Depression among adults with diabetes in Jordan: risk factors and relationship to

blood sugar control

Rasmieh M. Al-Amer
a,
, Maha M. Sobeh
b
, Ayman A. Zayed
c
, Hayder A. Al-domi
d
a
Department of Community Nursing, Faculty of Nursing, The University of Jordan, Amman, Jordan
b
Department of Clinical Nursing, Faculty of Nursing, The University of Jordan, Amman, Jordan
c
Department of Internal Medicine, Faculty of Medicine, The University of Jordan, Amman, Jordan
d
Department of Nutrition and Food Technology, Faculty of Agriculture, The University of Jordan, Amman, Jordan
a b s t r a c t a r t i c l e i n f o
Article history:
Received 2 April 2010
received in revised form 18 February 2011
accepted 8 March 2011
Available online 20 May 2011
Keywords:
Diabetes mellitus
Depression
PHQ-8
Objectives: The aims of this study were to estimate the prevalence of undiagnosed depression among adults
with diabetes mellitus in Jordan and to determine the factors that may indicate the presence of depression
and to examine the relationship between depression and blood sugar control among Jordanian subjects
with diabetes.
Methods: A systemic randomsample of 649 type 1 and type 2 diabetic patients aged 1875 years was selected
during the period from July 2009 to January 2010. A prestructured questionnaire was used for collecting the
information about sociodemographic data and clinical characteristics. Depression was evaluated using the
Patients' Health Questionnaire-8 (PHQ-8). A PHQ-8 score 10 has been recommended as a cutoff point for
depression. Self-care management behaviors and barrier to adherence were collected. Weights and heights
were measured. Glycated hemoglobin was abstracted from each patient directly after the interview.
Result: Of the 649, 128 (19.7) have depression according to the PHQ-8 scores. According to the multivariate
analysis, females are more likely to develop depression than males with [odds ratio (OR), 1.91; P=001] and
low-educated people versus educated people (OR, 3.09; P.002). Being on insulin treatment also has a
signicant association with depression (OR, 3.31; P=.001). Not following eating plans as recommended by
dietitians, lacking self-monitoring blood glucose and increased barriers to adherence scale scores were also
associated with depression among the subjects with diabetes.
Conclusion: The prevalence of depression among Jordanian subjects with type 1 and type 2 diabetes is high
compared with some developed countries. This was associated with gender, educational level, insulin
treatment, low self-management behaviors and increased barriers to adherence. This result shows the urgent
need to include the routine screening of depression during outpatient visit, which might help prevention,
early detection and management of depression.
2011 Elsevier Inc. All rights reserved.
1. Introduction
Diabetes mellitus (DM) prevalence is increasing worldwide, and
the World Health Organization (WHO) has described the rising
incidence as being of epidemic proportions. Moreover, the WHO
predicts that there will be 300 million people having this disease by
2025 (King, Aubert & Herman, 1998; King & Rewers, 1993); as a
matter of fact, an increase in the prevalence of type 2 DM is predicted
to occur in the Eastern Mediterranean countries and the Middle
Eastern ones in particular (King & Rewers, 1993; King et al., 1998),
along with the fact that the prevalence of diabetes in the developing
countries, such as the Arab countries, varies from 3% in Sudan to 35%
in Bahrain (Ajlouni et al., 2008). Considering Jordan, the overall
prevalence of DM among adult Jordanians was 17.1, while impaired
glucose tolerance was 7.8% in 2002 (Ajlouni et al., 2008). On the other
hand, the prevalence of diabetes in the developed countries among
adults has been estimated to be about 5% (Linda et al., 2003; Taylor,
Keeffe, & World blindness, 2001).
