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Depression and associated factors in diabetic patients attending an urban hospital of Bangladesh

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Introduction: Diabetes mellitus is frequently associated with co-morbid depression, contributing double burden to the individual and society. Aims & Objectives: To find out the proportion of depression among patients with type 2 diabetes mellitus and to determine factors associated with it. Methods: A cross sectional study was conducted among 178 patients with type 2 diabetes mellitus attending Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Dhaka. Data were collected through face-to-face interview and reviewing documents. Depressive symptoms were measured using Centre for Epidemiological Studies Depression Scale; considering score 16-21 as mild to moderate depression and score F 22 as severe depression. Results: The proportion of depression among the study population was 34.8% which included 14.6% with mild to moderate depression and 20.2% with severe depression. Both mild to moderate and severe depression were more common in females and among singles. Insulin users were six times more likely to develop severe depression (OR, 6.33 with 95% CI, 1.75 to 22.89) than users of oral anti-diabetic agents. Glycemic status measured by HbA1c was the best predictor. Both poor and fair glycaemic control were associated with any level of depression. Patients with poor glycemic control had odds ratio of 4.75 for mild to moderate depression (95% CI=1.37-16.41) and 10.39 for severe depression (95% CI,=3.66-29.43) in reference to good glycemic control. Patients with fair glycemic control were four times more likely to have mild to moderate depression (OR, 4.31 with 95% CI, 1.57 to 11.85) and severe depression (OR, 3.77 with 95% CI, 1.42 to 10.02) than patients with good glycemic control. Conclusion: Depression was identified as a significant health problem among patients with type 2 diabetes mellitus. Both diabetes and depression should be considered simultaneously during treatment plan.
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International Journal of Collaborative Research on Internal Medicine & Public
Health (IJCRIMPH)
ISSN 1840-4529 | Journal Type: Open Access | Volume 3 Number 1
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Correspondence concerning this article should be addressed to Dr. Mahbubur Rahman, Department of Community
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+8801712044103
Paper publication: 20 February 2011
To cite this Article:
Rahman M, Rahman MA, Flora MS, Rakibuz-Zaman M. Depression and
associated factors in diabetic patients attending an urban hospital of Bangladesh. International
Journal of Collaborative Research on Internal Medicine & Public Health. 2011; 3:65-76.
Article URL: http://iomcworld.com/ijcrimph/ijcrimph-v03-n01-07.htm
Depression and associated factors in diabetic patients attending an
urban hospital of Bangladesh
Mahbubur Rahman, Md. Anisur Rahman, Meerjady Sabrina Flora, Muhammad
Rakibuz-Zaman
International Journal of Collaborative Research on Internal Medicine & Public Health
Vol. 3 No. 1 (January 2011)
Special Issue on “Chronic Disease Epidemiology”
Lead Guest Editor: Professor Dr. Raymond A. Smego
Coordinating Editor: Dr. Monica Gaidhane
International Journal of Collaborative Research on Internal Medicine & Public Health
Rahman M, Rahman MA, Flora MS, Rakibuz-Zaman M Vol. 3 o. 1 (2011)
65
Depression and associated factors in diabetic patients
attending an urban hospital of Bangladesh
Mahbubur Rahman (1) *, Md. Anisur Rahman (2), Meerjady Sabrina Flora (2), Muhammad Rakibuz-
Zaman (3)
(1) Department of Community Medicine, Faridpur Medical College, Faridpur, Bangladesh
(2) Department of Epidemiology, National Institute of Preventive and Social Medicine (NIPSOM), Bangladesh
(3) Columbia University Arsenic and Health Research in Bangladesh, Dhaka, Bangladesh
* Corresponding author; Email: dr_mahbub@yahoo.com
ABSTRACT
Introduction: Diabetes mellitus is frequently associated with co-morbid depression, contributing double
burden to the individual and society.
Aims & Objectives: To find out the proportion of depression among patients with type 2 diabetes
mellitus and to determine factors associated with it.
Methods: A cross sectional study was conducted among 178 patients with type 2 diabetes mellitus
attending Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic
Disorders (BIRDEM), Dhaka. Data were collected through face-to-face interview and reviewing
documents. Depressive symptoms were measured using Centre for Epidemiological Studies Depression
Scale; considering score 16-21 as mild to moderate depression and score ≥ 22 as severe depression.
Results: The proportion of depression among the study population was 34.8% which included 14.6%
with mild to moderate depression and 20.2% with severe depression. Both mild to moderate and severe
depression were more common in females and among singles. Insulin users were six times more likely to
develop severe depression (OR, 6.33 with 95% CI, 1.75 to 22.89) than users of oral anti-diabetic agents.
Glycemic status measured by HbA1c was the best predictor. Both poor and fair glycaemic control were
associated with any level of depression. Patients with poor glycemic control had odds ratio of 4.75 for
mild to moderate depression (95% CI=1.37-16.41) and 10.39 for severe depression (95% CI,=3.66-29.43)
in reference to good glycemic control. Patients with fair glycemic control were four times more likely to
have mild to moderate depression (OR, 4.31 with 95% CI, 1.57 to 11.85) and severe depression (OR, 3.77
with 95% CI, 1.42 to 10.02) than patients with good glycemic control.
Conclusion: Depression was identified as a significant health problem among patients with type 2
diabetes mellitus. Both diabetes and depression should be considered simultaneously during treatment
plan.
Keywords: Bangladesh, depression, HbA1c, type 2 diabetes mellitus
Introduction
Diabetes mellitus is being increasingly
recognized as a serious global health problem.
In 2000, Bangladesh had 3.2 million people
with diabetes and was listed globally at 10
th
,
which would occupy the 7
th
position with 11.1
million in 2030.
