Epidemiology/Health Services/Psychosocial Research

O R I G I N A L

A R T I C L E

Depression and Diabetes

A large population-based study of sociodemographic, lifestyle, and clinical
factors associated with depression in type 1 and type 2 diabetes
ANNE ENGUM, MD1,2
ARNSTEIN MYKLETUN, MA3
KRISTIAN MIDTHJELL, MD, PHD4

ARE HOLEN, MD, PHD1

ALV A. DAHL, MD, PHD5

OBJECTIVE The purpose of this study was to investigate factors associated with depression in type 1 and type 2 diabetes and test whether these differ from factors associated with
depression in the nondiabetic population.
RESEARCH DESIGN AND METHODS In an unselected population study comprising 60,869 individuals, potential sociodemographic, lifestyle, and clinical factors were investigated in participants with and without diabetes. The associations between hyperglycemia and
depression in types 1 and 2 diabetes were also studied. The levels of depression were self-rated
by using the Hospital Anxiety and Depression Scale.
RESULTS Several factors were correlated with depression in types 1 and 2 diabetes. However, these factors were not different from those of the nondiabetic population. Comorbid
chronic somatic diseases were associated with depression in type 2 but not type 1 diabetes. In
type 2 diabetes, those without comorbidity had the same odds of depression as the nondiabetic
population with no chronic somatic diseases. No significant associations were found for hyperglycemia in relation to depression in type 1 and type 2 diabetes.
CONCLUSIONS Type 2 diabetes without other chronic somatic diseases did not increase
the risk of depression. Factors associated with depression in type 1 and type 2 diabetes were
shared with the nondiabetic population.
Diabetes Care 28:1904 1909, 2005

ast research has shown that a relationship exists between depression

and diabetes (1). Depression has
been associated with hyperglycemia (2),
diabetes-related complications (3), and
perceived functional limitations of diabetes (4). Moreover, depression among individuals with diabetes has also been
associated with potential sociodemo-

graphic, lifestyle, and clinical factors

shared with the general population. The
contributions of socioeconomic status
(5), marital status (6), obesity (7), smoking habits (8), and physical limitations
and inactivity (9) have been extensively
tested.
When the relationship between diabetes and depression is examined, the role

From the 1Department of Neuroscience, Faculty of Medicine, Norwegian University of Science and Technology, Verdal, Norway; the 2Nord-Trndelag Hospital Trust, Department of Psychiatry, Hospital Levanger,
Levanger, Norway; the 3Research Centre for Health Promotion, University of Bergen, Bergen, Norway; the
4
HUNT Research Centre, Department of Public Health and General Practice, Norwegian University of
Science and Technology, Verdal, Norway; and 5The Norwegian Radium Hospital, Oslo, Norway.
Address correspondence and reprint requests to Anne Engum, MD, Department of Psychiatry, Hospital
Levanger, N-7600 Levanger, Norway. E-mail: anne.engum@hnt.no.
Received for publication 13 December 2004 and accepted in revised form 3 May 2005.
Abbreviations: HADS, Hospital Anxiety and Depression Scale; HADS-D, Hospital Anxiety and Depression Scale, depression items; HUNT, Nord-Trndelag Health Study, Norway.
A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion
factors for many substances.
2005 by the American Diabetes Association.
The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby
marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

