You are here: Home >Current/Archive>Read Full Text>
Psychiatric morbidity in patients with Diabetes Mellitus: A hospital based study in Kashmir
*Read PDF Version*
RESEARCH PAPER |
Psychiatric morbidity in patients with Diabetes Mellitus: A hospital based study in Kashmir Sheikh Shoib1, Mohammad Maqbool Dar1, Haamid Bashir2, Tasleem Arif1 1 Department of Psychiatry, SMHS Hospital Srinagar 2 Department of Biochemistry, University of Kashmir |
| Abstract: Background: Diabetes mellitus (DM) is an illness that in addition to its physical consequences has psychological and social impairments. The association between DM and psychiatric disorders are considered bidirectional and this study looked at the pattern of psychiatric morbidity in patients with DM. Methodology: We conducted a cross-sectional study over a period of one year in SMHS Government medical college associated Hospital in Srinagar. We selected every alternate patient with DM attending the endocrinology outpatient clinic. A semi structured interview was conducted along with the administration of the Mini International Neuropsychiatric Interview –Plus (MINI - Plus) for evaluation of psychiatric symptoms and diagnosis. An age and sex matched control group (n = 200) was selected from among non-diabetic patients. Results: Out of total 200 subjects 87 were males (43.5 %), and 113 were females (56.5 %). The mean age was 45 ± 15 years. 71% were married and 11.5% were unmarried. 57% of patients with DM had significant psychiatric morbidity. Only 25.5% of the control group had psychiatric problems (p=<0.005). Depressive disorder (13.5%) was the most common presentation, followed by Adjustment disorder (7.5%), Premenstrual dysphoric disorder (6.5%), Panic disorder (6%), Generalized anxiety disorder (5.5%), Dysthymia (4.5%), Suicidality (4%), Mixed anxiety (1.5%) and OCD and agoraphobia (1.5%) each. Conclusion: The increased frequency of psychiatric morbidity among patients with DM raises the need for early diagnosis and treatment. Key words: Diabetes mellitus, psychiatric morbidity. |
Introduction
Diabetes represents a major public health burden, both locally and globally (Wild, Roglic, Green, Sicree, & King, 2004). An estimated 285 million people corresponding to 6-8% of the adult population lived with diabetes in 2010. The number is expected to increases to 438 million by 2030. With an estimated 50.8 million people living with diabetes, India has the world’s largest population followed by china with 43.2 million people (International Diabetes Federation, 2009). The prevalence of psychiatric morbidity among insulin-dependent patients is 18% and consists of depression, anxiety, and attendant symptoms (Wilkinson et al., 1988). In contrast the incidence of diabetes mellitus in psychiatric patients has been found to be two to eight times higher than in the general population (Blanz, Rensch-Riemann, Fritz-Sigmund, & Schmidt, 1993; Cassidy, Ahearn, & Carroll, 1999; Mukherjee, Decina, Bocola, Saraceni, & Scapicchio, 1996). Diabetics are twice as likely as the general population to suffer from depression, with the risk higher in women than in men. During 5 year follow up, up to 80% of diabetics have recurrence of depressive episodes (P. J. Lustman, Griffith, Freedland, & Clouse, 1997; Robinson, Fuller, & Edmeades, 1988). Diabetics suffering depression have a higher incidence of suicidal ideations (Goldston et al., 1997). Depression and anxiety in particular, are more frequent in diabetic patients, compared to the general population (P. J. Lustman et al., 2000; Pita et al., 2002). Psychological stress factors play an active role in both the etiology and the metabolic control of DM (Cox & Gonder-Frederick, 1992).Other contributing factors in type 2 DM pathogenesis include environmental and lifestyle factors (Bener, Zirie, Musallam, Khader, & Al-Hamaq, 2009; Bener, Zirie, Janahi, et al., 2009; Kriska et al., 2003), positive family history (Erasmus et al., 2001), ethnicity (Abate & Chandalia), and genetics (Bener, Zirie, Musallam, et al., 2009; Bener, Zirie, Janahi, et al., 2009; Sesti, Federici, Lauro, Sbraccia, & Lauro).
