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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 89-94

Association of demographic characteristics to depression, anxiety, and stress among diabetics: A cross-sectional report from resource-limited settings of South India


1 Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Kingdom of Saudi Arabia; Department of Pharmacy Practice, Raghavendra Institute of Pharmaceutical Education and Research, Anantapuramu, Andhra Pradesh, India
2 Department of Pharmacy Practice, Raghavendra Institute of Pharmaceutical Education and Research, Anantapuramu, Andhra Pradesh, India
3 Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Kingdom of Saudi Arabia

Date of Submission15-Oct-2019
Date of Decision15-Nov-2019
Date of Acceptance03-Dec-2019
Date of Web Publication27-Oct-2021

Correspondence Address:
Vigneshwaran Easwaran
Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_104_19

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  Abstract 


Background: In India, there is a scarcity of epidemiological data related to risk factors and prevalence of depression, anxiety, and stress (DAS) among diabetics. Therefore, their estimation may provide data for an effective management of these disorders in diabetic patients. Aim: The current study was undertaken to analyze the effect of sociodemographic characteristics toward DAS symptoms and to estimate the prevalence of DAS among diabetics. Materials and Methods: It was a cross-sectional study conducted among diabetics at the resource-limited settings of South India. Non probabilistic convenient sampling was used for recruitment fo study subjects. DAS scale 21 questionnaire is a validated self-report questionnaire designed to measure the severity of a range of symptoms for DAS. The patients with established psychiatric disorders were excluded from the study. Results: Overall, the prevalence of DAS symptoms was 57.5%, 55.9%, and 44.9%, respectively, and which ranges from mild to extremely severe. Gender plays a major role in increasing the prevalence of depressive and stress symptoms. The elderly age group was found to have more prevalence of all these three symptoms than younger age. Conclusions: The study showed that the prevalence of DAS symptoms was high. However, in our study, these symptoms are poorly associated to demographic characteristics. We recommend to screen all the diabetic patients for DAS symptoms.

Keywords: Anxiety, depression, diabetics, stress


How to cite this article:
Easwaran V, Kudumula Mulammagari SV, Lakkepogu C, Byram R, Alshahrani SM, Alavudeen SS, Khan NA. Association of demographic characteristics to depression, anxiety, and stress among diabetics: A cross-sectional report from resource-limited settings of South India. CHRISMED J Health Res 2021;8:89-94

How to cite this URL:
Easwaran V, Kudumula Mulammagari SV, Lakkepogu C, Byram R, Alshahrani SM, Alavudeen SS, Khan NA. Association of demographic characteristics to depression, anxiety, and stress among diabetics: A cross-sectional report from resource-limited settings of South India. CHRISMED J Health Res [serial online] 2021 [cited 2021 Dec 2];8:89-94. Available from: https://www.cjhr.org/text.asp?2021/8/2/89/329441




  Introduction Top


Diabetes and depression are two of the commonest public health problems affecting people all over the world.[1] Diabetes and depression are rapidly growing chronic health conditions that have significant negative impact on health and often leads to socioeconomic burden.[2],[3] The combination of mental disorders and diabetes is common and harmful, may have poor glycemic control, more diabetic complications, diminished quality of life, increased disability, and lower medication and self-care behaviors adherence.[4],[5] Depression and anxiety remain unrecognized and untreated in a high proportion of patients with diabetes.[6]

In India, there is a scarcity of epidemiological data related to risk factors and prevalence of depression, anxiety, and stress (DAS) among diabetics. In addition to that, the present study settings being a resource-limited area in southern part of India, where most of the subjects are illiterate (26.73%) and economically backward which may also have an impact on psychosocial aspects.[7] Therefore, the estimation of prevalence of DAS among diabetics may provide data for an effective management of these disorders in diabetic patients. Hence, the current study was undertaken to analyze the effect of sociodemographic characteristics toward DAS symptoms and to estimate the prevalence of DAS among diabetic subjects.


  Materials and Methods Top


Study design and sampling

This study was a cross-sectional study conducted in the outpatient area of government teaching hospital in the Anantapur, a district headquarters of Andhra Pradesh, India, during the period of November 2014–April 2015. The study center is located in one of the resource-limited settings of South India. A nonprobabilistic convenient sampling was done to recruit the study subjects based on their availability and willingness to participate in the study. A total of 186 individuals those who attended the diabetic outpatient clinic and general health checkup clinic were selected and enrolled in to this study. Both male and female subjects diagnosed as diabetic patients (both type 1 and type 2) with a minimum age of 18 years were included in the present study. Subjects those who had a history of diabetes mellitus (DM) for 6 months or more were included in test groups. Pregnant women, subjects with known psychiatric illness or any form of cognitive impairment, subjects with a history of drug abuse, and subjects those who were unable to communicate in Telugu (local regional language) or English were excluded from the study. Further, subjects those who had no interest to participate were also excluded.

