Mental health problems in association with type 1 diabetes among 15- to 50-year-old adolescents and adults in Germany

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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

Faculty of Medicine

Department of Preventive Medicine

Svea Huber

Mental health problems in association with

type 1 diabetes among 15- to 50-year-old adolescents and

adults

in Germany

MF VI

Master Thesis

Thesis Supervisor

Vilma Žaltauskė MD, PhD

Kaunas, 2019

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SUMMARY

Aim

To determine the prevalence and association of mental health problems in a population of 15- to 50-year-old adolescents and adults with type 1 diabetes (T1D) in Germany.

Objectives

1. To determine the prevalence of mental health problems (depression, anxiety, and eating disorders) among 15- to 50-year-old adolescents and adults with T1D. 2. To determine the insulin management among 15- to 50-year-old adolescents and adults with T1D. 3. To evaluate the association of depression, anxiety, and eating disorders with glycaemic control. Methods

A cross-sectional study was carried out in 2018. 184 (response rate 66 %) T1D patients aged between 15 and 50 years were enrolled in this study. In order to examine the mental health status of the participants, three common and validated questionnaires were used for assessing different mental health conditions ‒ Beck’s Depression Inventory, the Hamilton Anxiety Rating Scale, and the Eating Disorder Screen for Primary Care. Glycosylated haemoglobin (HbA1c) was assessed to determine the level of diabetes control. This parameter was determined by BIO-RAD’s D-10™ Haemoglobin Analyser.

Results

The mean age of the patients was 37.4 ± 9.9 years and 48.4 % were male. The results showed a high prevalence of disordered eating behaviours (48.9 %), depression (26.7 %), and anxiety (13.0 %). Males were more depressed than females. In addition to the high prevalence of mental health issues, the rate of patients who stated that they used less insulin than they should was also very high (13.7 %). The mean HbA1c level of 7.71 of the participants showed poor diabetes control. Glycaemic control was significantly correlated with age and worse in younger study participants. Not taking enough insulin unsurprisingly also affected glycaemic control negatively. Female participants reported more often than males that they manipulated their insulin intake; however, this difference was not statistically significant. There was significant correlation between age, insulin use, anxiety, and glycaemic control. Correlations with depressions or disordered eating and glycaemic control did not reach the significance level. Addressing mental health issues in all T1D patients might therefore be a useful way to improve glycaemic control and prevent future complications in addition to improving current quality of life.

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ACKNOWLEDGEMENTS

I am grateful to Dr. med. Carsten Volkery, Dr. med. Meinolf Behrens, Dr. med Götz Bramsemann and dietitian Jessica Fuchs (Diabetes Zentrum Minden) for their help, cooperation and effort.

I would also like to thank Joachim Weggen, M.Sc; Dipl.-Soz.-Wiss. (FH) Karin Gottschalk-Huber, and Dr. med. Toni Huber for their invaluable assistance and support.

I would like to acknowledge Dr. Vilma Žaltauskė, PhD for her expert advice and her professional guidance.

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CONFLICTS OF INTEREST

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PERMISSION ISSUED BY THE ETHICS COMMITTEE

Title

Mental health problems in association with diabetes type 1 among 15- to 50-year-old (adolescents and) adults in Germany.

Number

BEC-MF-470

Date of issue

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ABBREVIATIONS

BDI Beck’s Depression Inventory

DDG Deutsche Diabetes Gesellschaft

(German Diabetic Society)

DEPS-R Diabetes Eating Problem Survey – Revised

EDE-Q Eating Disorder Examination Questionnaire

ESP Eating Disorder Screen for Primary Care

HAM-A Hamilton Anxiety Rating Scale

HbA1c Glycosylated haemoglobin

MDD Major depressive disorder

SCOFF Sick, Control, One stone, Fat, Food-Questionnaire

T1D Type 1 diabetes

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TERMS

Anxiety Excessive worry that is difficult to control, causes distress or negatively impacts functioning, and happens the majority of time [1].

BMI A measure of body condition defined as the weight in kg divided by height in m2_[2].

Eating disorder A mental health condition that is characterized by abnormal eating habits [3].

Glycaemic control Describes how close the average glucose level of a diabetes patients come to glucose levels of a healthy person over time [4]. HbA1c Glycosylated haemoglobin, even in healthy people a part of the

haemoglobin is glycosylated over time. This proportion is the higher, the higher the glucose levels are and thus is a measure of average glucose levels and therefore glycaemic control [5]. Hyperglycaemia Abnormally high blood glucose levels (above 130 mg/dl) [6] Hypoglycaemia Abnormally low blood glucose levels (below 70 mg/dl) [7]

Major depressive disorder A mood disorder that cause loss of interest in usually enjoyed activities, and feelings of hopelessness and sadness [8].

