Emotional Correlates of the COVID-19 Pandemic in Individuals With and Without Diabetes

The coronavirus disease 2019 (COVID-19) pandemic has caused significant social, emotional, and economic disruptions worldwide. To limit the spread of the virus, the public has been urged to stay home or to meet with family and friends outdoors (1), wear a mask when in public, and wash hands frequently and/or use hand sanitizer. Businesses and public venues have been required to close and, as a result, lay off employees or reduce their work hours. Schools, both K–12 and universities, have also partially or fully pivoted to online education, requiring parents to stay home with their children, lose work hours, and/or find already-limited childcare. Restrictions on interpersonal interactions, even among extended family members, have limited parental access to childcare resources (2). With the added stress of becoming infected with the virus in conjunction with prolonged requirements for physical distancing, the pandemic has increased the risk of a global mental health crisis (3,4).

To date, multiple studies have documented the impact of the COVID-19 pandemic on mental health outcomes. In one of the earliest studies published on the pandemic, Whitehead (5) found that negative expectations about the pandemic (expected decline in income, long duration of the pandemic, and continuation of negative effects on daily life) were associated with higher perceived stress and negative affect. A review of 19 studies of mental health during COVID-19 published through 19 May 2020, primarily from China, showed the prevalence of depression symptoms ranged from 14 to 48% (6), with higher rates observed in female individuals and young adults. Rates of anxiety symptoms were highly variable, with studies reporting prevalence rates ranging from 6 to 50%. Levels of stress were variable but higher in younger and female individuals. A meta-analysis published in June 2020 found that the prevalence of anxiety was 33%, with higher rates reported in patients with COVID-19 and in those with preexisting conditions (7). A study comparing rates of depression symptoms before and during the pandemic found that rates of depression symptoms were higher during COVID-19 (27.8%) compared with prepandemic rates (8.5%), particularly in unmarried and lower-income individuals (8).

Increases in mental health symptoms are likely due to several factors, including reduced physical activity, increased screen time (9), and changes in employment and job insecurity. A cross-sectional online survey of 474 employed U.S. adults in April 2020 found that more than half of participants were at least somewhat worried about losing their job. Worry about job status and finances correlated with higher rates of anxiety and depression symptoms (10). A mail-based survey of ∼6,500 U.S. adults showed that pandemic-related restrictions resulted in greater mental distress (11), particularly in those with preexisting conditions and those who felt they would lose their job in the next 30 days.

COVID-19 has posed greater risk for individuals with diabetes than the general public (12), with a mortality rate 65% higher than that for those without diabetes (13). Increased risk of adverse outcomes and mortality sets the stage for differential mental health outcomes for individuals with diabetes and other comorbid disorders. In a meta-analysis of studies examining mental health during the pandemic, rates of anxiety were 40% among individuals with diabetes, compared with 33% in nondiabetes subgroups (7). Rates of depression were reported at 28% overall but were higher in those with diabetes. Other risk factors for psychological burden were female sex, low socioeconomic status, being at higher risk for COVID-19 social isolation, and longer time spent consuming COVID-19–related news (7).

The COVID-19 pandemic may also lead to increased diabetes-related distress and potentially increases in A1C attributable to changes in daily routines as well as to social isolation and decreased access to health care (14). In an April 2020 survey of 1,382 U.S. adults with diabetes, patients reported changes in health care access (telehealth appointments, canceled appointments), increases in general and diabetes-related stress and isolation, less physical activity, greater glucose variability, and changes in eating habits (15). Patients also shared concerns regarding accessing adequate food (33.0%), obtaining diabetes supplies (12.4%), and delayed and cancelled laboratory tests (30.5%). In a cross-sectional survey of 120 Brazilian adults with diabetes (data collected in late March 2020), 44.2% screened positive for depression and/or anxiety (type 1 diabetes 32.7%; type 2 diabetes 52.9%), 29.2% reported diabetes distress, 75.8% screened positive for an eating disorder, and 77.5% met criteria for a moderate or severe sleeping disorder (16).

