Anger Expression Styles, Cynical Hostility, and the Risk for the Development of Type 2 Diabetes or Diabetes-Related Heart Complications: Secondary Analysis of the Health and Retirement Study.

OBJECTIVE: Limited research has examined associations between trait anger and hostility and incident type 2 diabetes (T2D) and diabetes-related heart complications. However, anger expression styles (i.e., anger-in, anger-out) have not been examined. The present study used secondary data to examine the associations between anger expression styles, cynical hostility, and the risk of developing T2D (objective 1) or diabetes-related heart complications (objective 2). METHODS: Self-report data came from participants aged 50-75 in the Health and Retirement Study. Anger-in (anger that is suppressed and directed toward oneself), anger-out (anger directed towards other people or the environment), and cynical hostility were measured at baseline (i.e., 2006 or 2008). Follow-up data (i.e., diabetes status or diabetes-related heart complications status) were collected every two years thereafter until 2020. The objective 1 sample included 7,898 participants without T2D at baseline, whereas the objective 2 sample included 1,340 participants with T2D but without heart complications at baseline. RESULTS: Only anger-in was significantly associated with incident T2D after controlling for sociodemographic characteristics, HR = 1.08, 95% CI [1.01, 1.16], but the association did not hold after further adjustment for depressive symptoms. Only anger-out was significantly associated with incident diabetes-related heart complications after adjusting for sociodemographic characteristics, health-related covariates, and depressive symptoms, HR = 1.21, 95% CI [1.02, 1.39]. CONCLUSIONS: Anger expression styles were differentially related to diabetes outcomes. These findings demonstrate the value of expanding the operationalization of anger beyond trait anger in this literature and encourage further investigation of anger expression styles.

Effect of an entry-to-care intervention on diabetes distress in individuals with newly diagnosed type 2 diabetes: a study protocol for a cluster-randomized trial.

BACKGROUND: Diabetes distress (DD) affects at least 36% of T2DM patients and is often associated with insufficient support and care. This study examines an intervention that targets DD through enhanced cross-sectoral collaboration and treatment during the first 3 months following diagnosis. The intervention aims to improve care and self-management and to reduce DD. METHODS AND INTERVENTION: The study is designed as a cluster-randomized trial with the intervention focusing on four key elements of diabetes care: effective cross-sectoral communication and information sharing, systematic care, a "one-stop-shop" health screening and start-up conversation at the municipality, and improving patient insights into own care. This study requires 32 clusters (16/arm) to achieve 80% power and a 5% significance cut-off, with 270 patients required. GP recruitment occurred from May to Dec 2022. Patient recruitment is ongoing from May 2022 to Aug 2023. GPs were randomized 1:1 using computer-generated blocks of six. Participating GPs are located in Southern Denmark and are not participating in other trials. Patients must be 18 + years of age, have a T2DM diagnosis, and be fluent in spoken and written Danish. DD is the primary outcome and will be measured at baseline, at four months, and again at a 12-month follow-up. Secondary outcomes include quality of care, self-management, quality of life, and clinical factors. Tertiary outcomes comprise depression, stress, resilience, sleep quality, and social network quality. CONCLUSION: This study is among the first clinical trials exploring the development of DD from diagnosis to 12 months post-diagnosis. Many previous interventions did not directly target DD as the primary outcome. This research provides new insights into DD progression in patients newly diagnosed with T2DM and examines an intervention designed to lower DD in early diabetes stages, contributing to a better understanding of the development of DD and how this intervention affects patient well-being. TRIAL REGISTRATION: ClinicalTrial.gov NCT05571306. Registered on 07 October 2022.

Can online and app-based interventions be used by people with diabetes to reduce diabetes distress? A protocol for a scoping review.

