A longitudinal study of affective and anxiety disorders, depressive affect and diabetes distress in adults with type 2 diabetes
Open accessAbstract
AIMS: To report the prevalence and correlates of affective and anxiety disorders, depressive affect and diabetes distress over time. METHODS: In a non-interventional study, 506 patients with Type 2 diabetes were assessed three times over 18 months (9-month intervals) for: major depressive disorder (MDD), general anxiety disorder (GAD), panic disorder (PANIC), dysthymia (DYS) (Composite International Diagnostic Interview); depressive affect [Center for Epidemiological Studies-Depression (CES-D)]; Diabetes Distress Scale (DDS); HbA(1c); and demographic data. RESULTS: Diabetic patients displayed high rates of affective and anxiety disorders over time, relative to community adults: 60% higher for MDD, 123% for GAD, 85% for PANIC, 7% for DYS. The prevalence of depressive affect and distress was 60-737% higher than of affective and anxiety disorders. The prevalence of individual patients with an affective and anxiety disorder over 18 months was double the rate assessed at any single wave. The increase for CES-D and DDS was about 60%. Persistence of CES-D and DDS disorders over time was significantly greater than persistence of affective and anxiety disorders, which tended to be episodic. Younger age, female gender and high comorbidities were related to persistence of all conditions over time. HbA(1c) was positively related to CES-D and DDS, but not to affective and anxiety disorders over time. CONCLUSIONS: The high prevalence of comorbid disorders and the persistence of depressive affect and diabetes distress over time highlight the need for both repeated mental health and diabetes distress screening at each patient contact, not just periodically, particularly for younger adults, women and those with complications/comorbidities.
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- Findingown data
In patients with Type 2 diabetes, the prevalence of panic disorder at each study wave was significantly higher than in NCS-R community adults, by about 85%.
“85% higher for PANIC”
- Also stated in: § Results · plain
“85% for PANIC”
Quote in the paperNot a substantial claim0 of 2 sources checked - Also stated in: § Results · plain
- Findingown data
Across all study waves, the prevalence of diabetes distress and depressive affect was each 60-110% higher than the prevalence of major depressive disorder.
“the prevalences of diabetes distress and depressive affect were each between 60 and 110% higher than MDD across all study waves”
Quote in the paperNot a substantial claim - Findingown data
In patients with Type 2 diabetes, the prevalence of major depressive disorder at each study wave was significantly higher than in NCS-R community adults, by about 60%.
“60% higher for MDD”
- Also stated in: § Prevalence of disorder · plain
“60% higher for MDD”
Quote in the paperSubstantial claim0 of 2 sources checked - Also stated in: § Prevalence of disorder · plain
- Findingown data
In patients with Type 2 diabetes, the prevalence of general anxiety disorder at each study wave was significantly higher than in NCS-R community adults, by about 122-123%.
“122% higher for GAD”
- Also stated in: § Results · plain
“123% for GAD”
Quote in the paperSubstantial claim0 of 2 sources checked - Also stated in: § Results · plain
- Findingown data
The prevalence of depressive affect and distress was 60-737% higher than the prevalence of affective and anxiety disorders.
“The prevalence of depressive affect and distress was 60–737% higher than of affective and anxiety disorders.”
Quote in the paperNot a substantial claim
- Findingown data
Among patients with data at all three waves, 14.9%, 4.2%, and 1.7% recorded a diagnosis of major depressive disorder at one, two, and three waves, respectively.
“14.9, 4.2 and 1.7% of patients recorded a diagnosis of MDD at one, two and three study waves, respectively”
Quote in the paperSubstantial claim - Findingown data
The percentage of individual patients with high depressive affect or diabetes distress at any wave over 18 months was about 60% higher than at any single wave.
“the percentages for high depressive affect and diabetes distress were about 60% higher”
- Also stated in: § Results · plain
“The increase for CES-D and DDS was about 60%.”
Quote in the paperSubstantial claim - Also stated in: § Results · plain
- Findingown data
Patients with high depressive affect and no affective or anxiety disorder showed significantly greater persistence across waves: 15.5%, 11.8%, and 9.0% at one, two, and three waves (Bowker's test P < 0.001 for each contrast).
“15.5, 11.8 and 9.0% (Bowker's test of symmetry, P < 0.001 for each contrast)”
Quote in the paperSubstantial claim - Findingown data
There were no significant differences in the prevalence of each condition across the three study waves.