Type 1 diabetes An autoimmune disease in which the insulin-producing beta cells of the islets of Langerhans in the pancreas are being destroyed, leaving the patient unable to produce insulin [9].

Type 2 diabetes A metabolic disorder in which the patient is resistant to insulin action and/or is unable to produce adequate amounts of insulin to maintain glycaemic control [10]

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LIST OF TABLES

Table 1. Distribution of participants by age group 22

Table 2. Distribution of participants by gender and age group 22 Table 3. Proportion of participants with mental health problems 23 Table 4. Proportion of participants with mental health problems by gender 23 Table 5. Mean scores of mental health questionaries in different age groups

(SD) 24

Table 6. Proportion of severity of depression and anxiety 24

Table 7. Age distribution of participants with poor and good glycaemic

control 25

Table 8. Mean of HbA1c in the different age groups 25

Table 9. Mean of HbA1c based on appropriate insulin use 26

Table 10. Mean of HbA1c by gender 26

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1 INTRODUCTION

The incidence of diabetes has been increasing over the past years [11], and an association between diabetes and mental illness has been well established. Especially major depressive disorder (MDD) and diabetes has been researched [12, 13]. T1D as well as type 2 diabetes (T2D) prove a risk for developing MDD in adults, just as MDD increases the likelihood of diabetes [14, 15]. There is less scientific information on the connection between anxiety disorders and diabetes [16], which is surprising in light of the fact that anxiety disorders are the most common mental illness with an incidence of up to 30 % of the general population, at least in the US [17]. In T1D, mental illness is even more prominent than in T2D [15].

Concerning the association between eating disorders and diabetes, studies conducted have shown inconsistent results [11]. Nevertheless, diabetes goes hand in hand with a strict regimen regarding food intake, exercise, and insulin administration [11], and thereby provides an excellent breeding ground for eating disorders.

Especially when it comes to poor glycaemic control, patients presenting both diabetes and a mental illness are at risk [18]. Adolescents with T1D tend to have bad coping mechanisms with stress, which can generally lead to disordered eating behaviours (binge eating, among others) and, therefore, to poor glycaemic control. Moreover, eating disorders can present with purposeful manipulation of insulin intake in order to lower the body weight in patients with diabetes [19]. But depression and anxiety too have proven to be risk factors for poor glycaemic control [18].

Based on these findings, further research in the field of diabetes and glycaemic control is vital in order to prevent complications for patients where possible. For this purpose, comprehensive assessment and analysis of the association between glycaemic control and mental illness in patients with T1D is needed. Looking at Germany especially, which is also the focus of this paper, this need is confirmed.

The prevalence of diabetes in Germany is on the rise, with thousands of deaths attributed to diabetes and poor blood glucose management each year [14].

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2 AIM AND OBJECTIVES

2.1 Aim

To determine the prevalence and association of mental health problems in a population of 15- to 50-year-old adolescents and adults with T1D in Germany.

2.2 Objectives

I. To determine the prevalence of mental health problems (depression, anxiety, and eating disorder) among 15- to 50-year-old adolescents and adults with T1D. II. To determine the insulin management among 15- to 50-year-old adolescents

and adults with T1D.

III. To evaluate the association of depression, anxiety, and eating disorders with glycaemic control.

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3 LITERATURE REVIEW

3.1 Prevalence of mental health problems in a population of 15-

to 50-year-old diabetes patients

3.1.1 Adult patients

Anxiety and depression have been associated with somatic problems in the past. However, the severity of the psychiatric disorder is directly linked with the likelihood of developing medical conditions, such as ulcers with anxiety, and eyesight problems or migraines with depression. The link between psychiatric disorder and somatic illness is comparable to the association between BMI and somatic illness [17].

Narrowing somatic illnesses down to diabetes, anxiety is a prevalent psychiatric corollary in adults. In their 2006 study, Li et al. found that participants with diabetes were twenty times more likely to suffer from anxiety for their whole life than participants without diabetes [20]. Collins et al. found corresponding results, not only for anxiety but also for depression [18]. These findings were solidified and extended through further studies [12, 16, 21, 22]. Results show that especially T2D oftentimes is associated with major depression [20].

