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Depression and Anxiety in Older and Middle-aged

Adults With Diabetes ap_20 90..97

Kellee Poulsen and Nancy A Pachana

School of Psychology, University of Queensland

This study aims to compare rates of depressive and anxious symptoms among older adults with and without diabetes. The study also
examines differences in depression, anxiety, and diabetes-related emotional distress between middle-aged and older adults with diabetes. A
total of 224 participants completed a range of questionnaires measuring depression, anxiety, and diabetes-related emotional distress (if
applicable). One hundred and three adults with diabetes (55 middle-aged, mean age = 47 years, range 40–59 years and 48 older, mean
age = 69 years, range 60–81 years) were recruited from a tertiary diabetes clinic. One hundred and twenty-one adults without diabetes (72
middle-aged, mean age = 52 years, range 40–59 years and 49 older, mean age = 65 years, range 60–76 years) were recruited from either a
university student pool or a registry of adults aged 50 and above. Older adults with diabetes had significantly higher levels of depression and
comparable levels of anxiety with older adults without diabetes. Older adults with diabetes had significantly lower levels of depression,
anxiety, and diabetes-related distress than middle-aged adults with diabetes. Diabetes is associated with high rates of depression and anxiety,
with middle-aged adults more adversely affected than older adults.

Key words: emotional disorders; health attitudes and behaviour; health psychology; psychological aspects of physical disorders;
psychological disorders; psychological theories.

What is already known on this topic What this paper adds

1 People with diabetes experience disproportionately higher
rates of depression and anxiety than people without diabetes.
2 Depression plays an important role in both the development and
worsening of diabetes.
3 The risk of developing T2DM increases with age, with older
adults constituting half the diabetic population.
1 Older adults with diabetes experience significantly higher rates
of depressive symptoms than older adults without diabetes.
2 Diabetes is not associated with higher rates of anxiety symp-
toms among older adults.
3 Older adults with diabetes have lower rates of psychological
symptoms than middle-aged adults with diabetes.

Diabetes can severely impact on the psychological functioning
of those living with this chronic condition (Karlsen, Bru, &
Hanestad, 2002). There is considerable evidence to suggest that
individuals with diabetes experience disproportionately high
rates of psychological disorders and symptoms (Rubin & Peyrot,
2001). Depression and anxiety disorders have been found to be
the most common diagnoses, occurring far more often in people
with diabetes than in the general population (Peyrot & Rubin,
1997). Although it is clear that people with diabetes experience
an increased risk of psychological disturbance, the majority of
research has failed to include older adults, despite older adults
constituting half the diabetic population (Dunstan et al., 2002).
In Australia, more than 20% of the population aged over 60
years have type 2 diabetes mellitus (T2DM) (Dunstan et al.,
2002), yet most psychological research uses age-restricted
Correspondence: Kellee Poulsen, School of Psychology, University
of Queensland, St Lucia, Brisbane, QLD 4072, Australia. Fax: +61 (7) 3365
4466; email: k.poulsen@psy.uq.edu.au
Accepted for publication 27 August 2010
doi:10.1111/j.1742-9544.2010.00020.x
samples of individuals aged 60 years and younger. Given the
unique challenges of older adults with diabetes and the detri-
mental impact depression and anxiety can have on diabetes
self-management and health outcomes, it is essential that the
psychological impact of diabetes on older adults is understood.
The prevalence of depression has been found to be twice as
high among people with diabetes as among people without
diabetes (Anderson, Freedland, Clouse, & Lustman, 2001;
Gavard, Lustman, & Clouse, 1993; Nichols & Brown, 2003). A
meta-analysis investigating the prevalence of depression among
adults with diabetes found that major depression and elevated
depressive symptoms were present, respectively, in 11% and
31% of individuals with diabetes (Anderson et al., 2001).
Depression is equally common in type 1 diabetes mellitus
(T1DM) and T2DM. Depression has been found to play an
important role in both the development and worsening of dia-
betes (Brown, Majumdar, Newman, & Johnson, 2005; Carne-
thon, Kinder, Fair, Stafford, & Fortmann, 2003; Eaton, 2002;
Engum, 2007; Lustman & Clouse, 2005; Talbot & Nouwen,
2000). Epidemiological data indicate that not only is depression
an independent risk factor for the development of T2DM, but
that having diabetes increases the risk of developing depression

