Depression and type 2 diabetes mellitus: A case-control study in Tabuk, Saudi Arabia

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1 Basic Research Journal of Medicine and Clinical Sciences ISSN Vol. 4(11) pp November 2015 Available online http// Copyright 2015 Basic Research Journal Full Length Research Paper Depression and type 2 diabetes mellitus: A case-control study in Tabuk, Saudi Arabia *Abdelrauf Mursal Saadalla, Hyder Osman Mirghani, Osama Salih Mohammed, Abdullah Abdalkhalig Alyoussef, 2 Mustafa Hassan Alfarraj, 3 Abdulateef Sayed Elbadawi, 1 *Internal Medicine Department, Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia. 2 Ministry of health, Saudi Arabia. 3 Community Medicine Department, Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia. *Correspondence author [email protected] Accepted 18 November, 2015 ABSTRACT Background: Depression and diabetes are common health problems, leading to high morbidity and mortality worldwide. Depression is a known risk factor for diabetes, and people with diabetes mellitus are more likely to be depressed. Thus, depression may severely impact diabetes management and increase the risk of complications. The current study estimated the prevalence and severity of depression among patients with type 2 diabetes mellitus as opposed to healthier subjects. Methods: This cross-sectional case-control study included 200 patients with type 2 diabetes mellitus who attended the outpatient clinic center of diabetes in King Khalid hospital, in Tabuk, Saudi Arabia, as well as 100 healthy controls. Subjects were asked to sign written informed consent then responded to selfreported questionnaire using the Beck Depression (BDI) Inventory. Data collected included sociodemographic data, and the 21 components of Beck Depression scale, a comparison between diabetic patients with good control (HbA1c 8) and poor control (HbA1c> 8) was undertaken. The ethical committee of the University of Tabuk and King Khalid Hospital approved the research. Results: They were 300 subjects. 55% were males; male to female ratio was 1:1.2. One hundred and twenty-five 62.5% of diabetic patients had depression. Mild, moderate, and severe depression was reported in 32.3%, 16.3%, and 2.7% respectively. A statistically significant difference was found (P< 0.005), and an odd ratio of regarding depression between diabetic patients and control subjects. A high significant statistical difference (P value< 0.001) was evident between patients with poor and good diabetes control as regarding the prevalence of depression (75.8% vs.55.4%). Conclusions: Depression was common among patients with diabetes mellitus; furthermore patients with depression had poor diabetes control; it is prudent to implement better measures for early detection and management of depression among diabetic patients to achieve optimal glycemic control, as well as raising the awareness of the primary care health providers about comorbid mood disorders and diabetes. Keywords: Depression; Diabetes mellitus; Tabuk. INTRODUCTION

2 Saadalla et al. 249 Diabetes mellitus type 2 is a well-studied syndrome characterized by high blood sugar due to insulin resistance and relative deficiency of insulin (Vinay et al., 2005).Diabetes Mellitus type-2 is a chronic disease that causes short and long-term complications. Abbreviation (BDI): the Beck Depression Inventory. SPSS: Statistical Package for the Social Sciences Diabetes mellitus often leads to micro and macrovascular complications culminating in end-organ damage, especially to the eyes, kidneys, nerves, heart, and blood vessels (Diabetes Care 2012). Major depression is a disabling psychiatric condition that adversely affects an individual's work, education, sleep, and multiple measures of overall health (Hajra and Nawaz, 2012). A strong association between depression and diabetes has been previously reported (Anderson, 2001). Current epidemiological evidence shows that at least one-third of people with diabetes suffer from depression (Barnard et al., 2006; Anderson et al., 2001; Lustman et al., 2000) whereas the prevalence of depression among healthy population ranges from 1% to 16.9% worldwide (Ronald et al., 2013). Patients with both depression and diabetes are more likely to have higher macrovascular and microvascular complications and higher mortality rates than those who have diabetes mellitus only (De Groot et al., 2001; Katon et al., 2005). While depression may contribute to poor diabetes-related outcomes, diabetes and its complications may also lead to poorer depression outcomes (Lin et al., 2004; Egede et al., 2001; Black et al., 2003). Saudi Arabia is among the highest regarding Diabetes mellitus prevalence globally (Al-Nozha et al., 2004). However, few studies had been conducted to address the relationship between diabetes and depression. Even those studies focused on the central and eastern zones of Saudi Arabia. To our knowledge; the current study is the first one to estimate the prevalence and severity of depression among patients with type 2 diabetes