To date, a majority of studies examining the impact of COVID-19 on mental health of individuals with diabetes have been conducted internationally, indicating elevated rates of depression, anxiety, and distress. Only one study has examined the mental health of adults with diabetes early in the U.S. pandemic experience, but it lacked a comparison sample of adults without diabetes (15). It is unknown how individuals with diabetes compare with those without diabetes in terms of mental health outcomes including depression, anxiety, perceived stress, and resilience. The purpose of the current study was to characterize mental health experiences associated with COVID-19 in adults with and without diabetes over the course of the pandemic. Because of the increased risk of mortality from COVID-19 in individuals with diabetes, it was hypothesized that adults with diabetes would experience greater levels of stress and more difficulty coping during the COVID-19 pandemic compared with those without diabetes.

We conducted a longitudinal observational survey study over a 12-month period. In this article, we report findings from our baseline time point from 29 May 2020 to 30 June 2020. We recruited U.S. adults to complete an online survey. Participants were recruited from health registries and social media. Research Match is a national volunteer registry (148,000 registrants) created by academic institutions and supported by the U.S. National Institutes of Health as part of the Clinical and Translational Science Award program. E-mails were sent through Research Match (96,793 e-mails sent) to adults age ≥18 years, including those with a diagnosis of diabetes. All IN for Health is an Indiana-specific recruitment registry (7,794 e-mails sent) hosted by the Indiana Clinical and Translational Sciences Institute. E-mails were sent to registrants age ≥40 years. Recruitment e-mails contained a link to the REDCap consent and survey. Finally, recruitment was conducted in partnership with Diabetes Sisters, Inc., an online nationwide support network of women with diabetes, providing education and peer support. Recruitment of followers of Diabetes Sisters, Inc., included a notice in the monthly newsletter (13,500 recipients) and postings on the group’s Facebook (10,000 followers), Twitter (6,000), and Instagram (2,300) accounts. Notices and postings included a link to the REDCap consent form and survey.

Items included age, self-reported race/ethnicity, income, education and other demographic information, self-reported diabetes status, diabetes treatment, and health history. Additional questions assessed the effects of COVID-19 on the participant, including diagnosis of COVID-19, change in income as a result of the pandemic, employment status during the pandemic, and financial appraisal (“How hard has it been to make ends meet over the past 30 days?”, “Have you had difficulty paying your bills in the past 30 days?”, “How hopeful are you about your financial situation?”) (17).

Diabetes Distress Scale-17 (DDS) (18) measures emotional burden, physician-related distress, regimen-related distress, and interpersonal distress specific to diabetes. Responses use a 6-point Likert scale from 1 (not a problem) to 6 (serious problem). Total scale score is expressed as the mean of the item responses, with higher scores indicative of higher levels of distress. Scores <2 are indicative of little to no distress, between 2.0 and 2.9 moderate distress, and ≥3.0 high distress (19). Only participants with type 1 or type 2 diabetes were asked to complete the DDS.

Patient Health Questionnaire (PHQ-8) (20) is a brief measure of depression symptoms over a 2-week period based on DSM-IV (21) criteria for depression, minus the criterion on suicidal ideation. Participants are asked to indicate how often each of the criteria occurred on a scale from 0 (not at all) to 3 (nearly every day). Scores for each item are summed to arrive at a total item score, with higher scores suggestive of greater depression severity. Ranges for severity of scores on the PHQ-9 (with the suicidal ideation question included) are as follows: 0–4, none; 5–9, mild; 10–14, moderate; and 15–19, moderately severe (20).

Generalized Anxiety Disorder (GAD-7) (22) is a seven-item measure to assess symptoms of generalized anxiety disorder based on DSM-IV (21) criteria and are rated on a 4-point Likert scale from 0 (not at all) to 3 (nearly every day). Responses for each item are summed to calculate a total score. A score of ≥10 has a sensitivity and specificity of >0.80. It has high internal consistency (Cronbach α 0.92) and test-retest reliability (intraclass correlation 0.83).

Perceived Stress Scale (PSS) (23) is a 10-item measure assessing the perception of stress in the past month (e.g., “How often have you felt that you were unable to control the important things in your life?”). Responses are on a 5-point scale from 0 (never) to 4 (very often). Scores of ≤13 are indicative of low stress, 14–26 moderate stress, and ≥27 high perceived stress. It has adequate reliability and validity.