90 Australian Psychologist 47 (2012) 90–97

© 2011 The Australian Psychological Society
K Poulsen and NA Pachana
(Arroyo et al., 2004; Brown et al., 2005; Carnethon et al., 2003;
Eaton, Armenian, Gallo, Pratt, & Ford, 1996). Depression itself
is a disabling condition and has been shown to be an important
barrier to effective diabetes management (Ciechanowski, Katon,
& Russo, 2000; Ciechanowski, Katon, Russo, & Hirsch, 2003).
In people with diabetes, depression is associated with poorer
adherence to treatment regimens, greater symptom burden,
poorer glyceamic control, more diabetes-related complications,
exacerbations of health problems relating to diabetes, higher
hospitalisation rates, and higher mortality (Anderson et al.,
2001; Ciechanowski et al., 2003; de Groot, Anderson, Freed-
land, Clouse, & Lustman, 2001; Eaton, 2002; Egede, Zheng, &
Simpson, 2002; Lustman et al., 2000; Rubin & Peyrot, 2001).
Research suggests that people with diabetes also suffer from
high levels of anxiety, with anxiety occurring as frequently as
depression and at a much higher rate than the general population
(Rubin & Peyrot, 2001). A systematic review conducted
by Grigsby, Anderson, Freedland, Clouse, and Lustman (2002)
found elevated anxiety symptoms to be present in 40% of
individuals with diabetes. With regard to clinical anxiety disor-
ders, people with diabetes were found to have substantially
higher rates of generalised anxiety disorder, with 14% meeting
diagnostic criteria compared with 3–4% in the general popula-
tion (Grigsby et al., 2002). Although the majority of research has
focused on depression in people with diabetes, individuals with
elevated levels of anxiety have been found to consume a dispro-
portionately large share of health-care resources (De Beurs et al.,
1999) and experience a level of impairment equivalent to that
associated with depression (Kessler et al., 1994). Even when
individuals with diabetes do not meet criteria for the diagnosis of
a clinical anxiety disorder, they are likely to experience some
form of diabetes-related emotional distress such as worries about
long-term complications, burnout symptoms, and anxiety when
problems in self-management occur (Gonder-Frederick, Cox, &
Ritterband, 2002). In people with diabetes, anxiety and diabetes-
related emotional distress are associated with poor glycaemic
control, increased diabetic complications, and greater disability,
after accounting for the effects of comorbid depression (Anderson
et al., 2002; Ludman et al., 2006; Welch, Jacobson, & Polonsky,
1997). Given the detrimental impact of depression and anxiety
on diabetes, it is clear that identification and treatment of these
conditions are of central importance to providing high-quality
clinical care of people with diabetes.
Although considerable research indicates that people with
diabetes have higher rates of depression and anxiety than those
without, the majority of research has not included older adults
with diabetes, despite diabetes being more prevalent in later life.
Depression is a serious condition in older adults, affecting up
to 4% of older adults in community settings (Beekman et al.,
1995; Blazer, 2002). Rates of depression are much higher
among older adults with comorbid health problems than those
without, occurring in up to 10% of primary care patients, 11%
of medical inpatients, and up to 75% of nursing home residents
(Abrams, Teresi, & Butin, 1992; Ames, 1991; Palinkas, Barrett-
Connor, & Wingard, 1991). Community prevalence rates of
diagnosable anxiety disorders in older adults range from
approximately 2% to 19% (Flint, 1994). Similar to depression,
rates of anxiety disorders are higher among medically ill older
adults (Tolin, Robison, Gaztambide, & Blank, 2005). In older
Australian Psychologist 47 (2012) 90–97
© 2011 The Australian Psychological Society
Depression and anxiety in older and middle-aged adults with diabetes
populations, depression and anxiety have a detrimental impact
on compliance with medical regimens and are associated with
increased health costs, increased use of primary care visits, and
longer hospital stays, after adjusting for medical comorbidities,
and increased mortality and disability (Brenes et al., 2005; De
Beurs et al., 1999; Klap, Unroe, & Unutzer, 2003; Luber &
Hollenberg, 2000; Unutzer et al., 2000). Given that diabetes has
been shown to be associated with increased rates of depression
and anxiety, and older adults comprise the majority of those
with T2DM, it is essential that the relationship between these