INTRODUCTION: Diabetes distress has been defined as "the negative emotional or affective experience resulting from the challenge of living with the demands of diabetes". Diabetes distress affects 20%-25% of individuals living with diabetes and can have negative effects on both diabetes regulation and quality of life. For people living with diabetes distress, innovative tools/interventions such as online or app-based interventions may potentially alleviate diabetes distress in a cost-effective way. The specific research questions of this scoping review are: (1) what are the effects of online or app-based interventions on diabetes distress for adults with type 1 or type 2 diabetes, and (2) what are the characteristics of these interventions (eg, type of intervention, duration, frequency, mode of delivery, underlying theories and working mechanisms)? METHODS AND ANALYSIS: A scoping review will be conducted, using the methodological framework of Arksey and O'Malley along with Levac et al. Eligible studies are: studies of adults ≥18 years old with type 1 or 2 diabetes using an online or app-based intervention and assessing diabetes distress as the primary or secondary outcome. Five databases (Medline, EMBASE, CINAHL, PsycINFO and Scopus) will be searched and is limited to articles written in English, Danish, Norwegian, Swedish or Dutch. Two reviewers will independently screen potentially eligible studies in Covidence, select studies, and together chart data, collate, summarise, and report the results. We will adhere to the Preferred reporting Items for Systematic Reviews and Meta-Analysis for Scoping Reviews (PRISMA-ScR). ETHICS AND DISSEMINATION: The scoping review has been exempt from full ethical review by the Regional Committees on Health Research Ethics for Southern Denmark (case number: S-20232000-88). The results of the review will be published in a peer-reviewed journal and presented at relevant conferences and workshops with relevant stakeholders.

Prevalence, associations and health outcomes of binge eating in adults with type 1 or type 2 diabetes: Results from Diabetes MILES - The Netherlands.

AIMS: To examine the prevalence and health risks of binge eating in people with diabetes. METHODS: Self-report data were analysed from a subsample (n = 582 type 1 diabetes/735 type 2 diabetes) of Diabetes MILES - the Netherlands, an online survey. Prevalence of binge eating was compared across diabetes type and treatment and between participants with and without binges for eating styles, diabetes treatment and outcomes, weight, BMI and psychological comorbidity. Associations between binge eating, HbA1c , BMI, diabetes distress were assessed using hierarchical linear regression analyses. RESULTS: 23% (n = 308) of participants reported eating binges, with 16% at least monthly, and 6% at least weekly. Prevalence and frequency of binges did not differ across diabetes type or treatment. People reporting binges scored higher on dietary restraint, emotional and external eating and reported higher weight and BMI than those without binges. Only people with type 1 diabetes and eating binges had a higher HbA1c . Hierarchical regression analyses demonstrated that binge eating was independently associated with higher HbA1c (ß = 0.12, p=0.001), BMI (ß = 0.13, p < 0.001) but not with diabetes distress. CONCLUSIONS: This study found binge eating to be associated with eating styles, BMI and HbA1c . However, our cross-sectional data do not allow for conclusions on causality. Future studies could further examine the directions of these associations and their clinical implications.

Depression Is Associated With Progression of Diabetic Nephropathy in Type 1 Diabetes.

OBJECTIVE: To investigate the relationship between depression and diabetic nephropathy progression in type 1 diabetes. RESEARCH DESIGN AND METHODS: Data from 3,730 participants without end-stage renal disease (ESRD) at baseline, participating in the Finnish Diabetic Nephropathy Study, were included. Depression was assessed in three ways. Depression diagnoses were obtained from the Finnish Care Register for Health Care. Antidepressant agent purchase data were obtained from the Drug Prescription Register. Symptoms of depression were assessed using the Beck Depression Inventory (BDI). Based on their urinary albumin excretion rate (AER), participants were classified as those with normal AER, microalbuminuria, and macroalbuminuria. Progression from normal AER to microalbuminuria, macroalbuminuria, or ESRD; from microalbuminuria to macroalbuminuria or ESRD; or from macroalbuminuria to ESRD, during the follow-up period, was investigated. RESULTS: Over a mean follow-up period of 9.6 years, renal status deteriorated in 18.4% of the participants. Diagnosed depression and antidepressant purchases before baseline were associated with 53% and 32% increased risk of diabetic nephropathy progression, respectively. Diagnosed depression assessed during follow-up remained associated with increased risk of disease progression (32%). BDI-derived symptoms of depression showed no association with the progression, but the total number of antidepressant purchases modestly reduced the risk (hazard ratio 0.989 [95% CI 0.982-0.997]), P = 0.008). With the sample divided based on median age, the observations followed those seen in the whole group. However, symptoms of depression additionally predicted progression in those age ≤36.5 years. CONCLUSIONS: Diagnosed depression and antidepressant purchases are associated with the progression of diabetic nephropathy in type 1 diabetes. Whether successful treatment of depression reduces the risk needs to be determined.

Comorbid elevated symptoms of anxiety and depression in adults with type 1 or type 2 diabetes: Results from the International Diabetes MILES Study.

