الخلاصة: ارتبط الاكتئاب بمعدلات أعلى للوفيات وللمراضة لدى مرضى السكري، ورغم ذلك لم تحظ هذه القضية بدراسات كافية في جمهورية
إيران الإسلامية. وقد أجرى الباحثون هذه الدراسة العرضية لوصف معدل انتشار الاكتئاب لدى المراجعين لعيادة معالجة السكري في أوريميا،
وللتعرف على العوامل السريرية )الإكلينيكية( والسلوكية والاجتماعية والديموغرافية المصاحبة. وقد شملت الدراسة 295 مريضاً، كان لدى 128
%43.4 ( منهم أحراز الاكتئاب تساوي أو تزيد عن 15 وفق مسرد بيك للاكتئاب. وبلغ الحرز الوسطي لجميع المرضى 15.4 )والانحراف المعياري (
9.5 (. وقد كان مرضى السكري المصابون باكتئاب أكبر سناً وأقل تعليماً بشكل واضح ممن لا يعانون من الاكتئاب، كما كان لديهم فترة أطول من
الإصابة بالسكري، ومعاناة أكثر من مضاعفاته. وبالتحليل للتحوف اللوجستي وجد الباحثون أن التقدم في العمر كان هو المتغير الوحيد المصاحب
للاكتئاب تصاحباً يُعْتَدُّ به إحصائياً.
ABSTRACT Depression has been linked to greater mortality and morbidity in diabetic patients, but this issue has
not been adequately studied in the Islamic Republic of Iran. This cross-sectional study described the prevalence
of depression in patients attending a diabetes clinic in Urmia and determined the associated sociodemographic,
behavioural and clinical factors. Of 295 patients, 128 (43.4%) had depression scores (≥ 15) on the Beck Depression
Inventory. The mean score for all patients was 15.4 (SD 9. 5). Those with depression were significantly older and
less educated than those without depression, had a longer duration of diabetes and were more likely to suffer
complications. On logistic regression analysis, older age was the only variable significantly associated with
depression.
Introduction
Depression is recognized as an important
co-morbidity in a number of chronic
medical conditions such as diabetes
[1]. Reports indicate that patients with
diabetes are 1.5–2 times more likely
to have depression than those without
[1]. A recent meta-analysis of 39 studies
of patients with diabetes estimated the
prevalence of major depression (based
on psychiatric interviews) as 11% and
elevated depression symptoms (based
on depression rating scales) as 31%
[2]. Depression contributes to poor
metabolic control, decreased quality of
life and increased medical morbidity
and mortality in patients with diabetes
[2–5], as well as significantly higher
medical costs [6]. More encouragingly,
however, there is evidence that therapy
to treat depressive conditions is effective
and improves the mood, functioning
and quality of life in diabetic patients
[7,8].
Some sociodemographic, behavioural
and clinical factors seem to be
associated with depression in diabetic
patients although the results are conflicting.
Research has shown a high risk
for female sex, younger age, lower education
and lower income [2]. Another
study indicated that age and chronic
conditions may be significant independent
predictors of depressive symptoms,
but that depression was unrelated to
sex, ethnic group, duration or type of
diabetes [9].
Despite the many reports of an
association between depression and
diabetes, the validity of these findings
in different cultures and communities
remains to be shown [10]. Diabetes currently
affects approximately 3%–5% of
the population of the Islamic Republic
of Iran and this figure is expected to
rise considerably by the year 2025 [11].
Furthermore, the Global Burden of
Disease Survey estimated that by 2020
major depression will be second leading
cause of disease burden worldwide after
ischaemic heart disease [12].
In the Islamic Republic of Iran research
on depression in diabetic patients
is lacking, and depression frequently remains
unrecognized and undertreated.
The aim of this study was to describe the
prevalence of depression in individuals
with diabetes in Urmia, Islamic Republic
of Iran, and determine the associated
sociodemographic, behavioural and
clinical factors.
Methods
This was a cross-sectional study conducted
from February to August 2006.
