Anxiety and depression in diabetic patients

Anxiety and depression in diabetic patients


Anxiety and Depression in Diabetic Patients According to the Hospital Anxiety and Depression Scale (HADS) Scoring



Kader Ugur1, Gozde Ozkan1, Ahmet Karatas2, Burak Oz2, Abdullah Mubin Ozercan3, İbrahim Sahin4,5, Suleyman Aydin4* and Mustafa Ulas6


1Department of Endocrinology and Metabolism, Firat University Hospital, Elazig, Turkey

2Department of Rheumatology, Firat University Hospital, Elazig, Turkey

3Department of Gastroenterology, Firat University Hospital, Elazig, Turkey

4Department of Medical Biochemistry and Clinical Biochemistry, Firat Hormones Research Group, School of Medicine, Firat University Hospital, Elazig, Turkey

5Department of Medical Biology, Medical School, Erzincan Binali Yilidirim University, Erzincan, Turkey

6Department of Physiology, Medical School, Firat University, Elazig, Turkey



Journal of clinical and molecular endocrinology




This study primarily aimed to evaluate the distribution of depression and anxiety in patients with type 1 and type 2 diabetes mellitus (DM) using the Hospital Anxiety and Depression Scale (HADS) and to compare the obtained results with specific demographic, metabolic, and anthropometric parameters.



A total of 193 participants were included—52 had type 1 DM (females, 35; males, 17), 86 had type 2 DM (females, 47; males, 39), and 55 were controls (females, 34; males, 21). Depression, anxiety, and anxiety+depression in these patients were evaluated according to the HADS. Data on fasting blood glucose, hemoglobin A1C (HbA1c), triglyceride, total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, urea, and creatinine levels were evaluated for each patient.



Depression and anxiety scores were significantly higher in patients with type 2 DM than in patients with type 1 DM. In addition, depression, anxiety, and anxiety +depression were higher in females in both types 1 and 2 DM. Moreover, there was a positive correlation between depression and anxiety scores and HbA1c.



Thus, performing psychiatric treatment in addition to diabetic treatment might increase patients’ quality of life and social adaptation.


Anxiety; Depression; Diabetes mellitus



Diabetes mellitus (DM) is a complex disease; it leads to severe physical, psychological, and organic disorders and is frequently accompanied by anxiety and depression [1]. The prevalence of depression and anxiety in diabetic patients are 8.5%–32.5% and 30%, respectively, which are 2-fold higher than those in the general population [2,3].

As mentioned above, although DM leads to organic disorder, it has psychiatric and psychosocial aspects. Patients with DM experience different problems associated with physical, emotional, social, and sexual aspects. In addition, compared with the general population, diabetic patients are subject to 1.5- fold higher risk of depression-associated mortality [4]. Moreover, mental disorders accompanied by diabetes negatively impact chronic micro- and macro-complications. Hence, blood sugar regulation is impaired, thereby decreasing patients’ quality of life and the increasing mortality rates [5].

In fact, the prevalence’s of anxiety and depression were found to be higher in diabetic patients with poor blood glucose control than in those with good blood glucose control [6]. Diabetes affects sensory functions and leads to electroencephalographic (EEG) and neuropathologic changes in the central nervous system; changes in the sensory functions may be caused by recurrent hypoglycemic attacks [7].


Stress and anxiety are important factors even in patients with irregular blood sugar levels undergoing medical treatment. Epinephrine secretion, which reduces the effect of insulin, increases when an organism encounters anxiety. When one is angry, happy, or excessively emotional, free fatty acid, cortisol, and blood sugar levels are elevated and adrenaline, noradrenaline, growth hormone, and cortisol levels in the body increase due to stress, leading to hyperglycemia [8]. Moreover, neurohormonal changes, such as hypercortisolism seen in depression, reportedly lead to insulin resistance and diabetes as well as lifestyle changes owing to depression, which may be predisposing to diabetes [9]. Therefore, irregularities in the blood sugar levels can directly affect the brain and its functions.