Instrument

Depression, anxiety, and stress scale (DASS) 21 questionnaire is a validated self-report questionnaire designed to measure the severity of a range of symptoms for depression anxiety and stress. It is a 21-item questionnaire with three 7-item subscales including DAS, which hardly takes 10 min for completion. Items consist of statements referring to the past week and each item is scored on a 4-point scale (0 = “Did not apply to me at all,” to 3 = “Applied to me very much, or most of the time”). The score was categorized into normal, mild, moderate, and severe.[8] The questionnaire used in this study was translated into Telugu (regional language) by both medical and nonmedical experts. Further, the translated version of questionnaire was retranslated into English to ensure the exact meaning of the original version. Cronbach's alpha was calculated to ensure the internal consistency and reliability for the translated version of questionnaire.

Ethical considerations

All the study subjects were given with verbal and written explanation of research objectives and obtained an informed consent to participate in the study. No economical remuneration was provided to study subjects. The present study was approved by the Institutional Review Board of Raghavendra Institute of Pharmaceutical Education and Research (Approval number RIPERIRB/2015/05).

Data collection and analysis

Personal and familial history was obtained through patient data case sheet and structured interview designed specifically for this study. No clinical data were obtained for analysis. All subjects were assessed and confidentially interviewed by research assistants. Data management and analyses was carried out using Statistical package for social sciences version 21 for windows by (IBM Corp, USA). Chi-square test was employed to look for an association between DAS score and sociodemographic characteristics. Results were recorded and provided as frequencies, means ± standard deviations, P values, and Chi-square values.


  Results Top


Sociodemographic characteristics of study subjects

[Table 1] represents the sociodemographic characteristics of the current study subjects. The final sample consisted of 186 subjects of which 99 were male (53.2%). Most of the subjects were in the age group of 60–69 years (37) with a mean age of 50.72. The vast majority of study subjects were married (80.6%). The educational level was found to be low, and around half of the study population was found to be illiterate (51%). The occupation of the study subjects was classified into two types, including physical activity and no physical activity based on its nature. A significant portion of study subjects had no physical activity (64%). More than 75% of study subjects were not found to have alcoholic and smoking habits.
Table 1: Demographic characteristics of study subjects

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Depression, anxiety, and stress

Overall, the prevalence of DAS symptoms was 57.5%, 55.9%, and 44.9%, respectively, and which ranges from mild to extremely severe based on DASS 21 scale [Table 2].
Table 2: Frequency of depression, anxiety, and stress based on the severity

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With regard to demographic characteristics, it was observed that the prevalence of depression symptoms was higher among females than males (64.3% vs. 51.5%, P = 0.077). Statistically significant differences in the prevalence of clinical depressive symptoms were noted among different age groups, with higher frequency among those who are aged between 40 and 49 years and very less among the subjects aged between 20 and 29 years (93.1% vs. 14.2%, P = 0.000). The study subjects whose occupation requires a physical activity were found to have more depression than the subjects those who do not require physical activity (64% vs. 54%, P = 0.168). Similarly, the social habits are also found to have significant impact on depressive symptom among the study subjects inversely. The nonalcoholic subjects were found to have more depressive symptoms than alcoholic subjects (63% vs. 39%, P = 7.369) [Table 3].
Table 3: Frequency distribution of respondents by depression status based on demographic characteristics

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The elderly age group (age group 50–69 years) was found to have more prevalence of anxiety symptoms. However, we could not able to observe the significant statistical difference between the age groups and even among the genders for anxiety symptoms (P = 0.077, P = 0.321). Marital status also provides the similar results to gender and age group but not exactly (P = 0.948). The prevalence of anxiety symptoms was higher among illiterates than graduates (64% vs. 27%, P = 0.016) and showed statistically significant difference. The study subjects whose occupation requires a physical activity was found to have more depression than the subjects those who do not require physical activity for their occupation (64% vs. 51%, P = 0.088). We found statistical difference among smokers and nonsmokers in terms of anxiety symptoms (68% vs 52%, P = 0.041). Overall, most of the demographics characteristics failed to show the significant difference among the subjects who had anxiety symptoms [Table 4].
Table 4: Frequency distribution of respondents by anxiety status based on demographic characteristics

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In terms of stress, it was found to be higher among elderly people (age group 50–69 years). The males were found to have high prevalence for stress than females (46.4% vs. 42.65%, P = 0.590). Similar to depressive and anxiety symptoms, the highest prevalence of stress was found among illiterate people than graduates (41% vs. 46%). Unlike depressive and anxiety symptoms, the subjects whose occupation requires a physical activity were found to have lesser prevalence than the subjects' occupation does not requires physical activity (47% vs. 40.2, P = 0.373). Smokers and alcoholics do not seem to have significant association to stress symptoms. Overall, none of the demographic characteristics was found to have significant difference on their stress symptoms [Table 5].
Table 5: Frequency distribution of respondents by stress status based on demographic characteristics

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  Discussion Top


Despite the increasing confirmative evidence for psychiatry disorders such as DAS among chronic diseased subjects, it is often remain unrecognized and untreated in DM patients.[9] For instance, it was reported that primary care physicians fail to detect depression in majority of cases and most of the diabetes patients are treated with antidepressant therapy by their diabetologists.[10]

This study showed that the prevalence of DAS symptoms was high among diabetic individuals in Anantapur district, Andhra Pradesh, India. The prevalence of depression in this study was higher than that of anxiety and this is in contrast with an another literature in which anxiety rates are frequently higher than depression.[11]

Our findings concur with other chronic diseases such as chronic obstructive pulmonary disease (COPD), asthma, and epilepsy, reported by Dahlén and Janson, Ozcan A et al., Kanner et al. who found that patients with asthma and COPD have probability of depression and anxiety.[12],[13],[14]

The higher prevalence of depressive symptoms found in the current study is contrary to the several studies conducted among diabetic subjects, where they reported lesser rates of prevalence.[1],[15] A study conducted in Qatar using the same instrument as ours, i.e., DASS 21, found high prevalence of DAS symptoms among diabetics, these results are similar to current study findings.[16]

The study found significant association between depression and age group of respondents, a finding which contrasts with that of Agbir and Audu.[17] A study reported by Nichols and brown indicates that the majority of the patients diagnosed with depression are found to be of younger age group, where as in our study were elderly age group.[18] It is not surprising that females have a higher prevalence and risk of depression compared to males. Many factors have been implicated for this gender difference including sociocultural and biological factors.[19] Generally, it is recognized that being married is associated with less psychiatric morbidity including depression.[20],[21] However, the current study did not show any relationship between marital status and the depressive symptoms. Our study revealed that age group and the social habits such as alcohol and smoking were the major predictors of depression. In terms of alcohol consumption, our study showed that current drinking was an independent risk factor for depression only to certain extent. Several studies have established such an association.[22],[23]

It was found that anxiety is closely related to depression in diabetic patients. Although various social and clinical factors were cited to be associated with depression, our study failed to prove such an association. A study done by Raval et al.[24] in India proved that high prevalence of depression in patients with type 2 DM was associated with diabetic complications, particularly neuropathy and diabetic foot disease. However, in the present study, anxiety was severe and found in more than half of the study population. This is higher than the previous studies reported by Hermanns et al. and Balhara.[25],[26]

The current study results also showed that smoking is a significant predictor for anxiety among diabetic subjects. In addition to that, the present study showed that the educational level was found to have significant relationship to anxiety symptoms. These results are similar to previous studies conducted at Kingdom of Saudi Arabia.[27] Similar to depression and anxiety disorders, stress is also positively linked to DM as reported by other studies. The reports done by Tan et al. in Malaysia stated that occupation was the strong predictor of stress symptoms.[22] However, the current study failed to show any significant association to neither occupation nor any of the demographic characteristics.

The current study found few factors, which are associated to DAS among diabetic patients. However, other studies have shown a vast array of factors different from our study contributing to DAS. These differences might be due to the different studies being set in different cultures, demography, disease process, duration of disease, and financial situations.

A potential limitation to the current study was use of DASS-21 instrument which only determines the presence of DAS symptoms, rather than conducting a diagnostic interview which would have conclusively determined the prevalence of DAS in the population. In addition to that, the clinical characteristics have not been included for the analysis in the current study. For better representation and associations, we also recommend that future studies should be done involving a larger number of samples from multiple centers and by estimating the associations between clinical characteristics of DM too.


  Conclusions Top


The study showed that the prevalence of DAS symptoms was high. Though these symptoms are poorly associated to demographic characteristics, they should be considered together when managing diabetic patients. Our findings could help treating physicians to identify high-risk diabetics for screening of mental disorders. Gender and age group were the common predictors of at least two of these symptoms. Thus, we recommend to screen all the diabetic patients for DAS symptoms. In this regard, DASS-21 questionnaire may be used, because it is easy to perform and inexpensive.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Khan NA, Venkatachalam VV, Alakhali KM, Alavudeen SS, Dhanapal CK, Ansari SM. Therapeutic management of hypertension and hyperlipidemia in type-2 diabetes mellitus patients in southwestern region of Saudi Arabia: A pharmacist perspective. Asian J Pharm Clin Res 2014;7:241-45.  Back to cited text no. 3
    
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Lin EH, Katon W, Von Korff M, Rutter C, Simon GE, Oliver M, et al. Relationship of depression and diabetes self-care, medication adherence, and preventive care. Diabetes Care 2004;27:2154-60.  Back to cited text no. 5
    
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Von Korff M, Katon W, Lin EH, Simon G, Ludman E, Oliver M, et al. Potentially modifiable factors associated with disability among people with diabetes. Psychosom Med 2005;67:233-40.  Back to cited text no. 6
    
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Özcan A, Dursun AB, Cicek T. The comparison of anxiety and depression levels in asthma and COPD patients. World Allergy Organ J 2015;8 Suppl 1:A51.  Back to cited text no. 12
    
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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