The US study by Bajor et al. looked at simultaneous occurrences of T2D and serious mental illness, for instance, bipolar disorder or schizophrenia, among others [12]. Their findings indicate a one in three chance of comorbid anxiety under the given circumstances. Moreover, symptoms of depression under the given circumstances was linked with poorer glycaemic control, which was not affected by occurring anxiety [12].

Gendelman et al. focused their research on T1D. The results showed that the probability of adult patients with this form of the condition suffering from depression is double compared to adults without diabetes. Based on research, it has been found that sufferers of diabetes who also show signs of depression have a greater tendency for hyperglycaemia, generally worse diabetes-related self-care, and negative physical impacts up to a higher mortality [23].

Further, results show that suffering from anxiety can increase the likelihood of developing diabetes [16]. On the other hand, diabetes could not definitively be determined to be a risk factor for developing anxiety, even though, as mentioned, numerous studies have shown a

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15 bilateral association between the two that cannot be ignored. Based on the findings of Deschênes et al., patients with diabetes are susceptible to comorbid generalized anxiety disorder and major depressive disorder, which may intensify disability in diabetes patients [16]. Given the results of previous research and the potential negative outcomes for patients, further studies are needed in adult patients as well as in adolescent patients.

3.1.2 Adolescent patients

Results of the ERICA study support the previously stated findings partly, with a special emphasis on T1D, and centring solely on mental health problems connected to it, in young adults aged 15 to 17. The study shows an increased risk for subclinical symptoms of common mental health problems associated with T1D, however, not necessarily a direct link between clinical mental disorders and diabetes [24]. Nevertheless, an overall association is prominent. An appropriate psychosocial screening tool was developed in 2015. It addressed the needs of youth aged 18–25 with diabetes, showing that 9.7 % of all participants of the Australian study conducted by d’Emden et al. showed signs of a mental disorder, such as anxiety, depression, or eating disorders [25]. This emphasizes the importance of the topic at hand. Further studies conducted on the connection between type 1 diabetes and psychiatric illnesses in adolescents substantiate this [13, 26]. However, more research is needed, especially with regards to other psychiatric problems than anxiety and depression.

The study performed in Denmark by Dybdal et al., for instance, is based on mood disorders and anxiety, thereby including the prominent disorders examined in other studies. However, they also focus on eating disorders, dissociative disorders, psychoactive substance abuse, and personality disorders, all of which were generally more likely in association with diabetes. Moreover, they take differences between the sexes into account. This shows that the risk for developing a personality disorder is much higher in female patients with diabetes, whereas the risk for substance abuse is higher in males. Overall, they found the risk of developing mental disorders in adolescents the highest after five years or more of the diabetes onset [13].

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3.2 Evaluation of the association between mental illness and

glycaemic control

In addition to an association between common mental illness and diabetes, there is also the, possibly more pressing, issue of a potential association between mental illness and glycaemic control. Diabetes naturally throws glycaemic control off balance; however, it also has been found to impact the patient’s ability to handle glycaemic control negatively. Oftentimes due to diabetes-associated mental problems [27].

Maia et al. found that anxiety and depression are distinctly more likely to occur in patients with diabetes than in non-diabetic patients. Both conditions are linked with problems regarding glycaemic control and the according physical symptoms, such as a higher body weight, hypertension, or blindness, observed under hypoglycaemia and hyperglycaemia. Only 28.2 % of all participants did not present signs of either anxiety or depression, which only underlines the need for psychiatric screening [15].

Correspondingly, adult patients with T1D with higher Beck Depression Inventory (BDI) scores are reported to have more diabetes-associated complications due to poor glycaemic control than patients with lower scores [23].

Slightly different conclusions were reached by Bächle et al. based on the distinction between the sexes. The findings show that while female participants with T1D did not have any negative impacts of their mental health state on their glycaemic control, male participants showed an improvement in their glycaemic control associated with a decline of depressive symptoms [21]. Poor glycaemic control can also be merely perceived by patients with diabetes who also show symptoms of anxiety or depression, which does not have to be consistent with the actual glycaemic control. That said, this is only a possibility; overall, the cited study reached the same conclusions as the previously mentioned ones [18]. Therefore, an association is present, given the overall results of the studies discussed. However, with most psychiatric illnesses poor glycaemic control is a problem that occurs on its own due to the mood disturbances of the illnesses observed. But since glucose, food intake and body weight are directly linked, this particular difficulty is especially challenging in diabetes patients dealing with, or those vulnerable to eating disorders.

