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Revista da Associação Médica Brasileira

Print version ISSN 0104-4230

Rev. Assoc. Med. Bras. vol.60 no.1 São Paulo Jan./Feb. 2014

https://doi.org/10.1590/1806-9282.60.01.013 

Original article

Psychiatric comorbidity in diabetes type 1: a cross-sectional observational study

Comorbidade psiquiátrica no diabetes tipo 1: um estudo transversal observacional

Ana Claudia C. de Ornelas  Maia1 

Arthur de Azevedo  Braga1 

Flávia Paes1  2 

Sérgio Machado1  2  3  4  5 

Antonio Egidio  Nardi1  2 

Adriana Cardoso da  Silva1  2 

1Laboratory of Panic and Respiration – Institute of Psychiatry of Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil

2National Institute of Translational Medicine (INCT-TM), Rio de Janeiro, RJ, Brazil

3Institute of Philosophy, Federal University of Uberlândia, Uberlândia, MG, Brazil

4Chiropractic program of the Faculty of Medical Sciences, Central University (UCEN), Santiago, Chile

5Physical Activity Sciences Postgraduate Program - Salgado de Oliveira University, Niterói, RJ, Brazil


ABSTRACT

Objective

This study aims to investigate the prevalence of psychiatric disorders, i.e., the presence of signs and symptoms of anxiety and depression in type 1 diabetic patients, as well as to investigate the prevalence of psychiatric disorders in insulin dependent patients.

Methods

A cross-sectional observational study of 110 diabetic outpatients (mean = 58.3, SD = 14.5; 50 male and 60 female) was conducted in a public health clinic with patients diagnosed with diabetes mellitus who were under the medical supervision of an endocrinologist. The patients were evaluated through the Mini International Neuropsychiatric Interview and the Hospital Anxiety and Depression Scale(HADS).

Results

With respect to anxiety symptoms, we found a prevalence of 60% (n = 66) among patients, while in depression symptoms we found a prevalence of 53.6% (n = 59) concerning the 110 patients evaluated. More specifically, we found 28.2% (n = 31) of patients without depression or anxiety, 13.6% (n = 15) of patients with depression, 16.4% (n = 18) of patients with anxiety and 41.8% (n = 46) of patients with depression combined with anxiety. The most remarkable data were generalized anxiety disorder (22.7%), dysthymia (18.2%), panic disorder (8.2%) and social phobia (5.5%).

Conclusion

The need for accurate assessments about the presence of symptoms related to psychopathology in patients with type 1 diabetes is evident.

Key words: Anxiety; Depression; Prevalence and Diabetes

RESUMO

Objetivo

Elementos relacionados à saúde mental do paciente diabético tipo 1 são encontrados em várias pesquisas. O objetivo desse estudo é avaliar sinais e sintomas depressivos nesse grupo de pacientes, como também investigar as principais prevalências psiquiátricas que os acometem.

Métodos

Pesquisa realizada em 110 pacientes diabéticos atendidos em ambulatórios (média = 58.3, D = 14.5; 50 masculinos e 60 femininos) conduzida em Postos de Saúde Pública nos momentos de consulta médica com endocrinologista. A avaliação transcorreu com as escalas Mini International Neuropsychiatric Interview and Hospital Anxiety and Depression Scale (HADS).

Resultados

Os sintomas de ansiedade tiveram prevalência de 60% (n = 66), enquanto para depressão encontramos resultados de 53.6% (n = 59), considerando que 110 pacientes foram avaliados. Mais especificamente, nós encontramos 28,2 (n. 31) pacientes sem depressão ou ansiedade, 13,6 (n. 15) pacientes com depressão, 16,4 pacientes (n. 18) com ansiedade e 41,8 (n. 46) pacientes com depressão combinada com ansiedade. Outros transtornos comórbidos tiveram prevalência de ansiedade generalizada (22,7%), distimia (18,2%), pânico (8,2%) e fobia social (5,5%).

Conclusão

Sintomas ansiosos e depressivos são comuns em pacientes diabéticos do tipo 1, porém há prevalência de psicopatologias diversas nesse grupo de pacientes, levando em conta novas necessidades de pesquisas futuras para validar protocolos de tratamentos mais adequados para diabéticos do tipo 1.

