Depression and its association with socio-demographic characteristics among type 2

diabetes mellitus patients of Bangladesh

Abstract

Diabetes mellitus is being increasingly recognized as a serious global health problem and

it is frequently associated with comorbid depression. A cross sectional study was

conducted among 178 adult type 2 diabetes mellitus patients attending Institute of

Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM),

Dhaka, Bangladesh to find out influence of socio-demographic characteristics for

occurrence of depression among them. Data were collected through face-to-face

interview. Depressive symptoms were measured using Centre for Epidemiological

Studies Depression Scale. Proportion of depression was found 34.8% which included

20.2% with severe depression and rest with mild to moderate depression. Both mild to

moderate and severe depression were significantly more common in female, odds ratios

were 2.72 (95% CI=1.13-6.53) and 5.94 (95% CI=2.49-14.20), respectively. Currently

not married respondents were also suffered from higher depressive symptoms. For mild

to moderate depression odds ratio was 4.38 (95% CI=1.46-13.18) and for severe

depression odds ratio was 9.51 (95% CI=3.69-24.50). Among socio-demographic

characteristics marital status was identified as the best predictor of depression, which was

followed by education upto secondary level, female sex and primary education.

Depression was identified as a significant health problem among adult type 2 diabetes

mellitus patients. Its association with socio-demographic characteristics should be

considered while planning therapeutic approaches for diabetic patients.

Key words: depression, socio-demographic characteristics, type 2 diabetese mellitus,

Bangladesh

Introduction

Diabetes mellitus is being increasingly recognized as a serious global health problem and

it is frequently associated with comorbid depression, contributing double burden for the

individual and society.1 The course of depression in patients with both diabetes and

depression is chronic and severe. Up to 80% of patients with diabetes and depression will

experience a relapse of depressive symptoms over a 5-year period.2 Native Americans

with Type 2 diabetes mellitus are three times more likely to have coexisting depression.3

The prevalence of depression, diagnosed using the Beck Depression Inventory, was

found to be 46% in patients with type 2 diabetes in Mexico.4 In a rural Bangladesh 29.0%

of male and 30.5% of female with diabetes were found having depressive symptoms

rating ≥ 20 on the Montgomery and Asberg Depression Rating Scale (MADRS).5

Depression in diabetes mellitus patients frequently associated with their socio-

demographic characteristics. Depression among them found to be associated with sex,

age, marital status, occupation, economic status and duration of education.4,6,7,8

Depression plays an important role in non-adherence to medical treatment. Depressed

patients are three times more likely not to comply with medical regimens than non-

depressed patients.9 This strong relationship suggests that medical patients, particularly

those who are noncompliant, should be routinely screened and, if necessary, treated for

depression.10 Diabetes and depression should be treated simultaneously for proper

management of the individual and to limit the burden of the disease for the family and

society. This study has been designed with expectation to provide information regarding

association of socio-demographic characteristics with depression among urban and semi-

urban diabetic patients in clinical settings. This study is expected to help service

providers to set strategies considering socio-demographic characteristics during planning

therapeutic approaches for depressed type 2 diabetic patients.

Materials and Methods

Study area and study population

A cross-sectional study was undertaken from January to June 2009 in Outpatient

Department (OPD) of Bangladesh Institute of Research and Rehabilitation in Diabetes,

Endocrine and Metabolic Disorders (BIRDEM), Shahbagh, Dhaka. Availability of a large

number of patients with diabetes mellitus, being the largest tertiary level diabetic care

hospital of Bangladesh and well coverage for all kind of diabetic patients were among the

prime reasons for selecting the particular hospital as the study place. Diagnosed type 2

diabetic patients aged ≥ 18 years attending the OPD of BIRDEM, who agreed to

participate were included in the study. A total of 178 respondents were included using the

purposive sampling technique.

Ethical issues

Written informed consent was received from each individual prior to inclusion. They

were informed of their right to withdraw from the study at any stage or to restrict their

data from the analysis. Assurance had been given that the data would be collected

anonymously and the confidentiality concerning their information would be maintained

strictly. The protocol was approved by the BIRDEM Ethical Review Committee for data

collection.

Measurements

A semi-structured questionnaire was developed to collect data from face-to-face

interview incorporating CES-D (Centre for Epidemiological Studies Depression) scale to

assess depressive status. The CES-D contain 20-item to measure the frequency with

which participants have experienced a specific symptom within the preceding week,

using a four-point rating scale (0-3 response set). Scores range from 0 to 60, with higher

score indicating more severe depressive symptoms.11

CES-D has been found to be both reliable and valid measure of depression in the

medically ill. A score of 16 or greater differentiate depressed from non-depressed

adults.11 CES-D has got sensitivity of 61.4, specificity 81.0, positive predictive value

(PPV) 57.7 and negative predictive value (NPV) 83.3.12 A second cut off point of 22 was

used to differentiate severity of depression: 16-21 (mild to moderate depression) and ≥ 22

(severe depression).13,14 Cronbach’s α of Bangla version of CES-D was calculated 0.89,

which indicated sufficient internal consistency of that scale.

Data analysis and statistical methods

Data were registered using Statistical Package for Social Sciences (SPSS) for windows

version 16. As depression score did not follow normal distribution, for statistical analysis

log transformation of the depression score was done and geometric mean of the

depression score was used for comparison.

Depression score was constructed by summation of all 20 items of depression score. The

proportion of presence and level of depression were determined by percentages.

Statistical comparisons between different groups were made using t-test, ANOVA for

depression scores and chi-square tests for level of depression. The odds ratio (OR) with

95% confidence interval (CI) for risk factors was calculated taking the least proportionate

clinically relevant criteria as reference value. All the tests were two tailed and p<0.05 was

considered to be statistically significant.