Based on the previously mentioned prevalence of diabetes in
different parts of the world and based on the fact that DM is a
chronic disease that needs life management by patients, there is an
evidence that the risk of depression among diabetic patients is
higher than those who do not have diabetes (Anderson et al., 2001;
Zahida, Asghara, Claussena, & Huss, 2008), keeping in mind that
depression among those with diabetes has been acknowledged to
deteriorate and to harm their lives in terms of physical health,
functions and quality of life (Brown et al., 2000; Ciechanowski,
Katon, & Russo, 2000; Eged, 2004; McCollum, Ellis, Regensteiner,
Zhang, & Sullivan, 2007; Rubin & Peyrot, 1999), and it also has been
Journal of Diabetes and Its Complications 25 (2011) 247252
The University of Jordan provided the funding for this study.
Corresponding author. PO Box 3678, Amman(11953), Jordan. Tel.: +962 79
6523279; fax: +962 5 3826822.
E-mail address: rasmieh1512@hotmail.com (R.M. Al-Amer).
1056-8727/$ see front matter 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.jdiacomp.2011.03.001
Contents lists available at ScienceDirect
Journal of Diabetes and Its Complications
j our nal homepage: WWW. JDCJOURNAL. COM
proven that 80% of diabetic patients will experience depression
relapses (Lustman, Grifth, & Clouse, 1997); consequently, this will
lead to an increase on the health care system's burden, poor
glycemic control (Anderson et al., 2001), poor compliance with
treatment (Ciechanowski et al., 2000) and increased risk for
microvascular and macrovascular complications (Bruce, Davis,
Starkstein, & Davis, 2005; Eged, 2004).
Many previous studies also assessed the prevalence of depression
among type 1 and type 2 diabetic patients with diagnostic interviews,
and they reported rates of 41.8% (Sevincok, Guney, Uslu, & Baklaci,
2001) and 8.2% (Cohen, Welch, Jacobson, deGroot, & Samson, 1997).
On the other hand, assessment of depression in type 1 and type 2
diabetic patients as determined by using a cutoff score on depression
symptoms scale reported by many studies illustrated the following
prevalence: 8.0% (Lloyd, Dyer, & Barnett, 2000), 41.3% (Rubin, Poland,
Lesser, Winston, & Blodgett, 1997) and 32.4% (Bailey, 1996).
However, the WHO study conducted among 14 countries revealed
that 42% to 48% of the depressed people were misrecognized as
having psychiatric problems by the primary care system, and in
regard to diabetes, about 49% of the patients with major depression
were misrecognized by the primary care physician (Katon, Von, et al.,
2004; Katon, Simon, et al., 2004). This highlights and proves how
neglected and underlooked this issue is among the health care
systems of those with diabetes.
Thinking about depression among diabetic patients in a broader
way, considering other factors associated with DM that have a role in
increasing the likelihood of developing depression was the corner-
stone to a study held in 2004 stating that gender, having at least two
or more diabetes complications and being on insulin treatment have
been associated signicantly with higher incidence of depression
(Katon, Von, et al., 2004; Katon, Simon, et al., 2004). Also, body mass
index (BMI) 30 kg/m
2
and a glycemic control measured by Hba1c
8 have been associated with an increased risk of major depression
among diabetic patients (Katon, Von, et al., 2004; Katon, Simon, et al.,
2004; Engum, Mykletun, Midthjell, Holen & Dahl, 2005). However,
other studies reported that obesity had a protective effect (Zahida et
al., 2008). In regard to age, there are studies that reported that age is
linearly related to greater depression (Lloyd et al., 2000; Palinkas,
Barrett-Connor, & Wingard, 1991). On the other hand, a study
reported that middle-aged diabetic patients have the highest risk of
developing depression (Peyrot & Rubin, 1997), while others
suggested that the younger the age, the higher the prevalence to
develop depression (Egede & Zheng, 2003). To add to the confusion, a
lot of studies stated that there is no relationship between age and
depression among diabetic patients (Black, 1999; Karlson & Agardh,
1997; Miyaoka et al., 1997; Popkin, Callies, Lentz, Colon, &
Sutherland, 1998; Sevincok et al., 2001; Viinamaki, Niskanen, &
Uusitupa, 1995).
