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 !ndocrine and "etabolic Disorders #$IRD!"% Dha&a $angladesh to find out influence of socio'demographic characteristics for occurrence of depression among them( Data were collected through face'to'face inter)iew( Depressi)e symptoms were measured using *entre for !pidemiological +tudies Depression +cale( ,roportion of depression was found -.(8/ which included 20(2/ with se)ere depression and rest with mild to moderate depression( $oth mild to moderate and se)ere depression were significantly more common in female odds ratios were 2(72 #12/ *I31(1-'4(2-% and 2(1. #12/ *I32(.1'1.(20% respecti)ely( *urrently not married respondents were also suffered from higher depressi)e symptoms( 5or mild to moderate depression odds ratio was .(-8 #12/ *I31(.4'1-(18% and for se)ere depression odds ratio was 1(21 #12/ *I3-(41'2.(20%( Among socio'demographic characteristics marital status was identified as the best predictor of depression which was followed by education upto secondary le)el female se6 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 $angladesh

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 7he course of depression in patients with both diabetes and depression is chronic and se)ere( 8p to 80/ of patients with diabetes and depression will e6perience a relapse of depressi)e symptoms o)er a 2'year period(2 9ati)e Americans with 7ype 2 diabetes mellitus are three times more li&ely to ha)e coe6isting depression(7he pre)alence of depression diagnosed using the $ec& Depression In)entory was found to be .4/ in patients with type 2 diabetes in "e6ico(. In a rural $angladesh 21(0/ of male and -0(2/ of female with diabetes were found ha)ing depressi)e symptoms rating : 20 on the "ontgomery and Asberg Depression Rating +cale #"ADR+%(2 Depression in diabetes mellitus patients frequently associated with their socio' demographic characteristics( Depression among them found to be associated with se6 age marital status occupation economic status and duration of education(. 4 7 8 Depression plays an important role in non'adherence to medical treatment( Depressed patients are three times more li&ely not to comply with medical regimens than non' depressed patients(1 7his 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 indi)idual and to limit the burden of the disease for the family and society( 7his study has been designed with e6pectation to pro)ide information regarding association of socio'demographic characteristics with depression among urban and semi' urban diabetic patients in clinical settings( 7his study is e6pected to help ser)ice pro)iders 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 underta&en from ;anuary to ;une 2001 in <utpatient Department #<,D% of $angladesh Institute of Research and Rehabilitation in Diabetes

!ndocrine and "etabolic Disorders #$IRD!"% +hahbagh Dha&a( A)ailability of a large number of patients with diabetes mellitus being the largest tertiary le)el diabetic care hospital of $angladesh and well co)erage for all &ind 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 <,D of $IRD!" who agreed to participate were included in the study( A total of 178 respondents were included using the purposi)e sampling technique( Ethical issues =ritten informed consent was recei)ed from each indi)idual prior to inclusion( 7hey were informed of their right to withdraw from the study at any stage or to restrict their data from the analysis( Assurance had been gi)en that the data would be collected anonymously and the confidentiality concerning their information would be maintained strictly( 7he protocol was appro)ed by the $IRD!" !thical Re)iew *ommittee for data collection( Measurements A semi'structured questionnaire was de)eloped to collect data from face'to'face inter)iew incorporating *!+'D #*entre for !pidemiological +tudies Depression% scale to assess depressi)e status( 7he *!+'D contain 20'item to measure the frequency with which participants ha)e e6perienced a specific symptom within the preceding wee& using a four'point rating scale #0'- response set%( +cores range from 0 to 40 with higher score indicating more se)ere depressi)e symptoms(11 *!+'D has been found to be both reliable and )alid measure of depression in the medically ill( A score of 14 or greater differentiate depressed from non'depressed adults(11 *!+'D has got sensiti)ity of 41(. specificity 81(0 positi)e predicti)e )alue #,,>% 27(7 and negati)e predicti)e )alue #9,>% 8-(-(12 A second cut off point of 22 was used to differentiate se)erity of depression? 14'21 #mild to moderate depression% and : 22 #se)ere depression%(1- 1. *ronbach@s A of $angla )ersion of *!+'D was calculated 0(81 which indicated sufficient internal consistency of that scale(

Data analysis and statistical methods Data were registered using +tatistical ,ac&age for +ocial +ciences #+,++% for windows )ersion 14( 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( 7he proportion of presence and le)el of depression were determined by percentages( +tatistical comparisons between different groups were made using t'test A9<>A for depression scores and chi'square tests for le)el of depression( 7he odds ratio #<R% with 12/ confidence inter)al #*I% for ris& factors was calculated ta&ing the least proportionate clinically rele)ant criteria as reference )alue( All the tests were two tailed and pB0(02 was considered to be statistically significant(

