Association of depression with type 2 diabetes and relevant factors
Saeed Kalantari1, Alireza Jafarinezhad2, Behzad Zohrevand3
1 Department of Endocrinology, Guilan University of Medical Sciences, Rasht, Iran
2 Department of Internal Medicine, Guilan University of Medical Sciences, Rasht, Iran
3 Department of Emergency Medicine, Guilan University of Medical Sciences, Rasht, Iran
|Date of Submission||23-Nov-2013|
|Date of Acceptance||12-Mar-2014|
|Date of Web Publication||29-Nov-2014|
Department of Internal Medicine, Guilan University of Medical Sciences, Rasht
Source of Support: None, Conflict of Interest: None
Background : Based on the high prevalence of diabetes and depression in Rasht, we conducted a study to evaluate the prevalence of depression in type 2 diabetic patients, and its association with glycemic control, chronic complications, and some clinical and paraclinical parameters in this northern state of Iran.
Materials and Methods : Beck depression inventory was used for evaluating depression on 90 type 2 diabetics and 90 healthy controls selected. Information on demographic and clinical and paraclinical characteristics was collected by interviews and from medical records.
Results : This cross-sectional study was performed on 90 type 2 diabetic patients (63 female and 27 male with a mean age of 54.17 ± 10.57 years) and 90 healthy matched controls. Overall, depression was significantly more prevalent in case group [37.8% vs. 16%, odds ratio (OR) = 3.29, P = 0.001]. The prevalence of depression in diabetic women was significantly higher than nondiabetic ones (39.7% vs. 15%, P = 0.002). We could not find any significant correlation between depression and positive family history of depression, duration of diabetes, HBA1c level, and body mass index. The prevalence of depression was prominently more in diabetic patients with retinopathy than in those without this complication (55.6% vs. 24%, P = 0.015). Logistic regression analysis indicated that diabetes itself was the only significant determinant of having depression (OR = 3.29, P = 0.005, 95% confidence interval: 0.118-0.667).
Conclusion : There was a prominent prevalence of depression in type 2 diabetics overall. Depression was not correlated with duration of diabetes and glycemic control. There was a significant association between depression and retinopathy in diabetic patients. Diabetes itself was the only significant determinant of having depression after matching with other variables.
Keywords: Depression, diabetes complications, diabetes, glycemic control
|How to cite this article:|
Kalantari S, Jafarinezhad A, Zohrevand B. Association of depression with type 2 diabetes and relevant factors
. Adv Biomed Res 2014;3:244
| Introduction|| |
Diabetes mellitus is a frequently encountered metabolic disease with chronic features and involves numerous complications throughout its course, which causes severe restriction and disability in an individual's life. It has been reported that the incidence of depression is higher in diabetic patients and that diabetes is one of the risk factors in the development of depression. It has also been reported that comorbid depressive disorders cause further deterioration in the quality of life and diabetes complications in these patients. , The relationships between comorbid depression in people with diabetes and adverse outcomes including poor HbA1c control, adherence to medication, and mortality have been examined in several studies. ,,,,
The existing literature is inconsistent with regard to the relevance of poor glycemic control and depression. Besides contradictory reports regarding the correlation of depression with diabetic microvascular complications have been cited in the literature. ,, There are also some discrepancies concerning the prevalence of depression in type 2 diabetes ,,,,,, and also gender distribution of depression. , With regard to both national and international recommendations for screening of depression in people with diabetes  and the high prevalence of both diabetes and depression in Rasht, a northern state of Iran  with different socioeconomic and cultural situation with other countries, we conducted a cross-sectional study to find out the relationship between these two illnesses and the comorbid factors in this district.
| Materials and methods|| |
This cross-sectional study was conducted on 90 type 2 diabetic patients selected by consensus sampling in the endocrine clinic of Razi Hospital in Rasht city over the period between 2011 and 2012. Ninety healthy people referring to clinic for check up were selected as control group. Information on demographic and clinical and paraclinical characteristics was collected by face-to-face interviews and from medical records and inserted in a standard questionnaire. Age, gender, education, and other important factors were matched in both groups. The exclusion criteria was previous history of psychiatric problem antedating diabetes, patients with diabetes complications such as coronary artery diseases, history of coronary artery bypass graft (CABG), visual disturbance, renal failure, and comorbid medical diseases. Beck depression inventory was exploited for evaluating depression. A questionnaire including 21 questions (13 cognitive and 8 somatic questions) was used. Each question was then valued between zero and 3 scores according to Beck test. The scores were accumulated and were categorized as: 0-15 scores as no depression, 16-30 scores as mild depression, 31-47 scores as moderate depression, and 47-63 scores as severe depression. Chi-square statistical analysis was performed by SPSS version 10. Mantel-Haenszel, Chi-square, Pearson's correlation, and Logistic regression analysis were used to evaluate the study variables (age, gender, literacy level, marriage status, and severity of depression). A P < 0.05 was considered significant.
