Milda Staniulytė1, Tautvydas Joteika1
1Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
Abstract
Background
Depression occurs 2- 3 times more in people with diabetes mellitus (DM) with the majority of cases remaining under-diagnosed. Glycated hemoglobin (HbA1c) is an approved indicator for a long-term glycaemic control which is advised to be ≤ 7.
Aim: To determine the prevalence and severity of depression among people with DM and evaluate the possible links of glycaemic control with the severity of depression.
Methods: In 2019 – 2020 an anonymous survey of people diagnosed with DM type 1 and type 2 was carried out in Endocrinology Department, LUHS Kaunas Clinics, and online community ″Lietuvos diabetikai″. 281 adults with no previous record of depression were selected. An originally created questionnaire for respondents’ demographic data and Patient Health Questionnaire – 9 (PHQ-9) for the screening of depression was used. Depression score was assessed using the evaluation guidelines of PHQ-9. Statistical analysis was performed by “IBM SPSS 25.0”. Relations of qualitative variables were assessed by Pearson (χ2). Results were considered statistically reliable if p≤0,05.
Results: Out of 281 respondents only 31 (11 %) denied experiencing any mental health complaints during the past year. According to PHQ-9 score, 115 (40,9%) had minimal or none, 83 (29.5%) had mild, 41 (14,6%) had moderate, 25 (8,9%) had moderately severe, 17 (6%) had severe symptoms of depression.
When divided into 2 groups by their latest level of HbA1c, 50 (44,6%) respondents with HbA1c≤ 7 had minimal or none, 35 (31,3%) had mild, 17 (15,2%) had moderate, 10 (8,9%) had moderately severe and none of the respondents had severe depression symptoms. 55 (37,2%) respondents with HbA1c≥ 7 had minimal or none, 40 (27%) had mild, 22 (14,9%) had moderate, 14 (9,5%) had moderately severe, 17 (11.5%) had severe depression symptoms. There was a statistical significance of occurrence of depression and its possible severity between the two groups (p= 0,007).
Conclusions: 29 % of patients with DM could be suspected of having depression.
Insufficient control of DM had a link with the possible depression and its severeness.
Keywords: depression, diabetes mellitus, glycaemic control, HbA1c .
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37
Medical Sciences 2020 Vol. 8 (16), p. 37-47
Prevalence of depression in patients with diabetes mellitus type 1 and
type 2 and its possible relations with glycaemic control
Milda Staniulytė
1
, Tautvydas Joteika
1
1
Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
Abstract
Background
Depression occurs 2-3 times more in people with diabetes mellitus (DM) with the majority of cases remaining under-
diagnosed. Glycated hemoglobin (HbA1c) is an approved indicator for a long-term glycaemic control which is advised to be
≤ 7.
Aim: To determine the prevalence and severity of depression among people with DM and evaluate the possible links
of glycaemic control with the severity of depression.
Methods: In 2019 – 2020 an anonymous survey of people diagnosed with DM type 1 and type 2 was carried out in
Endocrinology Department, LUHS Kaunas Clinics, and online community ″Lietuvos diabetikai″. 281 adults with no
previous record of depression were selected. An originally created questionnaire for respondents’ demographic data and
Patient Health Questionnaire - 9 (PHQ-9) for the screening of depression was used. Depression score was assessed using the
evaluation guidelines of PHQ-9. Statistical analysis was performed by “IBM SPSS 25.0”. Relations of qualitative variables
were assessed by Pearson (χ2). Results were considered statistically reliable if p≤0,05.
Results: Out of 281 respondents only 31 (11 %) denied experiencing any mental health complaints during the past year.
According to PHQ-9 score, 115 (40,9%) had minimal or none, 83 (29.5%) had mild, 41 (14,6%) had moderate, 25 (8,9%)
had moderately severe, 17 (6%) had severe symptoms of depression.
When divided into 2 groups by their latest level of HbA1c, 50 (44,6%) respondents with HbA1c≤ 7 had minimal or none, 35
(31,3%) had mild, 17 (15,2%) had moderate, 10 (8,9%) had moderately severe and none of the respondents had
severe depression symptoms. 55 (37,2%) respondents with HbA1c≥ 7 had minimal or none, 40 (27%) had mild, 22 (14,9%)
had moderate, 14 (9,5%) had moderately severe, 17 (11.5%) had severe depression symptoms. There was a statistical
significance of occurrence of depression and its possible severity between the two groups (p= 0,007).
Conclusions: 29 % of patients with DM could be suspected of having depression.
