptoms: Score ≥ 10 for GAD-7 and PHQ-9. Co-variates Inclusion of covariates was based on extensive literature review and sampling those characteristics known to share associations with anxiety, depression and disability. Age, sex, marital status (married or partner/single/divorced or widowed), employment status 6   

(working full-or part-time/not working/retired), education (less than high school/high school

graduation/post

high

school)

and

body-mass

index

(BMI;

kg/m2:

underweight/normal/overweight/obese) were assessed with self-report questions (see (26)). Diabetes complications were assessed using the validated 17-item diabetes complications index which assesses for symptomatology of the following diabetes complications: coronary artery disease, cerebrovascular disease, peripheral vascular disease, neuropathy, foot problems and eye problems (DCI: (27). Chronic conditions were assessed by asking participants if they had ever been diagnosed with one of the eight most common chronic conditions in Canada. The conditions examined were asthma, high blood pressure, heart disease, stomach or intestinal ulcers, arthritis, migraine headaches, cancer and kidney disease (for details see (28, 29). Diabetes complications and chronic conditions were categorised as none, one or more than one in line with previous research (30). Data analysis Analysis of Variance (ANOVA) and crosstabulations were used to assess the association of anxiety and/or depressive symptoms on functional disability, frequent disability days and all co-variates. Logistic regression analysis assessed the association of having elevated anxiety and/or depressive symptoms with a.) Reporting moderate functional disability as indicated by a score of ≥ 21 on the WHO-DAS-II and b.) Reporting fourteen or more disability days in the past month. Both unadjusted and adjusted odds ratios with their 95% confidence

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intervals (CI’s) were calculated. Adjusted analyses controlled for age, sex, marital status, employment status, education, diabetes complications, chronic conditions and BMI. In order to test for potential interaction effects of anxiety and depressive symptoms with disability we used a certain synergy index (11, 31). The synergy index was used to calculate if the association of co-occurring anxiety and depressive symptoms with disability was even greater than the additive effect of depressive symptoms alone plus anxiety symptoms alone with disability. Presence of a synergistic interaction was indicated by a synergy index greater than 1. The synergy index and 95% confidence interval were calculated using the formula developed by Andersson et al (31). Two separate analyses were run for moderate functional disability and frequent disability days. Results Descriptive results: Differences between groups with high anxiety and/or depressive symptoms. Only participants who had completed the anxiety and depression questionnaires were included in the final analysis, leaving a total of 1,999 participants. Of the total population studied 85,1% (n=1,701) had below threshold anxiety and depression symptoms; 2,4% (n=48) had above threshold anxiety symptoms; 5,8% (n=115) had above threshold depression symptoms and 6,8% (n=135) had above threshold anxiety and depression symptoms. When all four groups were compared for severity of anxiety and depression there were significant differences between all four groups (see Table 2). Bonferroni-corrected post-hoc comparisons revealed those people with co-occurring elevated anxiety and depression had significantly higher anxiety and 8   

depression symptom scores when compared to all other groups. The group with elevated depression and elevated anxiety symptoms both had significantly higher depression and anxiety scores than the group with below threshold anxiety and depression symptoms. There was a significant association between anxiety and/or depressive symptoms with sex, marital status, education, employment status, BMI, diabetes complications and chronic conditions (see Table 2). However, there was no significant difference in age between groups. Those people with elevated anxiety symptoms, elevated depressive symptoms or elevated anxiety and depressive symptoms were more likely to be female. Those people who had elevated depressive symptoms both with and without co-occurring anxiety were less likely to be married. Those people who had co-occurring elevated anxiety and depressive symptoms were also more likely to have less than secondary school education and be unemployed. Those people who reported elevated anxiety symptoms and/or elevated depressive symptoms were less likely to be working full-time than those people with below threshold anxiety and depressive symptoms (see Table 2). Elevated depressive symptoms both with and without co-occurring anxiety was associated with an increased likelihood of being obese or underweight. Elevated anxiety symptoms were associated with an increased likelihood of being overweight. All three groups with elevated anxiety and/or depressive symptoms were also more likely to have one or more chronic conditions and one or more diabetes complications (see Table 2). (Insert Table 2)