“There were no significant differences in prevalence of each condition across the three waves”
Quote in the paperNot a substantial claim - Findingown data
Mean HbA1c did not differ significantly across the three study waves (F = 0.77, P = 0.46).
“Mean HbA1c did not differ significantly across the three study waves (F = 0.77, P = 0.46)”
Quote in the paperNot a substantial claim - Findingown data
About 50% of patients with affective and anxiety disorders in the sample reported taking psychotropic medication.
“about 50% of patients with affective and anxiety disorders in our sample reported taking psychotropic medication”
Quote in the paperSubstantial claim - Findingown data
The percentage of patients with affective and anxiety disorders reporting psychotropic medication was not significantly different from medication use among those with high depressive affect without an affective or anxiety disorder.
“this percentage is not significantly different from medication use reported among those with high depressive affect without an affective or anxiety disorder”
Quote in the paperSubstantial claim - Findingown data
DDS scores were significantly positively associated with HbA1c at each wave (r = 0.11-0.13, P < 0.01).
“DDS, r = 0.11–0.13 (P < 0.01)”
Quote in the paperSubstantial claim - Findingown data
Education, duration of diabetes, and non-HDL-cholesterol were not significantly independently related to the frequency of presentation over time for any of the six conditions.
“Education, duration of diabetes and non-HDL-cholesterol failed to display a significant, independent relationship with the frequency of presentation over time for any of the six conditions”
Quote in the paperNot a substantial claim - Findingown data
High HbA1c at T1 was associated with persistence of depressive affect over time.
“High HbA1c at T1 was also associated with persistence of depressive affect over time”
Quote in the paperSubstantial claim - Findingown data
No significant correlation was found between any affective or anxiety disorder and HbA1c at any study wave.
“no significant correlation was found between any affective or anxiety disorder and HbA1c at any study wave”
Quote in the paperSubstantial claim - Findingown data
CES-D scores were significantly positively associated with HbA1c at each wave (r = 0.11-0.17, P < 0.01).
“CES-D, r = 0.11–0.17 (P < 0.01)”
Quote in the paperSubstantial claim - Interpretationown data
Only high depressive affect and diabetes distress were consistently linked to high HbA1c over time.
“Thus, only high depressive affect and diabetes distress were consistently linked to high HbA1c over time”
Quote in the paperSubstantial claim - Study design and conductreasoning
The time interval between waves was only 9 months, which may not have allowed sufficient time to clarify potential confounding between the length and frequency of episodes.
“the time interval between waves was only 9 months. This may not have allowed sufficient time to clarify potential confounding between the length and frequency of episodes”
Quote in the paperNot a substantial claim - Study design and conductown data
The number of patients who reached criteria for dysthymia and panic disorder did not provide sufficient power for more detailed analysis.
“the number of patients who reached criteria for DYS and PANIC did not provide sufficient power for more detailed analysis”
Quote in the paperSubstantial claim - Study design and conductown data
Patients with CIDI conditions did not drop out more frequently than those without.
“Those with CIDI conditions did not drop out more frequently than those without”
Quote in the paperNot a substantial claim - Study design and conductnone given
The study compared the diabetes sample with a historical reference group and not a contemporaneous control group.
“we compared our diabetes sample with a historical reference group and not a contemporaneous control group”
Quote in the paperNot a substantial claim - Study design and conductown data
Of the 506 T1 patients, 411 (81.2%) completed all three study waves.
“Of the 506 T1 patients, 411 (81.2%) completed all three study waves”
Quote in the paperNot a substantial claim - Study design and conductown data
Significance was maintained in all analyses when only patients who reached a criterion for a condition at one, two, or three waves were included.
“Significance was maintained in all analyses when only patients who reached a criterion for a condition at one, two or three waves were included”
Quote in the paperSubstantial claim - Study design and conductown data
Overall attrition was 18.8% over 18 months.
“overall attrition was 18.8% over 18 months”
Quote in the paperNot a substantial claim - Premisecitation
Considerable data suggest that many health professionals minimize the seriousness of distress because they consider it expected among people with diabetes or other chronic conditions.
“Considerable data suggest that many health professionals tend to minimize the seriousness of distress because they feel that it is ‘expected’ among those with diabetes or other chronic conditions [19,20]”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [19] source
Not checked in the free run.
- cites [20]
Not checked in the free run.
- May combine two claims. 15
- The quote only partly states this claim. 1
- Classified as probably not a substantial claim. 9
May combine two claims.