The adverse influence of depression on the course of diabetes has been discussed extensively (P. Lustman & Anderson, 2002). Screening leads to high stress among those with a positive result, or false reassurance in those with a negative result where the subjects are less likely to take appropriate corrective action (Madhu & Sridhar, 2005).
Patients with mental health disorders receive even less intensive medical care for DM (Desai, Rosenheck, Druss, & Perlin, 2002; Frayne et al.). Adherence to treatment in DM was adversely affected by the occurrence of natural calamities (Ramachandran, 2005). A lesser degree of psychological distress not amounting to psychiatric morbidity is also more common (Sridhar & Madhu, 2002). The quality of life of the patient is adversely affected due to the knowledge about the course of illness, restriction of diet and activity, closely monitored management schedules and the continued risk of acute and chronic life threatening complications (Kovacs, Goldston, Obrosky, & Bonar, 1997). “Diabetes burnout” and “Diabetes overwhelmus” are the words used often to describe the distress experienced by DM patients (Balhara, 2011). The aim of the study was to assess the pattern of psychiatric morbidity in patients with DM.
Methodology
We conducted a cross-sectional study over a period of one year in the SMHS Government medical college associated Hospital in Srinagar. Every alternate patient attending the endocrinology outpatient clinic was included after informed consent. A total of 200 patients were included in the study. Demographic data and psychiatric history were recorded using a semi structured interview. Patients were subjected to the Mini International Neuropsychiatric Interview -Plus (MINI - Plus) for evaluation of symptoms and diagnosis. The MINI-Plus is a DSM-IV based diagnostic interview with high reliability and validity. An age and sex matched control group (n=200) was selected from non-diabetic patients were also administered the same instruments.
Diabetes was diagnosed based on drug treatment for diabetes (insulin or oral hypoglycemic agents) and/or criteria laid by the ADA in 2004 i.e. fasting plasma glucose (FPG) 126 mg/dl or 2 hour post-glucose value of 200 mg/dl. Impaired glucose tolerance (IGT) was diagnosed if FPG was <126 mg/dl and 2 hour. post- glucose value (140 mg/dl and <200 mg/dl (American Diabetes Association, 2004). The diabetics included both insulin dependent and non-insulin dependent patients. Patients with past history or family history of diabetes mellitus in both the groups were not included in this study. Similarly, patients suffering from other physical disorders were also excluded, as were those who were unwilling to participate. Ethical approval for the study was obtained.
Results
Two hundred diabetic patients from the endocrinological departments of Govt. Medical College, Srinagar hospital were included in the study. There were 87 males (43.5%), and 113 females (56.5%). Most of the participants were in the 41-50 year age group (33.5%) followed by 51-60 years (22.5%) (Table 1). Psychiatric co-morbidity was significantly higher among females than in the males (p=0.0097) (Table-2). Psychiatric co-morbidity was also higher in the rural population than in the urban population (p<0.001). There was no significant difference in the number of the patients in whom the psychiatric co-morbidity was present and in those in whom it was absent in the different socio-economic status of patients. The p-value of the comparison is 0.0025 which is significant.
Of the diabetics, 57% were found to have psychiatric morbidity in contrast to 25% in a non-diabetic control group (p=0.0027). Depressive disorder (13.5%) was the most common morbidity, followed by adjustment disorder (7.5%), premenstrual dysphoric disorder (6.5%), panic disorder (6%), generalized anxiety disorder (5.5%), dysthymia (4.5%), suicidality (4%), mixed anxiety (1.5%), OCD and agoraphobia (1.5%) and other disorders as tabulated. Among the control group, the most common diagnoses were depressive disorder and panic disorder (3.5%) and adjustment disorder (2.5%).