mellitus as opposed to healthier subjects in the Northern of Saudi Arabia. MATERIAL AND METHODS This cross-sectional study was conducted at the Diabetes center in King Khalid Civil Hospital in Tabuk City between January to June The diabetes center in King Khalid Hospital serves about five thousand diabetic patients referred from primary health centers and other hospitals in Tabuk City. The study included all patients age above 18 years who agreed to participate. We excluded those individuals with known psychiatric illnesses including depression, severely disabled patients, and those who were deaf or mute. The participants signed a written consent form. Two hundred patients with type 2 diabetes and 100 control subjects responded to the Beck Depression (BDI) Inventory. The BDI has been previously validated (Brantley P et al; 2004) and has high sensitivity and specificity for detecting severe depression. The BDI consists of 21 items including emotional, behavioral, and somatic symptoms. Each symptom is scored from 0 to 3. Mild, moderate, and severe depression has a rating of (10-18), (19-29) and ( 30), respectively (Beck et al., 1961). Data collected included age, sex, marital status, the number of children, income, and the components of the BDI scale. Comparison between healthy control subjects and diabetic patients and diabetic with good control and those with good control was carried. We utilized the statistical software (SPSS version 20) for data analysis, and a Chi-square test was used for determining statistical significance, with p < 0.05considered statistically significant. Approval of the study was obtained before hand from the ethical committees of both the University of Tabuk and King Khalid Hospital. RESULTS Table 1 shows the general characteristics of both cases and controls, about one-third of cases were in the age group between years old while 42% of controls were in the age group between years old. Most of cases and controls were male (55%, 55%), married (85%, 81%), lived in extended family (72%, 81%) and had high income (90.5%, 65%) respectively. Cigarette smoking was reported by 97.5% of cases and 76% of controls. Cases and controls were distributed insignificantly for sex, marital status, and family status. A significant difference was noticed between cases and controls in their distribution of age groups, income and cigarette smoking. Table 2 showed the cross-tabulation between depression and diabetes, depression was reported by 62.5% of cases patients and 29% of controls with statistically significant difference (P value = 0.000) and an odds ratio of Table 3 shows the relation between diabetes status and severity of depression, Diabetic patients represent 76.3% of cases of mild depression, 91.8% of cases of moderate depression, and 75% of cases of severe depression with statistically significant difference (P value = 0.000).Seventy-one (55.4%) of patients with good control diabetes had depression while 47 (75.8%) of patients with poor control were depressed (P value= 0.000) (Figure 1).

3 250. Basic Res. J. Med. Clin. Sci. Table 1. Shows the general characteristics of study subjects Character Diabetics Non-Diabetics P. value (N=200)Number (%) (N=100)Number (%) Age group (6) 2 (2) (12) 28 (28) (21.5) 42 (42) (34.5) 23 (23) (21) 5 (5) (5) 0 (0) Sex Males 110 (55) 55 (55) Females 90 (45) 45 (45) Marital status Married 170 (85) 81 (81) Single 2 (1) 0 (0) Separated 22 (11) 18 (18) Widow 6 (3) 1 (1) Cigarette smoking Smokers 195 (97.5) 76 (76) Non-smokers 5 (2.5) 24 (24) Family Status 0.58 Nuclear 56 (28) 19 (19) Extended 144 (72) 81 (81) Income Low 6 (3) 21 (21) Moderate 13 (6.5) 14 (14) High 181 (90.5) 65 (65) Table 2. Showed the cross-tabulation between depression and diabetes Subject Diabetic N= 200 Not diabetic N= 100 P value Odds ratio Depression status Depressed 125 (62.5) 29 (29) Non-depressed 75 (37.5) 71 (71) Table 3. Shows the relation between diabetes status and severity of depression: Character Mild depression N=97 Moderate depression N=49 Severe depression N=8 No depression N=146 Total N=300 Diabetes status Diabetic 74 (76.3) 45 (91.8) 6 (75) 75 (51.4) 200 (66.7) Non-diabetic 23 (23.7) 4 (8.2) 2 (25) 71 (48.6) 100 (33.3) P. value DISCUSSION Diabetes mellitus represents an increasingly significant danger to global health worldwide. The prevalence may rise to 4.4% of the population in the next two decades (Wild et al., 2004). The greatest increase in prevalence is expected to take place in the Middle East, sub-saharan Africa, and the Indian sub-continent. In the kingdom of Saudi Arabia, the prevalence has been reported, as 23.7% among those between30-70 years of age (Ashraf et al., 2010), although the number may be higher in unpublished literature. In the present study, 62.5%of diabetic patients had some degree of significant depression as compared to control subjects (29%)(P-value< 0.001), and an odd ratio (0.245).This incidence is higher than a study conducted in Jubail, Saudi Arabia in which depression was reported in 31.1% of patients(mohammad et al., 2014).