Education has also been considered as a relevant factor to affect
the prevalence of depression among diabetic patients; some studies
reported that a low level of education has been associated with an
increased depression rate (Black, 1999; Engum et al., 2005; Katon,
Von, et al., 2004; Katon, Simon, et al., 2004; Peyrot & Rubin, 1997).
However, other studies failed to show a signicant relationship
between the educational level and depression among diabetic
patients (Miyaoka et al., 1997; Sevincok et al., 2001).
The association of depression and diabetes has been acknowledged
by many studies, but the validity of these ndings between different
cultures and communities remains obvious. To our knowledge, data
on depression among the Middle Eastern countries are not addressed
in diabetic patients; the epidemiology of depression among diabetic
patients in Jordan is not investigated.
To the best of our knowledge, data on the prevalence of depression
among diabetic population in Jordan are almost nonexistent;
therefore, we examined the state of depression and associated risk
factors in diabetic patients in Jordan.
2. Methods
This study was approved by the University of Jordan in
coordination with the Jordan University Hospital's Ethics committee.
2.1. Participants
A systematic random sample (every third patient) of 649 patients
was selected from all patients with adult type 1 and type 2 diabetes
who attended the Jordan University Hospital over a period of 7
months in 2009 (from July 2009 to January 2010). In a systematic
randomsampling, a number within the sampling interval was chosen.
We chose a random number between 1 and 10 using randomnumber
tables; then every third person aged 18 years or above following the
rst number chosen was selected each day for the whole study period.
Participants were informed about the objective of the study. Based on
their approval, participants were asked to read carefully and sign a
consent form. Bearing in mind the importance of this issue, illiterate
patients were given a detailed description of the project.
Patients who are either younger than 18 years or older than 75
years were excluded from the study, along with mentally ill patients
(including any patient who was diagnosed of having any kind of
depressive disorder, on antidepression medications, or who have
been diagnosed of having any neurodegenerative disorder).
3. Data collection
3.1. Assessment of depression
The Patients' Health Questionnaire-8 (PHQ-8) was used (Spitzer,
Kroenke, & Williams, 1999). This questionnaire is a shorter version of
PHQ-9 (Kroenke & Spitzer, 2002), which consists of the actual nine
questions about the criteria for diagnosing major and minor
depression found in the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition. Diagnosis of major depression based on the
PHQ-9 results has been shown to have 73% sensitivity and 98%
specicity when compared with independent diagnosis made by
mental health professionals using a structure interview for DSM-IV
(Kroenke & Spitzer, 2002).
Depression using the PHQ-8 questionnaire was considered
according to the following algorithms: a severity score of 03 was
assigned to each item, (0=26 days, 2=711 days and 3=1214
days), yielding a total score between 0 and 24 points. A PHQ score
10 has been recommended as a cutoff point for depression (Spitzer
et al., 1999).
A preformed questionnaire (the standard questionnaire by PHQ-8)
was completed for each patient by two trained physicians (who had
been trained for both the symptoms and signs of psychiatric
disorders, specically depressive disorders and for lling out the
questionnaire) who were blind to glycemic control. Self-care
management behaviors were collected to assess the adherence to
diabetes regimens that included diet, physical exercise and blood
glucose testing. Medication adherence was measured using a
validated index proposed by Choo, Rand, Inui, Lee, and Platt (1999).
Barriers to adherence were assessed by a scale that was developed by
Glasgow, Maccaul, and Schafer (1986). The scale consisted of 15
items. Respondents were asked to rate how frequently they
experience various barriers to self-care activity using a seven-point
scale that ranges from1 (very rarely) to 7 (daily). The scale was scored
by averaging the responses across the items. Higher scores indicate a
higher frequency of barriers to regimen behavior.
Personal interviews were held to collect the data including age,
height, weight, gender, level of education and duration of diabetes.