Sample
A convenience sample was drawn from
attendees at the Taleghani diabetes
clinic in Urmia, Islamic Republic of Iran.
Based on a power analysis using a moderate
effect size and probability level of
0.05, significance level of 0.05 and 0.80
power, a sample size of 300 participants
was judged to be adequate.
Physicians referred patients for
participation in the study based on the
following criteria: currently taking any
diabetic medication, fasting blood glucose
> 126 mg/mL (confirmed with a
second out-of-range test); and a hospital
discharge diagnosis of diabetes.
Patients with a current diagnosis of type
2 diabetes and age > 30 years were assigned
consecutively to the study. Patients
diagnosed with type 1 diabetes
(onset < 30 years of age and insulin
as the first treatment prescribed) were
excluded [2].
The aim of the study was explained
to all participants, who signed the consent
form. Permission to conduct this
research was granted by the ethics committee
at the Urmia Medical Sciences
University. Only 5 patients refused to
participate and therefore 295 patients
were enrolled in this study.
Data collection
A questionnaire was used to collect data
about clinical status: age at onset and
duration of diabetes; complications of
diabetes; treatment intensity; current
smoking (daily and occasional smokers);
and body mass index (BMI).
Treatment intensity was classified into:
insulin therapy (alone or combination)
or other therapy (oral agents, diet). BMI
was divided into 2 categories: normal
< 25 kg/m2 or overweight ≥ 25 kg/m2.
Demographic data were also collected
about: age, sex, marital status, educational
level and income level. Marital
status was classified as unmarried (single/
divorced/widowed) or married.
Participants were classified into low or
middle/high income groups based on
total household income divided by the
number of household members. This
categorization was based on patients’
reports. Educational level was classified
as low (illiterate/primary/middle
school) or high (high school/college/
university).
All patients completed a Farsi version
of the Beck Depression Inventory
(BDI) [13]. The BDI is a standard selfreported
questionnaire containing 21
items that measure the presence and
severity of cognitive and somatic symptoms
of depression on a scale from
0–63, with higher scores indicating
greater depression. Each item evaluates
a category according to a scale of
4 possible responses of increasing severity.
It has been validated in patients
with diabetes and screens effectively
for major depression in this population
[3,14,15]. Standard cut-offs were used
in this study: 0–15 (no depression);
16–30 (mild), 31–46 (moderate) and
≥ 47 (severe).
All information was collected by interview.
Two trained medical students
interviewed the patients and filled out
the forms. They also helped patients to
fill out the BDI if they had any problems.
Analysis
All statistical analyses were done using
SPSS, version 12.0. The prevalence
was determined by simple percentages.
We also examined group differences
in sociodemographic, behavioural and
clinical variables between patients with
and without depression by using the
chi-squared test for categorical variables
and independent t-test for continuous
data. The effect of variables on depression
was also estimated in men and
women separately. The P-value was
significant at < 0.05.
Logistic regression models were
constructed to model the odds of having
depression versus no depression. All
variables were examined for the association
with depression including sociodemographic
factors (age, sex, education,
marital status and income), behavioural
risk factors (BMI and smoking) and
diabetes clinical factors (duration of diabetes,
treatment intensity and number
of complications). Odds ratios (OR)
and their 95% confidence intervals (CI)
were estimated for all variables in the
models.
Results
Background characteristics
The mean age of this sample of diabetic
patients was 52.4 [standard deviation
(SD) 12.0] years. Of the 295 patients
205 (69.5%) were women. The mean
age of males and females was not significantly
different [51.6 (SD 13) years
versus 53.5 (SD 12) years]. Three-quarters
(74.8%) of participants had a low
education level, below high school. The
sample was predominantly low income
with 55.9% of participants reporting an
income < US$ 150 per month.
The mean BMI was 28.4 (SD 4.9)
kg/m2, and 78.2% of participants were
overweight (BMI . 25 kg/m2). Treatment
intensity showed that 83.0% were
managed with oral agents/diet only
and 17.0% were on insulin (alone or
combination). Half of patients (50.9%)
reported having at least 1 complication
of diabetes, e.g. cardiovascular disease,
nephropathy, retinopathy and diabetic
foot; 10.1% experienced 2 or more complications.