1
The prevalence of type 2
diabetes in Bangladesh was 5.2% (rural 4.3%,
International Journal of Collaborative Research on Internal Medicine & Public Health
Rahman M, Rahman MA, Flora MS, Rakibuz-Zaman M Vol. 3 o. 1 (2011)
66
urban 6.9%) in 1994-95
2
and increased to
11.2% (urban)
3
and 6.8% (rural) in 2003-04.
4
Diabetes mellitus is frequently associated with
co-morbid depression, contributing double
burden to the individual and society.
5
These
associations may be related to increased risk
of depressive symptoms in individuals with
diabetes, increased risk of type 2 diabetes in
individuals with depressive symptoms, or
both.
6
At any single point in time,
approximately one-third of diabetic patients
have symptoms of depression severe enough
to warrant treatment.
7
However, depressed
adults have 37% increased risk of developing
type 2 diabetes mellitus.
8
Depression plays an important role in non-
adherence to medical treatment. Therapeutic
compliance, especially diligence in
maintaining dietary restrictions and exercise,
often declines in depressed patients for their
irregular life styles and loss of interest in
health.
9
This further leads to poor glycaemic
control, increased diabetes-related
complications, increased diabetic symptoms
burden
10-12
and ultimately increased health
care use and costs.
13
Both minor and major
depression are strongly associated with
increased mortality in patients with type 2
diabetes.
14,15
On the other hand, support to
encourage psychological well-being would be
expected to reduce not only the occurrence of
psychological problems but also metabolic
problems and complications.
12
Despite the specific relevance of depression to
diabetes and its serious impact on the disease
and health care system, it is estimated that
only one-third of people with both diabetes
and major depression are recognized and
appropriately treated for both disorders.
16
Clearly identifying diabetic patients with co-
morbid depression, knowledge about effective
psychological support and improving access to
effective treatments should be public health
and research priorities. This important
association between type 2 diabetes mellitus
and depression and its consequences on the
outcome of diabetes mellitus were observed
by studies, conducted in western
populations
5,7,9
. A few studies were done in
Asia.
17
Data on depression in the general
population in South Asia, including
Bangladesh are inadequate and so in type 2
diabetic patients. So far reviewed, only one
such study was found which was done in rural
Bangladeshi.
18
Diabetes is more prevalent in
urban than in rural population
2
and they are
frequently exposed to a number of
unfavorable conditions which make them
vulnerable to depression. Therefore, this study
was designed to explore the situation in urban
population of Bangladesh.
Subjects and Methods
A cross-sectional study was undertaken from
January to June 2009 in the Outpatient
Department (OPD) of Bangladesh Institute of
Research and Rehabilitation in Diabetes,
Endocrine and Metabolic Disorders
(BIRDEM), which is the largest tertiary
diabetic care hospital in Dhaka and provides
services to large number of patients with
diabetes mellitus. Adult patients (age 18
years) with type 2 diabetes mellitus selected
by convenient sampling were invited to
participate in the study and 93% agreed.
Patients were diagnosed as diabetic by the
attending physicians of BIRDEM as per
American Diabetic Association guidelines.
Those who had psychiatric problems before
diagnosis of diabetes, family history of
depression, been taking anti-depressant drugs
and seriously ill were excluded from the
study. Estimated sample size taking predicted
prevalence 29.7%
18
at 95% confidence level
with 7% absolute precision and considering
10% non response rate was 181. Three
samples were excluded during data analysis
for having missing data. Finally, data of 178
patients with type 2 diabetes mellitus were
analyzed.
International Journal of Collaborative Research on Internal Medicine & Public Health
Rahman M, Rahman MA, Flora MS, Rakibuz-Zaman M Vol. 3 o. 1 (2011)
67
The protocol was approved by the Ethical
Committees of National Institute of Preventive
and Social Medicine (NIPSOM) and
BIRDEM. Informed written consent was
obtained from each individual prior to data
collection. Data were collected by interview,
record review and anthropometry. A semi-
structured questionnaire was developed based
on Centre for Epidemiological Studies
Depression (CES-D) scale. The CES-D
contains 20-items using a four-point rating
scale. Scores range from 0 to 60, with higher
score indicating more severe depressive
symptoms.
19
CES-D has 61.4% sensitivity and
81.0% specificity. Positive and negative
predictive values of the scale were 57.5% and
83.3%, respectively.
20
A score of 16 or greater
differentiated depressed from non-depressed
adults
19
and cut-off 22 was used to distinguish
severity of depression; a score 16-21 for mild
to moderate depression and 22 for severe
depression.
15,21
Cronbach’s α of Bangla
version of CES-D was calculated 0.89, which
indicated sufficient internal consistency. Each
questionnaire took approximately 35 to 40
minutes to fill up.
Depression score was constructed by
summation of all 20 items of depression score.
As depression score did not follow normal
distribution, for statistical analysis log
transformation of the depression score was
done and geometric mean was used for
comparison. To determine glycemic status,
HbA
1c
level was categorized as HbA
1c
level <
7% as good glycemic control, 7 to 8 fair
glycemic control and > 8% considered as poor
glycemic control. Statistical comparisons
between different groups were made using t-
test, ANOVA for mean scores and chi-square
tests for level of depression. The odds ratio
(OR) with 95% confidence interval (CI) for
risk factors was calculated. All the tests were
two tailed and p<0.05 was considered to be
statistically significant. Multiple logistic
regressions were performed to adjust for
potential confounding factors.
Results
Among 178 respondents, 51% were male.
Their mean age was 54.96 years (SD 9.76
years). Most of them were from urban area
(72%) and married (82%). Average duration
since detection of diabetes was 10.10 + 6.15
years. Mean BMI of the patients was 25.22
(SD 3.25). Majority of them were treated with
oral anti-diabetic agents (60.5%). Average
HbA
1c
level (%) was 7.2 ± 0.97 and 36.5% of
the respondents presented with complications
of diabetes (Table 1).