AIMS: We examined: (a) the prevalence of comorbid elevated symptoms of anxiety/depression; (b) its demographic/clinical correlates; (c) associations with self-care behaviors, by diabetes type. METHODS: Cross-sectional self-report data of 6590 adults with diabetes (42% type 1; 58% type 2) from the Australian and Dutch Diabetes MILES studies were used. Elevated symptoms of anxiety/depression were defined as GAD-7 ≥ 10/PHQ-9 ≥ 10. RESULTS: In both diabetes types, comorbid elevated symptoms of anxiety/depression were present in 9% and symptoms of anxiety alone in 2%; symptoms of depression alone were present in 8% of adults with type 1 diabetes and 11% with type 2 diabetes. Shorter diabetes duration (type 1 only) was the only characteristic that distinguished those with comorbid elevated symptoms of anxiety/depression but not those with symptoms of anxiety/depression alone from the reference group (no/minimal symptoms of anxiety/depression). Those with comorbid elevated symptoms of anxiety/depression had increased odds of sub-optimal diabetes self-care behaviors compared with the reference group, with higher odds than those with symptoms of anxiety or depression alone. CONCLUSIONS: Comorbid elevated symptoms of anxiety/depression affected one in ten respondents, who also had increased odds of suboptimal diabetes self-care. Those with shorter type 1 diabetes duration may be at increased risk.

Psychosocial health care needs of people with type 2 diabetes in primary care: Views of patients and health care providers.

AIMS: This study examined (a) psychosocial health care needs of people with type 2 diabetes from the perspective of patients and diabetes healthcare providers in primary care, in terms of topics, attention in diabetes care and preferences and (b) factors associated with a positive attitude towards specialized psychosocial health care. DESIGN: Qualitative focus group study. METHODS: Using purposive sampling, participants were selected from general practices. In 2012-2013, three focus groups were conducted in people with type 2 diabetes (N = 20) and three with healthcare providers (N = 18). RESULTS: Opinions differed considerably on whether there was a need for psychosocial health care. Topics focused mainly on diabetes-specific issues ranging from a need for additional diabetes education to attention and support in regular diabetes care. However, not all healthcare providers felt competent enough to address psychosocial problems. Some participants reported a need for specialized psychosocial help. A positive attitude towards specialized psychosocial health care appeared to be influenced by care setting (e.g., in the primary care practice or 'outside' mental health care), care accessibility, proactive discussion of psychosocial issues with and referral by healthcare providers and previous experiences with psychosocial health care. CONCLUSION: Although only few participants expressed a need for specialized psychosocial care, attention for psychosocial well-being in regular diabetes care was generally appreciated. IMPACT: People with type 2 diabetes generally felt psychosocial care could be provided as part of regular diabetes care. Suggestions for healthcare providers to meet psychosocial health care needs include training and discussion tools.

The role of hypoglycemia in the burden of living with diabetes among adults with diabetes and family members: results from the DAWN2 study in The Netherlands.

BACKGROUND: To examine the relation between self-reported hypoglycemic events, worries about these episodes, and the burden of diabetes in adults with diabetes and family members from The Netherlands. METHODS: As part of the second multinational Diabetes Attitudes, Wishes and Needs (DAWN2) study, 412 Dutch adults with type 1 or type 2 diabetes and 86 family members completed questions about the burden of living with diabetes, the frequency of hypoglycemia, worries about these events, and several demographic and clinical factors. Analyses included hierarchical logistic regression. RESULTS: In total, 41% of people with diabetes and 56% of family members considered diabetes at least somewhat of a burden. In people with diabetes, diabetes burden was independently associated with self-reported current insulin use (fully adjusted OR = 2.75, 95% CI 1.49-5.10), self-reported frequent non-severe hypoglycemia in the past year (OR = 2.45, 1.25-4.83), self-reported severe hypoglycemia in the past year (OR = 1.91, 1.02-3.58), and being very worried about hypoglycemia at least occasionally (OR = 3.64, 2.18-6.10). For family members, the odds of experiencing living with diabetes as a burden was increased only for participants who were at least occasionally very worried about hypoglycemia (adjusted OR = 5.07, 1.12-23.00). CONCLUSIONS: Approximately half of adults with diabetes and adult family members experienced at least some diabetes burden. In both groups, diabetes burden appeared to be associated with being very worried about hypoglycemia at least occasionally. If these results are replicated, new intervention studies could test new ways of decreasing the traumatic consequences of previous or anticipated hypoglycemic events for people with diabetes and family members.