Patients' heights were measured to the nearest centimeter, and
their weights were measured to the nearest kilograms, while wearing
light clothes and being barefooted. The BMI for each patient was
248 R.M. Al-Amer et al. / Journal of Diabetes and Its Complications 25 (2011) 247252
calculated by dividing the weight in kilograms on the square of the
height in meters (weight/height
2
) (WHO, 1995). Blood pressure was
measured using standardized sphygmomanometers EN 1060 (RIE-
STER). A trained nurse performed the procedure while the patient was
in a sitting position with the arms at the level of the heart and after 5
min of rest. Regarding HbA1c, it was abstracted from the patients on
the examination day.
3.2. Operational denitions
The diagnosis of DM was reached according to the American
Diabetes Association criteria (American Diabetes Association, 2007).
Duration of diabetes in years since diagnosis of diabetes was
categorized as groups 1 (7 years) and 2 (N7 years). Age was
similarly divided into groups for reasons of comparison: group
1=40 years and 2=N40 years. People with systolic/diastolic
blood pressure levels 130/80 mm Hg or who were on antihyper-
tensive medication were dened as having hypertension (American
Diabetes Association, 2007). BMI was categorized as normal if BMI
was 25 kg/m
2
, overweight if BMI was 2529.9 kg/m
2
, and obese if
BMI was 30 kg/m
2
(WHO, 1995). Glycemic status was categorized
as good glycemic control if HbA1c b7% and poor if HbA1c 7%
(American Diabetes Association, 2007). Following an eating plan as
recommended by the dietitian refers to patients who followed the
eating plan for 3 or more days in the previous 7 days of surveying.
Patients were engaged in at least 30 min of physical exercise if they
walked 3 or more days in the previous 7 days of surveying. Self-
monitoring blood glucose was dened if patients performed home
glucose monitoring for 5 or more days in the previous 7 days of
surveying. Patients were classied as highly adherent if they never
missed their medications in the previous 7 days of surveying and
not adherent if they missed their medications once or more in the
aforementioned period.
3.3. Data analysis and statistical methods
Statistical analysis was carried using a Statistical Package for Social
Sciences (SPSS, version 17). Frequencies were utilized for categorical
variables; mean and standard deviation were obtained for continuous
variables. The prevalence rates were determined by simple percent-
ages and were presented with 95% condence intervals.
2
statistics
were used to assess associations. Logistic regressions were performed
for potential confounding factors in the assessment of risk factors, and
a P value b.005 was considered signicant. All tests performed were
two tailed.
4. Results
4.1. Participant's characteristics
This study included a total of 649 patients (282 male and 367
female) with type 1 and type 2 diabetes aged between 18 and 75
years, with a mean (S.D.) of 57.34 (12.08) years. Most of them had
type 2 DM (89.5%), while 10.5% had type 1 DM. Concerning
depression, which is the main variable of this study, 19.7% of our
sample met the criteria of depression according to the PHQ-8. Their
clinical, anthropometric and relevant characteristics are shown in
Table 1; 53.2% of our sample had BMI 30 kg/m
2
, 35.9% were illiterate,
about 67.7% had duration of DM of b10 years and 88.3% of our
participants have hypertension.
4.2. Depression among diabetic patients
Of the 649 patients, 19.7% scored 10 in the PHQ-8. Depression
rate among type 2 diabetes is 20.1% versus 16.2% among type 1
diabetic patients. Table 2 shows the proportion of patients with
depression according to demographic, anthropometric, clinical and
relevant characteristics. The results demonstrated that gender,
duration of DM, education, hypertension and BMI were associated
with an increased rate of depression among diabetic patients.
According to the results, depression rate among female diabetic
patients is 23.4% in comparison with male diabetic patients with a
percentage of 14.9%. Table 3 shows the proportion of patients with
depression according to diabetes self-care management behavior.
Depression was more common among patients who did not follow
diet regimens, did not participate in at least 30 min of physical
exercise and did not perform home glucose monitoring and among
those who were not adherent to medications.