Brief Resilience Scale (BRS) (24) is a 6-item measure assessing resilience, or “resistance to illness, adaptation, and thriving, the ability to bounce back or recover from stress” (24 p. 194). Items are phrased as declarations (e.g., “It is hard for me to snap back when something bad happens,” “I usually come through difficult times with little trouble”). Respondents are asked whether they agree or disagree with each of the items, on a scale from 1 (strongly disagree) to 5 (strongly agree). Item responses are averaged to calculate mean item score from 1 to 5, with higher scores indicative of greater resilience. Meaningful score cut points have not been established, but mean item score of <4 indicating low resilience has been used in prior studies (25). The measure has good internal consistency (Cronbach α range 0.80–0.91) and test-retest reliability (intraclass correlation coefficient 0.69 after 1 month).

The characteristics of the sample were summarized using means and SDs. Diabetes status (no diabetes, type 1 diabetes, type 2 diabetes, prediabetes, lifetime history of gestational only) was used as a grouping variable. Additional subgroup analyses were conducted to assess the differences by sex, race, ethnicity, and age grouping. For the racial groupings, participants were asked to identify their race from the following options: White, Black or African American, American Indian or Alaska Native, Asian, and Native Hawaiian or Pacific Islander. Participants could choose as many categories as they felt applied to their status. Because of the small number of participants who endorsed American Indian, Asian, and Native Hawaiian or Pacific Islander or who selected multiple categories, these were combined into a single category (i.e., Other). For the age groupings, the sample was divided into quartiles, resulting in four age groupings: 18–34, 35–50, 51–64, and 65–92 years.

Significance tests were calculated on all variables. Student t tests were conducted to compare differences in demographic variables among the diabetes and other subgroupings. Outcome measures were analyzed by diabetes status and demographic characteristics (e.g., age group, sex, race, ethnicity) using ANCOVAs and Tukey tests to evaluate differences among subgroups on continuous variables, controlling for relevant demographic characteristics (i.e., age, sex, race, diabetes status, income). Categorical variables were analyzed using χ² tests. All analyses were conducted using SAS 9.4 (SAS Institute, Inc.). Significance was determined at P ≤ 0.05.

A total of 2,176 adults completed all measures of the online survey. Participants were drawn from all regions of the U.S., including Alaska and Hawaii (Fig. 1). Demographic characteristics are shown in Table 1. Twenty-seven percent of the sample (n = 580) reported a diagnosis of diabetes, with a majority reporting a diagnosis of type 2 diabetes (n = 301; 52.1%), followed by prediabetes (n = 145; 24.9%), type 1 diabetes (n = 100; 17.2%), and gestational only (n = 34; 5.8%). Among those with type 1 diabetes, the primary mode of diabetes treatment was insulin pump (n = 70; 70.0%), followed by insulin injections (n = 24; 24.0%). For those with type 2 diabetes, the primary treatment mode was by oral medications (n = 147; 48.4%), followed by a combination of oral medications and insulin injections (n = 61; 20.1%). Mean age at diagnosis of diabetes was 18.3 (SD 9.9) and 47.3 years SD 13.3) for participants with type 1 and type 2 diabetes, respectively.

Participants were queried about other health diagnoses including depression (n = 728; 33.5%), high blood pressure (n = 610; 28.0%), and high cholesterol (n = 524; 24.1%). Other primary conditions listed by participants (n = 514; 23.6%) included asthma, fibromyalgia, arthritis, and anxiety. Mean number of comorbidities was 1.94 (SD 1.7) per person. We also calculated the number of COVID-19 risk factors per participant. Risk factors included a diagnosis of diabetes (type 1 or type 2 only), heart disease, cancer, cardiovascular disease, and asthma. Mean number of COVID-19 risk factors for all participants was 0.5 (SD 0.7).

Significant differences among the diabetes groups were found in the variables of age, sex, education, marital status, home ownership, income, race and ethnicity, A1C, and number of people who are supported by the household income. Significant differences were also found in number of COVID-19 risk factors, with the type 2 diabetes group having significantly more risk factors than each of the other diabetes groups (all P < 0.01). The comparisons between the type 1 diabetes group and each of the other groups were all significant with regard to these same variables (all P < 0.01). Participants with type 2 diabetes had significantly more comorbidities than participants in the other diabetes groupings (all P < 0.001).