Insufficient control of DM had a link with the possible depression and its severeness.
Keywords: depression, diabetes mellitus, glycaemic control, HbA1c .
Journal of Medical Sciences. May 18, 2020 - Volume 8 | Issue 16. Electronic-ISSN: 2345-059
38
Introduction
Diabetes mellitus (DM) is a chronic progressive disorder
with rapidly increasing prevalence in both developing
and developed countries. According to The Institute of
Hygiene, it affected 109 162 (3,89%) Lithuanians in
2018 and was one of the eight most common chronic
diseases in all age groups. (1) One of the most reliable
indicators of a long-term glycaemic control is glycated
haemoglobin (HbA1c) which provides evidence about
individual’s average blood glucose levels during the
previous two to three months. Nowadays HbA1c is
routinely performed and considered to be a standard for
monitoring an efficient glycaemic control which is said
to be achieved when the level of HbA1c is ≤ 7,0 percent.
(2 – 4)
Chronic hyperglycaemia correlates with the risk of long-
term diabetes complications while diabetes itself is often
associated with numerous neuropsychiatric
comorbidities. One of them is depression, which occurs 2
– 3 times more often in patients with diabetes than in
general population (5 – 8). Depression is considered as
one of the most overlooked symptoms in diabetics.
However, there are various reliable screening methods
which could be used in primary care and other medical
settings to recognise patients with potential symptoms.
One of them is Patient Health Questionnaire – 9 (PHQ –
9): a cut off score of 10 points or above identifies
possible major depression with sensitivity of 0.88 (95%
confidence interval 0.83 – 0.92), specificity of 0.85 (95%
confidence interval 0.82 – 0.88).
(9 – 12)
As depression is the leading cause of disability-adjusted
life-years lost in middle- and high-income countries, (13)
the purpose of this study was to evaluate its possible
prevalence among presumably more susceptible group of
diabetic patients in Lithuania and investigate its possible
connections with sufficiently or insufficiently controlled
diabetes.
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39
Methods
During the period of 2019 – 2020 an anonymous survey was
carried out in Endocrinology Department, LUHS Kaunas
Clinics, and an online community “Lietuvos diabetikai”
(“Lithuanian diabetics”). Patients who were diagnosed with
type 1 or type 2 diabetes, were 18 years or older, and did not
suffer from depression prior to index data were included in
the study. A total amount of 281 respondents fulfilled these
criteria. The survey consisted of questions about the
respondents’ sex, age, education, working capacity, marital
status, duration and type of their illness, latest HbA1c level,
and subjective evaluation of general health. The presence
and severity of current depressive symptoms were measured
by the Patient Health Questionnaire – 9 (PHQ – 9). This
questionnaire comprises nine questions regarding patients’
mental health, each scored as zero (no days), one (less than
half the days), two (more than half the days) and three
(almost every day). Respondents were stratified by the
severity of current depressive symptoms according to the
PHQ – 9 score: none-minimal (0 – 4 points), mild (5 – 9
points), moderate (10 – 14 points), moderately severe (15 –
19 points), and severe (20 – 27 points).
Afterwards, patients were divided in two groups depending
on the level of their latest HbA1c: group 1 (HbA1c≤ 7),
which consisted of 112 patients who were considered to
have a sufficient glycaemic control, and group 2 (HbA1c>
7), which consisted of 148 respondents who were
considered to have an insufficient glycaemic control. 21
patients were excluded from this part of the study due to the
lack of information about the level of their glycated
haemoglobin. The analysis of any statistical difference
between the sex, age, education, working capacity, marital
status, duration and type of illness, and subjective
evaluation of general health in both groups was performed.
PHQ – 9 was used again to determine and compare the
severity of possible depression between the two groups.
Statistical analysis was performed by “IBM SPSS 25.0”.
Relations of qualitative variables were assessed by Pearson
(χ2). Results were considered statistically reliable if p≤ 0,05
Results
1.1. General characteristics of suitable respondents
From 281 respondents suitable for the study 224 (79.7%)
were diagnosed with DM type 1 and 57 (20.3%) were
diagnosed with DM type 2. General characteristics of their
age and sex are shown in Table 1.