| Results|| |
There were 90 cases, 63 (70%) females and 27 (30%) males and 90 matched controls recruited in the study. The demographic features of subjects are shown in [Table 1]. In the case group mild, moderate, and severe depression was detected in 30%, 5.6%, and 2.2% of the patients, respectively, whereas in control group mild depression was observed in 11%, moderate depression in 3%, and severe depression in 2%. Overall depression was significantly more prevalent in case group [37.8% vs. 16%, odds ratio (OR) =3.29, P = 0.001]. The distribution of depression in the case and control groups is illustrated in [Figure 1].
Mantel-Haenszel statistical analysis depicted that diabetes mellitus was observed more in depressed patients older than 50 years (P = 0.014). The male-to-female ratio of depression in the case and control groups was 33% to 39.7% and 15% to 17%, respectively. The prevalence of depression in diabetic women was significantly higher than nondiabetic ones (39.7% vs. 15%, P = 0.002). In contrast, depression was nonsignificantly more in diabetic men than their matched controls (33.3% vs. 17.6%). The distribution and severity of depression with regard to gender and age are shown in [Figure 2] and [Figure 3], respectively.
|Figure 2: The distribution and severity of depression for gender in diabetics|
Click here to view
|Figure 3: The distribution and severity of depression for age in diabetics|
Click here to view
However, there was no significant relationship between depression and literacy in diabetic and nondiabetic patients overall. It was shown that depression in educated diabetic patients was less than that in illiterate patients. This study illustrated that married diabetic patients were more depressive than unmarried ones significantly (38.4 vs. 15.3%, P = 0.001).
The distribution and severity of depression for marital status is depicted in [Figure 4]. In this study we could not find any significant correlation between depression and positive family history of depression, duration of diabetes, HBA1c level, and body mass index. The prevalence of depression was prominently more in diabetic patients with retinopathy than in those without this complication (55.6% vs. 24%, P = 0.015). Logistic regression analysis indicated that age, gender, education level, and marital status were not correlated with depression, but in contrast diabetes itself was the only significant determinant of having depression (OR = 3.29, P = 0.005, 95% confidence interval: 0.118-0.667).
|Figure 4: The distribution and severity of depression for marital status in diabetics|
Click here to view
| Discussion|| |
It is now commonly accepted that depressive symptoms and major depressive disorders are twice as prevalent in diabetics as general population.  Depression has been associated with diabetes and poor glycemic control. There are also significant health care costs associated with depression in diabetes. Symptoms of depression and anxiety may be more prevalent in individuals with diabetes.  The prevalence of mood disturbances in diabetics are also approximately twice than in the general population, and affects health outcomes and patients' quality of life in an undesirable way. Although subsyndromal depression is an important predictor of a more serious clinical depression, it is often overlooked.  The relationship between depression and diabetes may be complicated by sociodemographic factors, such as education, race, ethnicity, social support, socioeconomic status, and access to health care.
In our study, 37.8% of diabetic patients had depression with different severities. It is consistent with some studies ,,, and in contrast with some others reporting a lower (15-30%) and higher rate (53-84%) of depression in diabetics. ,,,,, In disagreement with other studies, ,, and in line with other studies we found a more significant prevalence of depression in diabetic women than men. ,,,,
In this study, 39% of diabetic patients older than 50 years were depressed, which was statistically significant and consistent with previous studies. ,, Accordant to Musavi's study,  we found no significant relationship between the duration of diabetes and depression in our patients; this is in contrast with other studies reporting significant relationship between depression and duration of diabetes. ,,,
In accordance with the Sahota's study  we could not find any significant relationship between depression and BMI.
The existing literature is inconsistent with regard to the relevance of poor glycemic control and depression. Our study in line with others ,,,,, indicated a nonsignificant relationship between depression and HbA1c level. This is contradictory to other studies reporting higher HbA1c level in those with depression. ,,,,, This association remained significant in a multivariate linear regression model that included age, gender, duration of diabetes, and BMI. ,,,
In contrast, Engum et al.'s found that hyperglycemia was not associated with depression in type 1 or type 2 diabetes and there was actually an inverse relationship between A1C and level of depression in both types of diabetes, although the associations were not significant.  These findings are in accordance with those of some other studies. Kruse et al.  did not find positive associations between depression and A1C in a community sample. In addition, they concluded that individuals with diabetes and A1C level <7% more often had affective disorders than those with poor glycemic control. In the general population, patients with high A1C levels reported slightly but significantly higher levels of well-being than patients with low A1C levels.  One study  suggested that personality traits might be important in achieving glycemic control.
In the present study, diabetic patients with a family history of depression were nonsignificantly more depressive than ones with a negative history. This finding disagrees with the others reporting a significant relationship between these two diseases. ,
In our study, in comparison with other complications, patients with diabetic retinopathy had a significant more rate of depression. This is in contrast with some studies, reporting a significant correlation between depression and a variety of diabetes complications, including, diabetic retinopathy, nephropathy, neuropathy, macrovascular complications, and sexual dysfunction , ; and with Eren et al.'s study, describing a significant correlation between depression and neuropathy and no evidence for a notable association with nephropathy and retinopathy in depressed diabetic patients.  Contradictory to others, some studies failed to show any significant association between the specific complication of diabetes (neuropathy, nephropathy, and retinopathy) with depression. ,
In our study, in accordance with other studies, , there was found no significant relationship between depression prevalence and its severity, presumably because of a better understanding of the disease and thus more likely and education level, which can implicate the lack of self-care knowledge and skills even in literate population. This is in contrast with other studies reporting education level as the only social factor associated with depression in diabetics. Those with higher education were less likely to be depressed adherent to the diet, exercise, and drug regimens. ,, Contrary with our findings, some studies reported a significant more rate of depression in singles than married ones. , These findings disagree with Ranjbar's study  explaining a nonsignificant relationship between depression and marital status. Matching other variables, our study illustrated that diabetes itself was the only significant determinant of having depression.
| Conclusion|| |
There was a prominent prevalence of depression in type 2 diabetic women and older age groups. Depression was not correlated with duration of diabetes and glycemic control. There was a significant association between depression and retinopathy in diabetic patients. Diabetes itself was the only significant determinant of having depression after matching with other variables.
| Acknowledgments|| |
The authors express their sincere gratitude to Dr. Hosna Tajik for her assistance in conducting this study.
| References|| |
Katon W, Maj M, Sartorius N, Lloyd CE, Hermanns N, Nouwen A, et al
. The epidemiology of depression and diabetes. Australia: Wiley- Blackwell; 2010.
Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: Impact of depressive symptoms on adherence, function and costs. Arch Intern Med 2000;160:3278-85.
Katon WJ, Rutter C, Simon G, Lin EH, Ludman E, Ciechanowski P, et al
. The association of comorbid depression with mortality in patients with type 2 diabetes. Diabetes Care 2005;28:2668-72.
De Groot M, Anderson R, Freedland KE, Clouse RE, Lustman PJ. Association of depression and diabetes complications: A meta - analysis. Psychosom Med 2001;63:619-30.
Lustman PJ, Anderson RJ, Freedland KE, De Groot M, Carney RM, Clouse RE. Depression and poor glycemic control. A meta-analytic review of the literature. Diabetes Care 2000;23:934-42.
Kinder LS, Kamarck TW, Baum A, Orchard TJ. Depressive symptomatology and coronary heart disease in type 1 diabetes mellitus: A study of possible mechanisms. Health Psychol 2002;21:542-52.
Nabil S, Aisha H, Hani T, Dhafir AM, Doris Y. The prevalence and correlates of depression and anxiety in a sample of diabetic patients in Sharjah, United Arab Emirates. BMC Fam Pract 2010;11:80.
Zuberi SI, Syed EU, Bhatti JA. Association of depression with treatment outcomes in Type 2 Diabetes Mellitus: Cross sectional study from Karachi, Pakistan. BMC Psychiatry 2011;11:27.
Mohamed R, Abdul Kadir A, Yaacob LH. A Study on Depression among Patient with Type 2 Diabetes Mellitus in North-East coast Malaysia.Int J Collaborative Res Intern Med Public Health (IJCRIMPH) 2012;4:1589-600.
Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes. Diabetes Care 2001;6:1069-78.
Ali S, Stone MA, Peters JL, Davies MJ, Khunti K. Prevalence of co-morbid depression in adults with type 2 diabetes: A systematic review and meta-analysis. Diabet Med 2006;23:1165-73.