There were higher rates of
cardiovascular disease and nephropathy
compared with other complications.
Patients with 1 or more complication
had a significantly higher mean duration
of diabetes than those without any complications
[9.4 (SD 6.8) years versus
7.3 (SD 6.0) years] (P < 0.005) and a
significantly higher mean age [56.0 (SD
13) years versus 47.5 (SD 12) years] (P
< 0.001).
Prevalence of depression
Of the 295 patients, 128 (43.4%) met
the diagnostic criteria for depression
(BDI score . 15); 36.3% were classified
as minor (BDI score 16.30), 5.8%
as moderate (BDI score 31.46) and
1.3% as severe depression (BDI score .
47). The mean score on the BDI for the
whole sample of diabetic patients was
15.4 (SD 9.5).
Factors associated with
depression
Compared with the group without
depression, those with depression were
significantly older [mean age 55.6 (SD
12) years versus 50.4 (SD 13) years] (P
< 0.05) (Table 1). Patients who were .
50 years had a significantly higher risk
of having depression symptoms than
those < 50 years (OR 1.64, 95% CI:
1.21.2.42) (P < 0.01).
More women (94/205, 45.9%)
than men (34/90, 37.8%) had depression
scores on the BDI but this was not
statistically significant. However, mean
BDI scores for women were significantly
higher than for men [16.6 (SD 10.4)
versus 12.8 (SD 8.1)] (P < 0.02).
Depressed patients were less educated
than nondepressed patients (only
81.3% versus 68.3% had low educational
level) (P < 0.05) and poorer (64.1%
versus 52.4% had low income level)
(P < 0.05) (Table 1). There was also
significant difference regarding marital
status; a higher proportion of depressed
patients were married (97.4%) than
nondepressed patients (92.9%) (P <
0.05).
Clinical factors associated with depression
were duration of diabetes and
having complications of diabetes. The
mean duration of diabetes was 9.2
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إيران الإسلامية. وقد أجرى الباحثون هذه الدراسة العرضية لوصف معدل انتشار الاكتئاب لدى المراجعين لعيادة معالجة السكري في أوريميا،
وللتعرف على العوامل السريرية )الإكلينيكية( والسلوكية والاجتماعية والديموغرافية المصاحبة. وقد شملت الدراسة 295 مريضاً، كان لدى 128
%43.4 ( منهم أحراز الاكتئاب تساوي أو تزيد عن 15 وفق مسرد بيك للاكتئاب. وبلغ الحرز الوسطي لجميع المرضى 15.4 )والانحراف المعياري (
9.5 (. وقد كان مرضى السكري المصابون باكتئاب أكبر سناً وأقل تعليماً بشكل واضح ممن لا يعانون من الاكتئاب، كما كان لديهم فترة أطول من
الإصابة بالسكري، ومعاناة أكثر من مضاعفاته. وبالتحليل للتحوف اللوجستي وجد الباحثون أن التقدم في العمر كان هو المتغير الوحيد المصاحب
للاكتئاب تصاحباً يُعْتَدُّ به إحصائياً.
ABSTRACT Depression has been linked to greater mortality and morbidity in diabetic patients, but this issue has
not been adequately studied in the Islamic Republic of Iran. This cross-sectional study described the prevalence
of depression in patients attending a diabetes clinic in Urmia and determined the associated sociodemographic,
behavioural and clinical factors. Of 295 patients, 128 (43.4%) had depression scores (≥ 15) on the Beck Depression
Inventory. The mean score for all patients was 15.4 (SD 9. 5). Those with depression were significantly older and
less educated than those without depression, had a longer duration of diabetes and were more likely to suffer
complications. On logistic regression analysis, older age was the only variable significantly associated with
depression.