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40
Tab le 1. Research respondents’ gender and age
Var iabl e
Males
Females
Age group
18 - 25
25 - 35
35 - 45
45 - 59
60 - 74
75 - 90
Number of
respondents
(%)
67
(23.8%)
214
(76.2%)
61
(21.7%)
85
(30.2%)
63
(22.4%)
41
(14.6%)
30
(10.7%)
1
(0.4%)
When questioned about their education, 2 (0.7%)
respondents stated that they had primary, 19 (6.8%) had
middle school, 70 (24.9%) had high school, 63 (22.4%) had
college and 127 (45.2%) had university degree. 5 (1.8%)
respondents have affirmed that they had no working
capacity, 12 (4.3%) had 10-29% of working capacity, 18
(6.4%) had 30-39%, 100 (35.6%) had 40-59%, 10 (3.6%)
had 60-70% and 136 (48.4%) people had > 70% of working
capacity.
When asked about their marital status, 4 (1.4%) respondents
stated that they were widows, 146 (52%) were married, 53
(18.9%) were in a relationship, 54 (19.2%) were single and
24 (8.5%) people were divorced.
1.2. Complaints related to the mental
healthRespondents were asked if they had any
complaints related to their mental health over the
past year. Only 31 (11 %) of people claimed that
they had no mental health complaints. Most
common complaints were anxiety, panic, sadness,
loss of interests/ hobbies, tiredness, difficulties to
concentrate, reluctance to communicate, feeling of
guilt, hopelessness, grim thoughts about the
future, suicidal or self-harming thoughts, suicidal
or self-harming actions, sleeping disorders,
increased/ decreased appetite, stress, and episodes
of overeating while stressed (as shown in Figure
1). Every person who stated having some mental
health complaints over the past year mentioned an
average of 6,07 ± 3,77 complaints. 96 (34.2%)
patients stated that they have experienced these
negative feelings only briefly, 10 (3.6%) noted to
suffer for less than 2 weeks, 33 (11.7%) for more
than 2 weeks, 22 (7.8%) for more than 6 months
and 89 (31.7%) indicated that they have
experienced these complaints almost all the time
during the past year.
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41
Figure 1. Complaints related to the mental health
When asked to subjectively evaluate their current general
health, 2 (0.7%) patients indicated that their general health
was great, 17 (6%) thought that it was very good, 92
(32.7%) stated that it was good, 129 (45.9%) thought that it
was not bad and 41 (14.6%) stated that it was bad.
25 (8.9%) respondents believed that their health was much
better than before the diagnosis of DM, 32 (11.4%) people
stated that it was a little bit better and 58 (20.6%) told it was
simmilar as before. For 87 (31%) respondents their current
general health was a little bit worse and for 79 (28.1%) it
was much worse than before the diagnosis of DM.
The score of PHQ – 9 was also evaluated. It varied from 0
to 27 with the average of 7,57 ± 6,438. 115 people (40,9%)
had minimal or none, 83 (29.5%) had mild, 41 (14.6%) had
moderate, 25 (8.9%) had moderately severe, 17 (6%) had
severe depression symptoms.
1.3. Comparison between the respondents with
sufficiently and insufficiently controlled
diabetes mellitus
Out of 281 respondents there were 50 (17.8%) with HbA1c
≤ 6,5, 62 (22.1%) with HbA1c 6,5 – 7, 102 with HbA1c 7,1
– 8,4 and 46 with HbA1c ≥ 8,5. 21 people were not sure or
had no documentation of their latest HbA1c level.
Patients were divided into 2 groups according to their latest
level of glycated haemoglobin: group 1 (HbA1c ≤ 7), which
Anxiety
Panic
Sadness
Loss of interests/ hobbies
Tiredness
Dif ficult ies to concentrate
Reluctance to communicate
Feeling of guilt
Hopelessness
Grim thoughts about the future
Suicidal or self-harming thoughts
Suicidal or self-harming act ions
Sleeping disorders
Increased/ decreased appet ite
Stress
Episodes of overeat ing while stressed
0 10 20 30 40 50 60 70 80 90 100
61.9
26.7
59.8
38.4
63.3
35.2
37
19.9
39.1
38.4
9.3
5
44.1
32
76.2
22.4
Complaints related to the mental health
%
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42
was considered to have a sufficient glycaemic control, and
group 2 (HbA1c> 7), which was considered to have an
insufficient glycaemic control. 21 people with unknown
HbA1c were excluded from this part of the study.
General characteristics of both groups were analysed.
Statistically significant aspects are shown in Table 2. There
was no statistically significant difference of the type of
diabetes, age, and gained education in both groups.