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Association of anxiety and/or depressive symptoms with functional disability There was a significant association between having elevated anxiety symptoms, elevated depressive symptoms and co-occurring elevated anxiety and depressive symptoms with reporting impaired functioning as indicated by a score of ≥ 21 on the WHO DAS II (see Table 3). When a logistic regression was performed those people with elevated anxiety symptoms, elevated depression symptoms and co-occurring elevated anxiety and depressive symptoms were all more likely to meet criteria for moderate functional disability. This association persisted after controlling for all co-variates (see Table 3). (Insert Table 3) Association of anxiety and/or depressive symptoms with frequent disability days Having elevated anxiety symptoms, elevated depressive symptoms or co-occurring elevated anxiety and depressive symptoms were all associated with an increased likelihood of reporting frequent disability day (≥ 14 days in previous month). When a logistic regression was performed all three groups with elevated anxiety and/or depression were more likely to report frequent disability days in the previous month. These associations remained significant after adjusting for confounders for elevated depressive symptoms and co-occurring elevated anxiety and depressive symptoms (see Table 4). However, the association between elevated anxiety symptoms and frequent disability days was attenuated after controlling for co-variates. (Insert Table 4) 10   

Assessment of synergistic interaction for co-occurring depressive and anxiety symptoms with disability. The synergy index for co-occurring depression and anxiety with functional disability was 0.94 (0.47-1.88) indicating that there was no synergistic interaction for anxiety and depression symptoms with functional disability. The synergy index for co-occurring depression and anxiety with frequent disability days was 1.54 (0.74-3.22) indicating that there could be a positive interaction between high cooccurring anxiety and depressive symptoms with frequent disability days. However, as the 95% confidence interval overlapped with 1 this meant the effect was not significant. Discussion Results from this study indicate that elevated anxiety and depressive symptoms both alone and in combination are associated with an increased likelihood of reporting moderate functional disability and reporting experiencing frequent disability days in the preceding month. These associations were particularly pronounced in the groups with elevated depressive symptoms with and without co-occurring anxiety. There is a well-established relationship between depressive symptoms and disability in people with diabetes (8-11) and results from this study provide additional evidence for this association. However to our knowledge this is the first study that looks at the relative association of both anxiety and depression with disability in this population. Our results provide new evidence that high anxiety symptoms are independently associated with functional disability in people with diabetes. In addition, our results also indicate that there a particularly strong association with disability for the group with co-occurring anxiety and depressive symptoms. This group were 1101% more likely to report

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moderate functional disability and 785% more likely to report experiencing frequent disability days in the preceding month. However, when assessed using a synergistic interaction analysis there was no evidence that co-occurring anxiety and depressive symptoms had a synergistically greater association with disability than anxiety symptoms alone and depressive symptoms alone. Interestingly however, the point estimate for the interaction between co-occurring anxiety and depressive symptoms with frequent disability days was positive if non-significant. Our results provide preliminary evidence that in addition to examining depression in people with diabetes when assessing disability, it may also be important to examine anxiety. Diabetes is associated with an increased likelihood of being diagnosed with both depression (5) and anxiety (6). However, there is still a need to ascertain how these two disorders are associated with important clinical and functional outcomes in people with diabetes. Previous work from the general population has shown that the association of anxiety and depression with indicators of disability such as sickness absence can be particularly pronounced in a group that has co-morbid anxiety and depression compared to depression or anxiety alone (32, 33). General population studies have also indicated that people with co-morbid depression and anxiety have a poorer prognosis than people with anxiety or depression alone (17, 34). These findings coupled with observations from our research potentially means that those people with co-occurring depression and anxiety in diabetes could have worsened functioning over longer periods of time than if they had depressive symptoms alone or anxiety symptoms alone. As such, there is a need for research that will assess the longitudinal implications of psychological co-morbidity on clinical 12   