Insulin-dependent type 1 DM, wherein the blood sugar levels cannot be maintained, causes anxiety and depression by affecting the autonomic and central nervous systems as well as autoimmune mechanisms. In contrast, in older patients with type 2 DM, decreases in both mental and physical energies owing to diabetes, macrovascular complications associated with diabetes during diagnosis, and other comorbidities usually increase the prevalence of mental disorders. Thus, the association between depression and anxiety is high [5]. The Hospital Anxiety and Depression Scale (HADS), which was developed by Zigmond and Snait [10] is currently one of the most widely used scales to evaluate depression and anxiety in DM. The HADS not only helps in diagnosis but also determines the risk group by rapidly scanning anxiety and depression in patients with the disease [10].


Therefore, here, we aimed to evaluate the distribution of depression and anxiety in terms of sex, type and duration of DM, and some demographic and metabolic parameters in patients with type 1 and 2 DM.


Materials and Methods

A total of 193 patients were included in this study; 52 and 86 patients who applied to the Firat University Endocrinology Department had type 1 and 2 DM, respectively. In addition, 55 healthy individuals (age, >18 years) who were admitted to our hospital for annual checkups between June 2018 and December 2018 were included as the control group. The sample size was calculated using PASS software (version 14.0; NCSS, Silver Spring, MD). The power was set at 0.8, and the significance level was set at 0.05. The study was approved by the Firat University Ethics Committee (meeting no., 14; decision no, 2; date, 09. 0.6. 2018). The study was conducted in accordance with the principles of declaration of Helsinki, and written informed consent was obtained from all participants prior to study initiation.

Patients who were aged <21 years; pregnant; used antidepressant or antipsychotic drugs; physical illness, use of tobacco products and alcohol (former and current), and morbidly obese, any eating disorder as well as those with malignancies and/or advanced renal or hepatic disease, hyperthyroidism and hypothyroidism, malignancy, liver, kidney, acute or chronic inflammatory disease or were excluded from the study. The control group comprised healthy individuals who were not medically ill at the checkup. Fasting blood glucose, hemoglobin A1C (HbA1c), triglyceride, total cholesterol, lowdensity lipoprotein (LDL), high-density lipoprotein (HDL), aspartate aminotransferase (AST), alanine aminotransferase (ALT), albumin, urea, and creatinine levels were obtained from the medical records of all patients and controls. In addition, height, weight, body mass index (BMI), neck, waist, and hip circumference measurements were made and information about the patients’ exercise habits and drug use patterns were obtained. The participants’ anxiety and depression levels were determined via face-to-face interviews conducted using questions included in the HADS. The scale comprises a total of 14 questions, and the maximum score was 21 for both anxiety and depression. When both conditions were evaluated, the maximum score was 42. The patients were grouped as normal, borderline, and depression or anxiety based on their HADS scores. All patients with HADS scores between 0 and 7 were considered normal, those with scores between 8 and 10 as borderline, and those with scores ≥ 11 as having anxiety in the anxiety scale and having depression in the depression scale. The data were statistically analyzed using the SPSS software, percentage calculation, and student’s t-test; furthermore, oneway analysis of variance was performed for parametric data, Mann–Whitney U-test for nonparametric data, and chi-square test for categorical data. Based on the results of this study, the correlations between HADS and sex, anthropometric measurements, metabolic status, exercise status, complication status, ongoing treatment, and laboratory parameters were determined.


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Ugur K, Ozkan G, Karatas A, Oz B, Ozercan AM, et al. (2019) Anxiety and Depression in Diabetic Patients According to the Hospital Anxiety and Depression Scale (HADS) Scoring. J Clin Mol Endocrinol 4: 1 doi:10.21767/2572-5432.100049



© 2019 Ugur K, et al. This is an open-access article distributed under the terms of the Creative Commons attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.




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