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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 10  |  Page : 1431-1436

Undiagnosed depression among adults with diabetes mellitus in Jos


1 Department of Internal Medicine, Jos University Teaching Hospital, Lamingo; Department of Medicine, University of Jos, Jos, Plateau State, Nigeria
2 Psychiatry, Jos University Teaching Hospital, Lamingo; Psychiatry, University of Jos, Jos, Plateau State, Nigeria
3 Department of Internal Medicine, Jos University Teaching Hospital, Lamingo, Jos, Plateau State, Nigeria

Date of Submission01-Apr-2020
Date of Acceptance30-Jun-2020
Date of Web Publication12-Oct-2020

Correspondence Address:
Dr. J O Edah
Department of Internal Medicine, Endocrinology and Metabolism Unit, University of Jos/Jos University Teaching Hospital, Jos, Plateau State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_155_20

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   Abstract 


Background: Diabetes mellitus (DM) and depression are common chronic disease states of public health importance with huge burden and the potential to impact many aspects of life. They are said to be related though this relationship is not fully understood. The presence of depression among patients with DM is associated with poor glycemic control, complications, and poor self-care. Method: This was a descriptive cross-sectional study conducted at the Diabetes Clinic of the Jos University Teaching Hospital. Three hundred and ten (310) patients with diabetes mellitus were recruited consecutively. The depression module of the Mini International Neuropsychiatric Interview (M.I.N.I.) version 5.0 was used to ascertain depression among these patients. Other demographic data were obtained using a questionnaire. Blood pressure, weight, and height were also measured and the body mass index (BMI) calculated. Results: One hundred and eighty four (59.35%) of the study population were females and the mean age (SD) of the study population was 54 ± 12 years. The mean age (SD) of the females was 53 ± 11 years and that of the males was 54 ± 12 years with no significant statistical difference (P = 0.35). Two hundred and forty nine (80.32%) of the study population were urban dwellers with 140 (45.16%) earning less than N500, 000 (794 USD) yearly. Current major depression was found in 35 (11.3%) patients, among whom 7 (2.3%) had recurrent depression. The presence of DM complications (OR: 3.50, 95% CI 1.16–10.61) and a positive family history of depression (OR: 4.03, 95% CI 1.32–12.29) were found to be correlates of current major depression.
Conclusion: The prevalence of current major depression among patients with diabetes mellitus in this study is high. We recommend that all patients with DM should be screened for depression and treated appropriately to reduce its consequences.

Keywords: Correlates, diabetes mellitus, depression, prevalence


How to cite this article:
Edah J O, Goar S G, Odoh G, Lawal B, Dayom P S, Sunday Z F, Sawa I F, Obi C V, Ochigbo E E, Puepet F H. Undiagnosed depression among adults with diabetes mellitus in Jos. Niger J Clin Pract 2020;23:1431-6

How to cite this URL:
Edah J O, Goar S G, Odoh G, Lawal B, Dayom P S, Sunday Z F, Sawa I F, Obi C V, Ochigbo E E, Puepet F H. Undiagnosed depression among adults with diabetes mellitus in Jos. Niger J Clin Pract [serial online] 2020 [cited 2022 Dec 8];23:1431-6. Available from: https://www.njcponline.com/text.asp?2020/23/10/1431/297916




   Introduction Top


Diabetes mellitus (DM) is a chronic metabolic disorder due to relative or absolute deficiency of insulin with associated acute and chronic complications and a rising prevalence globally.[1],[2] According to the International Diabetes Federation (IDF), 424.9 million people had diabetes mellitus in 2017 with a projected rise to 628.6 million people by 2045.[2] There has also been an increase in the prevalence of DM in Nigeria.[3]

Depression is a common and serious medical illness that negatively affects how you feel, think, and act.[4] It is a significant contributor to the global burden of disease affecting people in all communities across the world and is estimated to affect 350 million people worldwide.[5] It still remains underdiagnosed and undertreated.[6]

Diabetes mellitus and depression are both chronic disease states of public health importance with huge burden and have the potential to impact many aspects of life.[2],[5] They are said to be related though this relationship is not fully understood.[7] The presence of depression in DM has been associated with significant negative impact in self-care, glycemic control, health outcomes, and quality of life.[6] It has also been associated with an increased risk of development of dementia,[8] cardiovascular risk factors with or without evidence of heart disease,[9] and complications of DM.[10],[11] In a study, Black et al.[11] found that the interaction of diabetes and depression was synergistic, predicting greater mortality and greater incidence of disability in activities of daily living.

The complications of DM are said to be significantly and consistently associated with depressive symptoms.[12] It has also been shown that depression may increase the risk for diabetes,[13] it is associated with hyperglycemia in types 1 and 2 diabetes[14] and increased severity of diabetes complications.[13] Depression has been found to be a risk factor for medical noncompliance.[15] Studies have found that the prevalence of depression is high among patients with DM with prevalence rates ranging from 4.1% to 41%.[13],[16],[17],[18],[19],[20] In Singapore, a study conducted among the elderly found a prevalence of depression to be 6%.[21] The varying prevalence rates may be as a result of different tools used in the assessment of depression.