Findingown dataAt each study wave, about 30% of patients with major depressive disorder and about 50% of patients with general anxiety disorder met criteria for a dual MDD/GAD diagnosis.
“about 30% of those with MDD and about 50% of those with GAD reached criteria for a dual MDD/GAD diagnosis at each study wave”
Quote in the paperNot a substantial claimThe quote only partly states this claim.
Findingown dataIn patients with Type 2 diabetes, the prevalence of dysthymia at each study wave was significantly higher than in NCS-R community adults, by about 6-7%.
“6% higher for DYS”
- Also stated in: § Results · plain
“7% for DYS”
Quote in the paperNot a substantial claim0 of 2 sources checked- Also stated in: § Results · plain
May combine two claims.
Findingown dataThe percentage of individual patients who met criteria for major depressive disorder or general anxiety disorder at any of the three waves over 18 months was approximately double the mean prevalence at any single wave (MDD 19.8% vs 10.1%; GAD 17.0% vs 8.0%).
“the percentage of individual patients receiving a diagnosis of MDD or GAD at any of the three waves was 19.8 and 17.0%, respectively. These were approximately double the rate for that condition assessed at one point in time”
- Also stated in: § Results · plain
“The prevalence of individual patients with an affective and anxiety disorder over 18 months was double the rate assessed at any single wave.”
Quote in the paperSubstantial claim- Also stated in: § Results · plain
May combine two claims.
Findingown dataFor the Diabetes Distress Scale, 50% of those with high distress at one wave scored similarly at a second, and 86% at a third.
“For the DDS, the percentages were 50 and 86%, respectively”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataAmong those with CES-D scores ≥16 at one time point, 76% scored similarly at a second wave and 77% at a third wave.
“76% of those with ≥ 16 CES-D scores at one time point scored similarly at a second wave, and 77% of these patients scored similarly at a third wave”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataYounger age, female gender, and high comorbidities were consistently and independently related to greater persistence of most conditions over time.
“younger age, female gender and high comorbidities were consistently and independently related to greater persistence of most conditions over time”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataOnly 28% of patients who met criteria for major depressive disorder at one wave did so at a second, and only 14% at a third.
“only 28% of those who reached criteria for MDD at one wave did so at a second, and only 14% of these did so at a third wave”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataFor general anxiety disorder, only 27% of patients who met criteria at one wave did so at a second, and 19% at a third.
“The comparable percentages for GAD were only 27 and 19%”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataBoth patients with affective and anxiety disorders and those with high depressive affect reported greater medication use than patients with high diabetes distress.
“both affective and anxiety disorders and high depressive affect patients reported greater medication use than those with high diabetes distress”
Quote in the paperSubstantial claimMay combine two claims.
Interpretationown dataDepressive affect and diabetes distress were more persistent over time than affective and anxiety disorders, which tended to be episodic.
“Persistence of CES-D and DDS disorders over time was significantly greater than persistence of affective and anxiety disorders, which tended to be episodic.”
- Also stated in: § Persistence of disorder · plain
“the vast majority of patients with affective and anxiety disorders received a diagnosis only at one wave, whereas more patients with high depressive affect or diabetes distress reached criteria at multiple study waves”
Quote in the paperSubstantial claim- Also stated in: § Persistence of disorder · plain
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationGender differences in reported mood and relationships between comorbidities and anxiety/depression are also found in the literature.
“Gender differences in reported mood and relationships between comorbidities and anxiety/depression are also found in the literature [24]”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [24] source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationStudies of the prevalence of co-occurring anxiety and affective disorders have yielded mixed results.
“Studies of the prevalence of co-occurring anxiety and affective disorders have also yielded mixed results [9–11]”
Quote in the paperNot a substantial claim0 of 3 sources checkedProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationSeveral studies have shown a negative relationship between age and psychological distress.
“Several studies have shown a negative relationship between age and psychological distress [21,22]”
Quote in the paperNot a substantial claim0 of 2 sources checkedProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataThe results were substantively the same when using a negative binomial regression.
“The results were substantively the same when using a negative binomial regression”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductown dataPatients who missed a wave more often spoke Spanish than English (r = 0.09, P = 0.04) and had more years with diabetes (r = 0.12, P = 0.01).
“those who missed a wave more often spoke Spanish than English (r = 0.09, P = 0.04) and experienced more years with diabetes (r = 0.12, P = 0.01)”
Quote in the paperNot a substantial claimMay combine two claims.
