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Prevalence of depression and anxiety in type 2 diabetes mellitus patients in tertiary care hospital

Background: The prevalence of depression and anxiety in diabetes is considerably higher than normal population and found to have a negative impact on diabetes. Objective of the study was to assess the prevalence of depression and anxiety and to identify their associated risk factors among people with type 2 diabetes mellitus. Methods: Descriptive study was done in Endocrine and medicine outpatient Department of Vijaya Hospital in Belagavi, South India. Total 384 patients with type 2 diabetes mellitus were interviewed for depression and anxiety by administering the Hospital Anxiety and Depression Scale (HADS). Results: Of the total 384 patients surveyed, depression and anxiety were found in 32.56%. (95%CI 27.8-37.2%) and 37.76% (95% CI 33.1-42.9%) respectively. In Multiple Logistic regression analysis age, unmarried, religion, duration of type II diabetes and type of treatment were significantly associated with depression symptoms, Anxiety symptoms were associated with age, Qualification, Occupation, Religion, Duration and type of treatment. Conclusions: This study found a high prevalence of depression and anxiety in patients with Type 2 DM. Therefore, the care of individuals with type 2 Diabetes Mellitus (DM) should include the screening and possible treatment of depression and anxiety in order to achieve and sustain treatment goals.


INTRODUCTION
Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. It has been classified as type 1 DM and type 2 DM. Type 1 DM, a subtype of Diabetes Mellitus results due to complete or near total insulin deficiency whereas Type 2 DM characterized by variable degree of insulin resistance, impaired insulin secretion and increased glucose production. 1 The WHO estimated the population of diabetes patients to increase from 171 million in 2000 to 366 million by 2030 worldwide. 2 Prevalence study also reported that there are currently 285 million people with diabetes worldwide and this number is set to increase to 438 million by year 2030. 3 Type 2DM is estimated to be 90-95% of the total global morbidity of DM. 4 India has more than 50 million Type 2 diabetes patients. 5 India will soon be the capital of diabetes. Depression and anxiety are other prevalent condition in diabetes mellitus. Approximately 340 million people worldwide suffer from depression at any given time. 6 The World-wide estimated prevalence of depression and anxiety is 25% and 7.3%. Depression disorders are more in women than men. Life time prevalence of depression is 10-2-%. 7 The prevalence of depression and anxiety in diabetes is considerably higher than normal population and lies between 12-28%. 8 However, the differences in prevalence rate may be 1 Department of Psychiatry, 2 Department of OBG, KAHER Institute of Nursing Sciences, Belagavi, Karnataka, India

METHODS
The study had Non-Experimental Descriptive study design. It was carried out from May 2018 to March 2019 among all 384 patients with Type 2 Diabetes mellitus who were attending the outpatient department of Endocrine and medicine of Vijay Hospital Belagavi, south India. Objectives and benefits of the study were explained in verbal and written form attached to the questionnaires.
Patients were assured that their participation was confidential and would not affect their medical treatment outcomes. A written consent was obtained from those who agree to participate in the study. The investigator was trained to conduct interview using Hospital Anxiety and depression Scale (HADS) by interviewing the patient and supplemented by patient records. The questionnaire was translated into the local Kannada language for better understanding.

Inclusion criteria
• Patients age between 30-60 years with Type 2 DM (Fasting glucose level more than or equal to 126 mg/dl and post prandial, more than or equal to 200 mg/dl) were considered for the study.

Exclusion criteria
• Excluding those who are diagnosed psychiatric problems/illness or those who are currently on antidepressants, pregnant women and seriously ill patients.
The study protocol was approved by the Ethics committee of the institute. Informed written consent was obtained from all the participants, after explaining the objectives of the study.

Statistical analysis
The Data collected during the study was entered in the Microsoft excel Format and was analysed and using Statistical Package for Social Sciences (SPSS) (V.20.0). A descriptive Statistical analysis was done for continuous and categorical variables.
Differences in characteristics between participants were tested with t-test for normally distributed variables. Multivariate regression analysis was used to evaluate the anxiety and depression symptoms singly or combination in relation to glycemic control. Results were expressed as odds ratio (OR) and 95% confidence intervals. The minimum statistical significance level foe all analysis was p<0.05.

RESULTS
A total of 384 participants were included in the study, in which 261 (67.97%) were male and 123 (32.03%) female participants. Most of the study participants i.e. about 200 (52.08%) belongs to the age group of 41-50 years 108 (28.13%) belonged to the age group of 30-40 years followed by 76 (19.79%) belonged to the age group of 51-60 years. Majority of 218 (56.77%) of the respondents were suffering with type II diabetes in the range of 0-5 years and 20 (5.21%) were suffering from type II diabetes for more than 16 years and almost 247 (64.32%) were on oral hypoglycaemia drugs, whereas 49 (12.76%) respondents received both insulin and oral hypoglycemic drugs. Most of the respondents 279 (72.66%) belonged to middle class families and 39 (10.16%) of the respondents belonged to lower class families. Majority of the respondents 294 (76.56%) were married, 44 (11.46%) were unmarried, 28 (7.29%) were widow and only 18 (4.69%) were divorced. Almost 164 (42.71%) respondents completed their graduation whereas, 68 (17.71%) did their higher secondary education, 57 (14.84%) completed their secondary school, 50 (13.03%) did not have any formal education and only 45 (11.72%) did their secondary school education. Around 136 (36.45%) of the respondents were private employees and (5.21%) were farmers. Table 1 Shows Distribution of study respondents by different characteristics.
Reveals the regression analysis of anxiety by demographic characteristics with age, qualification, religion, duration of type II diabetes and type of treatment showed significant contribution with anxiety (p<0.05). This shows that respondents who were above 50 years of age expressed more anxiety (Odd ratio-0.11, 95% CI:0.03-0.32). Respondents who were not educated and higher Secondary Education were more anxious about their condition (Odd ratio -3.91,95% CI:1.53-10.03 and 4.99,95% CI:1.70-14.65).  Various other studies found that prevalence of depression in T2DM ranging from 13.6% to 67.5%. 14,15 However, studies from US and UK reported the prevalence of depression in patients with T2DM varying from 30% to 83%. 16,17 Similarly, a meta-analysis identified the prevalence of depression in diabetes ranging from 8% to 61%. 18 Theses distinctions can be due to the differences in sample size, socio demographic condition, and others. In addition, the lack of documentation regarding relevant factors associated with the disease condition may confound results of clinical studies and skew rate.

CONCLUSION
Among diabetes mellitus, depression and anxiety is common co-morbidity. This correlation is governed by several socio demographic variables' endemic to the Indian subcontinent. Treating depression and anxiety in patients with type 2 diabetes is emerging as an integral part of holistic diabetic care worldwide.