The correlates of depression among patients with diabetes include a high body mass index[20],[22] and low education level.[19],[20] Sweileh et al.[19] in Palestine found correlates to include lack of a job, presence of comorbidities, and low medication adherence. In a study in Saudi Arabia,[20] increasing age, smoking, lack of exercise, duration of DM, and the use of insulin were reported to be correlates. A study conducted in Nigeria[17] found correlates to include lower income and higher number of children. While Thour et al. 18] in India found rural dwelling to be a correlate. Other correlates found include presence of diabetes complications[12] and hyperglycemia.[14]

We set out to determine the prevalence and correlates of current major depression among patients with DM at the Jos University Teaching Hospital.


   Methodology Top


This descriptive cross-sectional study was carried out among patients with DM attending the Diabetes Clinic at the Jos University Teaching Hospital (JUTH). JUTH is a tertiary health institution situated in Plateau State, North central zone of Nigeria. Three hundred and ten (310) patients diagnosed with DM who met the study criteria were recruited over a period of 7 months from October 2018. Sample size was calculated using EPI info unmatched case control (Fleiss) sat calc using 90% power and a prevalence of 30%[17] bringing the sample size to three hundred and ten (310). Patients were recruited using the convenient sampling method where consecutive subjects satisfying the inclusion criteria (age ≥18 years, on follow up for DM at the Diabetes Clinic in JUTH) were enrolled. All acutely ill patients were excluded. Also excluded were patients with DM being managed for any psychiatric illness, patients that do not understand the English language, pregnant women with pre-gestational DM, and women with gestational diabetes mellitus.

The depression module of the mini international neuropsychiatric interview (M.I.N.I.) 5.0 version was used to ascertain depression among these patients. This tool has been validated in France and the United States of America (USA)[23] and used in Nigeria.[24] The module contains different sections labelled A1-A4 with questions attached to these sections. A current major depressive episode was present if questions A1 and A2 were answered yes with at least three questions in section A3 also answered yes or if A1 or A2 was yes with at least 4 questions in section A3 also yes. If the number of questions answered yes were not up to the number as above, the patient was described as having symptoms of depression which also has implications. For a patient to be termed as having recurrent depression, the patient must answer yes to both questions in A4 in addition to having current major depression as above. Further data were gotten using a questionnaire including age, type of diabetes, duration of diabetes, use of insulin, alcohol use, and history of smoking. A structured interview was conducted for each patient. Presence of complications of DM and the fasting plasma glucose were gotten from the medical records. Weight, height, and blood pressure were also measured and body mass index (BMI) was calculated using the formula.

Weight (kilogramme)

Height2 (metres)

BMI was used to assess obesity. A BMI of <18.5 kg/m2 is underweight, BMI of 18.5–24.9 kg/m2 is normal, a BMI of 25.0–29.9 kg/m2 is overweight, while a BMI of 30 kg/m2 and above is obesity.[25]

Ethical consideration

The study was approved by the Ethics Committee of Jos University Teaching Hospital (JUTH) on the 23rd October, 2018. All participants provided written and informed consent. Information concerning all participants was treated with confidentiality.

Data analysis/statistical method

The EPI- Info version 7.2.2.6 (CDC Atlanta, Georgia USA) statistical software was used for data analysis. Quantitative variables were summarized using mean and standard deviation (SD). Categorical variables were expressed using frequencies and percentages. The Student t-test was used to compare means. Where the expected frequency of a cell was <5, Fisher's exact test was used. Chi-Square (X2) test was used to test the significance of association between categorical variables. Variables with P values of ≤0.25 were entered into a multiple logistic regression model to determine their independent association with depression. In all cases, P- value of <0.05 was considered statistically significant.


   Results Top


A total of 310 persons with DM were recruited for the study. The age range was 20–80 years with the mean (SD) being 54 ± 12 years. The mean age (SD) of the females was 53 ± 11 years and that of the males was 54 ± 12 years with no significant statistical difference (P = 0.35). There were 184 (59.35%) females with a male: female ratio of 1: 1.5. Most 241 (77.74%) of the study population had more than 6 years of education. Duration of diabetes ranged from 2 months to 36 years with the median (range) of 8.0 (4–15) years. Only 34 (10.97%) of the study population took alcohol with 6 (1.94%) having a history of cigarette smoking. One hundred and forty (45.16%) of the study population earned less than N500, 000 (794USD) with only 41 (13.23%) earning more than N1.5 million (4, 167 USD) yearly. Two hundred and fourteen (69.03%) of the study population had complications of diabetes with 226 (72.90%) having comorbidities. Less than half 115 (37.10%) of the study population were obese with the same number of patients being overweight. Only 11 (3.55%) of the study population had type 1 diabetes mellitus and 103 (33.32%) used insulin as a form of treatment. Two hundred and forty nine (80.32%) of the study population were urban dwellers with 19 (6.13%) having a family history of depression. More than half 162 (52.26%) of the study population had fasting plasma glucose level of 7.5 mmol/l or more. See [Table 1].
Table 1: Univariate analysis and characteristics of the study population

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The prevalence of current major depression was found in 35 (11.3%) patients, 18 (5.8%) were males while 17 (5.5%) were females. Among these patients, 7 (2.3%) had recurrent depression. Patients with symptoms of depression not enough to make a diagnosis of current major depression were 32 (10.3%).