Mean depression score was calculated 10.50
with SD 9.08. The proportion of depression
among the study population was 34.8% (CES-
D score 16) which included 20.2% with
severe depression (CES-D score 22) and
14.6% with mild to moderate depression
(CES-D score 16 to 21).
Mean depression score found higher among
females (p<0.001), singles (p<0.001), less
educated (p<0.005) and housewives (p<0.005)
(Table 1). Duration since detection of diabetes
mellitus showed positive correlation with
depression score (r = 0.171, p < 0.05).
Depression score was also higher among
insulin users than those orally treated
(p<0.005) and in those used syringe for insulin
administration than pen users (p<0.05).
Presence of diabetic complications was also
associated with higher depression score
(p<0.05). Moderate positive correlation was
found between glycemic status of the
respondents and depression score (r = 0.331, p
< 0.001). For each unit increment of HbA
1c
level, depression score was increased by 3.345
unit (b = 3.345). Respondents having good
glycemic control had least mean depression
score, whereas those with poor glycemic
control showed highest depression score
(Table 1). BMI was not correlated with
depression score. Multiple linear regression
analysis model was constructed to identify
predictors of depression score. Glycemic
status (HbA
1c
%) was the best predictor of
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Rahman M, Rahman MA, Flora MS, Rakibuz-Zaman M Vol. 3 o. 1 (2011)
68
depression score, followed by marital status,
gender and use of insulin device (Table 2).
Higher percentage of both mild to moderate
and severe depression were found among
female respondents (p<0.001), singles
(p<0.001) and respondents with up to
secondary level of education (p<0.05).
Housewives suffered more from severe
depression and retired persons from mild to
moderate depression (p<0.05) (Table 3).
Treatment with oral anti-diabetic drugs and
insulin together was associated with mild to
moderate depression, while only insulin use
was associated with severe depression
(p<0.01). Both mild to moderate and severe
depression were found prevalent among
patients with poor glycemic control (p<0.001)
(Table 4).
Logistic regression model was constructed
which identified HbA
1c
level, marital status
and gender as the best three predictors of
depression. Diabetic individuals with fair
glycemic control were six times and poor
glycemic control were seven and half times
more likely to develop depression than
individuals with good glycemic control.
Single respondents were five times and female
were three times more likely to develop
depression than their counterparts (Table 5).
Discussion
In this study, high proportion of depression
(34.8%) was found, which was much higher
than that in adult general population of
Bangladesh (4.6%)
22
and it supported the link
between diabetes and depression. Most of the
earlier studies supported the higher prevalence
of depression among patients with type 2
diabetes mellitus
5,23
except a few.
24
The
current study proportion was also higher than
that in rural diabetic population
(29.7%).
18
.This difference might accountable
to urban - rural difference in sample
characteristics. Moreover, rural prevalence
data were community-based while the current
study was done in a hospital. Earlier studies
found that prevalence of co-morbid depression
was higher in clinical than in community
samples.
5
A recent study done in United Arab
Emirates found that 12.5% of diabetic patients
obtained a score of 19 or above on the K6,
indicating possible mental health concerns.
17
This lower prevalence might be attributed to
the differences in socio-demographic
characteristics of the samples. Nationalities
other than Emirati in the same study showed
higher rates of scores of 19 or above. Further,
although K6 is an efficient screening tool for
“serious mental illness” (SMI) with a
sensitivity of 0.36 and specificity of 0.96,
25
but its efficiency as a screening tool for
depressive symptoms is yet to be explored.
Mean depression score among females was
found significantly higher than males. After
controlling for other socio-demographic
variables, gender still was significantly
associated with presence of depressive
symptoms [OR = 5.107, 95% CI (1.197-
21.792)]. This finding was supported by most
of the other previous studies
18,23
but not all.
26
The mean age of the respondents was 54.96
years and 60% of them were in the 45 to 64
years age group and age distribution was
comparable with that of type 2 diabetes in
developing countries.
27
No statistical
significant relation was found between age
and depression. It is consistent with other
studies.
26,28
One study found that major
depressive disorder was more common in 31-
59 year old group.
29
Current study found 40-
49 years age group suffered most from severe
depression, athough 60 69 years group had
highest percentages of overall depressive
symptoms.
Single respondents had shown higher
depression score than their married
counterparts [OR = 4.183, 95% CI (1.589-
11.010); p < 0.01] which was consistent with
other study findings.
13,28
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Rahman M, Rahman MA, Flora MS, Rakibuz-Zaman M Vol. 3 o. 1 (2011)
69
Educational status of this study sample was
much better than the national figure.
30
Selection of urban health centre and residence
of the respondents might explain this.
Although mean depression score was found
higher in lower education group, after
adjustment for other sociodemographic
variables the association did not exist.
Association of education with depression was
revealed by most other studies
24,31,32
except a
few.
28
Mean depression score found highest among
housewives and lowest among businessmen
and this was because depression associated
with female gender and females were most
commonly housewives in Bangladesh and so
in this study. Miyaoka et al. detected
correlation of unemployment with depression
score in their study.
28
Average monthly incomes of depressed and
non-depressed group were almost equal in this
study which is not consistent with other study
findings of higher prevalence of depression in
low income individuals.
13,28,33
Mean BMI among the depressed respondents
was 25.78 ± 3.59, which was close to the
findings of study among rural population of
Bangladesh.
18
No significant association could
be found between BMI and depression, which
was supported by most of the other
studies
18,31
, while some other studies found the
association.
14
On average, duration of diabetes in depressed
group was two years longer than in non-
depressed group. Depression score was
correlated with duration of diabetes mellitus.
Other studies did not detect this
relationship.
26,28
In this study more than 90% of the
respondents received pharmacological
treatment in addition to diet and discipline.
Respondents with pharmacological treatment
had higher depression score. Treatment with
oral agent revealed lowest depression score
and higher score was found when insulin was
used. Patients viewed oral treatment as the
least and insulin as the most burdensome
treatment
34
and insulin was associated with
higher frequency of depression.