psychological symptoms and diabetes is examined in order to
more adequately address both the psychological and physical
treatment needs of this age group.
Diabetes is likely to pose unique difficulties for older adults as
a result of their age, stage of life, and physical functioning. It is
evident that older adults face some of life’s hardest challenges
such as disability and grief, cognitive and physical decline, and
loss of certain roles and supports. Living with diabetes may
therefore be particularly challenging for older adults, given the
loss of physical health associated with diabetes, daily demands
of diabetes, self-management requiring frequent problem-
solving and planning skills, and increased need for support.
Furthermore, the risk of developing long-term complications of
diabetes increases with age. Older adults with diabetes are also
more likely to experience cognitive and physical decline, frac-
tures and falls, and other conditions associated with geriatric
syndromes than older adults without diabetes (Fontbonne, Berr,
Ducimetiere, & Alperovitch, 2001; Gregg & Brown, 2003; Gregg,
Engelgau, & Narayan, 2002; Gregg et al., 2000; Strachan, Frier,
& Deary, 2003; Yeung, Fischer, & Dixon, 2009). In addition,
older adults with diabetes are twice as likely to be hospitalised
than older adults without diabetes, with depression the stron-
gest predictor of adverse physical outcomes (Rosenthal, Fajardo,
Gilmore, Morley, & Naliboff, 1998). The disproportionate
burden of ill health that these older adults carry will have
increasing socio-economic consequences (Dornan, Peck, Dow, &
Tattersall, 1992). Given the unique diabetes-related issues that
older adults are likely to face, it is evident that research exam-
ining psychological outcomes for older adults with diabetes,
specifically, is clearly needed.
It is clear that adults with diabetes experience disproportion-
ately higher rates of depression and anxiety, with such psy-
chological conditions having a detrimental impact on health
practices and outcomes. Despite the wealth of literature exam-
ining psychological outcomes for people with diabetes, most
studies have excluded adults aged 60 years and older, those
most likely to develop T2DM and diabetes-related complica-
tions. Furthermore, although diabetes has been found to have
an adverse impact on psychological functioning, it is unclear
whether older adults with diabetes experience similar rates of
depression, anxiety, and diabetes-related emotional distress as
middle-aged adults, or whether the impact of diabetes is greater
for older adults because of threat of loss of independence,
changing social roles, decreased access to health care, and an
increased likelihood of complications because of increasing
age (Connell, Gallant, & Davis, 1995). Alternatively, because
chronic illness, especially T2DM, is more prevalent among older
adults and therefore a more normative occurrence, diabetes
may have a less negative impact on psychological functioning
91
Depression and anxiety in older and middle-aged adults with diabetes
among older adults than among middle-aged adults (Connell
et al., 1995). Older adults have been found to display better
emotional regulation skills and more flexible coping strategies
that may result in better adjustment to chronic illness
(Blanchard-Fields, Stein, & Watson, 2004). In addition, with the
exception of dementia, the prevalence of mental illness has
been found to decrease in late adulthood among individuals
without chronic illness (Jorm, 2000). Thus, diabetes may have a
less detrimental impact on older adults than middle-aged adults.
Furthermore, given that identification and treatment of psycho-
logical problems among adults with diabetes is low (Pouwer,
Beekman, Lubach, & Snoek, 2006), understanding which sub-
groups of people with diabetes are most at risk for adverse
psychological outcomes is imperative in improving detection
rates and the quality of care people with diabetes receive.
The present study examines anxiety and depressive symp-
toms in older adults with diabetes and compares them with
older adults without diabetes, as well as with middle-aged adults
both with and without diabetes.
Method
Participants
A total of 224 participants completed a range of questionnaires
measuring depression, anxiety, and (for those with diabetes)
diabetes-related emotional distress. One hundred and three par-
ticipants with diabetes were recruited from a diabetes clinic at a
tertiary hospital; they were either approached during their
routine clinic visit or contacted via mail. Individuals aged 40–59