4.3. Self-care management behaviors
Majority (64.7%) of the participants did not follow the nutritional
diet plan as recommended by the dietician, 60.7% did not participate
in at least 30 min of exercise and more than two thirds of themdid not
monitor their blood sugar levels. On the other hand, 72.9% of all
participants were highly adherent to their medications.
4.4. Factors associated with depression among adult diabetic patients
In the logistic regression model analysis, the odds ratio of being a
diabetic female that increases the risk of developing depression
during the course of DM was 1.91 (P=.001). Increased diabetes and a
low educational level were signicantly associated with increased
odds of being depressed, as shown in Table 4. Participants with a
Table 1
Anthropometric, clinical and relevant characteristics of participants
Variable No. (%)
Sex
Female 367 (56.5)
Male 282 (43.5)
Type of DM
1 68 (10.5)
2 581 (89.5)
PHQ-8 (mean=4.9892, S.D.=3.953)
10 128 (19.7)
b10 521 (80.3)
Age (years; mean=57.34, S.D.=12.084)
40 56 (8.6)
N40 593(91.4)
Duration (years; mean=8.88, S.D.=6.3248)
7 295 (45.5)
N7 354 (54.5)
Educational level
University 128 (19.7)
Diploma 121 (18.6)
Secondary school 107 (16.5)
Primary school 60 (9.2)
None 233 (35.9)
BMI (kg/m
2
; mean=30.5312, S.D.=5.69215)
b25 94 (14.5)
25-29.9 210 (32.4)
30 345 (53.2)
HBA1c (mean=8.025, S.D.=1.7265)
b7 189 (29.1)
7 460 (70.9)
Hypertension
Yes 573 (88.3)
No 76 (11.7)
Insulin
Yes 226 (34.8)
No 423 (65.2)
Oral hypoglycemic agents (OHA)
Yes 574 (88.4)
No 75 (11.6)
Combination of OHA and insulin
Yes 187 (28.8)
No 462 (71.1)
249 R.M. Al-Amer et al. / Journal of Diabetes and Its Complications 25 (2011) 247252
primary school educational level have the highest odds ratio among
other groups. Patients who are on insulin treatment alone have an OR
of 3.31 (P=001) compared with those who are on other treatment
modalities. Following eating plans as recommended by dietitians and
blood sugar testing were also signicantly associated in the logistic
regression model. Those who had barriers to adherence have a higher
chance of developing depression than do the adherent patients (OR,
1.39; P=002).
5. Discussion
This study estimates the proportion of undiagnosed depression
among type 1 and type 2 Jordanian adult diabetic patients and
identies demographic and disease-related risk factors for depression
in a large sample of diabetic patients. It also examines the
interrelationships of depression, glycemic control, diabetes self-care
management and barriers to adherence in patients with type 1 and
type 2 DM.
The study reported that the prevalence rate of undiagnosed
depression among Jordanian diabetic patients is 19.7%; this could be
compared with a meta-analysis study that was held in the United
States and reported a prevalence rate of depression among adult
diabetic patients ranging from 3.8% to 27.3% (Anderson et al., 2001).
On the other hand, other studies reported lower prevalence rates of
depression among adult diabetic patients than did our study; they
reported a prevalence rate of 5.4% (Zahida et al., 2008) and 8% (Lloyd
et al., 2000). Others reported higher prevalence rates than our study,
reaching 41.3% (Rubin et al., 1997) and 32.4% (Bailey, 1996).
Among the entire sample of patients, several demographic and
disease-related variables emerged as signicant independent pre-
dictors of depression. Female gender, low educational level, being on
insulin treatment, not following eating plans as recommended by
dietitians, self-monitoring blood glucose and barriers to adherence
were all signicantly associated with increased depressive symptoms.