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3.3 Eating disorders and glycaemic control

Generally, it is seen that glycaemic control worsens during puberty, one reason being the potential onset of mental illness. These are mostly anxiety or depression, as has been established before, but also developmental disorders, such as attention deficit hyperactivity disorder. Eating disorders were underrepresented in this study [26]. However, on the whole there is a different outcome to be found in research literature. In fact, there is a connection between both T1D and T2D and eating disorders: Both have to be treated differently, since their respective interference with each other is not the same and does not have the same influence on glycaemic control [19]. Especially in the context of T1D with an onset in adolescence, insulin manipulation to lower the body weight is regarded as common and serves as a predictor of the possible development of eating disorders [19]. Still, it was also found that eating disorder behaviour is not necessarily linked to deliberate insulin omission and therefore poor glycaemic control, as was expected. Despite this, a link between disordered eating behaviour and a higher BMI and higher HbA1c was visible [28]. Despite inconsistent results in studies, T1D is strongly associated with eating behaviours differing from the norm, or not fully formed eating disorders. Due to an oftentimes higher weight caused by the condition, unhealthy mechanisms to reduce the increased body weight can be observed, which may also lead to or involve deliberate poor glycaemic control [11]. Overall, an eating disorder linked with type 1 diabetes increases the likelihood of physical damage and mortality due to the diabetes [29]. This leads to the conclusion that even though some studies show different results, adolescents with T1D have to be screened carefully for symptoms of eating disorders to avoid diabetes-related complications later in life.

In general, there are several screening tools for eating disorders. Saßmann et al. used a screening tool more fitted for the given problem than previous ones. The Diabetes Eating Problem Survey – Revised (DEPS-R) showed better results than the SCOFF clinical prediction guide, a generic screening tool for eating disorders, and better results than the Eating Disorder Examination Questionnaire (EDE-Q) [29].

Using SCOFF, questions centre around eating behaviours and thoughts about the own body, which can be potentially shameful to answer and might therefore not be answered truthfully. This, of course, leads to inaccurate results. In general, SCOFF is reported to be less effective than other screening tools. Cotton et al., for instance, found that the Eating Disorder Screen for Primary Care (ESP) is more sensitive than SCOFF [22]. But neither of them is designed to determine an association between diabetes and poor glycaemic control and an eating disorder.

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18 The DEPS-R generally showed better results in detecting a connection between disordered eating behaviour and poor glycaemic control. In addition, the results showed that higher DEPS-R scores also linked with a higher BMI. The participants scoring higher also showed worse glycaemic control than those with lower scores and, therefore, less indication for an eating disorder [29].

This emphasizes the need for targeted screenings of comorbid eating disorders and diabetes.

3.4 Diabetes-related emotional distress and glycaemic control

Different to previous findings, the study by Strandberg et al. showed that in adult patients not always clinical depression or anxiety are linked with poorer glycaemic control but oftentimes diabetes-related, especially regimen-related, emotional distress. The proper distinction between the two is important, since diabetes-related distress can and has to be treated differently to fully formed psychiatric disorders. However, it has been found that it is difficult to say whether depression or anxiety and diabetes-related emotional distress are completely separate or two sides of the same coin; nevertheless, it is recommended to acknowledge the differences in order to treat the patient properly. Diabetes-specific positive well-being is directly linked with better glycaemic control [30].

3.5 Anxiety, depression, and disordered eating in combination

with type 1 diabetes

In 2014, Bernstein et al. examined the proposed association using the Beck’s Depression Inventory, the Screen for Child Anxiety Related Emotional Disorders-41, and the Eating Disorder Screen for Primary Care. Their study was set up cross-sectional, had 150 participants with T1D and an age range between 11 and 25 years. A positive result on any of the three related directly to poorer glycaemic control in the participants. Overall, the findings show strong associations between anxiety, depression, eating disorders and poor glycaemic control in adolescents with T1D, which concurs with previous findings [31] and emphasizes the

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4 RESEARCH METHODOLOGY AND METHODS

4.1 Procedures

The study was approved by the Ethics Committee of the hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania (No. BEC-MF-470), and written informed consent was obtained from all study participants and their parents or official caregivers, if necessary.

