The prevalence of Type 2 Diabetes (T2D), among the leading causes of mortality and disability, is increasing at alarming rates. For example, a recent global analysis suggested that more than 500 million people worldwide live with diabetes and this number will more than double and exceed 1 billion by 2030.1, 2, 3, 4. Type 2 Diabetes (T2D), a metabolic disease, also affects large segments of the population worldwide and is associated with comorbidities, reduced quality of life, and premature mortality.3, 4., 5, 6 For example, anxiety disorders are commonly comorbid among people living with T2D. Studies have also found that mental illnesses (e.g., anxiety) affect prognosis and outcomes of T2D, increase the risk of diabetes-related complications, lead to increased health care utilization, and decrease quality of life among people living with T2D.7, 8, 9, 10

.Various studies have suggested a possible bidirectional relationship between T2D and anxiety disorders. For example, Mersha and colleagues11 found that there is a link between anxiety and T2D, with anxiety patients having a 19 % increased risk of diabetes. In another study of adults 40 years or older, individuals with anxiety were more likely to experience progression from prediabetes to diabetes.12 Khambaty et al.13 measured anxiety with a short screening scale in older adults and found that after adjusting for demographic and metabolic variables, those with anxiety had a 1.4 times increased hazard of incident diabetes after a decade of follow-up. In contrast, a greater number of studies suggest that T2D occurrence may precede anxiety disorders among individuals.11,14, 15, 16 As an example, one of the largest studies using the Taiwan National Health Insurance data found that both the prevalence and incidence of mental illnesses were higher among those with T2D than the general population.15 This direction of association between T2D and anxiety is logical, as individuals with diabetes may have fears related to disease management, risk of complications, and stressors due to the disease, leading to anxiety disorders.7,16,17

Irrespective of the prevalence of anxiety with co-occurring diabetes or the directionality of the relationship between diabetes and anxiety, all of the aforementioned reviews and studies do not assess the long-term impact of co-occurring T2D and anxiety. Furthermore, many of the aforementioned studies call for an investigation into the long-term risk of having anxiety among those with T2D.11, 12, 13, 14, 15, 16, 17 Also, in a comprehensive review of literature, we could not find studies on long-term health outcomes among adults with T2D who have comorbid anxiety. Thus, the purpose of this study was to assess the burden of comorbid anxiety and risk of mortality due to co-occurring anxiety among a national random sample of middle and older-age Americans with T2D.