Results from logistic regression indicated that the odds of a PHQ-
8 score 10 were about 1.91, which was higher for women than for
men; hence, being a female is a strong predictor of depression, similar
to the following studies (Katon, Von, et al., 2004; Katon, Simon, et al.,
2004; Zahida et al., 2008). Loweducational level (primary school) and
the odds of being classied as depressed increased by a factor of about
3.09, similar to a other studies (Black, 1999; Katon, Von, et al., 2004;
Katon, Simon, et al., 2004), while other studies failed to show a
signicant relationship between depression and a low level of
education. Those who were on insulin have higher risk of having
depression with OR of 3.31 (P =.001); this result is consistent with
another study (Katon, Von, et al., 2004; Katon, Simon, et al., 2004).
Barriers to adherence showed a signicant relationship with
depression with OR of 1.39; the study also found that not following
eating plans as recommended by dietitians and lacking self-
monitoring blood glucose were signicantly associated with depres-
sion among diabetic patients with ORs of 1.49 and 1.09, respectively. It
is noteworthy that depressed diabetic patients do not pay much effort
on daily management activities (Lerman et al., 2004; Park, Hong, Lee,
Ha, & Sung, 2004), and this result is consistent with many studies that
reported that depressed diabetic patients are likely to have physical
limitations and a poor quality of life (Brown et al., 2000; Ciechanowski
et al., 2000; Eged, 2004; Finkelstein et al., 2003; McCollumet al., 2007;
Rubin & Peyrot, 1999), bearing in mind that self-care behaviors in
diabetes include adherence to dietary restrictions and medications,
Table 2
Proportion of diabetic patients with depression according to demographic, anthropo-
metric and clinical characteristics
Variable Total No. (%) P
Sex
Female 367 86 (23.4) .004
Male 282 42 (14.9)
Type of DM
1 68 11 (16.2) .275
2 58 117 (20.1)
Duration (years; mean=8.88, S.D.=6.3248)
7 295 55 (43.0) .298
N7 354 73 (57.0)
Educational level
University 128 17 (13.3) b.005
Diploma 121 11 (9.1)
Secondary school 107 25 (23.4)
Primary school 60 34 (56.7)
None 233 41 (17.6)
HBA1c (mean=8.025, S.D.=1.7265)
b7 189 30 (15.9) .069
7 460 98 (21.3)
Hypertension
Yes 573 101 (17.6) b.005
No 76 27 (35.5)
Insulin
Yes 226 32 (14.2) .087
No 423 40 (9.5)
Oral hypoglycemic agents (OHA)
Yes 574 106 (18.5) .022
No 75 22 (29.3)
Combination of OHA and insulin
Yes 187 38 (20.3) .66
No 462 85 (20.0)
Table 3
Proportion of patients with depression according to diabetes self-care management
behaviors
Variable Total No. (%) P
Following an eating plan as recommended by dietitian
Yes 229 35 (15.3) b.005
No 420 93 (72.7)
Participating in at least 30 min of physical exercise
Yes 225 21 (16.4) b.005
No 394 107 (83.6)
Self-monitoring blood glucose
Yes 158 24 (18.8) b.005
No 491 104 (81.3)
Medication adherence
Highly adherent 473 111 (86.7) b.005
Not adherent 176 17 (13.3)
Table 4
Logistic regression analysis of factors associated with depression among adult diabetic
patients
Variable OR (95% CI) P
Sex
Female 1.91 (1.161.16) .001
Male 1
Educational level
University 0.42 (0.190.95) .038
Diploma 0.50 (0.231.09) .084
Secondary school 0.99 (0.501.94) .981
Primary school 3.09 (1.506.35) .002
None 1
Being on insulin treatment
Yes 3.31 (1.756.27) .001
No 1
Following an eating plan as recommended by dietitian
No 1.49 (0.8332.341) .004
Yes 1
Testing blood glucose level
No 1.09 (0.601.99) b.005
Yes 1
Barriers of adherence
a
1.39 (1.04,1.86) .002
a
A higher score indicates a higher frequency of barrier to regimen behavior
(taking medications, blood glucose daily check, diet and exercise). This variable was
entered to the model as continuous variable.