Validation of the WHO-5 as a first-step screening instrument for depression in adults with diabetes: Results from Diabetes MILES - Australia.

AIMS: Screening for depression is recommended internationally. The World Health Organization's 5-item Well-being Index (WHO-5) is used clinically to screen for depression but its empirical suitability for this purpose is not well documented. We investigated the psychometric properties of the WHO-5 and its suitability for identifying likely depression in Australian adults with diabetes. METHODS: The Diabetes MILES - Australia study dataset provided a sample of N=3249 who completed the WHO-5 (positively-worded 5-item measure of emotional well-being) and the PHQ-9 (9-item measure of depressive symptoms). Analyses were conducted for the full sample, and separately by diabetes type and treatment (type 1, non-insulin-treated type 2, and insulin-treated type 2 diabetes). Construct (convergent and factorial) validity and reliability of the WHO-5 were examined. ROC analyses were used to examine the sensitivity and specificity of the WHO-5 as a depression screening instrument, comparing two commonly used WHO-5 cut-off values (≤7 and <13) with the PHQ-9. RESULTS: For the whole sample, the WHO-5 demonstrated satisfactory internal consistency reliability (α=0.90) and convergent validity with the PHQ-9 (r=-0.73, p<0.001). Confirmatory factor analysis partially supported factorial validity: Χ2(5)=834.94, p<0.001; RMSEA=0.23, 90% CI 0.21-0.24; CFI=0.98, TLI=0.96; factor loadings=0.78-0.92. The AUC was 0.87 (95% CI: 0.86-0.89, p<0.001). The sensitivity/specificity of the WHO-5 for detecting likely depression was 0.44/0.96 for the ≤7 cut-off, and 0.79/0.79 for the <13 cut-off, with similar findings by diabetes type and treatment. CONCLUSIONS: These findings support use of a WHO-5 cut-point of <13 to identify likely depression in Australian adults with diabetes, regardless of type/treatment.

Screening for and subsequent participation in a trial for depression and anxiety in people with type 2 diabetes treated in primary care: Who do we reach?

AIMS: This study investigated (factors related to) (a) the response to a screening procedure for depression and anxiety in people with type 2 diabetes in primary care, and (b) participation in a subsequent randomised controlled trial targeting depressive or anxiety symptoms. METHODS: People with type 2 diabetes (n=1837) received a screening questionnaire assessing depressive symptoms (PHQ-9) and anxiety symptoms (GAD-7). Eligible persons who scored above the cut-off score (PHQ-9≥7 or GAD-7≥8) were offered to participate in the trial. RESULTS: In total, 798 people (43%) returned the screening questionnaire. Non-responders were more often female (53% vs 44%, p<0.001), had higher LDL cholesterol levels (Cohen's d=0.17, p=0.001) and a higher albumin/creatinine ratio (Cohen's d=0.08, p=0.01). In total, 130 people (18%) reported elevated depressive or anxiety symptoms. Twenty-seven persons agreed to participate in the trial. Factors related to participation were a high education level, a higher level of diabetes distress and a history of psychological problems. CONCLUSIONS: Using screening as recruitment resulted in a small number of participants in a treatment trial for anxiety and depression. Research is needed to investigate whether screening is also followed by a low uptake of treatment in primary care outside a RCT setting.

Depression: a common and burdensome complication of diabetes that warrants the continued attention of clinicians, researchers and healthcare policy makers.

There is ample evidence that depression is a common comorbid health issue in people with type 1 or type 2 diabetes. Reviews have also concluded that depression in diabetes is associated with higher HbA1c levels, less optimal self-care behaviours, lower quality of life, incident vascular complications and higher mortality rates. However, longitudinal studies into the course of depression in people with type 1 diabetes remain scarce. In this issue of Diabetologia, Kampling and colleagues (doi: 10.1007/s00125-016-4123-0 ) report the 5 year trajectories of depression in adults with newly diagnosed type 1 diabetes (mean age, 28 years). Their baseline results showed that shortly after the diagnosis of type 1 diabetes a major depressive episode was diagnosed in approximately 6% of participants, while 8% suffered from an anxiety disorder. The longitudinal depression data showed that, in a 5 year period, 79% reported no depressive symptoms at any time, while 7% had a high depression score that improved and 14% reported worsening of depressive symptoms. Here, the clinical relevance of these findings is discussed and areas for further research are described.

