title: Anxiety and Depressive Symptoms as Predictors of All-Cause Mortality among People with Insulin-Naïve Type 2 Diabetes: 17-Year Follow-Up of the Second Nord-Trøndelag Health Survey (HUNT2), Norway.
abstract: OBJECTIVE
  To examine whether elevated anxiety and/or depressive symptoms are related to all-cause mortality in people with Type 2 diabetes, not using insulin.
  
  
  METHODS
  948 participants in the community-wide Nord-Trøndelag Health Survey conducted during 1995-97 completed the Hospital Anxiety and Depression Scale with subscales of anxiety (HADS-A) and depression (HADS-D). Elevated symptoms were defined as HADS-A or HADS-D ≥8. Participants with type 2 diabetes, not using insulin, were followed until November 21, 2012 or death. Cox regression analyses were used to estimate associations between baseline elevated anxiety symptoms, elevated depressive symptoms and mortality, adjusting for sociodemographic factors, HbA1c, cardiovascular disease and microvascular complications.
  
  
  RESULTS
  At baseline, 8% (n = 77/948) reported elevated anxiety symptoms, 9% (n = 87/948) elevated depressive symptoms and 10% (n = 93/948) reported both. After a mean follow-up of 12 years (SD 5.1, range 0-17), 541 participants (57%) had died. Participants with elevated anxiety symptoms only had a decreased mortality risk (unadjusted HR 0.66, 95% CI 0.46-0.96). Adjustment for HbA1c attenuated this relation (HR 0.73, 95% CI 0.50-1.07). Those with elevated depression symptoms alone had an increased mortality risk (fully adjusted model HR 1.39, 95% CI 1.05-1.84). Having both elevated anxiety and depressive symptoms was not associated with increased mortality risk (adjusted HR 1.30, 95% CI 0.96-1.74).
  
  
  CONCLUSIONS
  Elevated depressive symptoms were associated with excess mortality risk in people with Type 2 diabetes not using insulin. No significant association with mortality was found among people with elevated anxiety symptoms. Having both elevated anxiety and depressive symptoms was not associated with mortality. The hypothesis that elevated levels of anxiety symptoms leads to behavior that counteracts the adverse health effects of Type 2 diabetes needs further investigation.
authors.affiliation: Department of Health and Social Sciences, Centre for Evidence-Based Practice, Bergen University College, Bergen, Norway.|Department of Medicine, Section of Endocrinology, Stavanger University Hospital, Stavanger, Norway.
authors.forename: Marjolein M
authors.identifier: http://orcid.org/0000-0001-9954-171X
authors.initials: MM
authors.lastname: Iversen
authors.affiliation: Department of Medical and Clinical Psychology, Center of Research on Psychological and Somatic disorders (CoRPS), Tilburg University, Tilburg, the Netherlands.
authors.forename: Giesje
authors.initials: G
authors.lastname: Nefs
authors.affiliation: Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
authors.forename: Grethe S
authors.initials: GS
authors.lastname: Tell
authors.affiliation: Department of Health and Social Sciences, Centre for Evidence-Based Practice, Bergen University College, Bergen, Norway.
authors.forename: Birgitte
authors.initials: B
authors.lastname: Espehaug
authors.affiliation: Department of Community Medicine and General Practice, Norwegian University of Science and Technology, HUNT Research Centre, Levanger, Norway.
authors.forename: Kristian
authors.initials: K
authors.lastname: Midthjell
authors.affiliation: Department of Health and Social Sciences, Centre for Evidence-Based Practice, Bergen University College, Bergen, Norway.
authors.forename: Marit
authors.initials: M
authors.lastname: Graue
authors.affiliation: Department of Medical and Clinical Psychology, Center of Research on Psychological and Somatic disorders (CoRPS), Tilburg University, Tilburg, the Netherlands.
authors.forename: Frans
authors.initials: F
authors.lastname: Pouwer
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001007:Anxiety / Q000150:complications*; D003863:Depression / Q000150:complications*; D003924:Diabetes Mellitus, Type 2 / Q000150:complications* / Q000175:diagnosis / Q000453:epidemiology / Q000401:mortality*; D005260:Female; D005500:Follow-Up Studies; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D008297:Male; D008875:Middle Aged; D009664:Norway / Q000453:epidemiology; D011379:Prognosis
chemical_list: D006442:Glycated Hemoglobin; C517652:hemoglobin A1c protein, human