Keywords
Depression - diabetes - diabetes distress - United Arab Emirates
Introduction
Diabetes mellitus (DM) is a major chronic illness that causes significant morbidity
and mortality and has resulted in serious public health issues. According to the World
Health Organization, health is defined as not only by the absence of the disease and
infirmity but also by the presence of mental, physical, and social well-being.[[1]] As per the International Diabetes Federation World Atlas in 2019, the age-adjusted
prevalence of diabetes in adults in the United Arab Emirates (UAE) was 16.3% with
total cases of diabetes in adults totaling up to 1,223,400.[[2]] Another recent study has estimated that the total age-standardized prevalence of
diabetes in the UAE was 23% among Asian males, 20% in Asian females, 21% in Emirati
males, and 23% in Emirati females,[[3]] making UAE as one of the countries with a very high prevalence of diabetes.
One of the psychosocial problems of diabetes is depression. This is a global finding
and has been associated with both poor qualities of life and poor glycemic control
in patients with diabetes.[[4]] A systematic review and meta-analyses have shown that people with diabetes have
double the risk of developing depression when compared to people without diabetes.[[5]],[[6]] Other studies have shown that around 30% of people with diabetes have symptoms
of depression and 10% have major depression.[[7]],[[8]],[[9]] Depression is directly associated with poor compliance to treatment, poor glycemic
control, decreased quality of life, increased risk of diabetes-related complications
as well as increased mortality.[[10]],[[11]],[[12]],[[13]]
Diabetes distress is the combination of all the emotional responses generated in response
to the demands of this chronic lifestyle-changing disease.[[14]] Several studies have shown that diabetes distress, rather than depression, is significantly
correlated with glycemic control and self-management, which then directly influences
the diabetes outcome.[[15]],[[16]],[[17]]
Few studies have examined the combined influence of depression and diabetes distress
on glycemic control in the UAE and there are limited data regarding the burden of
diabetes distress, depression, and quality of life with diabetes. Therefore, this
study aims to determine the rate of depression and diabetes distress and their effects
on glycemic control among patients with Type 2 diabetes.
Patients and Methods
Study design
A cross-sectional study was conducted between the January 15, 2018 and the April 15,
2018 among outpatients with diabetes at the Dubai Diabetes Center (DDC) (Dubai Heath
Authority) in Dubai, UAE.
Setting
The DDC at Dubai Health Authority was established in 2009. It provides comprehensive
diabetes care and education according to international standards. DDC has a multidisciplinary
team consisting of endocrinologists, certified diabetes educators, nutritionists,
exercise physiologists, podiatrist, and psychologist. Lab evaluations and retinal
photography are performed in the facility. Continuous physician training and research
studies are also performed in the center. During each patient visit at DDC, vital
signs, anthropometric parameters, and blood glucose levels are recorded. Measurements
of glycosylated hemoglobin (HbA1c), urine micro albumin, and blood ketones are carried
out as indicated using point of care devices.
Study population
Patients with diabetes attending the outpatient clinic between the period of January
15, 2018 and April 15, 2018 who met the inclusion criteria were asked to be enrolled
in the study. To be included in the study, patients must have been diagnosed with
DM according to the American Diabetes Association (ADA) criteria, be mentally competent,
above 18 years of age, able to communicate verbally, and provide informed consent.
Patients with Type 1 diabetes, participants on psychiatric medications, those experiencing.
Those experiencing cognitive impairment, and anyone who did not consent to participate
was excluded from the study. All patients with diabetes who had an appointment at
DDC and met the criteria for enrollment into the study were invited to participate.
Face-to-face interviews were conducted for each patient individually in the diabetes
educator's clinic. Subject's verbal agreement and written consent were obtained.
Data collection
Sociodemographic and anthropometric measurements
Sociodemographic information including age, sex, level of formal education, employment
status, marital status, and monthly income, previous diabetes education, smoking status,
and diabetes duration was documented. Anthropometric measurements including height
measured without shoes, to the nearest 0.5 cm using a stadiometer with shoulders in
a relaxed position and the arms hanging freely. The weight was measured with the patient
wearing light clothing and no shoes and was measured to the nearest 0.5 kg. Body mass
index (BMI) was computed by dividing the weight (kilograms) with the height squared
(meters). Normal weight was defined as BMI 18.5–24.9 kg/m2; overweight was defined
as BMI 25–29.9 kg/m2 and obesity was defined as BMI ≥30 kg/m2.