1904

of comorbid chronic somatic diseases has

to be taken into account (10). In general,
previous research has indicated a higher
prevalence of depression in samples of patients with various chronic somatic diseases. The coexistence of chronic somatic
diseases is common (11,12), and there is a
strong connection between symptoms of
depression and the number of different
chronic diseases (13,14).
Nevertheless, the question remains:
Are the factors associated with depression
in types 1 and 2 diabetes different from
those in the nondiabetic population? We
have not been able to find any studies that
include interaction tests to investigate
whether factors associated with depression actually interact with having diabetes. Multiple health problems, as well as
personal, social, and community factors,
may combine to bring about depression
in individuals with diabetes. Several of the
factors claimed to be linked to depression
are not limited to those with diabetes and
may be related to the general psychological distress of having a chronic disease
(4).
In a large study of the general population, the relationship between diabetes
and reported symptoms of depression
were studied. This study investigated the
role of some sociodemographic, lifestyle,
and clinical factors associated with depression in types 1 and 2 diabetes and examined
whether these factors were different from
those of the nondiabetic population.
RESEARCH DESIGN AND
METHODS The population study
was part of the second Nord-Trndelag
Health Study, Norway (HUNT 2). The
data were collected from 1995 to 1997.
All inhabitants of Nord-Trndelag
County aged 20 years received written
invitations together with questionnaires
and appointed dates for physical tests and
blood samples. In the questionnaires, the
participants were asked about demographic characteristics, health status, lifestyle, health habits, and their living
conditions. Of 92,100 individuals invited, 65,648 (71.3%) responded. The
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Engum and Associates

youngest and oldest age-groups had the

lowest rates of attendance, whereas the
highest rates were found among women
and middle-aged persons.
Our sample comprised individuals
aged 20 89 years with valid ratings of
depression, self-report of diabetes, data
about marital status, level of education,
smoking habits, BMI, and physical activity. Included were also self-reports about
somatic diseases and physical impairments. The nondiabetic population comprised 59,329 individuals. A total of 223
had type 1 diabetes, 958 had type 2 diabetes, and 359 individuals had other subtypes of diabetes or did not take the
verifying blood tests and were left unclassified. In this study, the main topic was to
compare individuals with types 1 and 2
diabetes with nondiabetic responders.
Accordingly, individuals with unclassified diabetes were excluded from the
analyses.
Psychological features
Symptoms of depression were screened
using the Hospital Anxiety and Depression Scale (HADS) (15,16). The scale consists of seven items for depression
(HADS-D) and seven for anxiety. Only
HADS-D scores were utilized in this
study. A main characteristic of HADS-D is
that items covering somatic symptoms of
depression have been eliminated to avoid
false-positive results when used in somatic settings. In this study, we used the
recommended cutoff of eight for caseness
of depression. However, this should not
imply a level of clinical depression, which
cannot be inferred from the screening instrument used in the present study.
HADS has been extensively tested and has
well-established psychometric properties
(17). Several studies have demonstrated
good sensitivity, specificity, and receiver
operating characteristics of HADS. High
correlation between HADS scores has
been obtained in relation to other questionnaires and structured interviews detecting depression (18,19).
Somatic health
The initial selection of individuals with
diabetes was based on self-reports. Metabolic control was determined by HbA1c
(A1C) in all individuals who had diabetes.
A1C values reflect the average level of
blood glucose in the past 3 months. The
test is widely accepted as a reliable and
valid index of metabolic control. In addiDIABETES CARE, VOLUME 28, NUMBER 8, AUGUST 2005