Palavras-Chave: Unitermos; Ansiedade; depressão; diabetes; prevalência

INTRODUCTION

Studies indicate that groups of chronic diseases, such as type 1 diabetes, can present severe psychiatric disorders. Faced with direct relationship of type 1 diabetes with mental health, studies demonstrate that the prevalence of psychiatric disorders in diabetic patients may reach 84% for mood disorders and 80% for anxiety disorders1. A previous study2 evaluated the presence of psychiatric comorbidities both in patients with diabetes types 1 and 2. The first group showed higher values for the presence of general anxiety disorder (24%), dysthymia (20%), social phobia (6%), depression (9% for current and 5% for lifelong), panic disorder (5%) and suicide risk (3%), all values were higher than those found in the general population or in patients with type 2 diabetes. The instrument used in this study was the Mini International Neuropsychiatric interview, which is aimed to detecting psychiatric disorders2.

Patients with a high prevalence of psychiatric disorders have further compromising their mental health when assessed in terms of signs and symptoms. The presence of psychiatric signs and symptoms, and more specifically depression and anxiety, can increase morbidity, and lead to worse clinical prognosis.

OBJECTIVES

This study aims to confirm the prevalence of psychiatric disorder and assess the prevalence of depression and anxiety signs and symptoms in patients with type 1 diabetes.

METHODS

A cross-sectional observational study was conducted, consisting of 110 diabetic outpatients (mean = 58.3, SD = 14.5; 50 male and 60 female) from a public health clinic with diagnoses of type 1 diabetes mellitus who were under the medical supervision of an endocrinologist. To confirm the findings of a previous study2 regarding the prevalence of psychiatric disorders, patients were assessed with the Mini International Neuropsychiatric Interview (MINI). To evaluate the prevalence of depression and anxiety signs and symptoms the Hospital Anxiety and Depression Scale (HADS) was used. Patients signed a consent form and were aware of the experimental protocol (approved by the Ethics Committee at the Federal University of Rio de Janeiro) before participation commenced.

RESULTS

Descriptive data from participants diagnosed as having type 1 diabetes, including sex, age, education, occupation, religion, children, and the use of psychotropic drugs, are shown in Table 1.

Table 1 Characteristics of type 1 diabetic patients 

Patients with type 1 diabetes
Sex
Female 60 (54.5%)
Male 50 (45.5%)
Age 58.3 (±14.5%) Minimum=18; Maximum=82
Marital status
Single 17 (15.5%)
Married 60 (54.5%)
Divorced 11 (10%)
Widow/Widower 22 (20%)
Occupation
Student or housewife 22 (20%)
Unemployed 3 (2.7%)
Working 35 (31.8%)
On leave 5 (4.5%)
Retired 45 (40.9%)
Religion
Atheist 4 (3.6%)
Catholic 74 (67.3%)
Evangelic 24 (21.8%)
Other 8 (7.3%)
Education
Elementary school 74 (67.3%)
High school 25 (22.7%)
College or Higher education 11 (10%)
Children
Yes 95 (86.4%)
No 15 (13.6%)
Use of Psychotropic Drugs
Yes 20 (18.2%)
No 90 (81.8%)

With regard to prevalence of psychiatric disorders, table 2 shows the total number of patients with diabetes who presented each of the psychiatric disorders identified in the sample, with percentages in decreasing order.

Table 2 Prevalence of psychiatric disorders in type 1 diabetic patients 

Disorder N (%)
Generalized anxiety disorder 25 22.7
Dysthymia 20 18.2
Current depression 9 8.2
Panic disorder 6 5.5
Social phobia 6 5.5
Life-long depression 5 4.5
Hypomanic episode 3 2.7
Risk of suicide 3 2.7
Agoraphobia 1 0.9
Dependence/Abuse of substance 1 0.9
Manic episode 1 0.9

Considering that some patients may present signs and symptoms without necessarily meet the criteria for a diagnosis of a psychiatric disorder, we also considered important to assess the presence of anxiety and depression sings and symptoms, which may or may not be superimposed, at this level. According to HADS, 60% (n = 66) and 53.6% (n = 59) of the patients have signs and symptoms of anxiety and depression, respectively. Evaluating the clinical picture, considering possible superposition, we found only 28.2% of patients (n = 31) without depression or anxiety, 13.6% of patients (n = 15) with depression, 16.4% of patients (n = 18) with anxiety and the larger group, 41.8% of patients (n = 46), with depression combined with anxiety setting the most serious situation.

DISCUSSION

We observed that the prevalence of psychiatric comorbidity (mainly anxiety and depression) in type 1 diabetes, as a disorder as well as a set of signs and symptoms, is significantly higher in diabetic patients than those found in the general population.

