Depression among diabetic patients visiting a diabetes center in Nepal

Introduction Diabetes mellitus is increasing rapidly globally and the number of affected people is expected to reach over 366 million by the year 2030 [1]. Depression frequently occurs together with diabetes, although it is unrecognized and untreated approximately in two thirds of patients with both conditions. The course of depression in patients with both diabetes and depression is chronic and severe. More than 80% of patients with diabetes and depression experience a relapse of depressive symptoms over a 5-year period [2]. Studies have shown that diabetes was found to double the likelihood of having depression among diabetic patients when compared with non-diabetic patients [3]. Depression is found to increase the incidence of both macro vascular and micro vascular complications. It is also found to reduce quality of life and decrease compliance with medications and healthy lifestyle measures such as dietary regimes and exercise. It thereby increases health care use and expenditures and the risk of cardiovascular mortality due to poor control of hyperglycemia [4,5]. Recognition of depression is important to improve diabetic care because treatment is easily Received: 12 June 2018


Introduction
Diabetes mellitus is increasing rapidly globally and the number of affected people is expected to reach over 366 million by the year 2030 [1]. Depression frequently occurs together with diabetes, although it is unrecognized and untreated approximately in two thirds of patients with both conditions. The course of depression in patients with both diabetes and depression is chronic and severe. More than 80% of patients with diabetes and depression experience a relapse of depressive symptoms over a 5-year period [2].
Studies have shown that diabetes was found to double the likelihood of having depression among diabetic patients when compared with non-diabetic patients [3]. Depression is found to increase the incidence of both macro vascular and micro vascular complications. It is also found to reduce quality of life and decrease compliance with medications and healthy lifestyle measures such as dietary regimes and exercise. It thereby increases health care use and expenditures and the risk of cardiovascular mortality due to poor control of hyperglycemia [4,5]. Recognition of depression is important to improve diabetic care because treatment is easily available and cost-effective [6].
There are very few evidences on prevalence and associated factors of depression among diabetic patients in Nepal. This study aimed to identify the prevalence of depression and its associated factors among diabetic patients visiting a diabetic care center in Kathmandu valley, Nepal.

Methods
This study was an institution based cross-sectional study that enrolled 203 diabetic patients in an endocrinology care centre, Lalitpur in Nepal. All the patients who visited the endocrinology care centre from 7 July to 21 July 2013 were recruited for the study purpose. Inclusion criteria for the study participants was patients with diagnosis of diabetes for more than 1 year and those aged above 20 years. Patients were excluded if they had previous history of depression, unconsciousness and with other psychotic disorders.
Beck Depression Inventory scale (Nepali translated version) of Tribhuvan University Teaching Hospital (TUTH) was used for assessing and measuring severity of depressive symptoms.
Structured interview schedule in Nepali version was used to gather required information from the participants through face to face interview technique at outpatients setting. BDI Score was used to explore the prevalence of depression.
Data were entered and analyzed on SPSS version 17. Status of depression, socio-demographic and diabetes related characteristics were calculated using frequency and percentages. Confidence Interval at 95% was calculated to estimate prevalence of depression among diabetic patients. Bivariate analysis was performed using cross tabulation and association was identified using chi-squared test. Statistical significance was determined at p<0.05. Bivariate logistic regression was performed on factors with significant p value to identify unadjusted odds ratio with 95% CI. Then, multivariable logistic regression model was used to control confounding and calculate adjusted odds ratio with 95% CI. The adjusted variables were marital status, educational level, blood sugar level, treatment modality of diabetes, presence of co-morbidity, family support and stressful life events in the past.
Research proposal was approved by research committee of Nursing Campus Maharajgunj. Official request letter was submitted to administration of diabetes thyroid and endocrinology care centre and written permission was taken to conduct research. The purpose and the procedure of the study was explained to the participants including the autonomy during the process of informed written consent with each participants.

Discussion
The study showed quite high prevalence of depression among Nepali diabetic patients. The overall prevalence was 34% in which 17.7% were mild, 13.8% were moderate and 2.5% were severely depressed. Similar studies reported slightly higher prevalence from South India (37.5%), North India (41%) and Saudi Arabia (49.6%) respectively [8][9][10]. This study at bivariate analysis found among socio-demographic characteristics, marital status and education level were significantly associated with depression while in multivariable logistic regression analysis only secondary and above level education was found to have significantly low depression compared to no schooling. A study in Saudi Arabia also showed marital status significantly associated with depression [10] while a study done in Nigeria showing contrasting findings to this study that income and family size associated with depression among diabetic patients [11]. This may be because of not enough power of this study to detect the association. Previous studies showed comorbid conditions and increased fasting glucose level were significantly associated with depression [8,12]. Also, family support influences the psychosocial outcomes in diabetes patients [13]. A study in Ethiopia also showed similar findings that negative life events and poor social support were significantly associated with depression among diabetic patients [14]. Our findings on the association of treatment modality with depression is supported by a previous study which showed oral hypoglycemic therapy is potentially safer and caters less risk of depression in comparison to intensive management using multiple daily injections [15].
This study was limited to patients visiting a privately run care center in Kathmandu valley so these patients may not represent all diabetic patients in Nepal. Despite this limitation, the magnitude and associated factors identified by this study might be useful for programs to control depression among diabetes patients in Nepal.

Conclusion
More than one third of the diabetic patients had some degree of undiagnosed depression. Factors like no schooling, being on insulin therapy, having comorbid conditions and stressful life events increased the chances of developing depressive symptoms. Mental health counselling and education is an immediate priority for those with depressive symptoms and can benefit from regular glucose monitoring and screening of depression.