tion, all participants indicating a history

of diabetes (n 1,638) received a specific
questionnaire about the disease and
1,540 responded. Of those, 1,181 participated in additional fasting blood test for
glucose, C-peptide, and anti-GAD antibodies. According to autoantibodies to
GAD, C-peptide tests, and information on
start of insulin treatment, the responders
were further divided into types 1 and 2
diabetes. C-peptide was tapped by the radioimmunoassay method (Diagnostic
System Laboratories, Webster, TX), and
anti-GAD antibodies were measured via
immunoprecipitation by using [ 3 H]
leucine translation-labeled GAD65 as the
indicator.
A total of 19,979 individuals reported
a history of one or more of the following
health problems: cardiovascular diseases
(including angina pectoris, myocardial
infarction, stroke, and hypertension),
musculoskeletal diseases (including ankylosing spondylitis, osteoarthritis, rheumatoid arthritis, and osteoporosis),
thyroid diseases (including hypothyroidism, goiter, and hyperthyroidism), cancer, and asthma. A dichotomous variable
for somatic diseases was defined as one
or more of the above-mentioned health
problems, as opposed to none.
The participants were asked to assess
how much their function was impaired or
restricted with regard to vision, hearing,
and movement. Two dichotomous variables were made from the self-reported
data about the presence (moderately or
severely impaired vision and/or impaired
hearing and/or restricted movement) or
absence of physical impairment.
The variable somatic complaints including symptoms such as pain, stiffness,
or gastrointestinal symptoms (dyspepsia,
nausea, or diarrhea) were divided into
one or more complaints versus none.
Demographic and lifestyle variables
Education was classified into low and
high: low levels of education covered
compulsory education (9 years),
whereas high education was defined as
9 years of school. Two dichotomous
categories were developed for marital status: single (unmarried, widowed, divorced, or separated) versus married or
cohabiting.
Lifestyle variables covered information about smoking, BMI, and physical
activity. Smokers were defined dichotomously into current smokers or not. BMI

was treated as a continuous variable. The

participants were asked to give information about how many hours they spent on
physical activity in their spare time during
the last year (hours per week). In a dichotomous variable, physical inactivity was
scored as positive whenever the person
spent 1 h per week on physical activities.
Statistics
The t test or 2 test were used to investigate differences on demographic characteristics, somatic health, and depression
as measured by HADS-D between type 1
or type 2 diabetes and the nondiabetic
population. Then bivariate analyses between depression and demographic, lifestyle, and somatic variables were
computed in type 1 and type 2 diabetes
and in the nondiabetic population.
To determine whether the factors
identified in type 1 or type 2 diabetes as
correlating with depression were specific
or shared with the nondiabetic population, logistic regression models were used
with depression as a dependent variable.
The factors, type 1 (or type 2) diabetes,
and the interaction term between the factors and type 1 (or type 2) diabetes were
used as independent variables in 20 separate runs. The models were adjusted for
demographic, lifestyle, and clinical variables that were related to the exposure
and that in a stepwise logistic regression
were related to the outcome (depression)
with P 0.20. All the variables in the full
models contributed to the models and
were retained. No factors were strongly
correlated in a collinearity analyses. The
Hosmer-Lemeshow goodness-of-fit test
was used to assess model fit. If the interaction term was positive, the factor was
more associated with depression in type 1
or type 2 diabetes than in the nondiabetic
population and accordingly less associated if the interaction term was negative.
We examined the potential for effect
modification by including interaction
terms between age and sex with each factor in the analyses.
The relationship between A1C and
HADS-D was investigated by linear regression analyses adjusted for age and sex
in type 1 and type 2 diabetes. The dependent variable, HADS-D, was fairly normally distributed both in type 1
(skewness 1.092, kurtosis 1.458)
and in type 2 diabetes (skewness
0.813, kurtosis 0.353).
We undertook both unadjusted and
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Depression and diabetes

Table 1Characteristics of type 1 and type 2 diabetes compared with a nondiabetic population with regard to sociodemographics, somatic
health, and depression as measured by HADS-D

n
Age (years)
Female sex (%)
Low education (%)
Marital status (single) (%)
Smoking (%)
BMI (kg/m2)
Physical inactivity (%)
Chronic somatic diseases (1) (%)
Somatic complaints (1) (%)
Physical impairment (%)
Depression (HADS-D 8) (%)