35,36
Those
who used conventional method (syringe) for
insulin administration had higher mean
depression score than pen device users. Pain
of injection might be the reason for higher
prevalence of depression among insulin-
treated patients.
Depression is significantly associated with a
variety of diabetic complications (diabetic
retinopathy, nephropathy, neuropathy,
macrovascular complications, and sexual
dysfunction).
26,28,37
In this study mean CES-D
scores in diabetic patients with complications
were found higher than in patients without
complications. But no relation was found.
HbA
1c
has been considered as the direct
indicator of glycemic status of a diabetic
individual and its estimation as the most
accurate way of monitoring how well a
diabetic patient is being controlled.
38
Moderate correlation was revealed between
depression score and HbA
1c
level, which was
supported by other studies
29,37,38
, while Engum
et al. found no significant association between
them.
24
Although the present study was not based
upon a representative sample, it provided a
broader basis for the estimation of proportion
of depression and factors associated with it
among patients with type 2 diabetes mellitus.
Within limitations, the researchers tried to
have the best possible sample by choosing
BIRDEM, which is the largest service
provider for diabetic patients in Bangladesh.
Cross-sectional design of the current study
prevented the researcher to infer about the
causality between depression and diabetes.
Further, assessment of depression was based
on self-report, using a screening tool, rather
than a gold-standard diagnostic tool. However,
CES-D is a widely used, well validated
measure for depressive symptoms, particularly
suited for epidemiological studies, both in
general population and in diabetes patients. To
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Rahman M, Rahman MA, Flora MS, Rakibuz-Zaman M Vol. 3 o. 1 (2011)
70
minimize recall bias, some data were validated
by reviewing the documents.
Conclusion
This study has identified depression as a
significant health problem among patients
with type 2 diabetes mellitus and highlighted
some of the factors associated with depression
among them. This association need to be
further studied in depth and finding of the
current study should be replicated in order to
formulate effective intervention program.
Acknowledgements
We acknowledge authorities of Bangladesh
Institute of Research and Rehabilitation in
Diabetes, Endocrine and Metabolic Disorders
(BIRDEM) for their support. We are also
grateful to all the respondents for their sincere
cooperation.
Disclosure: None to declare any
competing interest.
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International Journal of Collaborative Research on Internal Medicine & Public Health
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Table 1: Depression (CES-D) score and socio-demographic and clinical characteristics of the respondents
Characteristics Number Percentage
Depression score p for the
differences of
mean values
Mean
(Geometric)
SD
Gender Male 91 51.1
8.15
7.17
<0.001
Female 87 48.9
13.70
9.69
Age (years) < 40 10 5.6
7.80
5.06
ns
40-49 46 25.9
11.37
10.79
50-59 60 33.7
9.24
8.04
60-69 52 29.2
12.37
9.16
≥ 70 10 5.6
9.04
5.90
Residence Urban 128 71.9
10.83
8.94
ns
Semi-urban 50 28.1
9.71
9.47
Marital status Married 146 82.0
18.39
8.87
<0.001
Single
32 18.0
9.29
8.38
Educational status Illiterate 7 3.9
14.60
11.21
<0.005
Primary 25 14.1
13.78
10.20
Secondary 57 32.0
12.48
9.60
Higher secondary 26 14.6
7.12
7.34
Graduate & above 63 65.4
9.11
7.25
Main occupation Service holder 38 21.5
9.25
7.76
<0.005
Housewife 73 41.2
13.18
10.17
Retired 41 23.2
10.44
7.77
Businessman 25 14.1
6.74
6.56
Drug treatment Oral 101 60.5
9.20
8.22
<0.005
Insulin 14 8.4
15.64
7.77
Oral + Insulin 52 31.1
12.76
9.75
Insulin device Syringe 42 15.52
9.37
42
<0.05
Pen 24 10.20
8.29
24
Diabetic complications Absent 113 63.5
9.59
9.02
<0.05
Present 65 36.5
12.30
9.06
HbA
level Good (< 7) 87 48.9
8.01
7.30
<0.001
Fair ( 7 to 8) 57 32.0
12.35
9.28
Poor ( > 8) 34 19.1
16.04
9.60
BMI (Kg/m
2
) Normal (<25) 86 48.3
10.46
8.52
ns
Overweight (25 to <30)
79 44.0
10.51
9.65
Obese(≥ 30) 13 7.3
10.72
9.61
ns = not significant; BMI = Body Mass Index
Single included widow/widower and separated
International Journal of Collaborative Research on Internal Medicine & Public Health
Rahman M, Rahman MA, Flora MS, Rakibuz-Zaman M Vol. 3 o. 1 (2011)
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Table 2: Factors associated with depression score
Variables Unadjusted Adjusted for other potential variables
p - value
95% CI
§
Beta
F-change p - value
95% CI
§
Lower Upper Lower Upper
Gender <0.001
-0.319
-0.132
0.161
4.527*
<0.05 0.008
0.202
Marital status <0.001
-0.394
-0.199
0.197
7.384**
<0.01 0.045
0.284
Secondary
education
<0.05
-0.215
-0.005
0.021
0.086
ns
-0.082
0.111
Higher secondary
education
<0.01
0.060
0.336
-0.129
3.705
ns
-0.247
0.003
Business man <0.005
0.077
0.374
-0.135
3.456
ns
-0.262
0.008
Housewife <0.005
-0.264