Tab le 2. Respondents‘ gender, working capacity, relationship status, duration of DM compared by their latest level of
glycated haemoglobin
Characteristics
n (%)
p
HbA1c < 7,
n=112
HbA1c > 7,
n=148
Tot al,
n= 260
Gender
Male
45 (40.2)
16 (10.8)
61 (23.5)
χ
2
= 30,620,
df=1,
p< 0,001
Female
67 (59.8)
132 (89.2)
199 (76.5)
Working
capacity
no working
capacity
2 (1.8)
0 (0)
2 (0.8)
χ
2
= 35,554,
df=5,
p< 0,001
10-29%
3 (2.7)
9 (6.1)
12 (4.6)
30-39%
2 (1.8)
16 (10.8)
18 (6.9)
40-59%
30 (26.8)
68 (45.9)
98 (37.7)
60-70%
2 (1.8)
8 (5.4)
10 (3.8)
> 70%
73 (65.2)
47 (31.8)
120 (46.2)
Relationship
status
Widow
0 (0)
4 (2.7)
4 (1.5)
χ
2
= 11,780,
df=4,
p= 0,019
Married
60 (53.6)
76 (51.4)
136 (52.3)
In a
relationship
24 (21.4)
25 (16.9)
49 (18.8)
Single
14 (12.5)
35 (23.6)
49 (18.8)
Divorced
14 (12.5)
8 (5.4)
22 (8.5)
Duration of
DM
< 6 months
15 (13.4)
0 (0)
15 (5.8)
χ
2
= 39,920,
df= 4,
p< 0,001
6-12 months
15 (13.4)
2 (1.4)
17 (6.5)
1-4 years
14 (12.5)
17 (11.5)
31 (11.9)
5-10 years
10 (8.9)
20 (13.5)
30 11.5)
> 10 years
58 (51.8)
109 (73.6)
167 (64.2)
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43
Analysis of mental health complaints which were experienced over the past year was performed. Frequencies of the same
malaises (anxiety, panic, sadness, loss of interests/ hobbies, tiredness, difficulties to concentrate, reluctance to communicate,
feeling of guilt, hopelessness, grim thoughts about the future, suicidal or self-harming
thoughts, suicidal or self-harming actions, sleeping disorders, increased/ decreased appetite, stress, episodes of overeating
while stressed) were examined. Statistically significant data is shown in table Table 3.
Characteristics
n (%)
p
HbA1c< 7,
n= 112
HbA1c> 7,
n= 148
Tot al,
n= 260
Tiredness
Ye s
63 (56.3)
104 (70.3)
167 (64.2)
χ
2
= 5,455, df=1,
p= 0,020
No
49 (43.8)
44 (29.7)
93 (35.8)
Difficulties to
concentrate
Ye s
31 (27.7)
63 (42.6)
94 (36.2)
χ
2
= 6,123, df=1,
p= 0,013
No
81 (72.3)
85 (57.4)
166 (63.8)
Episodes of
overeating while
stressed
Ye s
17 (15.2)
41 (27.7)
58 (22.3)
χ
2
= 5,770, df=1,
p= 0,016
No
95 (84.8)
107 (72.3)
202 (77.7)
Suicidal or self-
harming actions
Ye s
2 (1.8)
11 (7.4)
13 (5)
χ
2
= 4,280, df=1,
p= 0,039
No
110 (98.2)
137 (92.6)
247 (95)
Sleeping
disorders
Ye s
41 (36.6)
75 (50.7)
116 (44.6)
χ
2
= 5,107, df=1,
p= 0,024
No
71 (63.4)
73 (49.3)
144 (55.4)
Increased/
decreaed
appetite
Ye s
22 (19.6)
61 (41.2)
83 (31.9)
χ
2
= 13,653, df=1,
p< 0,001
No
90 (80.4)
87 (58.8)
177 (68.1)
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44
Tab le 3. Complaints related to the mental health compared by the latest level of respondents’ glycated haemoglobin
There was a statistical significance of subjective current
general health evaluation between the two groups (p=
0,003). In group 1 there were 2 (1.8%) patients who said
that their health was great, 5 (4.5%) who thought that it was
very good, 39 (34.8%) who said that it was good, 60
(53.6%) who thought that it was not bad and 6 (5.4%)
people who stated that it was bad. In group 2 there were no
patients who said that their health is great, 9 (6.1%) patients
who thought that it was very good, 41 (27.7%) who decided
that it was good, 67 (45.3%) who thought that it was not bad
and 31 (20.9%) people who stated that it was bad.
After the evaluation of average PHQ-9 scores in both
groups, a statistical significance was identified (p=0,002).