Type 1
diabetes

Type 2
diabetes

Nondiabetic
population

P value*

P value

223
57.2 16.9
39.9
43.4
40.1
18.5
27.2 4.4
62.5
60.5
52.0
30.5
15.2

958
67.2 11.4
48.3
66.2
36.4
16.2
29.6 4.8
65.5
74.0
59.0
34.6
19.0

59,329
48.4 16.4
52.8
34.6
39.1
29.8
26.2 4.0
61.8
31.8
48.2
14.3
10.7

0.001
0.001
0.013
0.760
0.001
0.001
0.862
0.001
0.284
0.001
0.034

0.001
0.007
0.001
0.086
0.001
0.001
0.036
0.001
0.001
0.001
0.001

Data are means SD unless otherwise indicated. *Significance of t test or 2 test for difference between type 1 diabetes and the nondiabetic population. Significance
of t test or 2 test for difference between type 2 diabetes and the nondiabetic population.

adjusted logistic regression analyses to assess the associations between groups with
and without chronic somatic diseases as
independent variables and depression
(HADS-D 8) as the dependent variable
with the no chronic disease group serving as the reference category. In a stepwise
logistic regression, all covariates were significantly related to the outcome and were
retained in the model. All the factors were
correlated, but a collinearity analyses revealed no factors were strongly correlated
with one another.
The level of significance was set at P
0.05. All tests were two way and SPSS-PC
12.0 was used as the statistical package.
The National Data Inspectorate and
the Board of Medical Research Ethics in
Health Region IV of Norway approved the
HUNT 2 study.

impairment. Furthermore, individuals

with type 2 diabetes were more physically
inactive and also reported more somatic
complaints.
In the nondiabetic population, 31.8%
(n 18,896) reported one or more
chronic somatic diseases: cardiovascular
diseases, 13.6%; musculoskeletal diseases, 13.2%; thyroid diseases, 5.2%;
cancer, 3.4%; and asthma, 8.4%. In type 1
diabetic subjects, 60.5% (n 135) reported comorbidity: cardiovascular diseases, 43.0%; musculoskeletal diseases,
19.7%; thyroid diseases, 13.0%; cancer,
4.0%; and asthma, 7.2%. In type 2 diabetic subjects, 74.0% (n 709) reported
comorbidity: cardiovascular diseases,
55.4%; musculoskeletal diseases, 28.9%;
thyroid diseases, 9.3%; cancer, 8.5%; and
asthma, 13.4%.

RESULTS In Table 1, the characteristics of participants with type 1, type 2,

and no diabetes were compared with regard to demographics, lifestyle variables,
somatic health, and depression as measured by HADS-D. Compared with the
nondiabetic population (n 59,329), individuals with type 1 (n 223) and type
2 diabetes (n 958) were more likely to
be depressed (15.2 and 19.0%, respectively, vs. 10.7% in the nondiabetic population). In both type 1 and type 2
diabetes, participants were older, were
more often male, had low levels of education, were considerably more obese, and
smoked less. In addition, they reported
more somatic diseases and more physical

Factors correlated with depression

Bivariate analyses between depression
(HADS-D 8) and demographic, lifestyle, and somatic covariates (Table 2) revealed several significant correlations
with depression in type 2 diabetes. Those
having depression compared with subjects without depression had significantly
lower levels of education (72.5 vs. 64.7%)
and were less physically active (77.2 vs.
62.8%). The subjects with depression
also had a higher proportion of comorbid
somatic diseases (83.5 vs. 71.8%), subjective somatic complaints (75.3 vs. 55.2%),
and physical impairment (45.65 vs.
32.0%). In type 1 diabetes, low levels of
education (62.5 vs. 40.0%) and physical

1906

impairment (50.0 vs. 27.0%) were significantly correlated with depression. Logistic regression analyses (both crude and
adjusted) demonstrated that the factors
correlated with depression in type 1 and
type 2 diabetes were not different from
those of the nondiabetic population; the
interaction terms (type 1 and type 2 diabetes by factors) were not significantly
different from the odds ratio (OR) of 1.
The interaction with age and sex did not
modify the results.
Association between hyperglycemia
and depression
The associations between hyperglycemia
and depression were tested by using linear regression analyses with HADS-D and
A1C as continuous variables and adjustments for age and sex. The analyses demonstrated nonsignificant associations for
both type 1 diabetes (b 0.094, P
0.164) and type 2 diabetes (b 0.030,
P 0.357).
Association between comorbidity
and depression
Dividing the participants into subgroups
with and without diabetes and with and
without other chronic somatic diseases,
the odds of depression were compared
with the reference category without any
reported chronic somatic diseases (Table
3). The associations were adjusted for age,
sex, marital status, level of education,
smoking, physical inactivity, BMI, somatic complaints, and physical impairment. In the nondiabetic population,
DIABETES CARE, VOLUME 28, NUMBER 8, AUGUST 2005