Does Mindfulness-Based Cognitive Therapy benefit all people with diabetes and comorbid emotional complaints equally? Moderators in the DiaMind trial.

OBJECTIVES: Research has shown the effectiveness of mindfulness-based interventions for a variety of emotional problems in different samples, but it is unknown which factors influence this effectiveness. Therefore, the aim of the current study was: which factors (demographic, personality, and baseline levels of mindfulness skills) moderate the effectiveness of Mindfulness-Based Cognitive Therapy (MBCT)? METHODS: Outpatients with diabetes (type 1 or type 2; N=139) and an elevated level of emotional distress participated in the Diabetes and Mindfulness (DiaMind) trial. They were randomized into MBCT (N=70) or a control group (N=69) that received treatment as usual and that was offered the intervention 6months later. Primary outcomes were anxiety, depressive symptoms, and perceived stress at post-intervention and at 6-month follow-up. RESULTS: Mixed models analyses showed that sex, extraversion, and baseline acting with awareness were significant moderators of effectiveness. In the MBCT group, women showed larger decreases in anxiety and depression across time (large effects) compared to men (medium to small effects). For extraversion divided into quartiles, the three lowest quartiles generally exhibited large decreases in symptoms, whereas the high extraversion group showed medium (perceived stress) to small (depression) decreases. CONCLUSION: MBCT seems to be effective to decrease symptoms of anxiety, depression, and perceived stress for a broad range of person characteristics in patients with diabetes. However, men and those high in extraversion showed considerably lower effectiveness compared to the other groups. The small effect in high extraverts may be due to the large dropout in this subgroup.

Correlates and outcomes of worries about hypoglycemia in family members of adults with diabetes: The second Diabetes Attitudes, Wishes and Needs (DAWN2) study.

OBJECTIVE: We examined (a) the demographic and clinical correlates of worries about hypoglycemia in adult family members of adults with diabetes, and (b) the association of these worries with measures of diabetes support. METHODS: The second multinational Diabetes Attitudes, Wishes and Needs (DAWN2) study cross-sectionally surveyed 2057 family members from 17 countries. Participants completed questions about demographics, diabetes, and psychosocial functioning, including worry about overall and nocturnal hypoglycemia. Analyses included hierarchical ordinal and linear regression. RESULTS: Eighty-five percent of family members (n=1661) were at least occasionally very worried about the risk of hypoglycemic events overall. Correlates of worries about hypoglycemia included female gender, higher age and lower education in the family member, younger age of the person with diabetes and this person being a parent or another adult (versus spouse or partner), insulin or non-insulin injectable treatment, severe or non-severe hypoglycemia in the past 12months, and family member recognition of hypoglycemia. Elevated worries about hypoglycemia had a significant independent association with increased odds of diabetes-related family arguments and family member frustration in providing helpful support (OR range 1.60-3.72). High levels of worries about hypoglycemia were associated with increased odds of attending diabetes-related health-care visits. Worries about hypoglycemia were not associated with family member involvement in diabetes care. Similar results were found for worries about nocturnal events. CONCLUSION: Worries about hypoglycemia were common in family members and were associated with suboptimal diabetes support. This issue therefore deserves increased clinician attention.

Mindfulness facets as differential mediators of short and long-term effects of Mindfulness-Based Cognitive Therapy in diabetes outpatients: Findings from the DiaMind randomized trial.

BACKGROUND: There is increasing evidence that mindfulness-based interventions reduce psychological distress in various medical populations. However, it has hardly been studied if these effects are mediated by an increase in mindfulness. The aim of this study was to examine mediating effects of various mindfulness facets on effects of a Mindfulness Based Cognitive Therapy (MBCT) on perceived stress and mood. METHODS: Outpatients with diabetes types 1 and 2 and low levels of emotional wellbeing were randomized into a group receiving MBCT (n=70) or a waiting-list control group (n=69). Primary outcomes were mood and perceived stress. Before, after and at follow-up (6months post intervention) relevant questionnaires were completed. RESULTS: Mediation analysis using bootstrap resampling indicated that increases in total mindfulness and the facets observing and nonreactivity mediated the effects of the intervention on depressed and angry mood, anxiety (only observing), and perceived stress (only nonreactivity) from pre- to post-intervention. In contrast, from post-intervention to follow-up, besides total mindfulness the facets of acting with awareness and nonjudging mediated the effects on depressed, anxious, and angry mood, while only nonjudging mediated the effects on perceived stress. DISCUSSION: The findings indicate that increases in levels of mindfulness mediate the effects of the Mindfulness-Based Cognitive Therapy in patients with diabetes. It is notable that different facets may be important for immediate change versus long-term outcome. These findings might be relevant for post-intervention care.

Depressive symptoms and all-cause mortality in people with type 2 diabetes: a focus on potential mechanisms.

BACKGROUND: Depression has been associated with increased all-cause mortality in people with type 2 diabetes. AIMS: To test whether anhedonia, dysphoria and anxiety are differentially associated with all-cause mortality and examine symptom-specific behavioural or pathophysiological mechanisms. METHOD: A total of 1465 people completed the Edinburgh Postnatal Depression Scale in 2005 and were followed until death or 31 December 2010. Cox regression analyses compared survival time for people with a low v. high baseline dysphoria/anhedonia/anxiety score and identified mediating mechanisms. RESULTS: After a mean follow-up of 1878 days (s.d. = 306), 139 participants had died. At all time points, people with anhedonia had an almost twofold increased mortality risk compared with those without anhedonia. Physical activity met criteria for mediation. Symptoms of dysphoria and anxiety were not associated with survival time. CONCLUSIONS: Symptoms of anhedonia predicted shorter survival time, whereas dysphoria/anxiety did not. Mechanistic pathways, in particular physical activity, should be explored further.

Working Together to Promote Diabetes Control: A Practical Guide for Diabetes Health Care Providers in Establishing a Working Alliance to Achieve Self-Management Support.

The quality of the "patient-carer" relationship is the foundation of self-management support and has been shown to influence treatment outcome in relation to psychological and somatic illness, including diabetes. It has long been accepted within applied psychology that the quality of the client-therapist relationship--termed the working alliance--is of central importance to treatment outcome and may account for a significant degree of the overall treatment effect. Diabetes healthcare providers have recently expressed a need for further training in communication techniques and in the psychological aspects of diabetes. Could we take a page from the psychological treatment manual on working alliance in therapy to guide the diabetes healthcare provider in their role of supporting the person with diabetes achieve and maintain better metabolic control? This paper examines the role of the working alliance in diabetes care and offers a practical guide to the diabetes healthcare provider in establishing a working alliance with the person with diabetes in managing diabetes.

Depressive Symptom Clusters Differentially Predict Cardiovascular Hospitalization in People With Type 2 Diabetes.

BACKGROUND: Depression has been associated with the development of cardiovascular disease in people with type 2 diabetes. OBJECTIVE: We examined whether symptoms related to the 2 core features of depression--dysphoria and anhedonia--and anxiety were differentially associated with cardiovascular hospitalization and whether there were symptom-specific mechanisms (alcohol, smoking, physical activity, body mass index, glucose, cholesterol, and blood pressure) in play. METHOD: A total of 1465 people in Dutch primary care completed the Edinburgh Depression Scale in 2005 and were followed up until first cardiovascular hospitalization during follow-up (event) or December 31, 2010 (study end). Cox regression analyses examined (1) differences in time to hospitalization for a cardiovascular event between people with a low vs a high baseline dysphoria/anhedonia/anxiety score (adjusting for demographic and clinical confounders) and (2) mediating mechanisms. RESULTS: A total of 191 people were hospitalized for a cardiovascular event. In univariable analysis, dysphoria predicted a shorter time to cardiovascular hospitalization (hazard ratio = 1.49, 95% CI: 1.02-2.17). After adjustment for confounders, neither dysphoria (hazard ratio = 1.55, 95% CI: 0.91-2.64) nor anhedonia (hazard ratio = 0.83, 95% CI: 0.47-1.48) was significantly associated with time to cardiovascular hospitalization. Anxiety was associated with a longer time to cardiovascular hospitalization (adjusted hazard ratio = 0.49, 95% CI: 0.27-0.89). However, none of the selected factors qualified as a mediator for the (adjusted) association between anxiety and time to cardiovascular hospitalization. DISCUSSION: Dysphoria was associated with a shorter time to cardiovascular hospitalization in unadjusted analyses only, whereas anxiety predicted later hospitalization after confounder adjustment. Anhedonia did not show a significant association. Mechanistic pathways remain unclear.