Biochemical analysis
HbA1c was analyzed using a DCA Vantage® Analyzer (Siemens Healthcare GmbH, Erlangen,
Germany), which meets the National Glycohemoglobin Standardization Program performance
criteria and uses a monoclonal antibody agglutination reaction. Patients with HbA1c
<7% were reported as having good DM control, whereas patients with HbA1c >7% were
reported as having poor DM control.[[18]]
Assessment of depression and diabetes distress
A face-to-face structured questionnaire interview was performed by the authors to
quantify depression symptoms and diabetes distress. The presence of depression symptoms
was measured using the Arabic version of the Beck Depression Inventory-Second Version
(BDI-II).[[19]] The Arabic version of the BDI-II was prepared by Ghareeb,[[20]] and the psychometric properties were assessed in 17 Arabic countries; they have
reported acceptable validity for BDI-II. Alpha Cronbach ranged from 0.82 to 0.93 in
these countries.[[21]] The BD I-II is considered the most widely used questionnaire for depression, and
it provides an estimate of the severity of the depression. It is a 21-item questionnaire
that takes approximately 15 min to complete. Participants entered a score on four
statements (rated 0–3) Likert-Type scale, possible scores range from 0 to 63, with
higher scores indicating greater depressive symptoms. The developers of the instrument
classified the scores into four groups as follows: minimal depression 0–13, mild depression
14–19, moderate depression 20–28, and severe depression 29–63.[[19]] Cutoff scores for BDI >16 indicated clinical depression.[[22]] Diabetes Distress was assessed using the Diabetes Distress Scale (DDS), developed
by Polonsky et al.[[23]] This scale consists of 17 items and has four subscales physician-related distress
(questions 2, 4, 9, and 15), emotional burden (questions 1, 3, 8, 11, and 14), diabetes-related
interpersonal distress (questions 7, 13, and 17), and regimen distress (questions
5, 6, 10, 12, and 16) and uses the 5-point Likert scale ranging from 1 (strongly disagree)
to 5 (strongly agree). Accordingly, a higher total score reflects greater diabetes
distress, and in this study, a score lower than 2 indicated no distress, a score between
2 and 2.9 indicated moderate distress, and a score >3 was considered high distress.
DDS has good internal consistency, with a Cronbach's alpha of 0.87 and validity.[[23]] We considered moderate and high distress score as having diabetes distress. The
Arabic version scale was used with permission.[[24]]
Statistical analysis
Statistical Program for Social Sciences software version 16.0 (SPSS Inc. Released
2007, SPSS for Windows, Version 16.0. Chicago, IL, USA) was used to analyze the data.
The means for each subscale were calculated. Descriptive statistics were used to describe
the sociodemographic and clinical characteristics of the sample. Multivariate logistic
regression analysis was used to estimate relationships between the subsets of sociodemographic
and clinical characteristics and the questionnaire scores. Statistical significance
was set at P < 0.05 with all tests being 2-sided.
Results
Demographic and clinical characteristics
The demographic and clinical characteristics are presented in [[Table 1]]. The sample consisted of 115 subjects; 54.8% were men and 45.2% were female. Of
the total sample, 80.9% were married and 43.5% reported being employed. The average
age was 53.12 ± 11.44 years and 63.5% were above the age of 60 years. Our findings
showed that 54.8% of the patients had diabetes distress.
Table 1: Sociodemographic characteristics of the study participants
Depression
Depression was found in 29.6% of our sample population. Their level of education showed
that 10.4% were illiterate, while 33.9% had a high school diploma. Around 57.4% were
nonsmokers, 26.1% were ex-smokers, and 16.5% were current smokers. The average duration
of diabetes was 12.64 ± 8.01 years. Out of the 115 subjects, 65 (56.5%) reported exercising,
only 10.4% had a BMI in the normal range; 34.8% were overweight; and 54.8% were obese.