outcomes in people with diabetes. It will be also be interesting to determine the association of depression and anxiety with disability over longer periods of time (as both measures in the current study only examined the past 30 days). Future research will also be necessary to ascertain how depression, anxiety and diabetes are associated with disability. Disability is a broad and multi-dimensional concept incorporating limitations and impairments in various domains of life from interpersonal and intrapersonal functioning to carrying out activities (35). It is possible that diabetes and anxiety/depression are associated with impairment and limitation in different domains, or it may be the case that anxiety/depression exacerbates the disability experienced by people with diabetes. Future work is also needed to ascertain how psychological interventions impact on the association of depression and anxiety with disability in this population. This research would be necessary to determine whether treatment of anxiety and depression ameliorates the observed associations with disability. The main strength of this study is the use of a large community-based representative population sample. The main limitation of this study is the use of screening scales for anxiety and depression. More valid conclusions and clinical implications could be drawn by using clinical diagnostic tests. The research is also limited by the use of crossectional data, limiting inferences on direction of causality. This research also relies on self-report data instead of clinical data. Finally it is also important to note that there were a small number of people in the anxiety and depression groups, particularly the high anxiety symptoms group. This means that results should be interpreted with caution as they may have been underpowered (particularly in the high anxiety symptoms group).

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However, this is the first study to our knowledge that has looked at both anxiety and depression when examining disability. It has important research implications, as many researchers working in the field of diabetes and mental health choose to focus on either depression or anxiety independently instead of looking at them both. Our findings indicate that in the future it may be important to consider psychological co-morbidity. Also our findings have important clinical implications indicating that clinicians should be mindful of screening for psychological co-morbidity in people with diabetes. Acknowledgements The authors would like to thank the CIHR for providing funding for this study. We would also like to thank all study collaborators and participants. Conflict of interest The authors declare that they have no conflicts of interest. References 1. WHO. Diabetes factsheet: number 312. World Health Organisation; 2011 [cited 2011 August 2011]; Available from: http://www.who.int/mediacentre/factsheets/fs312/en/. 2. WHO. The Global Burden of Disease. 2004. 3. Wong E, Backholer K, Gearon E, Harding J, Freak-Poli R, Stevenson C, et al. Diabetes and risk of physical disability in adults: a systematic review and meta-analysis. Lancet Diabetes Endocrinol. 2013;1(2):106-14. 4. Ali S, Stone MA, Peters JL, Davies MJ, Khunti K. The prevalence of co-morbid depression in adults with Type 2 diabetes: a systematic review and meta-analysis. Diabet Med.2006;23(11):1165-73. 5. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24(6):1069-78. 6. Smith KJ, Beland M, Clyde M, Gariepy G, Page V, Badawi G, et al. Association of diabetes with anxiety: A systematic review and meta-analysis. J Psychosom Res. 2013;74(2):89-99. 14   

7. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012 15;380(9859):2163-96. 8. Von Korff M, Katon W, Lin EH, Simon G, Ciechanowski P, Ludman E, et al. Work disability among individuals with diabetes. Diabetes Care. 2005;28(6):1326-32. 9. Von Korff M, Katon W, Lin EH, Simon G, Ludman E, Oliver M, et al. Potentially modifiable factors associated with disability among people with diabetes. Psychosom Med. 2005;67(2):233-40. 10. Huang H, Russo J, Von Korff M, Ciechanowski P, Lin E, Ludman E, et al. The effect of changes in depressive symptoms on disability status in patients with diabetes. Psychosomatics. 2012;53(1):21-9. 11. Schmitz N, Wang J, Malla A, Lesage A. Joint effect of depression and chronic conditions on disability: results from a population-based study. Psychosom Med. 2007;69(4):332-8. 12. de Beurs E, Beekman AT, van Balkom AJ, Deeg DJ, van Dyck R, van Tilburg W. Consequences of anxiety in older persons: its effect on disability, well-being and use of health services. Psychol Med. 1999;29(3):583-93. 13. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617-27. 14. Vogelzangs N, Seldenrijk A, Beekman AT, van Hout HP, de Jonge P, Penninx BW. Cardiovascular disease in persons with depressive and anxiety disorders. J Affect Disord. 2010;125(1-3):241-8. 15. Hofmeijer-Sevink MK, Batelaan NM, van Megen HJ, Penninx BW, Cath DC, van den Hout MA, et al. Clinical relevance of comorbidity in anxiety disorders: a report from the Netherlands Study of Depression and Anxiety (NESDA). J Affect Disord. 2012;137(1-3):106-12. 16. Bijl RV, Ravelli A. Current and residual functional disability associated with psychopathology: findings from the Netherlands Mental Health Survey and Incidence Study (NEMESIS). Psychol Med. 2000 May;30(3):657-68. 17. Fichter MM, Quadflieg N, Fischer UC, Kohlboeck G. Twenty-five-year course and outcome in anxiety and depression in the Upper Bavarian Longitudinal Community Study. Acta Psychiatr Scand. 2010l;122(1):75-85. 18. Epping-Jordan J. The WHODAS II. The World Health Organization, Geneva, Switzerland 2000. 19. Schmitz N, Gariepy G, Smith KJ, Malla A, Boyer R, Strychar I, et al. Longitudinal relationships between depression and functioning in people with type 2 diabetes. Ann Behav Med. 2014;47(2):172-9. 20. CDC. Measuring Healthy Days. Population Assessment of Health-Related Quality of Life: Atlanta: Centres for Disease Control and Prevention. 2000. 21. Brown DW, Balluz LS, Giles WH, Beckles GL, Moriarty DG, Ford ES, et al. Diabetes mellitus and health-related quality of life among older adults. Findings from the behavioral risk factor surveillance system (BRFSS). Diabetes Res Clin Pract. 2004;65(2):105-15.