-0.068
-0.021
0.025
ns
-0.184
0.157
Drug treatment <0.005
-0.260
-0.062
1.761
3.101
ns
-0.010
0.172
Insulin device <0.05
0.033
0.331
-0.220
5.007*
<0.05 -0.259
-0.015
Glycemic status
(HbA
%)
<0.001
0.283
16.541****
<0.001 0.049
0.142
§
CI = Confidence Interval for un-standardized regression co-efficient
Beta = Standardized regression co-efficient
ns = not significant; *p <0.05, **p <0.01, ***p <0.005, ****p <0.001
International Journal of Collaborative Research on Internal Medicine & Public Health
Rahman M, Rahman MA, Flora MS, Rakibuz-Zaman M Vol. 3 o. 1 (2011)
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Table 3: Level of depression and socio-demographic characteristics of the respondents
Characteristics
Level of depression
p value No depression Mild to moderate depression Severe depression
n (%) n (%) OR 95% CI n (%) OR 95% CI
Gender Male 73(80.2)
10(11.0)
Referent 8(8.8)
Referent
<0.001
Female 43(49.4)
16(18.4)
2.72
1.13-6.52
28(32.2)
5.94
2.49-14.20
Age (Years) < 40 9(90.0)
1(10.0)
0(0.0)
ns
40-49 27(58.7)
5(10.9)
14(30.4)
50-59 43(71.7)
8(13.3)
9(15.0)
60-69 30(57.7)
9(17.3)
13(25)
≥ 70 7(3.9)
3(1.7)
0(0)
Marital status Married 107(73.3)
19(13.0)
Referent
20(13.7)
Referent
<0.001
Single
9(28.1)
7(21.9)
4.38
1.46-13.18
16(50)
9.51
3.69-24.50
Educational status Illiterate 4(57.1)
1(14.3)
1.79
0.17-18.35
2(28.6)
4.17
0.63-27.73
< 0.05
Primary 11(44)
6(24.0)
3.90
1.09-13.89
8(32.0)
6.06
1.75-21.02
Secondary 31(54.4)
10(17.5)
2.30
0.80-6.68
16(18.1)
4.30
1.52-12.17
Higher secondary 20(76.9)
2(7.7)
0.71
0.14-3.74
4(15.4)
1.67
0.43-6.54
Graduate & above 50(79.4)
7(11.1)
Referent
6(9.5)
Referent
Main occupation Service holder 28(73.7)
5(13.2)
1.96
0.35-11.11
5(13.2)
3.93
0.43-36.12
<0.05
Housewife 38(52.1)
11(15.1)
3.19
0.65-15.70
24(32.9)
13.90
1.76-109.91
Retired 27(65.9)
8(19.5)
3.26
0.63-16.95
6(14.6)
4.89
0.55-43.71
Businessman 22(88.0)
2(8.0)
Referent 1(4.0)
Referent
ns = not significant; BMI = Body Mass Index
Single included widow/widower and separated
International Journal of Collaborative Research on Internal Medicine & Public Health
Rahman M, Rahman MA, Flora MS, Rakibuz-Zaman M Vol. 3 o. 1 (2011)
75
Table 4: Level of depression and clinical characteristics of the respondents
Characteristics
Level of depression
p value No depression Mild to moderate depression Severe depression
n (%) n (%) OR 95% CI n (%) OR 95% CI
Drug treatment Oral 76(75.2)
13(12.9)
Referent 12(11.9)
Referent
<0.01
Insulin 6(42.9)
2(14.3)
1.95
0.35-10.72
6(42.9)
6.33
1.75-22.89
Oral + Insulin 27(51.9)
10(19.2)
2.17
0.85-5.51
15(28.8)
3.52
1.46-8.46
Insulin device Syringe 17(40.5)
8(19.0)
17(40.5)
ns
Pen 16(66.7)
4(16.7)
4(16.7)
Diabetic
complications
Absent 77(68.2)
17(15.0)
19(16.8)
ns
Present 39(60.0)
9(13.8)
17(26.2)
HbA
1c
level Good (< 7) 72(82.8)
7(8.0)
Referent
8(9.2)
Referent
<0.001
Fair ( 7 to 8) 31(54.4)
13(22.8)
4.31
1.57-11.85
13(22.8)
3.77
1.42-10.02
Poor ( > 8) 13(38.2)
6(17.6)
4.75
1.37-16.41
15(44.1)
10.39
3.66-29.43
BMI (Kg/m
2
) Normal (<25) 62(72.1)
10(11.6)
14(16.3)
ns
Overweight (25 to
<30)
47(59.5)
14(17.7)
18(22.8)
Obese(≥ 30) 7(53.8)
2(15.4)
4(30.8)
ns = not significant; BMI = Body Mass Index
International Journal of Collaborative Research on Internal Medicine & Public Health
Rahman M, Rahman MA, Flora MS, Rakibuz-Zaman M Vol. 3 o. 1 (2011)
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Table 5: Risk factors associated with depression
Variables Categories
Unadjusted Adjusted for other potential
variables
p - value OR 95% CI
p -
value
OR /
Exp
(B)
95% CI for
Exp (B)
Gender Male
ψ
Female
<0.001
4.15
2.13 - 8.07
<0.01
3.12
1.32 - 6.84
Marital
status
Married
ψ
Single
<0.001
7.01
2.99 – 16.46
<.005
5.15
1.94 – 13.66
Education Graduate &
above
ψ
Illiterate
Primary
Secondary
Higher secondary
ns
<0.005
<0.005
ns
2.89
4.90
3.23
1.15
0.57 – 14.53
1.80 – 13.28
1.45 – 7.20
0.39 – 3.46
ns
ns
ns
ns
0.56
3.09
2.09
1.06
0.068 – 4.67
0.87 – 10.99
0.78 – 5.58
0.24 – 4.64
Occupation Businessman
ψ
Service holder
Housewife
Retired/aged
ns
<0.005
ns
2.62
6.75
3.80
0.64 – 10.68
1.86 – 24.56
0.97 – 14.94
ns
ns
ns
1.60
2.32
2.82
0.32 – 7.96
0.34 – 15.77
0.60 – 13.28
Drug
treatment
Oral
ψ
Insulin
<0.005
3.04
1.57 – 5.89
ns
2.06
0.91 – 4.66
Glycemic
status
(HbA
1c
%)
Good <7
ψ
Fair 7-8
Poor >8
<0.001
<0.001
4.03
7.75
1.88 – 8.63
3.19 – 18.84
<0.001
<0.001
5.96
7.27
2.49 – 14.26
2.67 – 19.79
ψ
Referral group;
Single included widow/widower and separated
OR = Odds Ratio; CI = Confidence Interval for Exp (B)
ns = not significant
... Existing literature points to a significant association between mental health conditions and chronic diseases, such as diabetes mellitus, cardiovascular diseases and pneumonia (Rozario & Masho 2018, Mukeshimana & Chironda 2019. The presence of depressive comorbidity with diabetes in Bangladesh varies from 34% to 60% depending on age, income, gender, and diabetes type (Rahman et al. 2011, Roy et al. 2012, Islam et al. 2015b). Amid the uncertainty and disruption of the COVID-19 pandemic in Bangladesh, mental health and chronic disease comorbidity may increase. ...