Univariate analysis showed that the presence of complications (P = 0.006), insulin use (P = 0.10), family history of depression (P = 0.004), place of residence (P = 0.16), sex (P = 0.17), level of education (P = 0.23), fasting plasma glucose value (P = 0.12), and yearly income (P = 0.04) were associated with current major depression. See [Table 1].

On multivariate analysis, the presence of DM complications (OR: 3.50, 95% CI 1.16-10.61) and a positive family history of depression (OR: 4.03, 95% CI 1.32–12.29) were found to be independent correlates of current major depression. See [Table 2].
Table 2: Independent correlates of current major depression

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   Discussion Top


Depression is a common illness worldwide and a major contributor to the overall global burden of disease; at its worst, it can lead to suicide.[5] DM, a disorder associated with complications also has a rising prevalence worldwide.[1],[2] In this study, we evaluated the prevalence and correlates of depression among patients with DM. The findings included a prevalence of current major depression to be 11.3% with the correlates being the presence of DM complications and a positive family history of depression. These findings confirm the presence of depression among patients with DM.[13],[16],[17],[18],[19],[20],[21],[26],[27],[28] The prevalence found in this study is similar to those conducted in Ethiopia where a prevalence of 15.4%[24] and 17%[27] were reported and in another study in Malaysia where a prevalence of 12.3% was found.[28] It is also similar to a study in a population in the United States of America (USA)[13] where a prevalence of 3.7% was found among men and 4.6% among women. In this study, the prevalence was slightly higher in men (5.8%) compared to 5.5% in women.

The prevalence is however higher than what was reported in a study conducted among the elderly in Singapore (6%).[21] The difference seen may be as a result of the population studied and the different tools used in identifying depression. The study in Singapore used the Automated Geriatric Examination for Computer Assisted Taxonomy (AGECAT) used in the elderly. The prevalence in this study is found to be less than what was reported in other studies conducted in Nigeria,[17] India,[18],[29] Palestine,[19] and Saudi Arabia[20] with the rates ranging from 30% in Nigeria, 37.5% and 41% in India, 40.2% in Palestine, and 33.8% in Saudi Arabia. The high prevalence in these studies may be as a result of the different tools used and patients' selection. The MINI tool diagnoses current major depression while tools like Hospital Anxiety and Depression Scale (HADS), Patient Health Questionnaire 9 (PHQ 9), and Beck depression inventory (BDI) are used for screening and rating of depression. The prevalence in this study is also lower than what was reported in a study done at JUTH 9 years previously where the prevalence of depression was reported to be 19.4%.[30] The low prevalence in this study is because we evaluated the prevalence of current major depression while the previous one studied the 1 year prevalence of depression. The difference may also be as a result of more awareness on depression among the patients that was raised during the previous study.

One of the correlates of depression found in this study is the presence of DM complications. The presence of DM complications as a correlate of depression was corroborated in other studies.[12],[29],[30],[31] In a study in USA, De Groot et al.[12] found a consistent, statistically significant relationship between depression and a variety of diabetes complications. They also found a statistically significant association between depressive symptoms and specific complications. In this study, only the presence of complications was looked at and specific complications were not studied individually. The association between depression and DM complications seems to be bidirectional, since depression might result probably with poor glycemic control leading to complications on one hand, while, on the other hand, complications might also have a negative impact on patients' physical and mental health and quality of life, thus fostering the development of depression.[6]

A positive family history of depression was also found to be a correlate of depression in this study. A positive family history of depression is said to be one of the three most consistent and powerful predictors of depression; the others being a recent major life event and a personal history of depressive episodes.[32]

This study has limitations and so the findings should be interpreted in the light of these limitations. This was a hospital-based study and so the findings cannot be generalized. We also excluded patients that do not understand the English language because we could not translate the instrument used (the depression module of M.I.N.I. version 5.0) to the indigenous languages; this may have reduced the prevalence. Despite these limitations, we have been able to demonstrate the prevalence and some correlates of current major depression among patients with DM. We recommend that screening of patients with DM for depression should be encouraged. Longitudinal studies aimed at evaluating cause and effect of individual DM complications on depression would be suggested for future research work.


   Conclusion Top


The prevalence of major depression among patients with DM in this study is high with 1 in every 10 person having depression. The correlates of depression in this study are the presence of DM complications and a positive family history of depression. Modalities targeted to reduce the complications of DM should be encouraged among all patients with DM as depression is associated with increase severity of DM complications.[12] Patients with type 2 DM present for the first time with complications of DM because of its insidious nature. We therefore, recommend that all patients with DM should undergo psychological evaluation and screened for depression so as to reduce the burden of the disease and its consequences.

Declaration of patient consent

The authors certify that they have obtained written and informed consent from the patients. In the form the patients have given consent for their clinical information to be published. The patients understand that their names and initials will not be published and their identity will be concealed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2]


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