Results

Among 178 respondents, 51.1% were male and aged 54.96 9.76 years (mean SD).

Almost two-third of them (62.9%) belonged to the age group of 50 to 69 years. Most of

them were from urban area (71.9%) and married (82.0%). Most of the respondents were

graduate or above (65.4%) and majority were housewives (41.2%). The average monthly

family incomes for more than half of the respondents (52.2%) were between Tk.20000 to

less than Tk.30000 with mean + SD of Tk.26556.18 + Tk.12410.57. (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 rest with mild to moderate

depression (CES-D score 16 to 21). Mean depression score found higher among female

respondents, in age group of 60 to 69 years, among respondents living in urban areas,

those who were single, with lower level of education, among housewives and among

those with income of TK. 30000 to <40000. (Table 1)

Females were suffering from both mild to moderate and severe form of depression more

than males. More than half of the female respondents were suffering from some kind of

depressive symptoms; where as less than one fifth of the male were suffering from

depressive symptoms. Respondents belonged to the 60 to 69 years age group had highest

percentages of depressive symptoms (42.3%). They also experienced highest percentage

of mild to moderate depression. But 40 to 49 years age group suffered from highest

percentage of severe depression. Respondents who were single (which included

widow/widower and separated) had more depressive symptoms than those who were

married (26.7% vs 71.9% for presence of depression). Highest percentages of depressed

persons were found in primary education group (56.0%) and lowest percentage in group

who were graduate or above (20.6%). Low education levels increased the likelihood of

presence of more severe depression. Housewives suffered more from severe depression

and retired persons from mild to moderate depression. Overall housewives were suffering

most from some sort of depressive symptoms (49.7%), which was followed by retired

persons (34.1%). Severe depression occurred more in income group TK. 30000 to

<40000 and TK. < 20000 and mild to moderate depression was comparatively more

prevalent in income group TK. > 40000. (Table 2)

Binary logistic regression model was constructed by forward LR method. Among the

socio-demographic characteristics marital staus found as the best predictor of depression

after adjustment of other variables. It was followed by secondary education, female sex

and primary education. (Table 3)

Discussion

In this study, high proportion of depression (34.8%) was found, which was consistent

with Asghar S, et al., where they found prevalence of depression in rural diabetic

population in community level was 29.7%.5

Mean depression score among female was found significantly higher than male

counterpart. This finding was supported by most of the other previous studies5,15 but not

all.16 After controlling effect of other sociodemographic variables, sex still was

significantly associated with presence of depressive symptoms [OR = 5.11, 95% CI

(1.20-21.79); p < 0.05].

The mean age of the respondents was calculated as 54.96 years and 60% of the

respondents were in the 45 to 64 age group. Age range accord with the age distribution of

type 2 diabetes in developing countries.17 We could not detect any statistical significant

age differences for proportion and severity of depression. It is consistent with other

studies among the same population.16,18 Larijani B. et al. found that major depressive

disorder was associated with the 31-59 year old group.19 We also found 40-49 years age

group suffered from highest percentages of severe depression, though 60 – 69 years

group had highest percentages of overall depressive symptoms.

Respondents of the study were belonged to urban or semi-urban areas. Urban people had

higher depression score than semi-urban people, but it showed no statistical significance.

Respondents who were single had higher depression score than those currently married

which supported other studies.18,20 Among the 32 single respondents 31 were

widow/widower and one was separated. Again among the unmarried respondents 28 were

female (statistically significant, p < 0.001), most had low level of education (60% had

upto secondary education) and half of them engaged in non-paid occupation (house wife

or retired). These might also influenced relationship between marital status and level of

depression. After adjusting other potential sociodemographic variables statistically

significant association exist between current marital status and higher depressive

symptoms [OR = 4.24, 95% CI (1.62-11.10); p < 0.005]. These findings remind about the

importance of social and economical support for the type 2 diabetic patients.

Educational status of the respondents was found much better than the national figure.21

Selection of study place and residence of the respondents might explain this. Mean

depression score found higher in lower education group. After adjustment of other

sociodemographic variables this association remained no more statistically significant.

Association of level of education with depression was supported by most other studies22,23

except few.18

Depression is more common in unemployed than the employed persons. Mean depression

score found highest among housewives and lowest among businessmen. This finding

might be explained by interaction of sex, economic status, family harmony, education

level and age. After blocking potential effects of other sociodemographic variables

occupational status no more remained as a potential predictor of depression. Miyaoka Y,

et el. had detected the correlation of unemployment to depression score in their study.18

Housewives and retired or aged persons are treated as unemployed in our society. This

finding had important implication regarding formulation of appropriate intervention

addressing unemployment problem and change of social concept of occupation to meet

problem of depression and diabetes. The average monthly family income of the

respondents was TK 26556.18 + 12410.57. This was quite high in relation to per capita

income of Bangladesh.21 This might be due to location of study place. This high income

status explained overall higher educational status of the respondents. The mean monthly

incomes of depressed and non-depressed group were almost equal (26290.32 TK. vs.

26698.28 TK.). We failed to find any association between income status and depression.

It might indicate the difficulty to measure economic status. Most of the other studies were

successful to explore the relation of prevalence of depression with low income.7,18,20

Conclusion

This study has identified depression as a significant health problem among type 2

diabetes mellitus patients and has marked some of the socio-demographic characteristics

as important factors associated with depression among them. This study has recognized

the need for future work in this area. Depression and its association with socio-

demographic characteristics in type 2 diabetes mellitus patients should be borne in mind

when formulating therapeutic management for the said population.

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