Diabetes and depression comorbidity and socio-economic status in low and middle income countries (LMICs): a mapping of the evidence

Prevalence of anxiety and depression among diabetic African patients in Guinea: association with HbA1c levels

AIM

The prevalence and risk factors associated with symptoms of anxiety and depression were determined in African people with diabetes.

METHODS

This cross-sectional study involved 491 outpatients with type 2 diabetes (T2D) recruited from four diabetes clinics (Conakry, Labé, Boké and Kankan) in Guinea. The Hospital Anxiety and Depression Scale (HADS) was used to evaluate symptoms of anxiety and depression. Logistic regression analysis stratified by gender was performed to identify the associated risk factors.

RESULTS

Anxiety and depression symptoms were present in 58.7% and 34.4%, respectively, of the 491 patients with T2D (62.7% women, mean±SD age: 57.9±10.2years). Odds ratios (95% CI) of risk factors independently associated with anxiety were urban residence [2.98 (1.81-4.89)] in women, and low socioeconomic status [0.19 (0.05-0.70)] and HbA1c≥9.0% [2.61 (1.0-6.39)] in men. Factors associated with depression were urban residence [2.13 (1.27-3.58)], older age [1.03 (1.01-1.06)], low socioeconomic status [2.21 (1.34-3.66)] and no previous measurement of HbA1c [12.45 (1.54-100.34)] in women, and insulin therapy [2.28 (1.05-4.92)] and HbA1c≥9.0% [3.85 (1.02-14.48)] in men.

CONCLUSION

Anxiety and depression symptoms in people with type T2D are common in Guinea. Urban residence, low socioeconomic status and high levels of HbA1c were significantly associated with a greater risk of anxiety and depression, highlighting the psychological burden related to diabetes in Africa.

The potential antidepressant and antidiabetic effects of galanin system

Epidemiological and clinical studies demonstrated that type 2 diabetes mellitus and depression are interconnected. Depression is an important risk factor for the development of type 2 diabetes mellitus, while patients with type 2 diabetes mellitus frequently have depressive symptoms. Despite many studies recently probed into the comorbid state of both diseases, so far the precise mechanism for this association is poorly understood. Experiments have demonstrated that neuropeptide galanin is involved in the pathogenesis of depression and type 2 diabetes mellitus. This review provides a new insight into the multivariate relationship among galanin, depression and type 2 diabetes mellitus, highlighting the effect of galanin system on the cross-talk between both diseases in human and rodent models. The current data support that activating central GalR2 attenuates insulin resistance and depressive feature in animal models. These may help us better understand the pathogenesis of both diseases and provide useful hints for the development of novel therapeutic approaches, i.e. to coadministrate GalR2 agonist with traditional antidepressive and antidiabetic medicines to treat depression and type 2 diabetes mellitus.

Leucocyte telomere shortening in relation to newly diagnosed type 2 diabetic patients with depression

The goal of this study is to investigate the association between oxidative stress and telomere length shortening in the comorbid depression and diabetes. Therefore, 71 patients with newly diagnosed type 2 diabetes (T2D) and 52 subjects with normal glycemic level (control, Ctrl) were enrolled. Depressive status was identified with the Depression Subscale of Hospital Anxiety and Depression Scale (HADS-D). Leukocyte telomere length ratio (T/S ratio) was determined with quantitative PCR. Oxidative stress status was evaluated with 8-hydroxy-desoxyguanosine (8-OHdG) assay kit. Some other biochemical blood testing was also performed. The data showed that T2D patients had higher proportion of depression evaluated by the HADS-D (x(2) = 4.196, P = 0.041). T/S ratio was significantly negatively correlated with 8-OHdG, HADS-D, age, HbA1c, FPG, and HOMA-IR. In addition, HADS-D was significantly positively correlated with HbA1c, FPG, HOMA-IR, and 8-OHdG. Both HADS-D and 8-OHdG were the major independent predictors for T/S ratio. This study indicates that oxidative stress contributes to both telomere length shortening and depression development in newly diagnosed type 2 diabetic patients, while in depression status, some other mechanisms besides oxidative stress may also affect the telomere length.

