Diabetes mellitus is one of the most prevalent non-communicable diseases globally. Likewise, depression is a major health problem worldwide and is expected to be the second leading cause of disability for all age groups by the year 2020.1
Over the past three decades, a mounting body of evidence has demonstrated that depression is a significant comorbid condition for patients with both type 1 and type 2 diabetes mellitus.2–4 People with diabetes mellitus are almost twice as likely to suffer from anxiety and depression as the general population, but this often remains unrecognized and thus untreated.5–7
The United Arab Emirates (UAE) is unfortunate in having a high prevalence of type 2 diabetes mellitus: 18.9%, according to the latest update from the International Diabetes Federation (IDF).8
In a diabetes mellitus survey conducted in the UAE, Saadi et al.9 randomly sampled households of Emirati citizens in the city of Al Ain. Of the 2455 adults surveyed, 10.2% had diagnosed diabetes mellitus whereas 6.6% had undiagnosed diabetes mellitus.9
In a study assessing psychiatric comorbidity in diabetic patients in primary care in Al-Ain, UAE, the authors found that 33.8% of diabetic patients had psychiatric comorbidity.10 In a more recent study conducted in the Emirate of Sharjah, UAE, approximately 12.5% of diabetic patients surveyed in a primary care setting obtained a score of 19 or above on the K6 depression scale. While not diagnostic, this score indicated the possible presence of psychopathology in this group of patients.11
Various authors have tried to look into the related sociodemographic factors that might be contributing to the development of depression in patients with diabetes mellitus. Different authors have used different screening tools that were relevant to their populations.4 However, very few studies have been conducted in UAE.
We conducted this study in an effort to understand the burden of depression in the diabetic patients attending our clinics and the sociodemographic factors that might be associated with it.
Study design and procedures
A cross-sectional survey was conducted at Rashid Hospital in the outpatient diabetes mellitus clinic. Prior to initiation of the study, approval was obtained from the institution’s review board, and the study protocol was checked for compliance with the Helsinki Declaration.
Patients between 18 and 75 years of age with type 1 or type 2 diabetes mellitus were included in the survey. Exclusion criteria included a diagnosis of diabetes mellitus for less than a year, pregnancy, history of recent bereavement (within the past 2 weeks), patients with established major depression or other psychiatric illness or those on antipsychotic medications, patients identified with substance abuse including alcohol and those below 18 years of age.
All eligible participants consented before proceeding with the interview. Demographic data were collected using a pre-structured questionnaire that included questions on age, gender, marital status, level of education, smoking habits, body mass index (BMI), duration of diabetes mellitus, control of diabetes mellitus (as assessed by HbA1c), type of antidiabetic medication used and presence of diabetes mellitus-related complications. The participants were then asked to fill in the K6 questionnaire. In a busy outpatient setting, we chose the K6 depression scale for assessing the risk of depression, as it is self-administered, well validated and applicable for use in most ethnic groups. This questionnaire was available in both English and Arabic.
The data obtained were analysed using the IBM Statistical Package for Social Sciences, version 21 (IBM Corporation, Armonk, NY, USA). The significance of the observed difference in categorical variables was determined using chi-squared tests. A P-value of < 0.05 was taken as being statistically significant.
This study included a total of 72 patients: 32 males and 40 females, 73.5% of whom were in the 35- to 65-year-old age group. The majority of them (86.1%) had type 2 diabetes mellitus, reflecting the global trend of a higher prevalence of type 2 diabetes mellitus than that of type 1 diabetes mellitus.
Using the K6 depression scale, 36.1% were identified as having a high risk of depression, with a score of 20 or more.
The sociodemographic and clinical characteristics of participants are shown in Table 1.
HbA1c, glycated haemoglobin.
As shown in Table 1, 41.7% had a BMI of > 30 kg/m2, 20.8% had no formal education, 51.4% had a duration of diabetes mellitus of longer than 10 years, 83.3% were married, 84.7% were non-smokers and 62.5% had no diabetes mellitus-related complications.