Engum and Associates

Table 2Factors correlated with depression in type 1 and type 2 diabetes compared with the nondiabetic population
Type 1 diabetes
HADS-D
8

Type 2 diabetes

HADS-D
8

P
value*

n
223
Age (years)
59.7 12.7 56.8 17.5
Female sex (%)
50.0
38.1
Low education (%)
62.5
40.0
Marital status (single) (%)
35.3
41.0
Smoking (%)
19.4
18.4
BMI (kg/m2)
26.5 4.6 27.3 4.3
Physical inactivity (%)
56.3
63.7
Somatic diseases (1) (%)
67.6
59.3
Somatic complaints (1) (%)
58.8
50.8
Physical impairment (%)
50.0
27.0

HADS-D
8

HADS-D
8

Nondiabetic population
P
value*

HADS-D
8

HADS-D
8

958
59,329
0.356 67.9 11.3 67.0 11.4 0.357 55.1 15.9 47.6 16.3
0.192
52.2
47.4
0.246
51.1
53.0
0.018
72.5
64.7
0.050
50.3
32.8
0.535
37.9
36.0
0.638
37.5
39.3
0.897
17.1
16.0
0.714
35.6
29.2
0.349 30.0 5.3 29.5 4.7 0.195 26.7 4.3 26.2 4.0
0.426
77.2
62.8
0.001
70.6
60.8
0.357
83.5
71.8
0.001
45.5
30.2
0.388
75.3
55.2
0.001
67.4
45.9
0.007
45.6
32.0
0.001
28.6
12.6

P
value*
0.001
0.006
0.001
0.006
0.001
0.001
0.001
0.001
0.001
0.001

Data are means SD unless otherwise indicated. To determine whether the factors correlated with depression identified in type 1 diabetes were specific or shared
with the nondiabetic population, logistic analyses with interaction terms between type 1 diabetes and the factors were carried out. Positive interaction occurred when
the interaction term (type 1 diabetes by factor) is significantly different from OR 1. The same analyses were conducted for type 2 diabetes. All interactions were
nonsignificant. *2 significance in type 1 diabetes, type 2 diabetes, and in the nondiabetic population, respectively.

those with chronic somatic diseases had

significantly higher odds of depression in
both crude (OR 1.93) and adjusted
(OR 1.16) analyses. In type 1 diabetes,
the odds of depression were also higher in
those with comorbid chronic somatic diseases, but the difference did not reach significance when adjusted. Individuals with
type 2 diabetes without comorbidity were
not at higher risks of depression than
those in the reference category when adjusted. However, comorbidity between
diabetes and chronic somatic diseases carried the highest adjusted odds of depression (OR 1.38). In analyses of the
subtypes of comorbid chronic somatic
diseases, only the comorbidity between

cardiovascular diseases and type 2 diabetes was significantly associated with depression (data not shown).
CONCLUSIONS There were three
major findings in this study. First, comorbid chronic somatic diseases were associated with depression in type 2 diabetes
but not in type 1 diabetes. Individuals
with type 2 diabetes without comorbidity
had the same odds of depression as the
nondiabetic population without any reported chronic somatic diseases. Second,
hyperglycemia was not associated with
depression in type 1 or type 2 diabetes.
Finally, the factors correlated with depression in type 1 and type 2 diabetes

were shared with the nondiabetic population.

