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Prevalence of depression in pati

Prevalence of depression in patients with type 2 Diabetes Mellitus.

 Farhan Fazal,* Safeekh A.T,** Ms. Ancy Ipe*

*Resident Father Muller Medical College, Mangalore -575002.

**Associate Professor,Dept. of Psychiatry,Father Muller Medical College, Mangalore.

***Lecturer, Psychiatric Social Worker Dept. of Psychiatry,Father Muller Medical College, Mangalore.


 


Abstract

Diabetes Mellitus is a chronic and disabling disease with an increasing prevalence all over the world and especially in developing countries. Depressive disorders in diabetic patients are found to be thrice of that found in non–diabetic group. A cross sectional study was done in the medical out- patient department of a tertiary care hospital to find out the prevalence of depression among the patients with Type 2 Diabetes Mellitus. In the diabetic group, depressive symptoms are higher in the female sex, younger age group (40-50) years, low educational status, and low income and in people with unskilled job.

Key Words:  Depression, Diabetes Mellitus

Introduction


Diabetes is one   of  the  ten  leading  causes  of  disability worldwide and  the prevalence  of  diabetes  has  increased  in  the past  two decades. The prevalence of diabetes was estimated to be 0.19% in persons below 20 years of age and 8.6% in persons above 20 yeras1. A high prevalence rate of type 2 diabetes mellitus was recorded in Ahmedabad. It was 4.6 % and 13.6% in age group 40-49 years and 50-59 years respectively, which is the highest recorded from among the Asian countries2.Incidence of diabetes increases with age. The incidence rate  is approximately 2/1000 in 25-44 years of age and  5/1000 in >45 years age group3.The prevalence of  depression in  diabetic group is  found to be thrice of that found in  non –diabetic group. Previous studies have found that depression is associated with bad blood glucose control, lower quality of life, and spending more time and more money on health care4.

Depression is generally under recognized, particularly among individuals with diabetes. It is estimated that only a third of depressed people with diabetes are diagnosed to have depression5. In another study by Lustman and colleagues, glucose levels were shown to improve as depression lifted. Therefore people with diabetes should be regularly screened for symptoms of depression6. Depressed patients with diabetes have been shown to have poor glycaemic control and a higher incidence of micro vascular and macro vascular complications. Treatment of the depression associated with diabetes with either pharmacotherapy or behavioural intervention has been shown to result in   improved glycaemic control and quality of life.7

This study aim is to identify the prevalence of depression in patients with diabetes and to see if there is a difference in the degree of depressive symptoms in diabetic and non-diabetic individuals. This study is also aimed at finding the association between depressive symptoms and different variables like age, sex, education and economic status etc. among diabetic and non- diabetic subjects.

Material and methods

This study was conducted in the medical out-patient department of the Father Muller Medical College Hospital, Mangalore. It is a general hospital in the private sector which provides advanced medical care of the inhabitants of coastal Karnataka and northern parts of Kerala. Patients  with type 2  diabetes  and  healthy subjects who fulfilled the  inclusion and  exclusion criteria (subjects n=50,control n=50) were  taken  up for  study after   obtaining  informed  consent.  Healthy controls who fulfilled both inclusion and exclusion criteria were taken as control. Inclusion criteria for the patients were 1) Patients  with type 2 diabetes mellitus and 2) Age  between the  40 and  60 years  and exclusion criteria were 1) Co morbid medical illness apart from diabetes mellitus 2)Organic mental disorder 3)Mental retardation and 4)Harmful use  or dependence of substance other  than tobacco. Inclusion criteria for controls were 1) Persons without diabetes mellitus and 2) Age between the 40 and 60 years. Exclusion criteria for controls were 1)Any medical  illness 2)Organic mental disorder 3)Mental retardation 4)Harmful use  or dependence of substance other  than tobacco.