years were categorised as middle-aged, and those aged 60 years
and above were categorised as older adults. The diabetes group
consisted of 55 middle-aged (mean age = 47 years, range 40–59
years, 24 men and 31 women) and 48 older (mean age = 69
years, range 60–81 years, 25 men and 23 women) adults. Given
the similarities between T1DM and T2DM in terms of effect on
blood glucose levels, treatment, and diabetes-related complica-
tions, the participants with diabetes were not separated accord-
ing to type of diabetes. One hundred seventy-five adults with
diabetes were initially invited to participate, representing a
response rate of 59%.
One hundred twenty-one participants without diabetes were
recruited from either a first-year undergraduate psychology
university student pool or the 50+ registry of the former Aus-
tralasian Centre on Ageing. The registry consists of people over
the age of 50 years who have indicated they are willing to
participate in research projects. The comparison group consisted
of 72 middle-aged (mean age = 52 years, range 40–59 years, 14
men and 58 women) and 49 older (mean age = 65 years, range
60–76 years, 10 men and 39 women) adults without diabetes. In
an attempt to obtain equal sample sizes, 175 participants
without diabetes were invited to participate, representing a
response rate of 69%.
Measures
Demographic/medical information
The participants provided the following demographic and
medical information: age, gender, level of education, marital
92
K Poulsen and NA Pachana
status, type of diabetes, date of diagnosis of diabetes, and other
medical conditions.
Center for Epidemiologic Studies Depression Scale
(CES-D; Radloff, 1977)
The CES-D consists of 20 items (e.g., “I was bothered by things
that usually don’t bother me”) that measure depressive symp-
toms. The participants are required to indicate how often,
during the past week, they may have felt or behaved in specific
ways. Items include disturbances of sleep, appetite, and mood,
and feelings of hopelessness, self-deprecation, and distractibility.
Scores range from 0 to 60, with a clinical depression cut-off
score of 16. The CES-D has been widely used in diabetic popu-
lations and identifies more affective than somatic symptoms of
depression, making it appropriate for individuals who present
with somatic symptoms secondary to a chronic illness. The scale
has good psychometric properties (Beekman et al., 1997; Devins
et al., 1988; McHale, Hendrikz, Dann, & Kenardy, 2008), and
internal consistency was high in the current sample (Cronbach’s
alpha = 0.94). The CES-D has been validated with older popu-
lations (Radloff & Teri, 1986).
Geriatric Anxiety Inventory (GAI; Pachana et al., 2007)
The GAI consists of 20 items designed to measure anxiety symp-
toms. The scale produces total scores ranging from 0 to 20, with
higher scores reflecting higher levels of anxiety, and a score of 9
or above indicating a clinical level of anxiety. The measure has
been validated with a range of older adult populations and has
demonstrated good psychometric properties (Pachana et al.,
2007). Internal consistency was high in the current sample
(Cronbach’s alpha = 0.94). This scale was chosen as it is sensi-
tive to age-related changes and therefore provides a more accu-
rate measure of anxiety in adults over 60 years, although it has
been shown to be valid in middle-aged samples as well (Pachana
et al., 2007).
Problem Areas in Diabetes Scale
(PAID; Polonsky et al., 1995)
The PAID consists of 20 items (e.g., “feeling overwhelmed by
your diabetes” and “coping with complications of diabetes”)
designed to assess sources of diabetes-related emotional distress.
The participants rate the extent in which an item is currently
problematic on a scale from “0 = not a problem” to “4 = serious
problem”. A total score is calculated by summing all items and
multiplying by 1.25 to obtain a score from 0 to 100, with higher
scores indicating higher emotional distress. The PAID has high
internal consistency (Cronbach’s alpha = 0.95), construct valid-
ity, and discriminant validity (Polonsky et al., 1995; Snoek,
Pouwer, Welch, & Polonsky, 2000; Welch et al., 1997). Internal
consistency reliability in the current sample was high (Cron-
bach’s alpha = 0.95).
Procedure
All participants completed a demographic questionnaire, the
CES-D, GAI, and PAID (if applicable). Demographic and medical
Australian Psychologist 47 (2012) 90–97
© 2011 The Australian Psychological Society
K Poulsen and NA Pachana Depression and anxiety in older and middle-aged adults with diabetes

