Generalised anxiety disorder and its determinants amongst patients with diabetes in primary healthcare clinics: a cross-sectional study in Kuwait City, 2024 | BMC Public Health

23% (133) of the participants displayed anxiety symptoms (GAD > 5) ranging from mild to moderate to severe anxiety. A large meta-analysis of 59 global studies (25,176 participants) assessing rates of different anxiety disorders in adult endocrinology outpatients found anxiety symptoms/disorders in a quarter (25·1%) of all endocrine outpatients. These rates were similar among patients with diabetes mellitus (25.5%) and those without diabetes [17].

Data on the prevalence of anxiety amongst diabetes patients in Kuwait is limited. A previous study conducted at primary healthcare facilities in Kuwait in 2012 showed a 1.2% prevalence of anxiety amongst patients with diabetes [12].

The prevalence of anxiety in our study is lower than the findings reported in countries such as Pakistan, Saudi Arabia, and the United Kingdom, where the Depression Anxiety and Stress Scale (DASS-21) [18] and the Hospital Anxiety and Depression Scale (HADS) [19, 20] were used. Studies using the Generalised Anxiety Tool (GAD-7) were conducted at the Chitwan Medical College Teaching Hospital in Nepal [21], at the Diabetes Foot Clinic at the National Centre for Diabetes Endocrinology and Genetics (NCDEG) in Amman, Jordan [22], at a tertiary care facility in Kolkata (Eastern India) [23] and the Government Medical College and Hospital Chandigarh India [24] showed a prevalence of anxiety of 49.7%, 37.7%, 36.2% and 34% among diabetes patients respectively. The primary difference between our findings and those of these studies pertains to the patient populations. In our study, participants were recruited from primary healthcare clinics, where most patients appeared to have glycaemic stability with minimal indications of diabetes-related complications. In contrast, other studies were conducted in tertiary hospitals or specialised clinics, where patients often present with co-morbidities and complications.

The pattern of anxiety symptoms in our study, while lower in prevalence (19% reporting mild symptoms and 4% reporting moderate-to-severe anxiety), reflects similar patterns observed in studies from Nepal, India, Saudi Arabia, and Jordan [18, 21, 22, 24].

Demographic and clinical factors Associated with anxiety symptoms

In our study. the 50–59 years age group had the highest prevalence of GAD. followed by the 40–49-year age group (28%) and the 60–69-year age group (21%). Although not statistically significant. both the 40-49- and 50-59-year age group showed an increased odds of anxiety in comparison to the 18–29 years. Previous studies have reported an increased prevalence and likelihood of anxiety amongst patients with diabetes with increasing age [25, 26].

A cross-sectional study was conducted in 2022 among Bangladeshi T2DM patients from February to March 2022 at the two diabetes hospitals named Ahad Diabetes and Health Complex and Kapotakkho Lions Eye and Diabetes Hospital in the Jashore District of Bangladesh [26] found a higher prevalence of anxiety among females and patients with primary school education or no formal education. Similarly, our study showed a higher prevalence of anxiety among females (52%) and patients who have primary school or no formal education, although these findings were not statistically significant.

Non-native Kuwaiti citizens were significantly more likely to have a GAD score > 10(AOR: 6.99 95%CI: 1.42–34.43) when compared to Kuwaiti nationals. A systemic review showed that communication difficulties, cultural differences in the workplace, daily life relationships with family and colleagues, financial problems and social inequality are among the most common predisposing factors for stress among expatriates [27]. In Kuwait, expatriates often face uncertainties regarding job security, restrictions on family visas, administrative barriers, and limited access to healthcare, all of which can increase stress levels and exacerbate anxiety, particularly among diabetes patients.

Patients attending the clinic every two months were significantly less likely to have GAD > 10 when compared to those attending monthly (AOR: 0.30; 95% CI: 0.002–0.50). Potentially, these patients have better blood glycaemic stability and may have a better social support structure.

Study limitations

Our study was conducted at a limited number of primary healthcare institutions in the capital governing party, which may not be representative of other governing parties due to the socioeconomic variations of residents. In our study, we did not request information on the income profile of participants. The study was cross-sectional by design limiting the ability to make causal inferences. The responses of some of the participants may have been influenced by the health educators resulting in social desirability bias as in many of the instances patients were assisted in completing the survey albeit electronically.