4 Saadalla et al. 251 Figure 1. Distributing of depression among patients with poorly controlled diabetes mellitus Figure 2. Distributing of depression among patients with optimally controlled diabetes mellitus The current results are also higher than two surveys conducted in Riyadh and western Saudi Arabia, which reported a prevalence of depression in 45.8% and 34% of diabetic patients respectively (Aisha et al., 2004; Shahrakivahed et al., 2012 ). There is a lack of awareness among the public about the complex relationship between diabetes mellitus and depression. Each disease is a risk factor for the other, and even mild depression can decrease diabetes selfmanagement and adherence to lifestyle, medication use, and diet, which in turn leads to inadequate control and microvascular complications. On the other hand, diabetes mellitus doubles the risk of developing depression (Ajilore et al., 2007; Nichols et al., 2007; McKellar et al., 2004). In this study, 32.3% of diabetic patients had mild depression, 16.3% had moderate, and 2.7% had severe depression. A study conducted by (Shahrakivahed et al., 2012), showed similar results, whereby38% of patients had mild depression, 30%had moderate depression, and 13% had severe depression. However, (Rahman et al., 2012) showed a different result in which severe depression was more prevalent than mild to moderate depression (20.2% versus 14.6%, respectively). This result may be explained partially by the relatively small size of the data sample in the later study. Similar to the current study (Mirghani et al., 2014), reported that mild depression (23%) was more prevalent than moderate (8%) and severe (13%) depression. The outstanding result of this research is that depression is more in patients with poor diabetes control than those with good control with a high significant statistical difference (P value <0.001) in agreement with Aisha et al, who reported higher depression in patients with poor diabetes control. Limitations of the study It is better to view this study in the presence of some limitations, firstly, the small number of the studied sample, and secondly the reliance on a self-reported questionnaire. Thirdly, the data were collected from a single diabetic center, so generalizability cannot be ensured. Lastly, we cannot control for confoundable

5 252. Basic Res. J. Med. Clin. Sci. variables, like age, income, and cigarettes smoking. CONCLUSIONS Depression is common among patients with diabetes mellitus in Tabuk, thus complicating diabetes management and may lead to poor glycemic control. Implementing better measures for early detection and management of depression among diabetic patients, as well as raising awareness of the health providers, are highly needed as diabetes continue to be an important health problem in Saudi Arabia. ACKNOWLEDGEMENT The authors would like to acknowledge the financial support of this work from the Deanship of Scientific Research (DSR), University of Tabuk, Tabuk, Saudi Arabia. Under grant number (S ). REFERENCES Aisha A, Al-Ghamdi (2004). The high prevalence of depression among diabetic patients at a teaching hospital in Western Saudi Arabia. Neurosciences. 