Table 1 Demographic Characteristics and Differences Between Older and Middle-aged Adults With and Without Diabetes

Older with diabetes Middle-aged with diabetes Older with no diabetes Middle-aged with no c2/F
(n = 48) (n = 55) (n = 49) diabetes (n = 72)

Gender
Male 52.1% (n = 25) 43.6% (n = 24) 20.4% (n = 10) 19.4% (n = 14) 7.32***
Female 47.9% (n = 23) 56.4% (n = 31) 79.6% (n = 39) 80.6% (n = 58) —
Mean age 68.65 years (SD = 6.47) 46.91 years (SD = 5.94) 64.80 years (SD = 4.47) 51.90 years (SD = 5.58) 176.60***
Type of diabetes
Type 1 14.6% (n = 7) 55.6% (n = 30) n/a n/a 22.09***
Type 2 85.4% (n = 41) 44.4% (n = 24) n/a n/a —
Mean duration of diabetes 17.52 years (SD = 12.06) 15.11 years (SD = 9.61) n/a n/a 1.26 ns
Marital status
Single 10.9% (n = 5) 7.3% (n = 4) 10.2% (n = 5) 9.9% (n = 7) 1.13 ns
Married 47.8% (n = 22) 44.4% (n = 24) 59.2% (n = 29) 52.1% (n = 37) —
De facto 2.2% (n = 1) 14.8% (n = 8) 10.2% (n = 5) 11.3% (n = 8) —
Separated 6.5% (n = 3) 11.1% (n = 6) 2.0% (n = 1) 1.4% (n = 1) —
Divorced 17.4% (n = 8) 20.4% (n = 11) 14.3% (n = 7) 21.1% (n = 15) —
Widowed 15.2% (n = 7) 1.9% (n = 1) 4.1% (n = 2) 4.2% (n = 3) —
Education
Less than high school 22.2% (n = 10) 1.9% (n = 1) 2.0% (n = 1) 0% (n = 0) 32.44***
Some high school 26.7% (n = 12) 29.6% (n = 16) 16.3% (n = 8) 1.4% (n = 1) —
Finished high school 20.0% (n = 9) 29.6% (n = 16) 18.4% (n = 9) 11.3% (n = 8) —
Trade cert/diploma 24.4% (n = 11) 29.6% (n = 16) 16.3% (n = 8) 26.8% (n = 19) —
University degree 6.7% (n = 3) 9.3% (n = 5) 46.9% (n = 23) 60.6% (n = 43) —
Mean CES-D total 14.96 (SD = 11.59) 21.18 (SD = 12.48) 7.19 (SD = 6.80) 8.29 (SD = 7.03) 25.26***
Mean GAI total 4.87 (SD = 6.26) 8.22 (SD = 6.76) 3.55 (SD = 4.05) 2.92 (SD = 3.00) 12.47***
Mean PAID total 22.47 (SD = 21.59) 34.49 (SD = 20.79) n/a n/a 8.01**

Note. CES-D = Center for Epidemiologic Studies Depression Scale; GAI = Geriatric Anxiety Inventory; ns = nonsignificant; n/a = not applicable; PAID = Problem
Areas in Diabetes Scale; SD = standard deviation.
*p < .05. **p < .005. ***p < .001.