Reorienting women's health in low- and middle-income countries: the case of depression and Type 2 diabetes

Women's health in low- and middle-income countries (LMICs) has historically focused on sexual and reproductive health. However, understanding how women acquire, experience, and treat non-reproductive health conditions, such as non-communicable diseases, has become a fundamental public health concern. Special attention to the social determinants of LMIC women's health can provide socially and culturally relevant knowledge for implementation of policies and programs for women increasingly confronting these ‘New Challenge Diseases’. This article uses the example of depression and Type 2 diabetes comorbidity to illustrate how attending to the social determinants of mental and physical health beyond the reproductive years contributes to a more holistic agenda for women's health. For instance, we must address the plurality of experiences that shape women's health from social determinants of depression, such as gendered subjugation within the home and public sphere, to the structural determinants of obesity and diabetes, such as poor access to healthy foods and health care. Attending to the complexities of health and social well-being beyond the reproductive years helps the women's global health agenda capture the full spectrum of health concerns, particularly the chronic and non-communicable conditions that emerge as life expectancy increases.

Efficacy and cost-effectiveness of a web-based intervention with mobile phone support to treat depressive symptoms in adults with diabetes mellitus type 1 and type 2: design of a randomised controlled trial

BACKGROUND

A diagnosis of diabetes mellitus types 1 or 2 doubles the odds of a comorbid depressive disorder. The combined diseases have a wide range of adverse outcomes, such as a lower quality of life, poorer diabetes outcomes and increased healthcare utilisation. Diabetes patients with depression can be treated effectively with psychotherapy, but access to psychological care is limited. In this study we will examine the efficacy and cost-effectiveness of a newly developed web-based intervention (GET.ON Mood Enhancer Diabetes) for people with diabetes and comorbid depressive symptoms.

METHODS/DESIGN

A two-arm randomised controlled trial will be conducted. Adults with diabetes (type 1 or type 2) with increased depression scores (> 22 on the German version of the Center for Epidemiological Studies Depression Scale (CES-D)) will be included. Eligible participants will be recruited through advertisement in diabetes patient journals and via a large-scale German health insurance company. The participants will be randomly assigned to either a 6-week minimally guided web-based self-help program or an online psychoeducation program on depression. The study will include 260 participants, which will enable us to detect a statistically significant difference with a group effect size of d = 0.35 at a power of 80% and a significance level of p = 0.05. The primary outcome measure will be the level of depression as assessed by the CES-D. The secondary outcome measures will be: diabetes-specific emotional distress, glycaemic control, self-management behaviour and the participants' satisfaction with the intervention. Online self-assessments will be collected at baseline and after a 2 months period, with additional follow-up measurements 6 and 12 months after randomisation. The data will be analysed on an intention-to-treat basis and per protocol. In addition, we will conduct an economic evaluation from a societal perspective.

DISCUSSION

If this intervention is shown to be cost-effective, it has considerable potential for implementing psychological care for large numbers of people with diabetes and comorbid depression in routine practice and improve health outcomes.

TRIAL REGISTRATION

German Clinical Trial Register (DRKS): DRKS00004748.

Prevalence of depression and associated risk factors among persons with type-2 diabetes mellitus without a prior psychiatric history: a cross-sectional study in clinical settings in urban Nepal

BACKGROUND

Diabetes is a growing health problem in South Asia. Despite an increasing number of studies exploring causal pathways between diabetes and depression in high-income countries (HIC), the pathway between the two disorders has received limited attention in low and middle-income countries (LMIC). The aim of this study is to investigate the potential pathway of diabetes contributing to depression, to assess the prevalence of depression, and to evaluate the association of depression severity with diabetes severity. This study uses a clinical sample of persons living with diabetes sequelae without a prior psychiatric history in urban Nepal.