9: Ajilore O, Haroon E, Kumaran S, Darwin C, Binesh N, Mintz J (2007). Measurement of brain metabolites in patients with Type 2 diabetes and major depression using proton magnetic resonance spectroscopy. Neuropsych opharmacology.32: Al-Nozha MM, Al-Maatouq MA, Al-Mazrou YY, Al- Harthi SS, Arafah MR, Khalil MZ (2004). Diabetes mellitus in Saudi Arabia. Saudi Med. J. 25: Anderson RJ, Freedland KE, Clouse RE, Lustman PJ (2001). The prevalence of co-morbid depression in adults with diabetes: A metaanalysis. Diabetes Care.24: Ashraf S, Menan AR, Ahmed Al-Shahry (2010). Prevalence and correlates of depressive disorders in elderly with type 2 diabetes in primary health care settings. Journal of Affective Disorders.123: Barnard K, Skinner T, Peveler R (2006).The prevalence of co-morbid depression in adults with type 1 diabetes: systematic literature review. Diabet Med. 23: Beck AT, Ward CH, Mendelson M, Mock J, Ebaugh J (1961). An inventory for measuring depression. Arch Gen Psychiatry.4: Black SA, Markides KS, Ray LA (2003). Depression predicts increased incidence of adverse health outcomes in older Mexican Americans with type 2 diabetes. Diabetes Care. 26: Brantley P, Dutton G, Wood K (2004). The Beck Depression Inventory II (BDI II) and the Beck Depression Inventory Primary Care (BDI PC). In M. E. Maruish (Ed.): The use of psychological testing for treatment planning and assessment outcome; 3rd ed; pp De Groot M, Anderson R, Freedland KE, Clouse RE, Lustman PJ (2001). Association of depression and diabetes complications: a meta-analysis. Psychosomatic Med.63: Diagnosis and Classification of Diabetes. Diabetes Care (2012). Volume 35, Supplement 1. Egede LE, Zheng D, Simpson K (2001). Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes. Diabetes Care.25: Hajra S and Nawaz A (2012). An Investigation of Consequences of Depression at Work Place: Evidence from Working Professionals at Karachi. Indus J. Manag. Soc. Sci. 6:1-8. Katon WJ, Rutter C, Simon G, Lin EH, Ludman E, Ciechanowski P (2005). The association of comorbid depression with mortality in patients with type 2 diabetes. Diabetes Care. 28: Lin EH, Katon W, Von Korff M, Rutter C, Simon GE, Oliver M (2004). Relationship of depression and diabetes self-care, medication adherence, and preventive care. Diabetes Care.27: Lustman PJ, Anderson RJ, Freedland KE, De Groot M, Carney RM, Clouse RE (2000). Depression and poor glycemic control: a metaanalytic review of the literature. Diabetes Care. 23: McKellar JD, Humphreys K, Piette JD (2004). Depression increases diabetes symptoms by complicating patients' self-care adherence. Diabetes Education 30: Mirghani HO, Mohammed OS, Saadallah AM (2014). Prevalence of Depression among Sudanese Patients with type-2 Diabetes Mellitus. Sudan JMS. 9, No.3. Mohammad Z, Maha M, Tarek E, Al-Baik S, Al-Dahan S, Nadeer A (2014). Screening for depression in diabetic patients. International Journal of Medical Science and Public Health. 3: Issue 2 Nichols L, Barton PL, Glazner J, McCollum M (2007). Diabetes, minor depression and health care utilization and expenditures: a retrospective database study. Cost Eff Resour Allo. c, 18:4. Rahman M1, Rahman MA, Flora MS, Karim R, Zaman MR (2012). Depression and its association wit Socio-demographic characteristics among type 2diabetes mellitus patients of Bangladesh. Mymensingh Med. J. 21: Ronald CK, Evelyn JB (2013). The epidemiology of depression across cultures. Annu Rev Public health. 34; Shahrakivahed A, Moushtagh Z, Firozkohi M (2012). Frequency and severity of depression in diabetic patients referred to the diabetic center of Zabol. Interdisciplinary Journal of Contemporary Research in Business. Institute of Interdisciplinary Business Research. 4, no 1. Vinay K, Nelson F, Abul KA, Ramzi SC, Stanley LR, Robbins C (2005). Pathologic Basis of Disease, 7th ed Philadelphia, Pa.: Saunders. ISBN Wild S, Roglic G, Green A, Sicree R, King H (2004). Global prevalence of diabetes: estimates for the year 2000 and projections for Diabetes Care. 27: