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Anxiety disorders in patients with diabetes mellitus

Popkin et al noted a lifetime prevalence of 28% for generalized anxiety disorders in the 140 candidates they evaluated for pancreas transplantation. They also noted a lifetime prevalence for major depressive disorder of 19.3%. Neither anxiety nor depression increased the risk for unfavorable transplantation outcome.

Lustman et al, using structured interview techniques in a sample of patients with type 1 and type 2 diabetes reported a lifetime prevalence of phobic disorders of 26.5% and of generalized anxiety disorders of 41%. These findings are six to seven times greater than that reported for the general population in the Epidemiological Catchment Area (ECA) study. Lustman et al also showed that the poorer a patient's glucose control (i.e., the higher the HbA1C) the greater their lifetime incidence of psychiatric illness.

Popkin et al, in a brilliant series of studies from the University of Minnesota showed that 51% of a group of patients with longstanding type 1 diabetes mellitus received one or more significant psychiatric diagnoses. The lifetime prevalence of major depression was comparable for female and male diabetics, and both evidenced rates that were significantly higher than that seen in their first degree relatives or in the general population. These investigators showed that the prevalence of generalized anxiety disorder (31.7%) was 3 times that which occurred in first degree relatives (9.5%). They noted that Lustman had similarly observed high rates of generalized anxiety disorders in both type 1 and type 2 diabetics, 44.4% and 37.5% respectively.

Peyrot and Rubin studied 634 patients in an out-patient diabetes education program for the presence of depression and anxiety. Depression occurred in 41.3% of patients. Anxiety disorders were reported in 49.2% of the patients. The rates were considerably higher than the 10% to 20% incidence reported in the general medical population. These authors reported that the probability of disturbance ranged from 5-7% for those patients with the lowest risk profile to 82-92% for those patients with the highest risk profile. The presence of diabetes-related complications was the only disease factor that was associated with a higher risk of disturbance for both depression and anxiety. Women, particularly those with less education, were at greatest risk. They concluded that diabetes is associated with an increased risk of psychological disturbance, particularly for those patients with more diabetic-related complications. They also concluded that socio-demographic factors accounted for much of the risk differential among patients with diabetes.

Lustman et al studied 58 patients with poor glycemic control, 16 of whom (27.6%) had symptoms of generalized anxiety disorder. The patients were placed in a randomized double blind, placebo controlled eight-week trial, using alprazolam up to 2 mg a day as the active agent. They demonstrated a statistically significant reduction in glycosylated hemoglobin level in the patients treated with alprazolam compared to those receiving a placebo (P=0.04). Treatment effect was not a function of compliance behavior. They concluded that a short course of alprazolam improved glucose regulation in patients with a history of poor diabetes control. They felt that the effect was not directly related to concomitant changes in the patient's anxiety. The authors believed that the alprazolam treatment of anxious patients with poorly controlled diabetes may result in decreased anxiety and improved glucose regulation through independent mechanisms.

Okada et al, in an interesting Japanese study, evaluated the effects of reducing stress on 20 patients with type 2 diabetes, 10 male and 10 female. Patients were treated with an anxiolytic (fludiazepam) for 12 weeks. Glycosylated hemoglobin levels were monitored. Patients took anxiety scale tests to evaluate their level of anxiety. Improvement in the trait anxiety scores was correlated with decreases in glycosylated hemoglobin levels. P<0.01 The authors concluded that suppressing anxiety in patients with type 2 diabetes reduced their glycosylated hemoglobin levels. These authors in another study showed that the high-density lipoprotein/cholesterol levels of these patients increased significantly after the administration of the anxiolytic, but other aspects of their lipid profile were unchanged. They concluded that the improvement of stress in patients with non-insulin-dependent diabetes mellitus increased their high-density lipoprotein levels.

Akinlade et al studied and compared the emotional and cognitive function of 37 insulin-dependent diabetics with 46 non-insulin-requiring diabetics using the Hospital Anxiety and Depressive Scale (HID) and Mini Mental State Examination (MMSE.) Five percent of the insulin-requiring diabetics and four percent of the non-insulin-requiring diabetics had significant clinical anxiety; while 37.8% of the insulin-requiring diabetics and 15.2% of the non-insulin-requiring diabetics had significant depression. The prevalence rate for depression for the entire cohort was 25.3%, while the rate for significant anxiety disorders was 4.8%. Cognitive function in both groups was normal.

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