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Original Research (Original Article) 


Mohammad Alkot et al, 2019;3(10):029–033.

International Journal of Medicine in Developing Countries

Prevalence of depression and associated factors among patients with diabetes mellitus in Makkah region, Saudi Arabia: a cross-sectional study

Mohammad Alkot1,2, Ahmed Saad Badri3*, Yahya Abdullah Alayyafi3, Fahad Rashed Alsulami3

Correspondence to: Ahmed Saad Badri

*Medical Intern, Umm Al-Qura University, Makkah, Saudi Arabia.

Email: ahsaba100 [at] gmail.com

Full list of author information is available at the end of the article.

Received: 12 June 2019 | Accepted: 21 July 2019


ABSTRACT

Background:

The prevalence of comorbid depression was found to be two to three times higher among patients with diabetes mellitus (DM) as compared to non-diabetics; thus the present study was conducted to estimate the prevalence of depression and its associated factors among patients with DM in Makkah region, Saudi Arabia.


Methodology:

A cross-sectional study was conducted among a convenience sample of 169 diabetic patients through an online link. The Arabic version of the Beck Depression Inventory tool was used to evaluate the presence of depression. The sociodemographic characteristics and clinical data were also assessed, and presented in frequencies and percentages. Univariate and multivariate analyses were conducted to identify potential risk factors, using adjusted odds ratios (OR) and confidence intervals (CI).


Results:

The prevalence of overall depression among patients with diabetes was 21.3%. The majority had no or minimal level of depression (N = 102, 60.4%), while 26 participants had mild depression (15.4%) and 27 had moderate depression. Fourteen participants had severe depression (8.3%). Depression was significantly more prevalent among males (p = 0.001) and obese participants (p = 0.03). Obesity (AOR = 2.43, 95% CI (1.1, 5.2) was the only significant independent risk factor for depression among patients with DM.


Conclusion:

Depression is highly prevalent among patients with DM and it most commonly coexists with obesity. Also, depression is more common among males and obese diabetic patients.


Keywords:

Depression, diabetes mellitus, beck depression inventory, Makkah, Saudi Arabia.


Introduction

Newly emergent diseases such as diabetes mellitus (DM) are among the main challenges for the 21st century’s medicine [1]. DM is a global health problem which has negative impacts on patients, their relatives, and the whole society at large [2,3]. In developing countries, the prevalence of DM in adult population is expected to raise by around 70% between 2010 to 2030 [4]. The Kingdom of Saudi Arabia (KSA) is one important example of the growing numbers of people with DM and the prevalence is predicted to rise from 32.8% in 2016 to 35.4 in 2020 reaching up to almost half of the Saudis (45.4%) in 2030 [5]. The prognosis of DM depends, to a large degree, on the individual’s lifestyle and self-control behaviors; thus comorbid psychological problems are considered significant barriers to successful DM management [6,7]. As one of the most common psychological disorders, depression has been reported to occur frequently in diabetic patients and it has a bidirectional relationship: DM increases the risk of depression, and depression also increases the risk of DM [1]. There are several epidemiological studies in the literature which confirm the increased occurrence of depression among patients with DM [810]. The prevalence of comorbid depression was found to be two to three times higher among patients with DM as compared to non-diabetics [11,12].

These findings warrant conducting more studies on the subject to facilitate developing intervention strategies as depressed diabetic patients have a higher risk of poor DM control, in part, due to physical inactivity, non-adherence to diet, poor compliance with medications, reduced quality of life, and cognitive issues [13,14]. One of the pioneering studies is the random controlled trial carried out in 2007 by Simon et al. [15]. In this study, successful treatment of depression in individuals with DM had significantly decreased financial costs due to frequent hospital visits, and increased depression-free periods. The authors recommended that screening for depression should become a routine part of DM care [15].

Data regarding the epidemiology of DM-depression relationship in the KSA are still limited. In a 2004 study by Al-Ghamdi, depression was found in 34% of diabetic patients versus 13% of non-diabetics and was associated with poorer glycemic control and increased risk of developing macro-and micro-vascular complications [16]. In another study by El Mahalli, the depression affected 49.6% of patients with DM [2]. Although the majority of previous studies have been focusing on type 2 DM, type 1 DM has also been found to carry a relatively similar high risk of depression in some studies such as that conducted by Gemeay et al. [17], which found depression to be as prevalent in patients with type 2 DM (37.9%) as in those with type 1 DM (37%).

The main objective of this study was to estimate the prevalence of depression among patients with DM in Makkah region, KSA.


Subjects and Methods

A cross-sectional study was carried out on the diabetic population of Makkah region, western Province of Saudi Arabia. The study was conducted during the period from September 2018 to May 2019 using a convenience sample of 169 Saudi diabetic patients from both sexes. The inclusion criteria were as follows: 1) type 1 and type 2 diabetic patients who self-reported a diagnosis of DM by a health care professional; and 2) those who were 18 years and above who gave an informed written consent; 3) those who were residents of Makkah region, Saudi Arabia. Patients with other types of DM, those who were under 18 years, and those who were lived outside Makkah region were excluded from the study.

Data were collected by a researcher-made check list and a questionnaire that was reported through an online link sent to the target populations using social media. The checklist and questionnaire included questions designed to fulfill the study objectives. First question was about whether participants have an established diagnosis of DM or not; positive responses were directed to other parts of questionnaire which included socio-demographic characteristics including sex, age, marital status and educational level. Other questions were of ‘yes or no’ nature and included data about blood pressure status, obesity, type of DM and duration, compliance with antidiabetic medications and the average HbA1C where applicable. Last part of the checklist assessed comorbid depressive symptoms using a standardized and valid Arabic version of Beck Depression Inventory II (BDI) [18]. A cut-off score of 21 or more on the BDI II tool was set to indicate depression. Responses were scored as following: 0–13 no depression, 14–19 mild depression, 20–28 moderate depression, and 29–63 severe depression [19].

Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 20; SPSS, Chicago, IL, USA. Data were checked to detect any coding errors or missing values. Categorical variables such as gender and DM type were presented in frequencies and percentages. Logistic regression was conducted to assess the association between depression and different explanatory variables. First, separate bivariate analyses were performed for each potential risk factor; then a multivariate logistic regression was done. Odds ratio (OR) and Confidence Interval (CI) were used to judge the strength of association. The significance level was set at p < 0.05.


Results

Of all 169 participants included in the present study, the mean age and standard deviation were 40.27 and 15.95, respectively, with age range of 18 to 85 years. The majority of participants were males (N = 117, 69.2). The majority of study subjects were single (N = 105, 62.1%). Regarding the educational level, the majority reported an education level of university level (N = 85, 50.3%), followed by those educated up to high school (N = 44, 26.0%). With 28 participants (16.6%) had level of education under intermediate school (Table 1).

Table 1. Sociodemographic characteristics of participants (N = 169).

Variable Category N %
Sex Male 117 69.2
Female 52 30.8
Mean age (SD) 40.27 (15.95)
Marital status Single* 105 62.1
Married 64 37.9
Level of education University 85 50.3
High school 44 26.0
Intermediate 9 5.3
Primary 10 5.9
Uneducated 9 5.3

SD: standard deviation.

*Including separated individuals.

The survey showed that half of the patients suffered from Type 1 DM (N = 85, 50.3%). Patients who were suffering from DM for more than five years or less comprised most of the sample (N = 103, 60.9%). The vast majority of patients self-reported being compliant to antidiabetic medications (N = 138, 81.7%). The survey also found that 30.2% (N = 51) of patients self-reported being obese and 24.2% (N = 46) being hypertensive (Table 2).

Using a cut-off score of 21 and above on the BDI-II scale, the prevalence of overall depression among participants with diabetes is 21.3% (N = 36). The majority had no or minimal level of depression (N = 102, 60.4%), while 26 participants had mild depression (15.4%) and 27 had moderate depression. Fourteen participants had severe depression (8.3%) (Table 3).

Table 2. Disease information of participants (N = 169).

Variable Category N %
Type of DM Type 1 85 50.3
Type 2 84 49.7
Duration of DM 0–5 Years 66 39.1
> 5 years 103 60.9
Compliance to medications Yes 138 81.7
No 31 18.3
Co morbidities Obesity 51 30.2
Hypertension 46 24.2

Table 3. Summary of BDI-II scores and their interpretation.

BDI II scores Interpretation N %
0–13 No depression 102 60.4
14–19 Mild depression 26 15.4
20–28 Moderate depression 27 16.0
31–40 Severe depression 14 8.3

The frequency of depression among the study participants according to their socio-demographic and clinical data is shown in Table 4. Depression was found to be more frequent in males (53.7%) than in females (46.3%), and more in married (61.2%) than in single participants. Regarding DM, more depressive symptoms were found in those who suffered from DM for more than 5 years (56.7%), those who were not compliant with their antidiabetic medications (54.8%), and those who selfreported having obesity (52.9%). Depression was almost equally distributed among Type 1 (49.3%) and Type 2 (50.7%) diabetics. A significant difference was observed in gender (p = 0.001) and obesity (p = 0.03).

After separate bivariate regression analyses were performed, only two significant risk factors (compliance with antidiabetic medications and obesity) were entered the multivariate regression. The results showed that obesity [AOR = 2.43, 95% CI (1.1, 5.2)] was the only significant independent risk factors for depression among patients with DM. These results mean that obese diabetics were 2.4 times more likely to have comorbid depression (Table 5).


Discussion

The aim of this study was to identify the prevalence of depression and its risk factors in Saudi patients with DM. The results showed that the overall occurrence of depressive symptoms in diabetic patients was 21.3%, which was consistent with the findings of previous studies [2,16,18,2023]. Significant associated factors with depression were sex and obesity. The latter was found to be a significant independent predictor of depression prevalence among patients with DM.

Depression in this study was more common among male than among female diabetics. Although this is not consistent with previous studies [24,25] that reported the contrary, it can be explained by the notion that males in

Table 4. Associated factors with depression among the study participants (N = 169).

Variable Category Frequency of depressive symptoms (%) X2 p value
Sex Male 36 (53.7) 12.519 0.001
Female 31 (46.3)
Marital status Married 41 (61.2) 0.041 0.87
Single 26 (38.8)
Type of DM Type 1 33 (49.3) 0.048 0.88
Type 2 34 (50.7)
Duration of DM 0–5 years 29 (43.3) 0.835 0.36
>5 years 38 (56.7)
Compliance to medications Yes 50 (36.2) 3.663 0.07
No 17 (54.8)
Obesity Yes 27 (52.9) 5.397 0.03
No 40 (33.9)

Table 5. Multivariate analysis of risk factors for depression among diabetic patients (N = 169).

Factors Depression COR (95% CI) AOR (95% CI) p value
Yes No
Compliance to DM medications
Yes 25 (69.4%) 113 (85.0%) 2.49 (1.06, 5.84) 2.24 (0.9, 5.4) 0.07
No 11 (30.6%) 20 (15.0%) Ref.
Obesity
Yes 17 (47.2%) 34 (25.6%) 2.61 (1.2, 5.6) 2.43 (1.1, 5.2) 0.02
No 19 (52.8%) 99 (74.4%) Ref.

COR = Crude Odds Ratio, AOR = Adjusted Odds Ratio, CI = Confidence Interval,* p value < 0.05.

Saudi Arabia may be more prone to stressful daily life as compared to their female counterparts, and this may be due to social and family requirements that Saudi males have to deal with.

The observation that depression was more common among patients with DM and comorbid obesity is in agreement with a large body of studies suggesting a strong relationship between obesity and depression [26,27]. Moreover, when obesity co-occur with DM, the prevalence of depression is expected to be higher as both conditions have been well associated with higher rates of depression [11,12].

The present study has some limitations. First, it is a crosssectional study and, due to its observational nature; it cannot identify the causal relationship between depression and DM. Second, the data were collected through a selfreported questionnaire; thus, it would be more appropriate to gather data through clinical interview to avoid misunderstanding of the survey items and to increase the specificity of the results. Third, an established diagnosis of DM by a professional health worker is better than a self-reported diagnosis. Both obesity and hypertension should be measured accurately rather than being selfreported by participants who may confuse normal blood pressure and body weight as abnormal.


Conclusion

Depression is highly prevalent among patients with DM and it coexists with obesity. Moreover, depression is more common among males and obese diabetic patients. Therefore, screening is highly recommended for depression among patients with DM, as well as offering proper psychological and pharmacological treatment and educating diabetic patients about DM self-management.