information was validated against the medical records of par- Table 2 Correlations Among Depression, Anxiety, PAID, Age, and Dura-
ticipants with diabetes. The study was cleared in accordance tion of Diabetes
with the ethical review processes of the University of Queen- 1. 2. 3. 4. 5.
sland and the Mater Health Services Human Research Ethics
Committee, within the guidelines of the National Health and 1. Depression 1. — — — —
Medical Research Council. 2. Anxiety 0.76*** 1. — — —
3. PAID 0.70*** 0.64*** 1. — —
4. Age -0.3** -0.26* -0.32*** 1. —
Analytic Strategy 5. Duration -0.00 -0.00 0.09 0.12 1.
Univariate analyses were used to determine which study vari-
Note. PAID = Problem Areas in Diabetes Scale.
ables differed between older and middle-aged adults with and
*p < .01. **p < .005. ***p < .001.
without diabetes. Pearson product moment correlations were
conducted to explore the relationships between the study vari-
ables for participants with diabetes. Three separate two-way
analyses of covariance were conducted to examine differences
Preliminary Analyses
in depression, anxiety, and diabetes-related emotional distress
between older and middle-aged adults with and without diabe- Pearson product moment correlations were conducted to
tes, controlling for gender, education, type of diabetes, and explore the relationships between depression, anxiety, diabetes-
age-within-age group difference. Given the multicollinearity related emotional distress, age, and duration of diabetes among
between depression, anxiety, and diabetes-related emotional participants with diabetes (see Table 2). Depression, anxiety,
distress, these variables were examined separately. and diabetes-related emotional distress were significantly
inversely correlated with age, suggesting that younger age is
Results associated with higher levels of depression, anxiety, and
diabetes-related emotional distress. Duration of diabetes was
A summary of descriptive statistics for each variable is presented not found to be related to age, depression, anxiety, or diabetes-
in Table 1. related emotional distress.