Introduction
Depression is recognized as an important
co-morbidity in a number of chronic
medical conditions such as diabetes
[1]. Reports indicate that patients with
diabetes are 1.5–2 times more likely
to have depression than those without
[1]. A recent meta-analysis of 39 studies
of patients with diabetes estimated the
prevalence of major depression (based
on psychiatric interviews) as 11% and
elevated depression symptoms (based
on depression rating scales) as 31%
[2]. Depression contributes to poor
metabolic control, decreased quality of
life and increased medical morbidity
and mortality in patients with diabetes
[2–5], as well as significantly higher
medical costs [6]. More encouragingly,
however, there is evidence that therapy
to treat depressive conditions is effective
and improves the mood, functioning
and quality of life in diabetic patients
[7,8].
Some sociodemographic, behavioural
and clinical factors seem to be
associated with depression in diabetic
patients although the results are conflicting.
Research has shown a high risk
for female sex, younger age, lower education
and lower income [2]. Another
study indicated that age and chronic
conditions may be significant independent
predictors of depressive symptoms,
but that depression was unrelated to
sex, ethnic group, duration or type of
diabetes [9].
Despite the many reports of an
association between depression and
diabetes, the validity of these findings
in different cultures and communities
remains to be shown [10]. Diabetes currently
affects approximately 3%–5% of
the population of the Islamic Republic
of Iran and this figure is expected to
rise considerably by the year 2025 [11].
Furthermore, the Global Burden of
Disease Survey estimated that by 2020
major depression will be second leading
cause of disease burden worldwide after
ischaemic heart disease [12].
In the Islamic Republic of Iran research
on depression in diabetic patients
is lacking, and depression frequently remains
unrecognized and undertreated.
The aim of this study was to describe the
prevalence of depression in individuals
with diabetes in Urmia, Islamic Republic
of Iran, and determine the associated
sociodemographic, behavioural and
clinical factors.
Methods
This was a cross-sectional study conducted
from February to August 2006.
Sample
A convenience sample was drawn from
attendees at the Taleghani diabetes
clinic in Urmia, Islamic Republic of Iran.
Based on a power analysis using a moderate
effect size and probability level of
0.05, significance level of 0.05 and 0.80
power, a sample size of 300 participants
was judged to be adequate.
Physicians referred patients for
participation in the study based on the
following criteria: currently taking any
diabetic medication, fasting blood glucose
> 126 mg/mL (confirmed with a
second out-of-range test); and a hospital
discharge diagnosis of diabetes.
Patients with a current diagnosis of type
2 diabetes and age > 30 years were assigned
consecutively to the study. Patients
diagnosed with type 1 diabetes
(onset < 30 years of age and insulin
as the first treatment prescribed) were
excluded [2].
The aim of the study was explained
to all participants, who signed the consent
form. Permission to conduct this
research was granted by the ethics committee
at the Urmia Medical Sciences
University. Only 5 patients refused to
participate and therefore 295 patients
were enrolled in this study.
Data collection
A questionnaire was used to collect data
about clinical status: age at onset and
duration of diabetes; complications of
diabetes; treatment intensity; current
smoking (daily and occasional smokers);
and body mass index (BMI).
Treatment intensity was classified into:
insulin therapy (alone or combination)
or other therapy (oral agents, diet). BMI
was divided into 2 categories: normal
< 25 kg/m2 or overweight ≥ 25 kg/m2.
Demographic data were also collected
about: age, sex, marital status, educational
level and income level. Marital
status was classified as unmarried (single/
divorced/widowed) or married.
Participants were classified into low or
middle/high income groups based on
total household income divided by the
number of household members. This
categorization was based on patients’
reports. Educational level was classified
as low (illiterate/primary/middle
school) or high (high school/college/
university).
All patients completed a Farsi version
of the Beck Depression Inventory
(BDI) [13]. The BDI is a standard selfreported
questionnaire containing 21
items that measure the presence and
severity of cognitive and somatic symptoms
of depression on a scale from
0–63, with higher scores indicating
greater depression. Each item evaluates
a category according to a scale of
4 possible responses of increasing severity.