Group 1 scored an average amount of 6,33 ± 4,855 points
while group 2 scored an average amount of 8,84 ± 7,399
points. What is more, there were 50 people (44.6%) in
group 1 who had minimal or none, 35 (31.3%) who had
mild, 17 (15.2%) who had moderate, 10 (8.9%) who had
moderately severe and none who had severe symptoms of
depression. In group 2 there were 55 (37.2%) respondents
who had minimal or none, 40 (27%) who had mild, 22
(14.9%) who had moderate, 14 (9.5%) who had moderately
severe and 17 (11.5%) who had severe symptoms of
depression. It was statistically significant (p= 0,007).
Discussion
In our study, 89% of respondents stated that over the past
year they have experienced some complaints related to their
mental health. Adding to this, more than a half (51.2%) of
them indicated that those complaints have lasted for a
period longer than two weeks.
After analysing the results of PHQ-9 questionnaire it was
discovered that 29 % of patients diagnosed with diabetes
scored more than 10 points meaning they have shown
moderate, moderately severe or severe signs of depression.
Considering that the standard cut off score of 10 points or
above in PHQ-9 questionnaire identifies depression very
sensitively and specifically, (9 - 12) a very strong suspicion
of possible depression in this group could be made. This
result would be similar to many recent studies which
showed that the prevalence of any degree of depression in
diabetics varies up to 41,7 % with most cases showing the
prevalence of about 30% (6, 16 - 18)
In our study, the presence of worse glycaemic control
(HbA1c > 7) in the population with diabetes mellitus was
higher in women and especially among widowed and single
adults, individuals who had lower working capacity, and
those who were diagnosed with DM for a longer period of
time. People who had HbA1c > 7 mentioned mental health
complaints like being fatigued, having concentration and
sleeping disorders, suffering from overeating episodes,
experiencing appetite changes and suicidal or self-harming
actions significantly more often than those with a sufficient
glycaemic control (HbA1c ≤ 7). They also reported negative
changes in their daily habits and duties at home, the urge to
spend less time at work, and a significantly worse
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45
evaluation of their general health than those with a lower
level of HbA1c. These results are similar to the ones
published by Ceretta et al. which suggested that the severity
of depressive episodes, dysthymia, mood disorders, and
suicidal ideation is associated with lower quality of life and
poor diabetes control. (14) Possible reasons might be
explained by de Ornelas Maia et al., which states that
diabetic individuals with symptoms of depression and
anxiety had worse quality of life due to physiological
changes that accompany illness and impose behavioural
changes in their lifestyle. What is more, a chronicity of the
illness itself was mentioned as a possible reason of many
dysfunctional thoughts. (15)
Even though there is a strong evidence that poor glycaemic
control and high levels of HbA1c in diabetic patients have a
negative effect on various cognitive functions, their roles for
the development of depression are on a constant debate. For
instance, in a research published by Fisher et al. glycaemic
control was associated with an experienced distress but not
linked to a depression suggesting that there was no
statistical relation. (19) On the other hand, a metanalysis of
Lustman et al. found that depression was linked with
hyperglycaemia in patients with both types of diabetes
although the nature of this link remained unclear. (20)
Lustman’s results were further confirmed in two
independent studies of Zhang et al. and Jacob et al. which
also stated that higher HbA1c level had a strong effect on
the risk of developing depression. (21 – 22)
The same significance was determined in our research. In
group 1, which was considered to have a sufficient
glycaemic control (HbA1c ≤ 7), there were no patients who
showed signs of severe depression while in group 2 (HbA1c
> 7) there were 11.5 % of respondents with these symptoms.
What is more, in group 1 there were 24.1% and in group 2
there were 35.8% people who scored more than 10 points in
PHQ-9 questionnaire meaning that they had moderate,
moderately severe or severe symptoms of depression. The
results were statistically significant and suggested that
people with HbA1c> 7 might be having depression more
often and to a more advanced extent. The reasons of this
finding might be explained by Tabac et al. who stated that
both depression and diabetes-distress might have a direct
adverse effect on glycaemic control via dysregulation of
stress hormones. (23) Alternatively, Snoek et al. claimed
that glycaemic control might be mediated via impaired self-
care behaviours because of depression or depressive
symptoms and result in a poor diabetes control and higher
levels of HbA1c. (24)
As a brief conclusion, it is important to remember that
diabetes and depression are common disorders and often
occur together. Therefore, there is a need for personalised
treatments and managements in order to prevent the
development of depression in patients with diabetes. As
depression remains underdiagnosed, an important aspect for
the diabetic specialist would be the awareness of this quite
common co-morbidity. A multidisciplinary approach of the
diabetic patient should be encouraged and would help to
improve the outcomes of both diseases.
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