Australian Psychologist 47 (2012) 90–97 93

© 2011 The Australian Psychological Society
Depression and anxiety in older and middle-aged adults with diabetes
Comparisons Between Older and Middle-aged
Adults With and Without Diabetes
Univariate analyses were used to examine differences between
older and middle-aged adults with and without diabetes for all
study variables. Table 1 shows that there were statistically sig-
nificant differences between the groups on age, gender, educa-
tion, depression, and anxiety. Post hoc comparisons using
Tukey’s Honestly Significant Difference Tests showed that the
middle-aged adults with diabetes were younger than, and the
older adults with diabetes older than, their comparison groups.
There were more women and more people with high levels of
education in the comparison groups than in the diabetes groups.
No significant differences were found between the groups with
regard to marital status.
Univariate analyses of variance showed significant differences
in type of diabetes between older and middle-aged adults with
diabetes, with older adults less likely to have T1DM than
middle-aged adults with diabetes. Duration of diabetes was not
found to differ between older and middle-aged adults with
diabetes.
Differences in Depression Scores Between Older
and Middle-aged Adults With/Without Diabetes
An analysis of covariance examined differences in depression
between older and middle-aged adults with and without diabe-
tes, controlling for education, gender, and type of diabetes.
Age-within-age group difference was entered as a covariate.
After adjustment, there were significant main effects of diabetes,
F(1, 198) = 25.53, p < .001, and age group, F(1, 198) = 4.58,
p < .05, but no interaction, F(1, 198) = 2.41, nonsignificant.
Both older and middle-aged adults with diabetes have signifi-
cantly higher levels of depression than older and middle-aged
adults without diabetes, while middle-aged adults have signifi-
cantly higher levels of depression than older adults. No signifi-
cant effects were found with regard to gender, F(1, 198) = 0.25,
ns; education, F(4, 198) = 0.94, ns; type of diabetes, F(1,
198) = 0.02, ns; or age-within-age group differences, F(1,
198) = 1.12, ns. When examining clinical levels of depression,
50% (n = 24) of older and 67% (n = 37) of middle-aged adults
with diabetes scored within the clinical range, compared with
17% (n = 8) of older and 15% (n = 11) of middle-aged adults
without diabetes.
Differences in Anxiety Scores Between Older and
Middle-aged Adults With/Without Diabetes
An analysis of covariance was conducted to examine differences
in anxiety between older and middle-aged adults with and
without diabetes, controlling for education, gender, and type of
diabetes. Age-within-age group difference was entered as a
covariate. After adjustment, the main effects were not signifi-
cant, but there was a significant interaction between diabetes
and age group, F(1, 192) = 9.13, p = .003. These results indicate
that differences in anxiety levels between people with and
without diabetes differ by age group. Middle-aged adults with
diabetes had significantly higher levels of anxiety than older
adults with diabetes, whereas middle-aged adults without dia-
94
K Poulsen and NA Pachana
betes had comparable levels of anxiety with older adults
without diabetes. Middle-aged adults with diabetes had signifi-
cantly higher levels of anxiety than middle-aged adults without
diabetes. However, older adults with diabetes had comparable
levels of anxiety with older adults without diabetes. No signifi-
cant effects were found with regard to gender, F(1, 192) = 3.66
ns; type of diabetes, F(1, 192) = 0.04 ns; education, F(4,
192) = 2.22 ns; or age-within-age group differences, F(1,
191) = 0.05 ns. When examining clinical levels of anxiety, 22%
of older (n = 10) and 47% (n = 26) of middle-aged adults with
diabetes scored within the clinical range compared with 17%
(n = 8) of older and 14% (n = 10) of middle-aged adults without
diabetes.
Differences in Diabetes-related Emotional Distress
Among Adults With Diabetes
A univariate analysis of variance was conducted to examine
differences in diabetes-related emotional distress between older
and middle-aged adults with diabetes, controlling for type of
diabetes. There was a significant difference between the groups,
F(2, 93) = 4.03, p < .05, indicating that middle-aged adults with
diabetes have higher levels of diabetes-related emotional dis-
tress than older adults with diabetes.
Discussion
The present study examined symptoms of depression and
anxiety in a sample of middle-aged and older adults with dia-
betes and compared them with adults without diabetes.
Although a wealth of research has examined psychological con-
ditions in people with diabetes, most of this literature excludes
adults over the age of 60 years. Consistent with previous
research (Anderson et al., 2001), the current study found that
people with diabetes have higher rates of depression than
people without diabetes. When examining older adults specifi-
cally, those with diabetes were found to have significantly
higher rates of depression than those without diabetes. Nearly
50% of adults aged 60 years and above were found to have
clinically diagnosable symptoms of depression, compared with
approximately 15% of older adults without diabetes. These
results are consistent with the general finding that older adults
with a chronic illness have much higher rates of depression than
those without (de Ridder, Geenen, Kuijer, & van Middendorp,
2008). Thus, it is evident that diabetes is not only highly preva-
lent among older adults, but a significant proportion of this
population also suffers from clinically significant levels of
depression. Despite these findings, misdiagnosis of depression in
older adults has been found to be common, with reports of
70–90% of late-life depression being undiagnosed or attributed
to medical problems (Goldman & Neilson, 1999). Research has
found that older adults are less likely than younger adults to
receive specialty mental health care and are more likely to
consult with general medical providers for the treatment of
depression (Cole & Yaffe, 1996; Cooper-Patrick, Crum, & Ford,
1994; Crabb & Hunsley, 2006; Unutzer et al., 2000). Such
results emphasise the importance of identifying mental health
problems among older adults, especially given that depression is
Australian Psychologist 47 (2012) 90–97
© 2011 The Australian Psychological Society
K Poulsen and NA Pachana
associated with increased health costs, increased use of primary
care visits, and longer hospital stays (Charlson & Peterson, 2002;
Unutzer et al., 2000).