The prevalence of depression was significantly higher in subjects with types 1
and 2 diabetes compared with the nondiabetic population. Several factors were
correlated with depression in type 2 diabetes, such as low levels of education,
physical inactivity, subjective somatic
complaints, and physical impairment. In
type 1 diabetes, low levels of education
and physical impairment were correlated
with depression. In types 1 and 2 diabetes, a large proportion of subjects had one
or more comorbid chronic somatic diseases with cardiovascular diseases being
the most prevalent condition. Comorbid-

Table 3Odds ratios of depression as function of chronic somatic diseases in groups with and without diabetes
HADS-D 8
n (%)
Nondiabetic population
Without any known chronic somatic diseases
With one or more chronic somatic diseases
Type 1 diabetes
Without comorbid chronic somatic diseases
With one or more comorbid chronic somatic
diseases
Type 2 diabetes
Without comorbid chronic somatic diseases
With one or more comorbid chronic somatic
diseases

OR crude
(95% CI)

P value

OR adjusted*
(95% CI)

P value

59,329
40,433 (68.2)
18,896 (31.8)
223
88 (39.5)
135 (60.5)

1.00
1.93 (1.832.04)

0.001

1.00
1.16 (1.081.24)

0.001

1.53 (0.822.89)
2.21 (1.413.46)

0.185
0.001

1.18 (0.562.49)
1.28 (0.762.15)

0.671
0.355

958
249 (26.0)
709 (74.0)

1.47 (1.002.16)
2.93 (2.443.52)

0.048
0.001

1.08 (0.701.65)
1.38 (1.101.74)

0.740
0.005

*OR obtained from logistic regression analysis with HADS-D as a dependent variable adjusted for age, sex, marital status, level of education, smoking, physical
inactivity, BMI, somatic complaints, and physical impairment.

DIABETES CARE, VOLUME 28, NUMBER 8, AUGUST 2005

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Depression and diabetes

ity was associated with depression in type

2 diabetes but not in type 1 diabetes. In
type 2 diabetes, those without comorbidity had the same odds of depression as the
nondiabetic population without chronic
somatic diseases. This suggests that type 2
diabetes without other chronic somatic
diseases does not increase the risk of depression. The result is in accordance with
previous research. In a previous study
(14), it was reported that increased risk of
depressive symptomatology in diabetes
occurred only when comorbid diseases
such as cardiac diseases were present. Another study showed that the impact of diabetes itself on depression was not strong
but that depression was connected to comorbid diseases (20).
In the present study, hyperglycemia
was not associated with depression in
type 1 or type 2 diabetes. We actually
found an inverse relationship between
A1C and level of depression in both types
of diabetes, although the associations
were not significant. The existing literature is inconsistent with regard to the relevance of poor glycemic control and
depression. A meta-analysis (2) reviewed
28 studies and measured associations of
depression in relation to glycemic control. They concluded that depression was
associated with hyperglycemia in patients
with types 1 and 2 diabetes but revealed
neither the mechanism nor the direction
of the association. The results of the metaanalysis were rather heterogeneous, as the
study designs and methods differed considerably. The authors suggested that the
relationships might have been stronger in
patients with clinical rather than with
subclinical depression.
Our findings are in accordance with
those of some other studies. Kruse et al.
(21) did not find positive associations between depression and A1C in a community sample. In addition, they concluded
that individuals with diabetes and A1C
level 7% more often had affective disorders than those with poor glycemic control. In the general population, patients
with high A1C levels reported slightly but
significantly higher levels of well-being
than patients with low A1C levels (22).
One study (23) suggested that personality
traits might be important in achieving glycemic control. Lower scores on neuroticism and associated personality features
of anxiety, hostility, depression, selfconsciousness, and vulnerability were associated with poor glycemic control. Less
1908