The sociodemographic factors showing significant association with depression risk scores are presented in Table 2.
|< 35||14||3 (21)|
|> 50||33||13 (39)|
|No education||14||7 (50)|
|Secondary schooling||21||2 (10)|
|University graduate||17||10 (59)|
|Diabetes mellitus duration (years)||0.045|
|< 5||15||6 (40)|
|> 10||37||9 (24)|
|BMI category (kg/m2)a||0.323|
|< 25||13||7 (54)|
|> 30||29||9 (31)|
|< 7||18||13 (73)|
|> 9||15||4 (27)|
No statistically significant association was found between the depression risk score and age, gender, BMI of patients or type of diabetes mellitus.
Factors found to be significantly associated with depression among diabetic patients were duration of diabetes mellitus [χ2 = 6.189, degrees of freedom (df) = 2, P-value = 0.045], HbA1c level (χ2 = 12.8, df = 2, P-value = 0.002) and level of education (χ2 = 11.33, df = 3, P-value = 0.010).
The results of our study also shed some light on the demographic characteristics of patients attending the outpatient clinic in the UAE.
In our study, age, gender, degree of obesity or type of diabetes mellitus did not feature as an important factor for the risk of depression.
Interestingly, we found a statistically significant association between HbA1c level and risk of depression. It is well known that depression is associated with poor glycaemic control in diabetics, partly as a result of poor self-care behaviour such as reduced adherence to diet, exercise and medication regimens.
The level of education was also related to the risk of depression. Although the general assumption is that a lower education level produces greater stress on a patient with diabetes mellitus, a study carried out in Pakistan showed that skilled workers have higher rates of depression, and this was attributed to greater levels of stress in skilled jobs.13 On the other hand, greater awareness of one’s disease and the associated distress in trying to meet targets could also be contributory. However, a larger sample size is necessary to confirm this association.
In this study, a relationship between the duration of diabetes mellitus and the risk of developing depression was found. Extrapolation from other studies suggests that a longer duration of diabetes mellitus could contribute to the higher risk of depression.12–14
This study emphasizes the need for comprehensive psychological evaluation of patients with diabetes mellitus attending outpatient clinics. There is mounting evidence in the literature that significant functional, monetary and psychological costs are associated with depression in patients with diabetes mellitus.15–19 Moreover, the presence of depression in diabetes mellitus is associated with higher rates of diabetes mellitus-related complications. Most importantly, depression worsens cardiovascular morbidity and mortality, which is the leading cause of death in these patients.20,21
There is growing interest in establishing the connection between diabetes mellitus and depression, and some studies point to this relationship being bidirectional.22,23 However, whichever comes first, the presence of both has a significant impact on the management of diabetes mellitus, as well as on its long-term outcomes.
As pointed out by the authors of the study done in the Emirate of Sharjah, there is great social stigma attached to the presence of mental or psychological disorders in the culture there, and patients tend to deny symptoms and resist referrals to departments dealing with such disorders. This can be overcome by providing psychological screening and counselling for all patients with diabetes mellitus in the outpatient setting and by training diabetes mellitus educators or nurses to provide this service.
We note that our study had several limitations. The sample size was too small to estimate the exact prevalence. As it was a cross-sectional study, we could not accurately assess the temporal association between depression and other diabetes mellitus-related variables or attribute causality.
All the study participants were from clinics run at a large tertiary centre catering for a select population within the Emirate of Dubai; therefore, our results cannot be generalized.
Results from our study highlighted that patients with diabetes mellitus are at considerable risk of developing concomitant depression. The contributing factors need to be examined in greater detail and with a larger cohort. There is a definite need to identify the most appropriate screening tool that can be used effectively in a busy outpatient setting to identify those most at risk and offer appropriate treatment or referral. In a diabetes mellitus specialist clinic, the provision of psychological counselling by experienced staff would help to decrease the associated comorbidities of these two disorders.