Goldney RD, Philips PJ, Fisher LJ, Wilson DH. Diabetes, depression and quality of life. Diabetes Care 2004;27:1066-70.
Sahota PK, Knowler WC, Looker HC. Depression, Diabetes, and Glycemic control in an American Indian community. J Clin Psychiatry 2008;69:800-9.
Adriaanse MC, Dekker JM, Nijpels G, Heine RJ, Snoek FJ, Pouwer F. Associations between depressive symptoms and insulin resistance: The Hoorn study. Diabetologia 2006;49:2874-7.
Pan A, Ye X, Franco OH, Li H, Yu Z, Zou S, et al
. Insulin resistance and depressive symptoms in middle-aged and elderly Chinese: Findings from the Nutrition and Health of Aging Population in China study. J Affect Disorder 2008;109:75-82.
Nichols GA, Brown JB. Unadjusted and adjusted prevalence of diagnosed depression in type 2 diabetes. Diabetes Care 2003;26:744-9.
Nouwen A, Winkley K, Twisk J, LIoyd CE, Peyrot M, Ismail K, et al
. Type 2 diabetes mellitus as a risk factor for the onset of depression: A systemic review and meta analysis. Diabetoiogia 2010;53:2480-6.
Modabbernia MJ, Shodjai T, Fallahi M, Shirazi M, Modabbernia AH. Prevalence of depressive disorders in Rasht, Iran: A community based study: Clin Pract Epidemiol Ment Health 2008;4:20.
Sepehrmanesh Z, Sarmast H, Sadr SF, Sarboluki SH. Evaluation of prevalence and type of depression and related factors in diabetic patients. Feiz Sci Res J 2004;7:69-75.
Mousavi SA, Aghaian SH, Razavianzade N, Norouzi N, Khosravi A. Evaluation of depression and general health in type 2 diabetic patients. Sci Health J 2009;3:44-8.
Zahiroddin AR, Sadighi G. Depression among 100 diabetics referring to university hospitals. J Fac Med 2003;27:203-7.
Grandinetti A, Kaholokula JK, Crabbek M, Kenui C, Chen R, Changh K. Relationship between depressive symptoms and diabetes among native Hawaiians. Psychoneuroendocrinology 2000;25:239-46.
Singh PK, Looker HC, Hanson RL, Krakoff J, Bennet PH, Knowler L. Depression, Diabetes, and Glycemic control in pima Indians. Diabetes Care 2004;27:618-9.
Taziki S, Bazrafshan H, Behnampour N, Paviz M. Relation between depression and diabetes. Sci J Gorgan Univ 2002;3:59-64.
Talbot F, Nouwen A. A review of the relationship between depression and diabetes in adults: Is there a link. Diabetes Care 2000;23:1556-62.
Sevincok L, Guney E, Uslu A, Baklaci F. Depression in a sample of Turkish type 2 diabetes patients, Turkey. Eur Psychiatry 2001;16:229-31.
Behnam B, Ghorbani R. Epidemiologic features of depression in non-insulin dependent diabetic patients in. Semnan. Pejouhesh 2005;29:45-9.
Garduno- Espinosa J, Tellez- Zenteno JF, Hernandez Ronquillo L. Frequency of depression in patients with diabetes mellitus type II. Rev Invest Clin 1998;50:287.
Rajala U, Keinänen-Kiukaanniemi S, Kivelä SL. Non-insulin-dependent diabetes mellitus and depression in a middle-aged Finnish population. Soc Psychiatry Psychiatr Epidemiol 1997;32:363-7.
Salehi B, Rezvanfar M, Shirian F. The relation of HbA1C Levels and major depression in patients with type 2 diabetes mellitus, referring to endocrine clinic of Arak. Arak Med Univ J 2008;10:58-65.
Kaholokula JK, Haynes SN, Grandinetti A, Chang HK. Biological, psychosocial, and sociodemographic variables associated with depressive symptoms in persons with type 2 diabetes. J Behav Med 2003;26:435-58.
Trief PM, Morin PC, Izquierdo R, Teresi J, Eimicke JP, Goland R, et al
. Depression and glycemic control in elderly. Diabetic Care 2006;29:830-5.
Ikeda K. Associations of blood glucose control with self efficacy and rate of anxiety/depression in type II diabetes mellitus patients. Psychol Rep 2003;92:540-4.