dysphoric emotions may lower the motivation for maintaining the self-care regimen, which was suggested as the
explanation for the decreased metabolic
control.
Factors correlated with depression in
type 1 and type 2 diabetes were not different from those in the nondiabetic population. In general, sociodemographic,
lifestyle, and clinical variables are often
reported to correlate with depression in
diabetic populations, leaving the impression that these are of particular relevance
to individuals with diabetes. Our findings
indicate that this is far from the case.
There are no obvious reasons for why factors correlated with depression would
have a particular impact on persons with
diabetes. Nevertheless, contributors to
depression have been examined within
rather diverse clinical and epidemiological diabetic populations. By reviewing
prior research, we have been unable to
find any reports demonstrating that factors correlated with depression interact
with diabetes.
Findings of this study indicate that
factors correlated with depression in diabetes have the same relevance as those in
the general population and that the presence of comorbid chronic somatic diseases might explain the association
between type 2 diabetes and depressive
symptoms. This supports the notion that
the general burden of having chronic diseases is linked to depression. Comorbidity between diabetes and other chronic
somatic diseases may increase the risks of
depression as a result of the psychosocial
consequences of the diseases due to an
additive effect of the perception of having
the diseases as disabling or an awareness
of having a chronic disease. As illustrated
in a population-based study (13), individuals in whom diabetes has already been
diagnosed had significantly higher rates
of depressive symptoms than those with
newly diagnosed diabetes. In addition,
having a number of coexisting chronic
conditions was a significant and independent predictor of depressive symptoms.
Furthermore, a community-based study
showed that general aspects such as physical limitations might be more important
determinants of depression than specific
diagnoses (24).
However, this conclusion does not
exclude other hypotheses addressing the
connections between depression and diabetes. The analyses of this study indicated

increased risks of depression in type 2 diabetes only when comorbid cardiovascular diseases were present; this is a
frequently occurring macrovascular complication in type 2 diabetes. The result
may support theories suggesting that depression increases the risks of developing
type 2 diabetes and diabetes-related vascular complications (25). Hypotheses
have advanced that underlying factors
may include increased insulin resistance
and reduced glucose uptake (26). Another hypothesis is that stress-induced
disturbances of the hypothalamopituitary
adrenal axis and the development of visceral obesity as a pathway to type 2 diabetes in individuals with genetic
susceptibility (27).
The study was carried out on an unselected population, thus reducing selection bias. The population was large
enough to allow for statistical adjustments of potential moderators. Some limitations of the present study have to be
addressed. First, HADS is a self-report
symptom scale that measures depressive
symptoms only. Studies of HADS
(18,19,28) have shown that the cutoff
point chosen has sensitivity and specificity of 0.80 for depression as defined in
the Diagnostic and Statistical Manual of
Mental Disorders III/III-R. Second, our
study focused on current, not lifetime,
psychiatric disorders. Third, the sample
was predominantly of white origin and
race as a possible correlate may not be
studied. Fourth, the diagnosis of diabetes
and other chronic somatic diseases was
based on self-reported data. This approach may lead to underreporting of diagnoses. It seems unlikely, however, that
this is a major bias as earlier research has
reported relatively good agreement between self-report and in-person interview
with regard to chronic somatic diseases
such as diabetes (29,30). Finally, it is also
worth considering that a proportion of
the nondiabetic population might have
undiagnosed diabetes. In this study, only
218 (0.003%) individuals in the nondiabetic population had increased nonfasting blood glucose levels 11 mmol/l,
indicating the diagnosis of diabetes.

Acknowledgments The HUNT Study is a

collaboration between the HUNT Research
Centre, Faculty of Medicine, Norwegian University of Science and Technology (NTNU),
Verdal, Norway, The National Institute of

DIABETES CARE, VOLUME 28, NUMBER 8, AUGUST 2005

Engum and Associates

Public Health, The National Health Screening

Service of Norway, and the Nord-Trndelag
County Council.
11.
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