A cross-sectional study was carried out between September 2017 and December 2018. A sample calculation was performed with 95 percent of confidence interval. The sample size was chosen from the diabetic centre’s population of patients between the age of 15 and 59 years with T1D who make regular visits. A sample of 279 adolescents and adults was recruited from a German diabetic centre in East-Westphalia Lippe that treats paediatric and adult patients with different diabetes severities. The response rate was 66 % (n = 182). Participants were selected for the study if they were diagnosed with T1D defined by the DDG (Deutsche Diabetes Gesellschaft/German Diabetic Society). The patients were required to be able to read and understand German. They were offered enrolment by clinic personnel either before or during health care visits.

Glycosylated haemoglobin (HbA1c) was assessed to determine the level of diabetes control. This parameter was determined by BIO-RAD’s D-10™ Haemoglobin Analyser. The blood samples were taken by doctors’ assistants.

The first value was gathered at the time when the participants filled in the questionnaires and, additionally, during chart reviews every quarterly period for one year. Participants with a HbA1c value greater than or equal to 7.5 % were considered to have poorly controlled diabetes; participants with values less than 7.5 % were considered to have well-controlled diabetes. Cut-off values were determined by thresholds defined by DGD for T1D patients. They reflect increased risks for long-term complications [31].

Participants were screened for mental health problems with the following tools:  Beck’s Depression Inventory (BDI),

 Hamilton Anxiety Rating Scale (HAM-A)

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21 The BDI is a widely used and verified instrument for screening depression in outpatient settings. At first, the BDI was developed for adults, but it turned out to be a meaningful screening tool for adolescents, too [31]. A mild mood disturbance was present when the patient had a score between 11 and 16, borderline clinical depression between 17 and 20, moderate depression between 21 and 30, severe depression between 31 and 40, and extreme depression over 40.

The HAM-A is a validated rating scale developed to measure the severity of anxiety symptoms. It is widely used in clinical and research settings and designed for children, adolescents, and adults. “The instrument consists of 14 items with a total score range of 0‒56. <17 indicates mild severity, 18‒24 mild to moderate severity, and 25‒30 moderate to severe” [32].

The ESP is a 5-question screening tool to diagnose disordered eating. Primarily, it was designed to screen for disordered eating behaviour in adults. Today, it is also frequently used to screen adolescents because of its easy usage. It was scored positive when either the first question was answered with no, or when one or more of the questions 2‒5 were answered with yes [31].

Participants were also screened for deliberate insulin omission or dose reduction with the question: “Do you take less insulin than you should?” Additionally, the participants were asked to write down their birth date and gender on each of the four questionnaires.

4.2 Statistical analysis

Analysis was performed using SPSS 23.0. The limit of significance was defined as a two-sided p-value lower than 0.05.

Prevalence of depression, anxiety, disordered eating, and insulin lowering was determined. Descriptive data was expressed as percentages, means. The chi-square test was used to detect a possible link between age group and insulin omission. The f-test was used in ANOVA to test for the statistical significance in a linear regression with influencing variables. To find an association between insulin omission, age, and gender, the logistic regression module was used with the gender binary coded.

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5 RESULTS

5.1 Demographics

184 patients participated in this study. The mean age of the participants was 37.4 ± 9.9 years. The youngest patient was 19 years and the oldest 58 years old. 48.4 % (89) of the enrolled patients were male. The majority of the participants were in their early and middle adulthood (50.5 % and 46.9 % respectively), and only 2.7 % of patients were adolescents (Table 1). There was no difference in gender distribution across the different age groups (Table 2).

Table 1. Distribution of participants by age group

Age group Percentage (%) N

Adolescence 13‒19 years 2.72 5 Early adulthood 20‒39 years 50.54 93 Middle adulthood 40‒59 years 46.74 86 Total 100 184

Table 2. Distribution of participants by gender and age group

Age groups Gender Total

n (%) Male n (%) Female n (%) 13‒19 years 3 (3.37) 2 (2.11) 5 (2.72) 20‒39 years 41 (46.07) 52 (54.74) 93 (50.54) 40‒59 years 45 (50.56) 41 (43.15) 86 (46.74) Total 89 (48.37) 95 (51.63) 184 (100) p 0.474

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5.2 Prevalence of mental health problems

Slightly more than half of the participants (51.1 %, n = 94) reported disordered eating (Table 3) and none of them was content with their eating behaviour. The result showed that 26.7 % of patients were screened positive for depression. Almost the same percentage of participants suffer from anxiety and insufficient insulin intake (respectively, 13.0 % and 13.6 %). The gender distribution of the patients with mental health conditions is shown in

*Patient may suffer from more than only one mental health issue

Table 4. There was no significant difference in respect to the prevalence of anxiety, eating disorders, or insufficient use of insulin among the genders in the study population. Statistically significant difference was found between the different genders for the prevalence of depression. Males were more depressed than females (0.0451).