Study design and conductown dataThere were no significant differences between eligible patients who participated at T1 and those who refused in age, sex, ethnicity, years with diabetes, number of comorbidities, DDS and CES-D scores, or any CIDI condition.
“There were no significant differences between eligible patients who participated at T1 and those who refused in age, sex, ethnicity, years with diabetes, number of comorbidities DDS and CES-D scores, or any CIDI condition”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationSeveral studies have shown negative associations between anxiety disorders and HbA1c.
“several studies have shown negative associations with HbA1c [7,8]”
Quote in the paperNot a substantial claim0 of 2 sources checkedClassified as probably not a substantial claim.
PremisecitationPrevious reports suggested that most patients with high depressive affect are not necessarily clinically depressed but instead suffer from high diabetes-related distress.
“Previous reports have suggested that most patients with high depressive affect are not necessarily clinically depressed, but rather, are suffering from high levels of diabetes-related distress [5,6]”
Quote in the paperSubstantial claim0 of 2 sources checkedMay combine two claims.
PremisecitationThe treatment literature indicates that the combination of anxiety and depression is more difficult to treat, with greater risk of relapse and poorer treatment response, than either alone.
“The treatment literature indicates that the combination of anxiety and depression is more difficult to treat, with greater risk of relapse and poorer treatment response, than either alone [25,26]”
Quote in the paperSubstantial claim0 of 2 sources checkedClassified as probably not a substantial claim. May combine two claims.
Study design and conductnone givenAssistants were trained by a CIDI-certified trainer, attended weekly supervisory sessions, and scored standard protocols throughout the study to prevent rater drift over time.
“Assistants were trained by a CIDI-certified trainer (P.A.), they attended weekly supervisory sessions and they scored standard protocols throughout the course of the study to prevent rater drift over time”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductnone givenThe study included only three waves, and more waves over a longer time might reveal a different pattern of disorder.
“the study included only three waves. More waves over a longer time might reveal a different pattern of disorder”
Quote in the paperNot a substantial claim
The paper relies on this without support.
No prior study has provided information about the prevalence of mental disorders in the same sample over time.
“More importantly, none, to our knowledge, has provided information about the prevalence of mental disorders in the same sample over time.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
In a community sample of type 2 diabetes patients, the point prevalence of diabetes distress (18.0%) is substantially higher than that of major depressive disorder (10.7%).
“In comparative analyses of a community sample of patients with type 2 diabetes, we showed a substantially higher point-prevalence of diabetes distress (DD) (18.0%) than of major depressive disorder (MDD) (10.7%);”
From Predicting diabetes distress in patients with Type 2 diabetes: a longitudinal study (2009) · cites this paper as [3]
High depressive affect in patients with diabetes is often not clinical depression but instead diabetes-related emotional distress.
“Previous studies have shown that most patients with diabetes who display high levels of depressive affect are not necessarily clinically depressed 1, 2; instead, they experience high levels of emotional distress stemming from concerns and worries associated with their diabetes and its management 1,3.”
From Predicting diabetes distress in patients with Type 2 diabetes: a longitudinal study (2009) · cites this paper as [3]
Diabetes distress is significantly related to HbA1c and several disease management measures, whereas MDD and depressive affect are not significantly related to these variables in controlled analyses.
“the analyses indicated a significant relationship between diabetes distress, HbA1c and several disease management measures, whereas no significant relationships were found in controlled analyses among MDD, depressive affect and these variables 1,3.”
From Predicting diabetes distress in patients with Type 2 diabetes: a longitudinal study (2009) · cites this paper as [3]
High DD, once it occurs, is a relatively persistent condition.
“We reported previously that the point prevalence of high DD was about 18% of patients in our diverse community sample, and that high DD, once it occurs, is a relatively persistent condition (3).”
From Predicting diabetes distress in patients with Type 2 diabetes: a longitudinal study (2009) · cites this paper as [3]
Diabetes-related distress is more chronic than major depressive disorder in patients with diabetes.
“diabetes-related distress, or significant negative emotional reactions to the diagnosis of diabetes, threat of complications, self-management demands, unresponsive providers, and/or unsupportive interpersonal relationships, has been found to be far more common, more chronic, and more closely related to diabetes self-care and glycemic control than MDD (5–7).”
From Depression in diabetes: have we been missing something important? (2011) · cites this paper as [5]
The prevalence of major depressive disorder among adults with diabetes is about 60% more common than among community adults.