250 R.M. Al-Amer et al. / Journal of Diabetes and Its Complications 25 (2011) 247252
adequate physical exercise and blood glucose monitoring (Lerman et
al., 2004; Park et al., 2004).
The present study did not showan association between the type of
DMand depression. However, the prevalence of depression as dened
by a cutoff score of 10 was higher among type 2 diabetes patients
(20.1%) versus type 1 (16.2%), although this nding was not
signicant. Only few studies compared depression prevalence ratio
in type 1 and type 2 diabetes, two of which reported that the
prevalence of depression in type 1 is higher than in type 2 diabetes
patients (Konen et al., 1996; Lustman et al., 1997). While in another
similar comparative study, this difference did not reach any
signicance (Lustman, Grifth, Clouse, & Cryer, 1986). Surprisingly,
our study showed that there is no signicant association between
glycemic control and depression on either patient with type 1 or type
2 diabetes, and this could be explained by the fact that the PHQ-
8 examines the patient's psychological status within the last 2 weeks,
while the HBA1c reects the glycemic control during the last 3
months. However, there have been other studies that found a
signicant relationship between depressive symptoms and poor
glycemic control in diabetic patients (Anderson et al., 2001; Mazze,
Lucido, & Shamoon, 1984). Our study found that the duration of DM
was not signicantly associated with depression among diabetes. This
is consistent with many studies that reported that the duration of
illness was not associated with depression among diabetic patients
(Karlson & Agardh, 1997; Miyaoka et al., 1997; Popkin et al., 1998).
However, because the incidence of diabetes complication increases
with increased illness duration (Ajlouni et al., 2008; Taylor et al.,
2001), one could expect greater depression risk in those who have
been ill for a longer time.
5.1. Strengths of the study
This study is the rst to be conducted in Jordan to determine the
prevalence of undiagnosed depression among diabetic patients, to
determine the factors associated with poor glycemic control and to
include a large sample of patients. In addition to that, the large
database available at the Jordan University Hospital offers a complete
data to study this important problem at minimum time and cost.
Using these data, we answered all questions posed in the objectives.
Being the pioneer to discuss such an issue in Jordan offers the
future similar studies in Jordan and in the neighboring countries a
baseline for their comparative purposes.
5.2. Limitations of the study
This study is cross-sectional where causal relationship between
the independent and dependent variables cannot be established. The
factors identied as predictors of depression may precede depression,
but in some cases, these factors could also occur as a result of
depression; thus, undiagnosed depression among diabetic patients
must be interpreted with caution. Mortality and survival bias are
likely to occur, and specialized clinics such as endocrinology clinics
may overestimate the true population prevalence.
The primary limitation of this study was its partial reliance on
self-report for its measures, including depression and self-care
management behaviors; therefore, a clinical interview to assess
depression maybe a superior measure because of its higher level of
specicity. Accordingly, a longitudinal study of a community-based
sample is needed to assess the relationship between those variables
at the same time.
6. Conclusion
The prevalence of depression among type 1 and type 2 Jordanian
diabetic patients is high and has never been approached before. Being
a female, not adherent to diabetes self-care behaviors and having a
low educational level were associated with an increased likelihood of
developing major depressive disorders.
We highly recommend the introduction of the psychological
aspect among the diabetic health care plan, to reduce the number of
the depressed or the misrecognized depressed diabetic patients and
consequently offer them a better quality of life.
Acknowledgments
We thank the patients who participated in this study. We also
thank all the doctors and the whole medical staff in the Medical
Endocrine Clinic in the Jordan University Hospital for their help during
the conduction of the study. We also thank Dr. Azmi Taleb, who
shared us the idea of this study, but could not share us the joy of its
conduction and completion; unfortunately, he passed away in a tragic
road trafc accident, and we all dedicate this article to him. May his
soul rest in peace.
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