Table 3. Proportion of participants with mental health problems

Mental health problem _Percentage _N

Depression 26.7* 49

Anxiety 13.0 24

Disordered eating 51.1 94

Insulin restriction 13.6 25

*Patient may suffer from more than only one mental health issue

Table 4. Proportion of participants with mental health problems by gender Mental health problem Males Females P n (%) n (%) Depression 30 (16.3) 19 (10.4) 0.0451 Anxiety 16 (8.7) 8 (4.3) 0.0784 Eating disorder 43 (23.4) 51 (27.7) 0.5552 Insulin restriction 9 (4.9) 16 (8.7) 0.2029

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24 Mean scores in the three mental health questionnaires were similar in all three age groups, showing that there was no significant difference between the age groups (Table 5).

Table 5. Mean scores of mental health questionaries’ in different age groups (SD) Mental health

questionaries’ 13‒19 years 20‒39 years 40‒59 years

BDI 4.4 (2.7) 8.6 (7.0) 7.5 (7.4)

HAM-A 4.6 (3.1) 9.1 (7.4) 9.8 (9.4)

ESP 1.8 (1.3) 1.6 (0.8) 1.5 (0.8)

The frequencies of the different severities of anxiety and depression were analysed. Results show that 59.2 % of patients with depression had mild symptoms, 12.2 % suffered from moderate and 28.6 % from severe depression. In total, 13 % of the participants were screened positive for an anxiety disorder. 58.3 % of those with anxiety showed anxiety symptoms of a mild to moderate severity and 41.7% of those with anxiety had moderate to severe symptoms (Table 6). 13.7 % (n = 25) of patients admitted to taking less insulin than they should. A Pearson’s chi-Square test showed that these differences were not significant with a p-value of exactly p = 0.05.

A chi-square test of age distribution versus the sum of the ESP questionnaire showed a significantly different distribution for the three age groups, with older study participants being more likely to having lower scores. The p-value was p = 0.049.

Table 6. Proportion of severity of depression and anxiety

Severity Percentage n

Depression

Mild 59.2 29

Moderate 12.2 6

Severe 28.6 14

Anxiety Mild to moderate 58.3 14

Moderate to severe 41.7 10

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5.3 Insulin management among 15- to 50-year-old adolescents

and adults with type 1 diabetes

5.3.1 Diabetes control

The mean HbA1c level of the participants was 7.71, as measured by HbA1c level >7.5 %. Half (57.7 %) of participants (Table 7). There were significant differences by age groups and HbA1c value. Adolescents had the poorest diabetes control (mean HbA1c = 8.64) compared to the other age groups. The higher the age, the lower the HbA1c value, meaning glycaemic control was better with increasing age (Table 8).

Table 7. Age distribution of participants with poor and good glycaemic control

Level of glycaemic control

Age groups (years)

Total n (%) 13–19 n (%) 20–39 n (%) 40–59 n (%)

Good control (HbA1c < 7.5) 0 (0.0) 39 (42.4) 38 (44.7) 77 (42.3) Poor control (HbA1c ≥ 7.5) 5 (100) 53 (57.6) 47 (55.3) 105 (57.7)

Total 5 (100) 92 (100) 85 (100) 182 (100)

p = 0.039

Table 8. Mean of HbA1c in the different age groups

Age in years Mean SD

13‒19 8.640 0.86

20‒39 7.788 1.20

40‒59 7.569 0.94

Total 7.709 1.09

Patients who admitted to taking less insulin than they should had a higher HbA1c value (mean HbA1c = 7.94 mmol/mol) than the participants who do not omit insulin (mean HbA1c = 7.59 mmol/mol). This difference was significant (p = 0.004) (Table 9). Females also had a higher mean of HbA1c compared to males, and the percentage of those patients who reported to use less insulin than they should was higher among females compared to males. However, these differences did not reach statistical significance (p = 0.428) (Table 10).

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26 Taken together, lower than recommended insulin use and younger age are predictive for worse glycaemic control. There was also a trend for female gender being correlated with worse glycaemic control, but it was not statistically significant.