METHODS

A cross-sectional study was conducted among 385 persons living with type-2 diabetes attending tertiary centers in Kathmandu, Nepal. Patients with at least three months of diagnosed diabetes and no prior depression diagnosis or family history of depression were recruited randomly using serial selection from outpatient medicine and endocrine departments. Blood pressure, anthropometrics (height, weight, waist and hip circumference) and glycated hemoglobin (HbA1c) were measured at the time of interview. Depression was measured using the validated Nepali version of the Beck Depression Inventory (BDI-Ia).

RESULTS

The proportion of respondents with depression was 40.3%. Using multivariable analyses, a 1-unit (%) increase in HbA1c was associated with a 2-point increase in BDI score. Erectile dysfunction was associated with a 5-point increase in BDI-Ia. A 10 mmHg increase in blood pressure (both systolic and diastolic) was associated with a 1.4-point increase in BDI-Ia. Other associated variables included waist-hip-ratio (9-point BDI-Ia increase), at least one diabetic complication (1-point BDI-Ia increase), treatment non-adherence (1-point BDI-Ia increase), insulin use (2-point BDI-Ia increase), living in a nuclear family (2-point BDI-Ia increase), and lack of family history of diabetes (1-point BDI-Ia increase). Higher monthly income was associated with increased depression severity (3-point BDI-Ia increase per 100,000 rupees, equivalent US$1000).

CONCLUSIONS

Depression is associated with indicators of more severe diabetes disease status in Nepal. The association of depression with diabetes severity and sequelae provide initial support for a causal pathway from diabetes to depression. Integration of mental health services in primary care will be important to combat development of depression among persons living with diabetes.

Reward-based, task-setting education strategy on glycemic control and self-management for low-income outpatients with type 2 diabetes

AIMS/INTRODUCTION

The purpose of the study was to determine the feasibility and effect of a reward-based, task-setting strategy for low-income outpatients with type 2 diabetes.

MATERIALS AND METHODS

Indigent diabetes outpatients without glucometers were eligible to participate in this trial. A total of 132 cases were randomly recruited. Participants in group B used glucometers for self-monitoring at no cost. Group A participants could keep the glucometers only if the glycosylated hemoglobin level declined compared with the baseline visit; for those not achieving a reduction in the glycosylated hemoglobin level, the glucometers would have to be returned. Group C served as the control group without self-monitoring setout. Diabetes education was provided to all groups. Metabolic indices and self-management were evaluated after 6 months of follow up.

RESULTS

Group A had a significant decline in the glycosylated hemoglobin level (-0.97%) and medical costs (-159 yuan) compared with the baseline visit, whereas groups B and C had a decrease in the glycosylated hemoglobin levels alone (-0.62 and -0.57%, respectively). The body mass index did not change significantly in any group. There was a statistical difference in the glycosylated hemoglobin level of group A compared with groups B and C. Self-management in group A improved the outcome relative to groups B and C.

CONCLUSIONS

This preliminary evidence suggests that the program is feasible, acceptable for improving patient self-management, and cost-effective in reducing the glycosylated hemoglobin level and medical costs.

The comorbidity between depression and diabetes

Comorbidity of depression and diabetes is common, and each disorder has a negative impact on the outcome of the other. The direction of causality is not certain as each disorder seems to act as both a risk factor and consequence for the other in longitudinal studies. This bidirectional association is possibly mediated by shared environmental and genetic risk factors. Comorbid depression is associated with reduced adherence to medication and self-care management, poor glycaemic control, increased health care utilization, increased costs and elevated risk of complications, as well as mortality in patients with diabetes. Psychological and pharmacological interventions are shown to be effective in improving depression symptoms; however, collaborative care programs that simultaneously manage both disorders seem to be most effective in improving diabetes-related outcomes.