The subjects were chosen using purposive sampling technique. Socio-demographic variables of the study population were be collected by using a semi- structured proforma. Beck Depression Inventory II (BDI-II)8 is a scale for the  assessment  of  degree  of depression consisting of 21 groups of  statements to be  answered by  the patient based on  his/ her  feelings during  the  past  2 weeks, were  administered  to both  subjects and  controls to assess the  depressive  symptoms. The data were assessed and analysed for   statistical significance by Chi square test and student t test.

Results

The  majority  of  the people in the  diabetic group and  control group are  in  the   age   group  of  51-60 years  . The   variation of  age  in  the    people of  2  groups  is  statistically  insignificant .Sixty percent of  the  diabetic patients  are  males  and  in  the  control  group males were only forty six percent. This  variation  on  distribution of  gender in  the  2 group is  not  significant .There is no significant variation in the educational status  between the  2 groups or in the financial status   between the  2 groups. The maximum numbers (30%) in diabetic group have a skilled job as compared to only 18% in the control group. The maximum numbers of people in the control group was housewives (36%) as compared to only 28% in diabetic group. There is no significant variation between the 2 groups based on their occupation. The majority  (52%) of  the  people in  diabetic group are  Christians and  in  the  control group Hindus  are  a  majority (40%). There is no statistical significance in religion between the 2 groups.  In the diabetic group, there is no significant difference between the age group with respect to the BDI score. Similar observation is found in the control group also (Table No. 1).

There  is  no significant  variation in  the  mean BDI score between males and  females in the   diabetic group and the  same  is  true in  the  control group. There is no significant difference in the mean BDI score between people with different educational levels in the Diabetic group. The mean BDI score in the control group is highest (22.5%) in people with education of <7th standard and this finding is statistically significant (Table No.2). The people in the diabetic group earning <10000 rupees/ month have significantly higher BDI score than others. In the  control  group similar  results  are  observed  but  the  variation is not  significant . The  mean BDI score  is  higher  in the  people  with  unskilled  job in  the  diabetic group, but  the  differences in  score  is  not  significant. in the  control  group  Housewives  had  a  higher  mean BDI score  and  the  difference is  not significant.   Hindus in the diabetic group have a significantly higher mean BDI score than others. Muslims in  the  control group have  a  higher mean BDI score   than  others and  the  variation of  score with  religion is  highly significant (Table No.3). The maximum (48%) patients are suffering from diabetes for duration of 1-5 years. Though the patients on injections (Insulin) have a higher mean BDI score in the diabetic group, the result does not show any statistical significance.

 The mean BDI score is significantly higher in the diabetic group compared to the control group in age group 40-50 years. Whereas in the  age  group 51-60 years  , no significant  difference  between diabetic and   control group with  respect  to  mean  BDI score is  found (Table No.4). The BDI score in males is higher in the diabetic group compared to control group. This finding is statistically not significant, whereas the  mean  BDI score  in  females  is significantly  higher   in  the  diabetic group compared  to  the  control group. The  people educated  < 7th standard  in  the control group have  a  higher score than  those in  the diabetic group, but the  difference is  not  significant. The mean BDI score in people with education level of 8th-12th standard is significantly higher in diabetic group compared to control group. Similar results are seen in the group of   people having education of degree and above. The  mean  BDI  score  is  significantly higher  in  the  diabetic  group  compared  to  control  group in  people  earning  <10000 rupees / month. Whereas the mean BDI score is higher in the diabetic group compared to control group in people earning 10000-30000 rupees / month. The results are not statistically significant. The mean BDI score  is  higher in  the   diabetic  group compared  to  control  group  irrespective of  type  of  occupation, and  the  variation on  score  was  statistically insignificant. The  depressive symptoms  is  higher  in people suffering  from  diabetes  mellitus  when  compared  to  subjects  in  the  control  group. This finding is statistically highly significant (Table No. 5). Though the  mean BDI score is  higher in patients suffering from  diabetes  for  a duration of 11-15 years the  difference  in  the  mean  BDI score  is  not  statistically  significant.   


 

Table 1: Comparison of mean BDI scores in the 2 groups based on Age.