It has been validated in patients
with diabetes and screens effectively
for major depression in this population
[3,14,15]. Standard cut-offs were used
in this study: 0–15 (no depression);
16–30 (mild), 31–46 (moderate) and
≥ 47 (severe).
All information was collected by interview.
Two trained medical students
interviewed the patients and filled out
the forms. They also helped patients to
fill out the BDI if they had any problems.
Analysis
All statistical analyses were done using
SPSS, version 12.0. The prevalence
was determined by simple percentages.
We also examined group differences
in sociodemographic, behavioural and
clinical variables between patients with
and without depression by using the
chi-squared test for categorical variables
and independent t-test for continuous
data. The effect of variables on depression
was also estimated in men and
women separately. The P-value was
significant at < 0.05.
Logistic regression models were
constructed to model the odds of having
depression versus no depression. All
variables were examined for the association
with depression including sociodemographic
factors (age, sex, education,
marital status and income), behavioural
risk factors (BMI and smoking) and
diabetes clinical factors (duration of diabetes,
treatment intensity and number
of complications). Odds ratios (OR)
and their 95% confidence intervals (CI)
were estimated for all variables in the
models.
Results
Background characteristics
The mean age of this sample of diabetic
patients was 52.4 [standard deviation
(SD) 12.0] years. Of the 295 patients
205 (69.5%) were women. The mean
age of males and females was not significantly
different [51.6 (SD 13) years
versus 53.5 (SD 12) years]. Three-quarters
(74.8%) of participants had a low
education level, below high school. The
sample was predominantly low income
with 55.9% of participants reporting an
income < US$ 150 per month.
The mean BMI was 28.4 (SD 4.9)
kg/m2, and 78.2% of participants were
overweight (BMI . 25 kg/m2). Treatment
intensity showed that 83.0% were
managed with oral agents/diet only
and 17.0% were on insulin (alone or
combination). Half of patients (50.9%)
reported having at least 1 complication
of diabetes, e.g. cardiovascular disease,
nephropathy, retinopathy and diabetic
foot; 10.1% experienced 2 or more complications.
There were higher rates of
cardiovascular disease and nephropathy
compared with other complications.
Patients with 1 or more complication
had a significantly higher mean duration
of diabetes than those without any complications
[9.4 (SD 6.8) years versus
7.3 (SD 6.0) years] (P < 0.005) and a
significantly higher mean age [56.0 (SD
13) years versus 47.5 (SD 12) years] (P
< 0.001).
Prevalence of depression
Of the 295 patients, 128 (43.4%) met
the diagnostic criteria for depression
(BDI score . 15); 36.3% were classified
as minor (BDI score 16.30), 5.8%
as moderate (BDI score 31.46) and
1.3% as severe depression (BDI score .
47). The mean score on the BDI for the
whole sample of diabetic patients was
15.4 (SD 9.5).
Factors associated with
depression
Compared with the group without
depression, those with depression were
significantly older [mean age 55.6 (SD
12) years versus 50.4 (SD 13) years] (P
< 0.05) (Table 1). Patients who were .
50 years had a significantly higher risk
of having depression symptoms than
those < 50 years (OR 1.64, 95% CI:
1.21.2.42) (P < 0.01).
More women (94/205, 45.9%)
than men (34/90, 37.8%) had depression
scores on the BDI but this was not
statistically significant. However, mean
BDI scores for women were significantly
higher than for men [16.6 (SD 10.4)
versus 12.8 (SD 8.1)] (P < 0.02).
Depressed patients were less educated
than nondepressed patients (only
81.3% versus 68.3% had low educational
level) (P < 0.05) and poorer (64.1%
versus 52.4% had low income level)
(P < 0.05) (Table 1). There was also
significant difference regarding marital
status; a higher proportion of depressed
patients were married (97.4%) than
nondepressed patients (92.9%) (P <
0.05).
Clinical factors associated with depression
were duration of diabetes and
having complications of diabetes. The
mean duration of diabetes was 9.2
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