... Each item score is on a four-point Likert scale ranging from zero to three, with higher scores indicating a higher frequency or intensity of the item. The total score for depressive symptoms was categorized into normal (0-9), mild depression (10-12), moderate depression (13)(14)(15)(16)(17)(18)(19)(20), severe depression (21)(22)(23)(24)(25)(26)(27), and extremely severe depression (28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42). The total anxiety subscale score was categorized into normal (0-6), mild anxiety (7-9), moderate anxiety (10)(11)(12)(13)(14), severe anxiety (15)(16)(17)(18)(19), and extremely severe anxiety . ...
... Questions 1,6,8,11,12,14, and 18 formed the stress subscale. The total stress subscale score was categorized into normal (0-10), mild stress (11)(12)(13)(14)(15)(16)(17)(18), moderate stress (19)(20)(21)(22)(23)(24)(25)(26), severe stress (27)(28)(29)(30)(31)(32)(33)(34) ...
Article
Background: Individuals with certain pre-existing chronic health conditions have been identified as a high-risk group for fatalities of COVID-19. Therefore, it is likely that individuals with chronic diseases may worry during this pandemic to the detriment of their mental health. This study compares the mental health of Bangladeshi adults affected by chronic disease to a healthy, matched control group during the COVID-19 pandemic. Subjects and methods: A matched case-control analysis was performed with data collected from 395 respondents with chronic diseases and 395 controls matched for age, gender, and residence. Inclusion criteria for cases were respondents who self-reported having asthma, cardiovascular disease symptoms and/or diabetes. Respondents were recruited using an online survey, which included the DASS-21 measure to assess symptoms of stress, anxiety, and depression. Chi-square test, t-test, Fisher’s exact test and a conditional logistic regression were performed to examine associations among variables. Results: The prevalence of anxiety symptoms and depression symptoms and the level of stress were significantly higher among cases (59%; 71.6%; 73.7%, respectively) than among controls (25.6%; 31.1%; 43.3%, respectively). Chi-square and t-test showed significant associations and differences between having chronic diseases and mental health outcomes. A conditional logistic regression showed that respondents with asthma, diabetes, cardiovascular disease symptoms, or any combination of these diseases had higher odds of exhibiting symptoms of stress, anxiety, and depression than healthy individuals. Conclusion: These results underscore a subpopulation vulnerable to mental health consequences during this pandemic and indicate the need for additional mental health resources to be available to those with chronic diseases.
... In consonant with previous findings [32,58], we found that participants who used insulin for treating diabetes were more likely to experience DD. Previously it was reported by individuals with T2DM that oral treatment was considered less burdensome and insulin most burdensome [59]. ...
... Previously it was reported by individuals with T2DM that oral treatment was considered less burdensome and insulin most burdensome [59]. Injection pain may generate more unfavorable psychological effects including DD in insulin-treated patients [58]. Furthermore, living alone was a predominant predictor for both DS and DD in the present study, raising the possibility that lonely people may develop both DS and DD [60]. ...
Article
Aims Psychological concerns relating to “diabetes distress” (DD) and depressive symptoms (DS) in individuals with type-2 diabetes mellitus (T2DM) may negatively impact adherence to medical treatments and overall mental health. Thus, this study was undertaken to investigate DS and DD in relation to fasting during the month of Ramadan. Methods A cross-sectional survey was conducted among 735 patients with T2DM in 2021. DD and DS were measured by the Problem Areas in Diabetes scale and Patient Health Questionnaire-9, respectively. Logistic regression and correlation analyses were executed. Results More than one-third of the participants (41.2%) had DD and DS (36.9%). DS was significantly higher in participants who did not fast (p=0.027). Participants who had higher dietary diversity were less likely to have DD (p=0.004) and DS (p=0.001). Females (AOR=1.89, 95% CI: 1.25-2.85) and those who lived alone (AOR=1.89, 95% CI: 1.25-2.85) were more likely to have DS. Participants with diabetes-related complications were more likely to experience DS (AOR= 2.17; 95% CI: 1.5-3.13) and DD (AOR= 3.46; 95% CI: 2.42-4.95). DD was also associated with being younger (p=0.003), having hypertension (p=0.030), having heart disease (p=0.012), and taking insulin (p=0.010). Conclusions Individuals with T2DM who were not fasting experienced more mental health concerns. Psychosocial support and other interventions from health professionals should be examined and empirical interventions implemented to promote the mental health and well-being of individuals with T2DM.
... Other pre-COVID-19 studies showed lower estimates of depression (25.9%) among individuals with gestational diabetes mellitus (Natasha et al., 2015) or coronary artery disease (21.9%) (Thombs et al., 2008). The current percentage more closely approximates that observed among diabetic patients in an urban hospital of Bangladesh (34.8%) (Rahman et al., 2011). ...