Table 9. Mean of HbA1c based on appropriate insulin use Insulin restriction Mean of HbA1c SD No 7.94 1.17 Yes 7.48 0.95 P=0.004

Table 10. Mean of HbA1c by gender

Gender Mean of HbA1c SD

Female 7.75 0.94

Male 7.67 1.23

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5.3.2 Association of depression, anxiety, and eating disorders

with glycaemic control

A regression analysis showed that insulin restriction and anxiety were the only factors that significantly correlated with glycaemic control (Table 11). Depression or eating disorders were not significantly correlated with glycaemic control. Age was negatively correlated, as indicated by a negative beta-value, i. e. the older the patients, the better the glycaemic control. For anxiety and insulin restriction, the correlation was positive, as indicated by a positive value for beta. In the case of anxiety, this means patients with worse anxiety symptoms had worse glycaemic control. Patients who restricted their insulin use also had worse HbA1c values.

Table 11. Correlation of different parameters with glycaemic control

Independent Variable β 95% CI P Lower bound. Upper bound. Age -0.142 -0.566 0.003 0.048 Gender -0.052 -0.424 0.199 0.478 Depression -0.066 -0.046 0.025 0.570 Anxiety 0.262 0.005 0.064 0.023 Eating disorders -0.035 -0.239 0.145 0.630 Insulin restriction 0.212 0.223 1.112 0.003

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6 DISCUSSION

The aim of this study was to determine the prevalence and association between mental health problems in 15- to 50-year-old patients with T1D in Germany and to evaluate the relationship of these factors with glycaemic control. 184 German participants were enrolled in this study. The demographics of the patients reflected the expected values with no gender preference and the expected age distribution for this chronic illness [33]. In line with previously published data [33], there were also no significant differences between the gender distribution for different age groups.

The results showed a high prevalence of mental health problems in the study population. This is in line with a number of previous publications on mental health status of T1D patients that showed that these patients have a higher prevalence of a number of mental health problems, namely depression, anxiety, and eating disorders when compared to the general population [1, 12, 16, 18, 20, 27, 30, 34]. In this study, depressive symptoms and anxiety occurred, as suspected, more often than in an otherwise healthy population where one would expect only about 5‒10 % to have depression or anxiety, respectively [35, 36], with positive depression scores in this study of 26.7 % in all participants and positive anxiety screenings in 13 %. Corresponding with previous findings, not all positive screenings alluded to fully formed mental disorders, similar to what was found in the ERICA study [24], but in large parts indicated subclinical symptoms. Results showed that mild symptoms of depression made the majority all positive screenings, with moderate symptoms and severe symptoms being less frequent. Likewise, anxiety screenings also showed that less intense symptoms were more common than severe symptoms, with 7.6 % of all cases displaying mild to moderate symptoms and 5.4 % more severe symptoms. These numbers are very similar to those found in the ERICA study that also detected a higher prevalence of mild symptoms compared to severe symptoms [24].

The prevalence of eating disorders was especially high in our population with 48.9 % of all participants exhibiting disordered eating behaviours. Thus, eating disorder behaviours proved to be the most common mental health problem in patients with T1D. The prevalence found in the present study is about twice that found by Wisting and co-workers in a similar study. The difference might be explained by their use of the Diabetes Eating Problem Survey – Revised as the tool to detect disturbed eating behaviours that might have a higher threshold than the survey used here [37]. 13.7 % of all participants admitted to using less insulin than they should, which emphasises the enormous prevalence of eating disordered behaviour. This percentage

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29 is very similar to the 13.3 % of patients found by Bernstein et al. in T1D patients between the age of 11 and 25 years that admitted the same non-compliance with their treatment recommendations [31]. This study found a similar overall number of depression and anxiety compared to the study presented here.

This also provides insight into the second aim of the study. Insulin management in patients with T1D and mental health problems can be suboptimal, in connection with eating disordered behaviour even on purposes. Th study results showed that significant differences were found among age groups and HbA1c value. Clements and co-workers found that glycaemic control worsens between the age of 16 and 18 and then improves steadily up to the age of 26, which was the oldest age these researches examined [38]. Here too, adolescents had the poorest glycaemic control compared to the older age groups. However, a significant correlation between eating disorders and glycaemic control was not detected. It is possible that this was due to the relatively small sample size when considering the large variability of HbA1c values. There was a significant correlation between the less than appropriate use of insulin and higher HbA1c values, which is unsurprising, since insulin use directly affects glycaemic control. What is, however, not clear at this point are the reasons for suboptimal insulin use. While, on one hand, it is possible that access to insulin, insulin costs, or inconvenience of insulin administration might be hurdles to use as much insulin as should be used to achieve optimal glycaemic control. On the other hand, given the high prevalence of disordered eating, on could also speculate that at least some patients use suboptimal insulin use as a means of inducing weight loss. A follow-up study that would investigate the reasons for suboptimal insulin use would be very important and interesting in order to clarify this point and to improve patient care. Overall, the findings on the correlation between mental health issues and glycaemic control concur with previous studies conducted on the topic of mental illness and diabetes. Which have mostly shown similar results, primarily regarding depression and anxiety: There is an increased likelihood of suffering from one or more of the mentioned psychiatric disorders alongside diabetes [24, 31].