Although older adults with diabetes were found to be nearly
three times as likely to have clinically significant levels of
depression than older adults without diabetes, no differences
were found between the two groups in anxiety. On the other
hand, middle-aged adults with diabetes did have higher levels of
anxiety than those without. Given that living with a chronic
illness is a relatively normative occurrence for older adults, it is
likely that diabetes may not increase levels of anxiety in this age
group. In Australia, more than 20% of the population aged over
60 years, and nearly one in four people aged 75 years and over
have T2DM compared with one in 1,000 people in their 20s
(Australian Institute of Health and Welfare, 2009). Thus, indi-
viduals may be more likely to expect to have a chronic illness
later in life.
With regard to depression, research suggests that depression is
a precursor of diabetes. Research has found an approximate
twofold increase in the risk of T2DM among individuals with a
history of a major depressive disorder or depressive symptoma-
tology (Arroyo et al., 2004; Brown et al., 2005; Eaton et al.,
1996; Kawakami, Takatsuka, Shimizu, & Ishibashi, 1999). Thus,
it is possible that depression may be a primary disorder among
people with T2DM, and this may explain why older adults with
T2DM have higher rates of depression than older adults without
diabetes. In addition, medical illness has been found to be a
significant risk factor for depression among older adults, further
supporting the relationship between diabetes and depression.
Middle-aged adults with diabetes reported significantly higher
rates of depression, anxiety, and diabetes-related emotional dis-
tress than older adults with diabetes. However, middle-aged
adults without diabetes also reported high levels of depression;
it was only anxiety that appeared to be differentially elevated
among middle-aged people with diabetes.
Psychological factors such as how stressful life events are
cognitively appraised have also been shown to influence emo-
tional functioning (Beck, 1964). Thus, norms and beliefs regard-
ing healthy ageing are likely to shape the experience of illness.
Researchers have argued that events that are “off time” affect
self-evaluations, and consequently emotional functioning, more
than events that are “on time” (Settersten, 1997, 1999). These
different expectations and health-related norms are likely to
influence the psychological impact of living with diabetes. Given
anxiety symptoms represent an exaggerated emotional response
to the fears people have, it is postulated that living with diabetes
is less likely to be a source of anxiety among older adults,
because of chronic illnesses such as diabetes being more preva-
lent among older adults. Thus, diabetes may be associated with
less anxiety among older adults, whereas developing a chronic
illness at a younger age may be less normative and therefore
more anxiety provoking. Consistent with this, older adults were
found to have lower levels of diabetes-related emotional distress
than middle-aged adults with diabetes, suggesting living with
diabetes is less distressing for older adults than middle-aged
adults. When examining specific sources of diabetes-related
emotional distress, middle-aged adults appear more likely to feel
scared, overwhelmed, and angry because of living with diabetes,
suggesting difficulties adjusting to the diagnosis of a chronic
Australian Psychologist 47 (2012) 90–97
© 2011 The Australian Psychological Society
Depression and anxiety in older and middle-aged adults with diabetes
illness. Middle-aged adults with diabetes are also more likely to
experience social difficulties because of diabetes and difficulties
coping with their treatment regimen, indicating that diabetes
may be more socially isolating for middle-aged adults because of
chronic illness being less common. It is evident that psychologi-
cal, social, and age-related changes are likely to influence psy-
chological outcomes of people with chronic illnesses.
Some limitations of the present study must be kept in mind.
The age range of the present study was restricted to those aged
40 years and older, and although an upper age range was not
specified as a criterion for inclusion in the study, the oldest
participant was 81 years. Thus, it is impossible to determine
whether the relationship between age and psychological symp-
toms such as depression and anxiety is consistent across the full
life-course pattern among people with diabetes. As with all
cross-sectional research on age differences, this study could not
separate age effects from cohort effects, nor cause from effect.
Longitudinal research is required to examine the role of cohort
effects and to explore the causal patterning of diabetes and
psychological distress.
In summary, diabetes is associated with adverse psychological
conditions. People with diabetes are more likely to have higher
rates of depression than people without diabetes, with this rela-
tionship persisting into later adulthood. Given the high preva-
lence of depression among people with diabetes and the
detrimental impact depression has on adherence to diabetes
treatment regimens, glycaemic control, and general physical
health, identifying and treating depression is a vital element of
high-quality diabetes care. The results emphasise the impor-
tance of improving detection of depression among older adults
with diabetes, especially as older adults are more likely to be
misdiagnosed and less likely to receive specialist mental health
intervention. Although diabetes was found to be associated with
higher rates of depression among older adults, comparable
levels of anxiety symptoms were found between older adults
with and without diabetes. Furthermore, among people with
diabetes, older adults had lower levels of depression, anxiety,
and diabetes-related emotional distress than middle-aged
adults, suggesting that factors related to ageing may influence
psychological health. Although late adulthood is often described
as period of life characterised by multiple losses, research sug-
gests older adults are particularly resilient (Staudinger &
Fleeson, 1996). Future research is needed to examine the rela-
tionship between age and psychological health among people
with a chronic medical condition in order to understand factors
that may contribute to adjustment to chronic illness.
Acknowledgements
We would like to acknowledge the assistance of the participants
of the 50+ Registry at the University of Queensland and Mater
Adults Hospital for their assistance with this research.
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