Their current pharmacological treatment consisted of oral hypoglycemic medications
in 63.5% of the patients and 36.5% using a combination of insulin and oral hypoglycemic
medications. The mean value for glycemic control as measured by their HbA1c was 7.43%
±1.55%; with 45.2% having good glycemic control and 54.8% having an HbA1c level of
≥ 7%, suggesting uncontrolled glycemia. The most frequent microvascular complications
were nephropathy (35.7%), retinopathy (29.6%), and neuropathy (20%). Nearly 91.3%
of the study participants had dyslipidemia and 63.5% had hypertension. Bivariate correlation
analysis between the continues variables was measured showed in [[Table 2]]; this analysis revealed a significant association between HbA1c and diabetes distress,
HbA1c and DM durations, and depression and diabetes distress, with P < 0.05. On the
other hand, across tab correlation test measured in [[Table 3]], the test showed 50.8% of the employed participants have poor glycemia control
with significant P value results. While more than 50% of those taking both oral and
insulin treatment had poor glycemic control with appositive correlation. Around 30%
of the participants without diabetes distress have good glycemia control, while more
than 60% of the distressed participants have poor glycemic control and this correlation
found to be significant [[Table 4]].
Table 2: Clinical characteristics of the study participants
Table 3: Bivariate correlations between the continues variables
Table 4: Across tab correlation between the variables
Predictors of diabetes distress are presented in [[Table 5]]. The analysis showed that there was no significant correlation between diabetes
distress and the patients' sex, marital status, level of education, smoking status,
BMI, waist circumference, duration of diabetes, microvascular complications, hypertension,
dyslipidemia, or exercise. However, a significant correlation was found between diabetes
distress on depression (P-value 0.004) and participants aged ≤50 years old (P-value
0.004). Furthermore, [[Table 5]] shows the significant predictors of depression which included diabetes distress,
decreased educational level, and decreased diabetes duration, while the rest of the
other variables showing no significant association.
Table 5: Predictors of diabetes distress and predictors of depression
Table 5: Contd...
A separate logistic regression analysis examining the relationship between each variable
with HbA1c was conducted. The significant predictors of poor glycemic control from
each variable were included in a logistic regression model to estimate their independent
effects on HbA1c [[Table 6]]. We found that patients on both oral medications and insulin treatment for diabetes
to be more likely to exhibit poor glycemic control (odds ratio = 7.35 and (P-value
0.004).
Table 6: Determinants of glycosylated hemoglobin (binary regression)
Discussion
We found that more than half of the participants (54.8%) had uncontrolled diabetes
with a mean HbA1c of 7.4%. This was higher than a study done in the UAE by Alajmani
et al.,[[25]] in which they reported 47% of the study participants had an HbA1c >7.0% and it
may be due to the difference in both the study settings. In this study, the patients
were recruited from a specialized diabetes center, while the study by Alajmani et
al.[[25]] recruited the participants from the primary health-care centers and their mini
diabetes clinics where they refer patients with poor glycemic control or difficult
to treat patients before referring them to a specialized diabetes center. Our mean
HbA1c was however close to what was reported by Tsujii et al. (mean HbA1c 7.5%).[[26]]
The rate of diabetes distress (54.8%) in this study was almost similar to that from
a study conducted among South Asian Canadians[[27]] and slightly higher than what was reported in a study done in Bangladesh.[[28]]
Of all the patients with Type 2 diabetes, 29.6% were found to suffer from depressive
symptoms, with a cutoff point score >16 as suggested to be accurate among patients
with diabetes.[[29]] Once again, our study's result is higher than what was reported by Alajmani et
al.,[[25]] which showed a depression prevalence of 17%. A literature review conducted for
42 studies revealed that around 20%–40% of the patients with Type 2 diabetes had comorbid
depression.[[30]]
Our study found no association between depression and HbA1c levels, but there was
a significant correlation between diabetes distress and HbA1c in the bivariate analysis,
and this was consistent with the results of another study conducted by Fisher et al.[[31]] The high prevalence of diabetes related-distress suggests that patients living
with diabetes may struggle emotionally and socially due to the demands of diabetes
management. Further analysis is needed to establish the correlation of various factors
and the level of distress.
Participants taking both oral and insulin for diabetes treatment more likely to have
abnormal glycemic control than those on oral hypoglycemic agents (OHA) only. A possible
explanation for this finding may be that both OHA and insulin treatment are usually
prescribed as a secondary or tertiary treatment in patients with Type 2 diabetes and
both are introduced into the therapy as a result of worsening glycemic control. Higher
rates of abnormal glycemic control may also be due to the patient's emotional response
to the introduction of a new treatment regimen. Further research is needed to analyze
the patient's perception of introducing insulin to the treatment regimen and the impact
of changing the treatment regimen on the patients' emotional well-being.
The impact of diabetes distress and depression highlights the importance of a multidisciplinary
approach in the treatment of diabetes, which includes a mental health professional.