Furthermore, the study conducted that mental health problems have a significant influence on glycaemic control. HbA1c levels of all participants were 7.71 % on average, which classifies as uncontrolled diabetes (with HbA1c levels above 7.5 %). With more advanced age, HbA1c levels improved; the younger the patient, the worse glycaemic control. These results align with other research, e. g., the study conducted by Almeida et al. who also stated that glycaemic control generally is likely to worsen during puberty due to a possible onset of mental illness [18]. Additionally, patients who willingly did not take enough insulin had worse glycaemic control than participants who did not engage in this behaviour, which is expected and has

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30 already been shown to be the case in the early 1990s [39]. Moreover, patients who stated to not be satisfied with their eating behaviours on the ESP were more likely to have poor glycaemic control, which has also been shown in other studies ‒ in some of which disordered eating and insulin withholding has been shown to be more prevalent in younger and female patients [40–43]

Our study pointed out that anxiety had a distinct influence on HbA1c levels. The higher the scores in the HAM-A, the higher were the HbA1c levels, regardless of age or sex. This contradicts the findings of Bajor et al. stating that anxiety has no effect on glycaemic control [12]; however, they looked at T2D, whereas this paper focused on T1D. It might indicate that there is a difference between the two types of diabetes with regards to their connection with mental illness. Based on the results of studies previously conducted mental illnesses appears to be more common in T1D than in T2D [12].

Regarding depression, it was previously found that depressive symptoms in patients with diabetes have an impact on insulin management and thereby also on glycaemic control, due to the nature of depression and the effect symptoms can have on self-care and more specifically also diabetes-related self-care [26]. It is therefore possible that the study presented here did not find a significant correlation between depression and glycaemic control due to the small samples size. This finding might hence represent a type II error.

Overall, focusing on the found prevalence of mental disorders, an association between T1D and depression, anxiety, and eating disorders can be confirmed. Regarding eating disorders, the patients’ self-reported satisfaction with their eating behaviour is an especially important aspect. Deliberate insulin omission to lower the body weight is a factor that should be taken into consideration in the treatment of patients, not only in young adult patients, as was found before [23]. Also, in patients in middle adulthood, mostly females. This is confirmed in this study, even though most participants did not classify as young adults. However, insulin omission was reported by altogether almost 14 %, and it was found that diabetes control was poorest in young adults. This indicates a connection to omitting insulin purposely and would substantiate the direct connection between young adulthood and insulin omission, even though from all participating young adults only one admitted to omitting insulin.

This finding would be consistent with previous studies. The overall direction shows that T1D and disordered eating behaviours, if not fully formed eating disorders, go hand in hand. This is also due to a distinct association between T1D and a higher BMI [15].

To sum up, it can be put on record that while depression is a very prevalent psychiatric illness occurring alongside diabetes, anxiety and eating disorders should also be focused on more in

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31 the current diabetes research. Since the findings generally suggest strong associations and a large potential for negative impact due to both of the conditions, even in their subclinical forms.

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32

7 CONCLUSION

I. Half of participants with T1D reported disordered eating. 26.7 % of patients were depressed. Nearly the same percent of participants suffer from anxiety and insufficient insulin intake (respectively, 13 % and 13.7 %). Males were more depressed than females. The prevalence of eating disorders was with around 50 % in either gender especially high in this patient group.

II. The mean HbA1c level of the participants showed poor diabetes control. The older the patients are, the better the glycaemic control.

III. There was significant correlation between age, insulin use, anxiety, and glycaemic control. Younger patients had poorer glycaemic control. Insulin restriction and the presence of anxiety also were correlated with higher HbA1c levels.

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33

8 PRACTICAL

RECOMMENDATIONS

I. An evaluation of all T1D patients for mental health problems and according treatment might therefore improve patient care and also reduce health care costs.

II. To design a new study that investigates the reason for not using adequate insulin amounts in order to devise measure that could correct this problem.

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