List of Abbreviations

CI Confidence interval
DM Diabetes mellitus
OR Odds ratio

Conflicts of interest

The authors declare that they have no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all participants.


Ethical approval

Ethical approval (reference no.: REC40/6 S027, date: 17/08/2018) was obtained from the Scientific Research Ethics Committee at Umm Al-Qura University.


Author details

Mohammad Alkot1,2, Ahmed Saad Badri3, Yahya Abdullah Alayyafi3, Fahad Rashed Alsulami3

  1. Professor of Family Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
  2. Menoufia University, Al Minufya, Egypt
  3. Medical Intern, Umm Al-Qura University, Makkah, Saudi Arabia

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How to Cite this Article
Pubmed Style

Alkot M, Badri AS, Alayyafi YA, Alsulami FR. Prevalence of depression and associated factors among patients with diabetes mellitus in Makkah region, Saudi Arabia: a cross-sectional study. IJMDC. 2019; 3(10): 29-33. doi:10.24911/IJMDC.51-1560342498


Web Style

Alkot M, Badri AS, Alayyafi YA, Alsulami FR. Prevalence of depression and associated factors among patients with diabetes mellitus in Makkah region, Saudi Arabia: a cross-sectional study. http://www.ijmdc.com/?mno=52481 [Access: October 18, 2019]. doi:10.24911/IJMDC.51-1560342498


AMA (American Medical Association) Style

Alkot M, Badri AS, Alayyafi YA, Alsulami FR. Prevalence of depression and associated factors among patients with diabetes mellitus in Makkah region, Saudi Arabia: a cross-sectional study. IJMDC. 2019; 3(10): 29-33. doi:10.24911/IJMDC.51-1560342498



Vancouver/ICMJE Style

Alkot M, Badri AS, Alayyafi YA, Alsulami FR. Prevalence of depression and associated factors among patients with diabetes mellitus in Makkah region, Saudi Arabia: a cross-sectional study. IJMDC. (2019), [cited October 18, 2019]; 3(10): 29-33. doi:10.24911/IJMDC.51-1560342498



Harvard Style

Alkot, M., Badri, . A. S., Alayyafi, . Y. A. & Alsulami, . F. R. (2019) Prevalence of depression and associated factors among patients with diabetes mellitus in Makkah region, Saudi Arabia: a cross-sectional study. IJMDC, 3 (10), 29-33. doi:10.24911/IJMDC.51-1560342498



Turabian Style

Alkot, Mohammad, Ahmed Saad Badri, Yahya Abdullah Alayyafi, and Fahad Rashed Alsulami. 2019. Prevalence of depression and associated factors among patients with diabetes mellitus in Makkah region, Saudi Arabia: a cross-sectional study. International Journal of Medicine in Developing Countries, 3 (10), 29-33. doi:10.24911/IJMDC.51-1560342498



Chicago Style

Alkot, Mohammad, Ahmed Saad Badri, Yahya Abdullah Alayyafi, and Fahad Rashed Alsulami. "Prevalence of depression and associated factors among patients with diabetes mellitus in Makkah region, Saudi Arabia: a cross-sectional study." International Journal of Medicine in Developing Countries 3 (2019), 29-33. doi:10.24911/IJMDC.51-1560342498



MLA (The Modern Language Association) Style

Alkot, Mohammad, Ahmed Saad Badri, Yahya Abdullah Alayyafi, and Fahad Rashed Alsulami. "Prevalence of depression and associated factors among patients with diabetes mellitus in Makkah region, Saudi Arabia: a cross-sectional study." International Journal of Medicine in Developing Countries 3.10 (2019), 29-33. Print. doi:10.24911/IJMDC.51-1560342498



APA (American Psychological Association) Style

Alkot, M., Badri, . A. S., Alayyafi, . Y. A. & Alsulami, . F. R. (2019) Prevalence of depression and associated factors among patients with diabetes mellitus in Makkah region, Saudi Arabia: a cross-sectional study. International Journal of Medicine in Developing Countries, 3 (10), 29-33. doi:10.24911/IJMDC.51-1560342498