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22. Li C, Ford ES, Mokdad AH, Balluz LS, Brown DW, Giles WH. Clustering of cardiovascular disease risk factors and health-related quality of life among US adults. Value Health. 2008;11(4):689-99. 23. Lowe B, Decker O, Muller S, Brahler E, Schellberg D, Herzog W, et al. Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Med Care. 2008;46(3):266-74. 24. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med.2001;16(9):606-13. 25. Manea L, Gilbody S, McMillan D. Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): a meta-analysis. Cmaj. 2012;184(3):E191-6. 26. Smith KJ, Gariepy G, Pedneault M, Beland M, Clyde M, Schmitz N. Exploring the association of psychological status with self-rated diabetes control: results from the montreal evaluation of diabetes treatment study. Psychosomatics. 2013;54(1):35-43. 27. Fincke BG, Clark JA, Linzer M, Spiro A, 3rd, Miller DR, Lee A, et al. Assessment of long-term complications due to type 2 diabetes using patient self-report: the diabetes complications index. J Ambul Care Manage. 2005;28(3):262-73. 28. Schmitz N, Messier L, Nitka D, Ivanova A, Gariepy G, Wang J, et al. Factors associated with disability and depressive symptoms among individuals with diabetes: a community study in Quebec. Psychosomatics. 2011;52(2):167-77. 29. Schmitz N, Nitka D, Gariepy G, Malla A, Wang J, Boyer R, et al. Association between neighborhood-level deprivation and disability in a community sample of people with diabetes. Diabetes Care. 2009;32(11):1998-2004. 30. Badawi G, Gariepy G, Page V, Schmitz N. Indicators of self-rated health in the Canadian population with diabetes. Diabet Med. 2012;29(8):1021-8. 31. Andersson T, Alfredsson L, Kallberg H, Zdravkovic S, Ahlbom A. Calculating measures of biological interaction. Eur J Epidemiol. 2005;20(7):575-9. 32. Knudsen AK, Harvey SB, Mykletun A, Overland S. Common mental disorders and long-term sickness absence in a general working population. The Hordaland Health Study. Acta Psychiatr Scand. 2013;127(4):287-97. 33. Wedegaertner F, Arnhold-Kerri S, Sittaro NA, Bleich S, Geyer S, Lee WE. Depression- and anxiety-related sick leave and the risk of permanent disability and mortality in the working population in Germany: a cohort study. BMC Public Health. 2013;13:145. 34. Penninx BW, Nolen WA, Lamers F, Zitman FG, Smit JH, Spinhoven P, et al. Two-year course of depressive and anxiety disorders: results from the Netherlands Study of Depression and Anxiety (NESDA). J Affect Disord. 2011;133(1-2):76-85. 35. WHO. Disability and health: Fact sheet no 352. http://wwwwhoint/mediacentre/factsheets/fs352/en/. 2013.