Groups             Age(yrs)

N

Mean

Std. Deviation

 

Diabetic B.D.I    40-50

                          51-60

16

34

17.06

12.06

9.313

7.996

T=1.958,

P=0.056,NS

Control B.D.I    40-50

                         51-60

38

12

9.61

7.17

7.664

8.706

T=0.930,

P=0.356,NS

 

Table 2: Comparison of mean BDI scores in the 2 groups based on    
Educational level of the subjects.

Groups            

N

Mean

Std. Deviation

F

P

Diabetic <7thstd

8th -12th std

Degree

7

13

30

14.00

15.77

12.67

7.118

9.075

8.911

.577

.566

NS

Control  <7thstd

8th -12th std

Degree

4

11

35

22.50

7.82

7.86

4.203

8.352

6.687

8.176

.001

Sig

 

Table 3:  Comparison of mean BDI score in the 2 groups based on Religion   
of subjects
.

Groups            

N

Mean

Std. Deviation

F

Sig

Diabetic  Christian

               Hindu

               Muslim

26

17

7

10.73

17.94

14.14

7.357

9.608

7.267

4.005

.025

Sig

Control  Christian

               Hindu

               Muslim

19

20

11

10.58

5.05

13.55

7.763

5.568

8.948

5.572

.007

HS

 

Table 4:  Comparison of mean BDI score between the 2 groups in different    
Age groups.

Age(in yrs) Groups

Mean

Std. Deviation

Z

P

40-50   BDI  Diabetic

                      Control

17.06

9.61

9.313

7.664

3.061

.003

Sig

51-60   BDI  Diabetic

                      Control

12.06

7.17

7.996

8.706

1.781

.082

NS

 

 

 

 

Table 5: Comparison of mean BDI score between Diabetic and the Control     
group.

Groups            

N

Mean

Std. Deviation

Z and p

B.D.I      

                 Diabetic

                 Control          

 

50

50

 

13.66

9.02

 

8.670

7.904

 

Z=2.797,

P=0.006,

 


Discussion

This  study  in done  in  the out-patient   department  of  a  medical  college hospital to  find the  prevalence of  depression in patients  with  type 2 diabetes mellitus. For the study two groups were taken, a diabetic group (n=50) and control group (n=50) some of the findings of this study are comparable with the studies done   earlier. This study  found  that  majority  of  the   patients  with  type 2  diabetes mellitus (68%)are  in  the  age  group 51-60 years . These findings are similar to the findings of Gupta et al 2. This is  due  to  the  availability  of  patients in  the  age group given  above in the  medical  outpatient department during  the period  of   the  study. This study  shows  that  depression  is  significantly higher in  females  in  the  diabetic group, which is  comparable  to  the  study done  by  Ali. S et al 9 and differs from the findings of the   study done    by   Yoshiko M et al 10. The  difference   in findings could  be  due  to the  difference in  ethnicity and  culture as  the  study done  by Yoshiko M et al 10 is  not based in  India. There is a  higher preponderance of  depression in  females  with  diabetes therefore in  treating female patients  with  diabetes, clinicians must evaluate for  presence  of  depressive symptoms. The  results  of  this  study shows  that  most of  the  people in  the  diabetic group having low income  (<10000 rupees/ month)have  a  higher  mean BDI score indicative of  higher depressive symptoms. This finding is similar to the findings of the study done by Yoshiko M et al 10. This finding may  be  explained  on the  basis  that  low income  is  associated  with  decreased  access to materialistic goods  and  satisfying basic needs of  life, thereby  making the individual more depressed.

  The  present study  shows  that  people  in  the  diabetic  group  who  are  on  Insulin had  a higher  BDI score suggesting   higher  degree of  depression. A similar finding is seen in the study done by Li. C et al 11. This finding signifies  that  the  mode of  treatment  of  diabetes  plays  an  important role  in  the  degree of  depression. The study also shows that  people in  diabetic and  control group with education level of  8th-12th standard had  a  higher  mean  BDI score  suggesting that  low education level is  related  to degree of  depression. This was similar to the findings of the study done   by Blazer DG et al 12. These findings could be  due to  decreased  health literacy among the  people with low education level  leading  to decreased  knowledge about diabetes  and  its complication, and  thereby affecting the  degree of  depression.                