Few participants reported a diagnosis of COVID-19 at baseline (n = 21; 1.0%) or a household member receiving a diagnosis (n = 18; 0.8%). Approximately one-third of participants (n = 636; 29.7%) indicated that their income had changed because of the pandemic, with a majority reporting a small or large decrease (88.8%). Employment status across the sample was variable, with working from home (n = 832; 38.2%) and not working and wasn’t working before (n = 692; 31.80%) most frequently endorsed. Fourteen percent of the sample (n = 303) indicated that they had difficulty paying bills in the last 30 days, with a greater proportion in the prediabetes subgroup reporting difficulty (16.7%; P < 0.001) compared with participants without diabetes.

Significant differences were found among the diabetes groups in the mental health measures after controlling for age, sex, race, income, and diabetes status (Table 2). Assessment of depressive symptoms (PHQ-8) for the whole sample was mean of 7.1 (SD 5.8), indicating mild symptoms. Significant differences were found between the type 2 diabetes group (mean 7.7; SD 5.9) and the group without diabetes (mean 6.9; SD 5.7; P < 0.001). Mild levels of anxiety on the GAD-7 (mean 5.9; SD 5.3) were observed across all groups (P < 0.001), with significant differences between the type 2 diabetes group and the group without diabetes (P < 0.05). Moderate levels of stress were observed on the PSS (mean 16.1; SD 8.03) across groups (P < 0.001), with significant differences between the type 2 diabetes group and the group without diabetes (P < 0.05). Finally, adults with type 1 diabetes (mean 2.6; SD 0.7) reported higher levels of diabetes distress than the type 2 diabetes group (mean 2.4; SD 0.9; P < 0.05), with both in the moderate range of severity of diabetes-specific distress.

Women were significantly younger than the men, with a mean age of 48.2 (SD 16.5) versus 54.8 (SD 17.0) years, respectively (P < 0.001) (Table 3). Significant differences in demographic variables were observed in home ownership (P < 0.05), diabetes status (P < 0.001), A1C (P < 0.001), and number of comorbidities (P < 0.001). Women fared significantly worse than men in all mental health outcomes, including mean DDS, PHQ, GAD-7, PSS, and BRS scores (all P < 0.01). Significantly higher percentages of women scored in the moderate and moderately severe categories on the PHQ (P < 0.001), screened positive for anxiety on the GAD (P < 0.001), and scored in the moderate and high ranges of stress on the PSS (P < 0.001), after controlling for covariates.

Significant age differences were found when grouping by race and ethnicity, with White participants being the oldest (mean 50.2; SD 16.9) (Table 3), followed by African Americans (M mean 48.0; SD 14.1; P < 0.001). Hispanic and Latino participants were younger (mean 41.7; SD 14.2) when compared with non-Latinos (mean 50.0; SD 16.9; P < 0.001). Rates of diabetes were significantly higher among African Americans (P < 0.01). Worse mental health scores were found in the Other racial category, followed by the White category (all P < 0.001). African American participants reported the lowest levels of depression, anxiety, and stress. Mean PHQ scores for Other, White, and African American participants were 8.9 (SD 6.4), 7.1 (SD 5.7), and 6.2 (SD 5.6; P < 0.001), respectively. This same pattern held for the GAD (P < 0.001), PSS (P < 0.001), and BRS (P < 0.001). Lowest scores on the DDS were observed among White participants (mean 2.5; SD 0.9), followed by African Americans (mean 2.6; SD 0.9) and participants in the Other category (mean 2.6; SD 0.83; P < 0.001).

Analyses by age group (Table 3) yielded significant but expected differences in marital status (P < 0.001), income (P < 0.001), education (P < 0.001), diabetes status (P < 0.001), other diagnoses (all P < 0.05), number of COVID-19 risk factors (P < 0.001), and number of comorbidities (P < 0.001). After controlling for covariates, the youngest age group (18–34 years) had higher levels of depression, anxiety, distress, and stress compared with all other groups, with the oldest group (65–92 years) showing the least impact (all P < 0.001). Additionally, the highest rates of diabetes distress were found in the youngest age group, with 53% scoring in the high distress range, compared with 20% of those in the oldest age group (P < 0.001). Forty-three percent of participants age 18–34 years scored in the moderate or moderately severe categories on the PHQ, compared with ∼16% in the 65+ years group (n = 71; 15.8%; P < 0.001). Rates of anxiety and stress were significantly higher in the youngest two age groups compared with the oldest two groups (both P < 0.001).