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Age Sex Marital status Employment status Education Household income Duration of Diabetes (years since diagnosis) Treatment Diabetes complications Index Chronic conditions BMI

Frequency

Percentage

60.51 ± 8.4 Female Male Married/partner Widowed/divorced/separated Never married Working full/part time Not working Retired Less than high school High school graduation Post high school < $15,000 $15,000-$50,000 > $50,000 4,59 ± 3,1

1014 1007 1320 463 239 788 302 933 814 617 568 280 853 633

50,2 49,8 65,3 22,9 11,8 39,0 14,9 46,1 40,7 30,9 28,4 15,9 48,3 35,8

Oral medication Lifestyle None One complication Two or more complications None One condition Two or more conditions Underweight Normal Overweight Obese

1825 203 718 603 588 374 584 997 9 327 738 853

90,0 10,0 37,6 31,6 30,8 19,1 29,9 51,0 0,5 17,0 38,3 44,3

Table 1: Baseline characteristics of EDIT sample (n=2028). Table showing the baseline characteristics of the EDIT sample. The three most commonly observed diabetes complications (using the DCI) were peripheral vascular disease symptoms (36.9%), coronary artery disease symptoms (19.5%) and neuropathy symptoms (26.6%). The three most commonly observed chronic conditions in the sample were high blood pressure (54.8%), arthritis (29.2%) and asthma (17.6%)

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Sociodemogra phic

Health indicators

Anxiety and  

Sex ***

Female Male Marital Married/partn status *** er Single Widowed/div orced Education Less than ** secondary school Secondary school graduation Post high school Employm Working full ent status time/part time *** Unemployed Retired Age (years ± SD)

BMI ***

N

Below threshold depressive/an xiety symptoms % (N=1,701) 47.1 52.9 67.7 10.9 21.4

Depress ive sympto ms only % (N=115 ) 65.2 34.8 47.0 16.5 36.5

75,0 25,0 64,6 12,5 22,9

Co-morbid depressive and anxiety symptomol ogy % (N=135) 64,9 35,1 53,0 17,4 29,5

998 997 130 4 233 456 802 611 560

39.6 31.2 29.2

38.1 33.6 28.3

37,0 41,3 21,7

56,7 22,4 20,9

782 294 918

41.7 11.8 46.6

28.1 27.2 44.7

29,2 16,7 54,2

21,5 40,7 37,8

60,59 ± 8,4

61.42 ± 8.1 0 20,0 42,2 37,8 27,3 38,6 34,1

59.09 ± 8.6

0.3 17.7 39.2 42.8 41.2 31.7 27.1

59,90 ± 8,2 1.8 12.6 25.2 60.4 15.7 31.5 52.8

1,6 8,6 37,5 52,3 15,7 29,8 54,5

21.4 31.7 46.9

4.6 21.3 74.1

13,6 18,2 68,2

3,2 16,9 79,8

1.51 ± 2.3

5.24 ± 2.5

12.47 ± 2.1

14.58 ± 3.3

Underweight 9 Normal 321 Overweight 729 Obese 844 Diabetes No 713 complicati complications 598 ons index 1 576 *** complication 2 plus complications Chronic No conditions 369 conditions 1 condition 576 *** 2 plus 985 conditions GAD-7 (Mean anxiety score ± SD) ***

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Anxiet y sympto ms only % (N=48)

depressio n summary scores

PHQ-9 (Mean depression score ± SD) ***

2.50 ± 2.6

12.45 ± 2.9

6.13 ± 2.3

15.88 ± 4.3

Table 2: Comparison between groups: descriptive data All categorical variables were compared using crosstabulations. All continuous variables (presented as mean ± standard deviation) were compared using one-way ANOVA with Bonferonni-corrected comparisons There was no significant difference between groups for age (F(3,1998)=1.72, P=0.2), but there was for depression severity (F(3, 1998=1354.11, p

Association of depression and anxiety symptoms with functional disability and disability days in a community sample with type 2 diabetes.

There is a well-documented association between depression and disability in people with diabetes. However, less is known about the possible associatio...
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