Sample characteristics found in this study for variables such as sex, age, marital status, occupation, education and even religion were similar to those found in a previous study2 as well as prevalence rates for psychiatric disorders. In addition, this study presents data on the prevalence of signs and symptoms of anxiety (60%) and depression (53.6%), also considered elevated and definitely higher than those found in the non-clinical population. When mental health was evaluated only by disorder, the higher prevalence found was for GAD (22.7%) and Dysthymia (18.2%) while all other disorders had prevalence below 10%. Thus, understanding the presence of psychiatric impairment at the level of signs and symptoms enables us to better understand the actual mental health status of the patient.

Considering that anxiety and depression are factors that affect the clinical picture of diabetes and also compromise treatment adherence, fundamental for these patients, the severity of mental health impairment in these patients is clear. This is especially true when we realize that only 28.2% of them show no anxiety or depression, according to the HADS, while 41.8% of the subjects present both anxiety and depression combined.

The prevalence of depression in patients with diabetes is about 2 to 4 times greater than that seen in the general population, which may affect up to 30% of diabetics, and a meta-analysis confirmed the double risk of depression in diabetics, as well as demonstrated that diabetic women have a higher risk of depression (28%) than diabetic men (18%)3. Another relevant factor is anxiety in type 1 diabetic patients, which can be related to glycemic control. The contingency to be in balance with health can generate greater concern compared to people who don’t have the disease3,4.

With respect to depression, some studies demonstrated that type 1 diabetic patients have a probability 3 or 4 times higher to develop suicidal ideation, compared to non-diabetic patients (13.3% vs. 3.5%, respectively; p = 0.001)5. Moreover, the findings in research6 showed that there is a high prevalence of psychiatry disorders in type 1 diabetic patients (e.g., 1% of agoraphobia, 3% of hypomanic episode, and 1% of manic episode) associated with anxiety-phobia and depression disorders, which supports our results. The study7 revealed that among 224 type 1 diabetic patients with hypoglycemic episodes, for instance, 74% had agoraphobia. Other studies indicated that the prevalence of mood disorders is significantly higher in type 1 diabetic patients8 (i.e., 15% of dysthymia, 11% of current depression and 5% of panic disorder), reaching up to 67%9. A possible explanation for such high prevalence, more specifically in the case of dysthymia, was probably due to the inadequacy of psychological and psychiatric treatment performed in the study. Dysthymia, which is usually accompanied by significant functional impairment, is related to estimative of individuals who are managing it at any given time, reaching around 4% to 6% of the general population10,11. In line with this, the study12 demonstrated that dysthymic patients are at increased risk for poor general health, and when compared with the general population, they frequently use medical services and are among patients with several medical disorders.

Another important evidence comes from a meta-analysis13 that the odds of depression in type 1 diabetic patients were twice that of the non-diabetic patients (OR, 2.0; 95% CI, 1.8-2.2). With regard to anxiety disorders, panic disorder, a severe and devastating condition marked by recurrent and unexpected attacks of sudden onset and short duration related to physiological anxiety sensations (such as subsequent hyperventilation, palpitations, chest pain, nausea, numbness)14,15 seems similar to the symptoms of hypoglycemia, frequently observed in type 1 diabetes.

In addition to the signs and symptoms of anxiety and depression in type 1 diabetes, both the physiological changes in the chronic course of the disease: weight gain, pain, hypertension, heart disease, loss of motor skills, or blindness directly affect the emotional state2.

CONCLUSION

Therefore, we observed high prevalence of psychiatric disorders in type 1 diabetes. Moreover, we observed that 60% and 53.6% of the patients have signs and symptoms of anxiety and depression, respectively. More specifically, taking into account the clinical picture and possible superposition, we found only 28.2% of patients without depression or anxiety, 13.6% of patients with depression, 16.4% of patients with anxiety, and the larger group, 41.8% of patients, with depression combined with anxiety setting the most serious situation. Thus, we propose that physiological symptoms of hypoglycemia and hyperglycemia, such as, weight gain, pain, hypertension, heart disease, loss of motor skills, or blindness, can be associated with anxiety disorders, due to the generation of sensations similar to anxiety disorders, which can also change the mood of individuals.

The need for accurate assessments for the presence of symptoms related to psychopathology in patients with diabetes is evident, as well as the development of therapeutic protocols that consider the physical, psychological and social conditions of this population.

Study conducted at the Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil

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Received: December 13, 2012; Accepted: June 05, 2013

Institute of Psychiatry Federal University of Rio de Janeiro – INCT Translational Medicine Rua Visconde de Pirajá, 407/702 – Rio de Janeiro – RJ – Brazil ZIP Code: 22410-003 Phone: +55 21 2521-6147 Fax: +55 21 2523-6839 acornelas@yahoo.com.br

Conflict of interest:none

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