McGrady A, Horner J. Role of mood in outcome of biofeed back assisted relaxation therapy in insulin dependent diabetes mellitus. Appl Psychophysiol Biofeedback 1999;24:79-88.
Shaw C, Abrams K, Marteau TM. Psychological impact of prediction individual's risks of illness. Soc Sci Med 1999;49:1571-98.
Engum A, Mykletun A, Midthjell k, Holen A, Dahl A. A large population-based study of sociodemographic, lifestyle, and clinical factors associated with depression in type 1 and 2 diabetes. Diabetes Care 2005;28:1904-9.
Pouwer F, Snoek FJ. Association between symptoms of depression and glycemic control may be unstable across gender. Diabetes Med 2001;18:595-8.
Polonsky WH, Anderson BJ, Lohrer PA, Welch G, Jacobson AM, Aponte JE, et al
. Assessment of diabetes-related distress. Diabetes Care 1995;18:754-60.
Eren MA, Torun AN, Tabur S, Ýngeç M, Demir M, Sabuncu T, et al
. The relationship between microvascular complications and depression in patients with type 2 diabetes mellitus who use insulin. J Clin Exp Invest 2013;4:34-9.
Bundó Vidiella M, Aubà Llambrich J, Massons Cirera J, Trilla Soler MC, Pérez Villegas R, Pérez del Campo AM. Anxiety and depression in type II diabetics. Aten Primaria 1996;17:58-62.
Fisher L, Chesla CA, Mullan JT, Skaff MM, Kanter RA. Contributors to depression in latino and European American patients with type 2 diabetes, Diabetes Care 2001;24:1751-70.
Kaplan H, Sadock B. Synopsis of psychiatry. 8 th
ed. Philadelphia: Williams and Wilkins; 1998.
Ranjbar KH, Sharif PH, Dejbakhsh T. Frequency and severity of depression in adult diabetic patients that use oral agent and insulin. Med Fac Res J 2006;4:363-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
|This article has been cited by|
||Biopsychosocial factors associated with a current depressive episode in diabetes: the ELSA-Brasil study
| ||E. Duinkerken,A. B. Moreno,F. N. Eto,P. Lotufo,S. M. Barreto,L. Giatti,M. C. Viana,M. A. Nunes,D. Chor,R. H. Griep |
| ||Diabetic Medicine. 2020; |
|[Pubmed] | [DOI]|
||The Prevalence of Comorbid Depression in Patients with Diabetes: A Meta-Analysis of Observational Studies
| ||Mahdieh Sedighi Pashaki,Jamal Asad Mezel,Zahra Mokhtari,Reza Ghanei Gheshlagh,Parisa Shahbazi Hesabi,Taban Nematifard,Soore Khaki |
| ||Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 2019; |
|[Pubmed] | [DOI]|
||The prevalence of comorbid depression in patients with type 2 diabetes: an updated systematic review and meta-analysis on huge number of observational studies
| ||Mohammad Khaledi,Fahimeh Haghighatdoost,Awat Feizi,Ashraf Aminorroaya |
| ||Acta Diabetologica. 2019; |
|[Pubmed] | [DOI]|
||The relationship between diabetic retinopathy and psychosocial functioning: a systematic review
| ||Krystal Khoo,Ryan E. K. Man,Gwyn Rees,Preeti Gupta,Ecosse L. Lamoureux,Eva K. Fenwick |
| ||Quality of Life Research. 2019; |
|[Pubmed] | [DOI]|
||A comparative study of negative life events and depressive symptoms among healthy older adults and older adults with chronic disease
| ||Han Zhang,Tingting Gao,Jinglei Gao,Yixi Kong,Yueyang Hu,Ruimei Wang,Songli Mei |
| ||International Journal of Social Psychiatry. 2017; 63(8): 699 |
|[Pubmed] | [DOI]|
||Differences in depression between unknown diabetes and known diabetes: results from China health and retirement longitudinal study
| ||Huaqing Liu,Xiaoyue Xu,John J. Hall,Xuesen Wu,Min Zhang |
| ||International Psychogeriatrics. 2016; : 1 |
|[Pubmed] | [DOI]|
||Diabetes Onset at 31–45 Years of Age is Associated with an Increased Risk of Diabetic Retinopathy in Type 2 Diabetes
| ||Wenjun Zou,Lisha Ni,Qianyi Lu,Chen Zou,Minjie Zhao,Xun Xu,Haibing Chen,Zhi Zheng |
| ||Scientific Reports. 2016; 6: 38113 |
|[Pubmed] | [DOI]|