“recent studies—which have used structured clinical interviews, the gold standard in the diagnosis of MDD—suggest that it is only about 60% more common (5).”
From Depression in diabetes: have we been missing something important? (2011) · cites this paper as [5]
Diabetes-related distress is far more common than major depressive disorder in patients with diabetes.
“diabetes-related distress, or significant negative emotional reactions to the diagnosis of diabetes, threat of complications, self-management demands, unresponsive providers, and/or unsupportive interpersonal relationships, has been found to be far more common, more chronic, and more closely related to diabetes self-care and glycemic control than MDD (5–7).”
From Depression in diabetes: have we been missing something important? (2011) · cites this paper as [5]
Diabetes-related distress is more closely related to diabetes self-care and glycemic control than major depressive disorder.
“diabetes-related distress, or significant negative emotional reactions to the diagnosis of diabetes, threat of complications, self-management demands, unresponsive providers, and/or unsupportive interpersonal relationships, has been found to be far more common, more chronic, and more closely related to diabetes self-care and glycemic control than MDD (5–7).”
From Depression in diabetes: have we been missing something important? (2011) · cites this paper as [5]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
GAD prevalence increase is given two different values
MinorOne Results passage says GAD was 123% higher than community adults, but another says it was 122% higher. These are conflicting statements about the same comparison.
“Diabetic patients displayed high rates of affective and anxiety disorders over time, relative to community adults: 60% higher for MDD, 123% for GAD, 85% for PANIC, 7% for DYS.”
“First, patients with diabetes had a significantly higher rate of MDD, GAD, DYS and PANIC at each wave than prevalence rates reported by the NCS-R: 60% higher for MDD, 122% higher for GAD, 85% higher for PANIC and 6% higher for DYS.”
Abstract overstates the conditions associated with female gender
MinorThe abstract says female gender was related to persistence of all conditions, whereas the discussion specifies depressive symptoms, diabetes distress and panic disorder-not all the conditions assessed.
“Younger age, female gender and high comorbidities were related to persistence of all conditions over time.”
“Female gender is likewise linked to persistence of depressive symptoms, diabetes distress and PANIC.”
Prevalence comparisons differ between the abstract and results
MinorThe abstract gives increases of 123% for GAD and 7% for dysthymia, while the results give 122% and 6%, respectively, for the same comparisons.
“60% higher for MDD, 123% for GAD, 85% for PANIC, 7% for DYS.”
“60% higher for MDD, 122% higher for GAD, 85% higher for PANIC and 6% higher for DYS.”
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“Indeed, 20–40 % of people with diabetes experience feelings of anxiety, depression, diabetes-specific or general distress (Fisher et al., 2008; Grigsby et al., 2002; Pouwer et al., 2010); and the presence of J.”
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- Authors
- Fisher, L., Skaff, M. M., Mullan, J. T., Arean, P., Glasgow, R., & Masharani, U.
- Affiliations
- University of California, San Francisco (US)
- Kaiser Permanente (US)
- Corresponding author
- Fisher, L.
- Venue
- Diabetic Medicine
- Publisher
- Wiley
- Published
- 2008-08-29
- Volume
- 25
- Issue
- 9
- Pages
- 1096-1101
- ISSN
- 0742-3071 (ISSN-L)
- 1464-5491
- PMC
- PMC2635496
- OpenAlex
- W1928379077
- Semantic Scholar
- ae5608921689ac866274592a2a4d2a3942de10e8
- Cited by
- 524
- References
- 26
- Citations by year
- 2026: 17 · 2025: 22 · 2024: 24 · 2023: 27 · 2022: 29 · 2021: 29 · 2020: 30 · 2019: 33 · 2018: 34 · 2017: 54 · 2016: 44 · 2015: 44 · 2014: 27 · 2013: 29 · 2012: 33
- FWCI
- 11.34
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Diabetic Medicine (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Diabetes and Digestive and Kidney Diseases (DK-061937, DK062732, R01DK061937, R01DK062732)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- type 2 diabetes, mood disorders, anxiety disorders, major depressive disorder, generalized anxiety disorder, panic disorder, dysthymia, depressive affect, diabetes distress, comorbidities, disease persistence, HbA1c, mental health screening
- MeSH terms
- Adult, Age Factors, Aged, Anxiety Disorders, Diabetes Mellitus, Type 2, Female, Humans, Longitudinal Studies, Male, Middle Aged, Mood Disorders, Young Adult
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-09-28.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-09-28.
Statistics and arithmetic are recomputed, not judged.
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