     The  study  by  Yoshiko M et al 10 shows  that  depression is unrelated  to age, gender, education and  duration of illness, which  is  contrary  to  the findings of  this study. This study shows  that depressive  symptoms are  higher in  the  female  sex, younger  age  group (40-50) years , low educational status  (<7th standard), low income (<10000 rupees/month)and in people with unskilled  job in  the  diabetic group. This could be due to difference in culture and ethnicity, as these two criteria play an important role in the outcome of depression in diabetes. The study found that the mean BDI score increased with the duration of diabetes. This is not is not similar to the   findings of   the    study done    by    Yoshiko M et al 10. This   could be   due to difference  in  the  treatment  modalities between the  patients   of  the  two studies  affecting  their  depressive  symptoms. The  BDI has limitations  in  that  scores  can  be  easily  exaggerated  or   minimized by   the   person  completing  it   Like all questionnaires, the way  the instrument is  administered can  have  an  effect  on  the  final  score. This might be the reason for   the high BDI score and results.

Conclusion

This study   is  conducted  to  identify the prevalence of  depression  in  patients with type 2 diabetes and  the  results show that  high degree of depression is present in the diabetic group compared to the control group.


The results shows that depressive symptoms are higher in the female sex, younger age group (40-50) years, low educational status (<7th standard), low income (<10000 rupees/ month) and in people with unskilled job in the diabetic group. (Figure 15,16,17,18,19).

The strong association between these 2 illnesses indicates  that  screening of depression in  patients suffering from  diabetes  is  important as  it can  reduce morbidity, complications, health cost and  improve  the overall quality  of life   of the  individual . In treating diabetic patients, one of the main clinical aim should be to identify and  treat these depressive symptoms.

References

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2.        Gupta OP, Joshi MH, Dare SK, Prevalence of diabetes in India. Adv Metabolic Disorders, 1978,8: 147-165,.

3.        Harris;Clinical Geriatric Medicine.,1990,6(4):703-19,

4.        Egede, L.E, Nietert P.J and Zheng ,D. Depression and all- cause and coronary heart disease mortality among adults with and without diabetes  Diabetes Care 2005,28:1339-1345,.

5.        Lustman PJ, Harper GW: Non psychiatric physicians identification and treatment of depression in patients with diabetes. Comprehensive Psychiatry 1987,28: 22-27,

6.        Lustman PJ, Griffith LS, Clouse RE; Effects of nortriptyline on depression and  glycemic control in diabetes: results of a  double  blind placebo controlled trial; Psychosomatic Med 59,1997;241-250.1997

7.        Michael D. Harris Current Diabetes Reports, 2003,3 (1), 49-55,

8.        Beck AT, Steer RA, Ball R, Ranieri W. “Comparison of Beck Depression inventories-IA and II in psychiatric outpatients”. Journal of personality assessment 1996 67 (3):588-97.

9.        Anderson R, Freedland KE, Clouse RE.; The prevalence comorbid depression in adults with diabetes. Diabetes Care 2001, 24:1069-1078,

10.     Yashiko Miyaoka md, hitoshi Miyaokamd,Tetsuya Motomiya md, Shin-Ichi Kitamura md’ Masahiro Asai md , psychiatry and  clinical neurosciences. 2008, volume 51 issue 4, 203-206.

11.     Li C Ford ES, Strine TW, Mokdad AH,Prevalence of  depression among U.S adults with diabetes: findings  from the 2006 behavioral risk factor surveillance system.-Diabetes Care.2008;31(1):105-7.

12.   Blazer DG, Moody-Ayers S, Craft-Morgan J, Burchett B, Depression in Diabetes, Psychosom Res2002.; 53:913.