... In this study, depression and anxiety were strongly linked to being female, in line with several previous pre-COVID-19 studies from India (Islam et al., 2015;Katon et al., 2004;Rahman et al., 2011;Rajput et al., 2016). Depression is expected to be the leading cause of disease burden by 2030 and is already the leading cause of disease burden in women globally (World Health Organization, 2004). ...
Article
Full-text available
Background Coronavirus disease 2019 (COVID-19) disproportionately impacts individuals with medical conditions, including with respect to their mental health. The present study investigated depression and anxiety and their correlates among individuals with medical conditions in Bangladesh. Methods Subjects were recruited to participate in an internet-based survey. Data were collected from November 2020 to January 2021 using convenience sampling by a semi-structured questionnaire through online platforms. Multiple regression analyses were performed to determine associations applying Bonferroni correction (p < 0.004). The Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) measured depression and anxiety, respectively. Results Nine-hundred-and-seventy-one participants (50.1% male; mean age = 42.29 ± 15.86 years; age range = 18-80 years) with medical conditions were included in final analyses. The most frequently reported conditions were diabetes, hypertension, obesity, heart disease, asthma, and anemia. Estimates of moderate to severe depression and anxiety were 38.9% and 35.2%, respectively. The mean depression and anxiety scores were significantly higher among participants who reported having hypertension, obesity, heart disease, asthma, anemia, cancer and chronic obstructive pulmonary disease (COPD). Using Bonferroni correction (p < 0.004), depression was associated with being female and a student, having poorer quality of life, poorer health status and greater numbers of co-morbidities, not engaging in physical exercise and tobacco smoking. Anxiety was associated with being female and a student, having lower socioeconomic status, poorer quality of life, poorer health status and greater numbers of co-morbidities, less sleep and tobacco smoking. Conclusions Depression and anxiety are prevalent among individuals with medical conditions and correlate with sociodemographic, quality-of-life and smoking measures. Interventions targeting vulnerable groups should be employed and investigated.
... Patient health questionnaire (PHQ-9) was used for assessing and measuring severity of depressive symptoms. The PHQ-9 scores and cases were categorized into no depression (0-4), mild depression (5-9), moderate depression (10)(11)(12)(13)(14) moderately severe depression (15)(16)(17)(18)(19) and severe depression (20)(21)(22)(23)(24)(25)(26)(27) . PHQ-9 score ≥10 had a sensitivity of 88% and a specificity of 88% for major depression. ...
... 21 Long duration of illness and uncontrolled condition of DM were determined as contributing factors for depression among diabetic patients in our study which is also supported by several other studies. 17,22 This study finding on the association of treatment modality with depression is supported by previous studies which showed oral hypoglycemic therapy is potentially safer and cater less risk of depression in comparison to intensive management using daily injections. 12,23 Various studies have confirmed that the use of insulin in treatment of diabetes was associated with increased risk of developing depression. ...
Article
Full-text available
Introduction: Both diabetes and depression are major public health problems. Depression is a frequent comorbidity associated with diabetes. This study was aimed to find the prevalence of depression among patients with diabetes and to identify various factors associated with it. Material And Method: This is a cross-sectional study of diabetic patients visiting Internal medicine OPD of Universal College Of Medical Sciences, Bhairahawa, Nepal and referred for psychiatric evaluation. Sample size of 137 was included in 6 months period. Face to Face interview was conducted to gather socio-demographic and clinical profile of patients. Patient Health Questionnaire-9 was used to identify and classify depression. Frequency, Percentage, Chi-square test, Multivariate regression were applied. Results: The overall prevalence of depression was 27%. Depression was found to be significantly higher among female patients (p=0.009), patients suffering from diabetes mellitus for more than 15 years (p=0.054), patients under insulin therapy (p=0.034) and patients whose blood sugar level was uncontrolled(p=0.020) even with treatment. On regression analysis, treatment modality, blood sugar level, gender and treatment modality were found to be independent predictors of depression among diabetic patients. Patients on insulin therapy were four times more likely to have depression (OR=4.344, CI: 2.129 – 8.865, p<0.001). Female patients were two times more likely to have depression (OR=1.825, CI: 0.221 - 2.855, p<0.052). Conclusion: Almost one-fourth patients with diabetes also have depression. Factors like female sex, longer duration of diabetes, use of insulin therapy, uncontrolled diabetes increases the risk of developing depression in diabetic patients. Hence, routine screening of depression is necessary in patients with diabetes.
... One study which was a part of a larger longitudinal epidemiological study on diabetes in rural Bangladesh [31] found 15.3% of the participants with depression [32]. An urban facility-based study reported presence of depression in one in every three diabetes patients [33]. ...
... Current epidemiological evidence suggested at least one third of people with diabetes are suffering from depressive disorders [50,51]. Although in this review we found four articles [26,30,32,33] which reported similarly high prevalence of depression among diabetics. It is reported that more than half of the cancer patients suffer from depression [27,28] which is conceivable given the severity and progressive nature of the disease, high cost and lack of adequate care facilities available. ...
Article
Full-text available
Background: Mental disorders constitute a major public health problem globally with higher burden in low and middle-income countries. In Bangladesh, systematically-collected data on mental disorders are scarce and this leaves the extent of the problem not so well defined. We reviewed the literature on mental health disorders in Bangladesh to summarize the available data and identify evidence gaps. Methods: We identified relevant literature on mental disorders within Bangladesh published between 1975 and October, 2013 through a systematic and comprehensive search. Relevant information from the selected articles was extracted and presented in tables. Results: We identified 32 articles which met our pre-defined eligibility criteria. The reported prevalence of mental disorders varied from 6.5 to 31.0% among adults and from 13.4 to 22.9% among children. Some awareness regarding mental health disorders exists at community level. There is a negative attitude towards treatment of those affected and treatment is not a priority in health care delivery. Mental health services are concentrated around tertiary care hospitals in big cities and absent in primary care. Conclusions: The burden of mental disorders is high in Bangladesh, yet a largely unrecognized and under-researched area. To improve the mental health services in Bangladesh, further well-designed epidemiological and clinical research are needed.