Results Among 178 respondents 21(1/ were male and aged 2.(14 1(74 years #mean +D%( Almost two'third of them #42(1/% belonged to the age group of 20 to 41 years( "ost of them were from urban area #71(1/% and married #82(0/%( "ost of the respondents were graduate or abo)e #42(./% and maCority were housewi)es #.1(2/%( 7he a)erage monthly family incomes for more than half of the respondents #22(2/% were between 7&(20000 to less than 7&(-0000 with mean D +D of 7&(24224(18 D 7&(12.10(27( #7able 1% "ean depression score was calculated 10(20 with +D D 1(08( 7he proportion of depression among the study population was -.(8/ #*!+'D score : 14% which included 20(2/ with se)ere depression #*!+'D score : 22% and rest with mild to moderate depression #*!+'D score 14 to 21%( "ean depression score found higher among female respondents in age group of 40 to 41 years among respondents li)ing in urban areas those who were single with lower le)el of education among housewi)es and among those with income of 7E( -0000 to B.0000( #7able 1% 5emales were suffering from both mild to moderate and se)ere form of depression more than males( "ore than half of the female respondents were suffering from some &ind of

depressi)e symptomsF where as less than one fifth of the male were suffering from depressi)e symptoms( Respondents belonged to the 40 to 41 years age group had highest percentages of depressi)e symptoms #.2(-/%( 7hey also e6perienced highest percentage of mild to moderate depression( $ut .0 to .1 years age group suffered from highest percentage of se)ere depression( Respondents who were single #which included widowGwidower and separated% had more depressi)e symptoms than those who were married #24(7/ )s 71(1/ for presence of depression%( Highest percentages of depressed persons were found in primary education group #24(0/% and lowest percentage in group who were graduate or abo)e #20(4/%( Iow education le)els increased the li&elihood of presence of more se)ere depression( Housewi)es suffered more from se)ere depression and retired persons from mild to moderate depression( <)erall housewi)es were suffering most from some sort of depressi)e symptoms #.1(7/% which was followed by retired persons #-.(1/%( +e)ere depression occurred more in income group 7E( -0000 to B.0000 and 7E( B 20000 and mild to moderate depression was comparati)ely more pre)alent in income group 7E( J .0000( #7able 2% $inary logistic regression model was constructed by forward IR method( Among the socio'demographic characteristics marital staus found as the best predictor of depression after adCustment of other )ariables( It was followed by secondary education female se6 and primary education( #7able -% Discussion In this study high proportion of depression #-.(8/% was found which was consistent with Asghar + et al( where they found pre)alence of depression in rural diabetic population in community le)el was 21(7/(2 "ean depression score among female was found significantly higher than male counterpart( 7his finding was supported by most of the other pre)ious studies2 12 but not all(14 After controlling effect of other sociodemographic )ariables se6 still was significantly associated with presence of depressi)e symptoms K<R 3 2(11 12/ *I #1(20'21(71%F p B 0(02L(

7he mean age of the respondents was calculated as 2.(14 years and 40/ of the respondents were in the .2 to 4. age group( Age range accord with the age distribution of type 2 diabetes in de)eloping countries(17 =e could not detect any statistical significant age differences for proportion and se)erity of depression( It is consistent with other studies among the same population(14 18 IariCani $( et al( found that maCor depressi)e disorder was associated with the -1'21 year old group(11 =e also found .0'.1 years age group suffered from highest percentages of se)ere depression though 40 M 41 years group had highest percentages of o)erall depressi)e symptoms( Respondents of the study were belonged to urban or semi'urban areas( 8rban 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 -2 single respondents -1 were widowGwidower and one was separated( Again among the unmarried respondents 28 were female #statistically significant p B 0(001% most had low le)el of education #40/ had upto secondary education% and half of them engaged in non'paid occupation #house wife or retired%( 7hese might also influenced relationship between marital status and le)el of depression( After adCusting other potential sociodemographic )ariables statistically significant association e6ist between current marital status and higher depressi)e symptoms K<R 3 .(2. 12/ *I #1(42'11(10%F p B 0(002L( 7hese findings remind about the importance of social and economical support for the type 2 diabetic patients( !ducational status of the respondents was found much better than the national figure(21 +election of study place and residence of the respondents might e6plain this( "ean depression score found higher in lower education group( After adCustment of other sociodemographic )ariables this association remained no more statistically significant( Association of le)el of education with depression was supported by most other studies22 2e6cept few(18 Depression is more common in unemployed than the employed persons( "ean depression score found highest among housewi)es and lowest among businessmen( 7his finding

might be e6plained by interaction of se6 economic status family harmony education le)el and age( After bloc&ing potential effects of other sociodemographic )ariables occupational status no more remained as a potential predictor of depression( "iyao&a N et el( had detected the correlation of unemployment to depression score in their study(18 Housewi)es and retired or aged persons are treated as unemployed in our society( 7his finding had important implication regarding formulation of appropriate inter)ention addressing unemployment problem and change of social concept of occupation to meet problem of depression and diabetes( 7he a)erage monthly family income of the respondents was 7E 24224(18 D 12.10(27( 7his was quite high in relation to per capita income of $angladesh(21 7his might be due to location of study place( 7his high income status e6plained o)erall higher educational status of the respondents( 7he mean monthly incomes of depressed and non'depressed group were almost equal #24210(-2 7E( )s( 24418(28 7E(%( =e failed to find any association between income status and depression( It might indicate the difficulty to measure economic status( "ost of the other studies were successful to e6plore the relation of pre)alence of depression with low income(7 18 20

onclusion 7his study has identified depression as a significant health problem among type 2 diabetes mellitus patients and has mar&ed some of the socio'demographic characteristics as important factors associated with depression among them( 7his study has recognized the need for future wor& 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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