The inclusion of a screening protocol for diabetes distress and depression in the
routine treatment of diabetes can provide a more thorough understanding of the patients'
needs and improve clinical outcomes. There is a significant need to further explore
the relationship between diabetes distress, depression, and diabetes self-management.
Further understanding of the role of mental health, social factors, and family dynamics
is needed to improve psychosocial care in diabetes management. Consistent with The
ADA recommendations, the importance of emotional well-being must be taken into consideration
when managing diabetes.[[32]] A multidisciplinary team approach including behavioral, family, and mental health
interventions shows the most beneficial outcomes in diabetes management.[[32]] This study also establishes that depression is not always correlated with higher
HbA1c; therefore, screening for depression is imperative regardless of HbA1c levels.
Moreover, as per the ADA recommendations, it is vital that all care providers screen
for the emotional well-being of patients during the initial screening and on follow-up
appointments regardless of patient presentation.[[32]]
We found that age was a predictor of diabetes distress as younger patients were more
likely to report distress than their older counterparts with Type 2 diabetes. As suggested
by Wardian and Sun,[[33]] additional life stressors such as work, family, and finances may enhance the level
of diabetes distress experienced by patients with type 2 diabetes.
Diabetes distress predicted higher rates of depression, with depression also being
a predictor of distress. We hypothesized that symptoms of depression including fatigue,
hopelessness, loss of interest, and diminished ability to concentrate may have contributed
to symptoms of distress due to the complexity of diabetes management in addition to
other life stressors.
Finally, our study also found diabetes duration as well as educational level to be
predictors of depression. The initial emotional response to the diabetes diagnosis
and difficulty adjusting to lifestyle changes may contribute to mood changes, leading
to increased depression symptoms. We hypothesized that newly diagnosed patients may
find living with diabetes difficult in the early stages due to the importance of self-management,
lifestyle changes, and behavioral changes needed to maintain a healthy HbA1c. With
time, patients may adjust more appropriately to such life stages, hence decreasing
the symptoms of depression. As suggested by Wardian and Sun,[[33]] in order to reduce diabetes-related distress, it is important to further assess
specific diabetes-related distress factors such as emotional distress, regimen-related
distress as well as self-management behaviors and the level of social support that
they have.
There are several limitations to this study. First, the recruitment of participants
was performed in only one government-specialized diabetes center located in Dubai,
and the sample size was small, which can raise questions concerning the generalizability
of our findings. Therefore, the results of this study should be interpreted with caution.
Second, the cross-sectional nature of the study limits the definitive causal interpretations
between depression, diabetes distress, and glycemic control.
To be able to show causality, future longitudinal prospective studies are needed.
Third, the possibility of recall bias cannot be ruled out in self-reports, making
the findings of this study reliant upon the accuracy of the subject's self-evaluation.
The social stigma of depression could have also contributed to an underreporting of
depressive symptoms. Finally, a clinical psychological interview with patients was
not conducted which may have highlighted other factors that contributed to diabetes
distress and depression. However, despite these limitations, the findings of this
study have succeeded in confirming previous findings from other studies. Finally,
future research should address these questions in a larger and more representative
sample for all patients with diabetes across the UAE.
Conclusion
This study has identified psychosocial issues as a significant health problem among
adult patients with Type 2 diabetes and offers data confirming the relevance of diabetes
distress and depression among them. The results of this study can help the policymakers
and service providers to improve and modify the existing diabetes treatment criteria.
The impact of diabetes distress and depression, as well as the causal factors on self-care
management efforts and long-term diabetes-related health outcomes needs to be further
examined in depth to create effective rehabilitation and intervention programs. This
study establishes the importance of addressing diabetes distress, depression, and
the importance of establishing more frequent screening early on in treatment and on
regular follow-ups. Early screening and intervention will also provide practitioners
with increased awareness of patients' needs and provide improved treatment outcomes.
If a patient is found to be with increased emotional distress, a referral to a mental
health practitioner is recommended. Only by identifying how diabetes distress and
depression influence diabetes management, can we develop effective and appropriate
treatment approaches.
Authors' contribution
All named authors confirm that they fulfill the ICMLE authorship criteria and have
approved the final version of the article.
Compliance with ethical principles
Approval from the Ethical Committee at the Dubai Health Authority was obtained. Informed
consent was obtained, and then data were collected from the patients. Data were collected
and analyzed anonymously.