... Maintaining a dietary regimen and exercise often decrease in depressed patients, irregular lifestyles, and loss of interest in health. 8 In diabetic patients, depression has been shown to have adverse effects on social, physical functioning, and quality of life (QoL) that are independent of the effects of the medical illness. 9 Regarding association between depression and types of diabetes, Raval et al 10 concluded an approximately 2-5% increase in the prevalence rates of depression in people with diabetes in South Asian settings compared with people without diabetes. ...
... Previous studies showed that patients with diabetes treated with oral drugs had lower depression scores than patients using insulin. 31,36 However, in our study, we studied subjects aged from 30 to 60 years old. The majority of patients were controlled blood glucose by lifestyle modifies, adjusting their diet, and using oral drugs (71.9%), the proportion of patients using insulin was very low (10.0%) ...
Article
Full-text available
Background: Depression is a common mental disorder in people with type 2 diabetes mellitus (T2DM). Depression and T2DM have a reciprocal interaction through many factors, of which the most important is the multifactorial control and microvascular complications of T2DM. Aim: This research aims to determine the rate of depression and the association between depression and multifactorial control and microvascular complications in patients with T2DM aged 30-60 years in Vietnam. Methods: A cross-sectional and descriptive study was conducted on 231 outpatients with T2DM at Bach Mai hospital, Hanoi, Vietnam. Depression severity was measured with the Patient Health Questionnaire-9 (PHQ-9). Results: The rate of depression in patients with T2DM aged 30-60 years was 16.9% (in which, the rate of mild depression was 15.2% and moderate depression was 1.7%; no serious depression). The prevalence of depression was higher in female patients than in male patients (p = 0.049). There is a statistically significant difference in the rate of depression by age, duration of diabetes, and treatment method for type 2 diabetes. Poor HbA1c control and microvascular complications increase the risk of depression (OR = 2.37; 95% CI 1.11-5.02, p = 0.033 and OR = 2.62; 95% CI 1.15-5.93, p = 0.027, respectively). When the multivariate analysis was performed, it was shown that sex, treatment for glycemic control, and microvascular complications had a statistically significant influence on PHQ-9 score. Conclusion: In Vietnam, there are 16.9% of patients with T2DM aged 30-60 years suffer from depression. Poor HbA1c control, the presence of microvascular complications, and without antihyperglycemic treatment increase the risk of developing depression.
... A 20-item depression scale was used to measure the student's depression on the day of data collection. The Bangla depression scale was adapted from the study entitled Depression and associated factors in diabetic patients attending an urban hospital in Bangladesh (Rahman, Rahman, Flora &Rakibuz-Zaman, 2011). Further, a 36-item school climate scale was developed based on the literature review and ecological systems theory. ...
Article
Full-text available
This study attempted to explore the factors contributing to depression in educational settings. Apart from contributing factors, the study also gives an insight into how malfunctioning ecological systems can ignite depression. The nature of the study was quantitative and a total of 120 adolescents from grades IX and X were taken as participants in this study. The study employed a self-reported depression scale, school climate scale, and a demographic survey. The findings showed that 60% of secondary school students were suffering from depression. Female students were reported to be more depressed than their male counterparts. Furthermore, depression prevailed more among the students of Grade X from humanities compared to the students from other streams. Three major contributing factors were found in secondary school student depression including parental pressure, negative self-perception, and cosmetic issues such as acne. The findings of the study have implications to address, promote and support adolescent mental health issues, particularly in secondary schools. Keywords: Adolescent, Depression, Ecological systems
... Based on multivariable logistic regression, the sociodemographic factors including age, gender, education, marital status and employment were not associated with depression. Related studies have gotten varying results with many similarly finding no association with this set of factors [1,17,[58][59][60][61][62][63]; but, some individual studies showing associations with them [64][65][66][67]. In the present study, three quarters of the participants were females. ...
Article
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Background Depression is associated with chronic physical illnesses and negatively affects health outcomes. However, it often goes undiagnosed and untreated. We investigated the prevalence of depression among adult type 2 diabetes mellitus (T2DM) patients attending non-communicable diseases (NCD) clinics in Lilongwe, Malawi, and estimated the level of routine detection by NCD clinicians. This study set out to determine the prevalence of major depression and its detection among adult type 2 diabetes mellitus (T2DM) patients attending NCD clinics in Lilongwe, Malawi. Methods In a cross-sectional study design, 323 T2DM patients aged ≥ 18 years were screened for depression with the Patient Health Questionnare-9 (PHQ-9) followed by diagnostic assessment with the Structured Clinical Interview for DSM-IV (SCID). We analysed the association between presence of major depression and sociodemographic factors using logistic regression. Results Three quarters of the participants (76%) were females. The participants’ ages ranged from 21–79 years. Of the 323 participants, 58 (18%) met criteria for DSM-IV major depression. None of the cases of major depression had been identified by the NCD clinicians. Major depression was found not to be significantly associated with any of the sociodemographic factors. Conclusions We found that depression is common among NCD clinic attendees with T2DM in Malawi, and poorly detected by NCD clinicians. Given the high prevalence and challenges in clinical identification, integration of depression screening with a standardized validated tool should be a high priority so as to link patients to appropriate services.
... 17,18 There is a need of intense care of these depressed diabetic patients by involving their family members as a support. 19 A most recent research 20 showed consistent findings that women with diabetes have high ratio of depression 52.7% than men 36% while in Bangladesh, rates of depression in diabetic patients 28% to 34% 16,21,22 with marked variances in the ratio of males and female of 22% and 35% respectively. 16 Further research in Pakistan has exposed that depression also took place in people with T2DM in the presence of other psycho-social and demographic factors i.e.; history of diabetes and hypertension, living in a separate setup, fatness, being married, and unhealthy habit of smoking. ...
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