Characteristic |
Present |
Absent |
p value |
|||
n |
% |
n |
% |
|||
Age (years) |
≤ 25 |
8 |
53.3 |
7 |
46.7 |
0.0043 |
26 to 40 |
23 |
71.8 |
9 |
28.1 |
||
41 to 50 |
38 |
62.2 |
23 |
37.7 |
||
51 to 60 |
23 |
51.1 |
22 |
48.8 |
||
61 to 70 |
14 |
45.2 |
17 |
58.8 |
||
> 70 |
8 |
50 |
8 |
50 |
||
Gender |
Male |
38 |
43.7 |
49 |
56.3 |
0.0097 |
Female |
76 |
67.6 |
37 |
32.8 |
||
Dwelling |
Rural |
71 |
62.2 |
51 |
44.7 |
p < 0.001 |
Urban |
43 |
55.1 |
35 |
44.9 |
||
Marital status |
Unmarried |
11 |
47.8 |
12 |
52.2 |
1.257 |
Married |
90 |
63.3 |
52 |
36.6 |
||
Widowed |
13 |
37.1 |
22 |
62.9 |
||
Occupation |
Household |
68 |
63.6 |
39 |
36.4 |
0.0058 |
Unskilled |
19 |
61.2 |
12 |
38.7 |
||
Semiskilled |
17 |
51.5 |
16 |
48.4 |
||
Skilled |
9 |
36 |
16 |
64 |
||
Professional |
1 |
25 |
3 |
75 |
||
Family type |
Nuclear |
49 |
56.3 |
38 |
43.7 |
p < 0.005 |
Joint |
21 |
43.8 |
27 |
56.2 |
||
Extended |
44 |
67.7 |
21 |
32.3 |
||
Literacy status |
Illiterate |
68 |
58.1 |
49 |
41.9 |
0.0016 |
Literate |
46 |
55.4 |
37 |
44.6 |
||
Family Income (Rs) |
< 5000 |
19 |
51.4 |
18 |
48.6 |
2.572 |
5000 to 10000 |
82 |
71.9 |
52 |
38.1 |
||
> 10000 |
13 |
44.8 |
16 |
55.2 |
||
Socioeconomic status (Kuppuswamy Scale) |
Lower |
11 |
52.4 |
10 |
47.6 |
0.0025 |
Upper lower |
7 |
36.8 |
12 |
63.2 |
||
Middle |
81 |
63.8 |
53 |
41.7 |
||
Upper middle |
10 |
41.7 |
14 |
58.3 |
||
Upper |
5 |
55.5 |
4 |
44.5 |
||
Table 1 - Demographic characteristics of the studied patients |
Characteristic |
n |
% |
|
Age (years) |
≤ 25 |
15 |
7.5 |
26 to 40 |
32 |
16 |
|
41 to 50 |
61 |
30.5 |
|
51 to 60 |
45 |
22.5 |
|
61 to 70 |
31 |
15.5 |
|
> 70 |
16 |
8 |
|
Mean ± SD |
45 ± 15 |
||
Gender |
Male |
87 |
43.5 |
Female |
113 |
56.5 |
|
Dwelling |
Rural |
122 |
61 |
Urban |
78 |
39 |
|
Marital status |
Unmarried |
23 |
11.5 |
Married |
142 |
71 |
|
Widowed |
35 |
17.5 |
|
Occupation |
Household |
107 |
53.5 |
Unskilled |
31 |
15.5 |
|
Semiskilled |
33 |
16.5 |
|
Skilled |
25 |
12.5 |
|
Professional |
4 |
2 |
|
Family type |
Nuclear |
87 |
43.5 |
Joint |
48 |
25 |
|
Extended |
65 |
32.5 |
|
Literacy status |
Illiterate |
117 |
58.5 |
Primary |
13 |
6.5 |
|
Secondary |
22 |
11 |
|
Matric |
27 |
13.6 |
|
Graduate |
17 |
8.5 |
|
Postgraduate/Professional |
4 |
2 |
|
Family Income (Rs) |
< 5000 |
37 |
18.5 |
5000 to 10000 |
134 |
67 |
|
> 10000 |
29 |
14.5 |
|
Socioeconomic status (Kuppuswamy Scale) |
Lower |
21 |
10.5 |
Upper lower |
19 |
9.5 |
|
Middle |
127 |
63.5 |
|
Upper middle |
24 |
12 |
|
Upper |
9 |
4.5 |
|
Group |
Number of patients with psychiatric comorbidity |
Percentage of psychiatric comorbidity |
p value |
Index group (n=200) |
114 |
57 |
p < 0.0027 |
Control group (n=200) |
57 |
25.5 |
Table 3 - Morbidity compared with control group |
Psychiatric disorders |
Index group |
% |
Control group |
% |
p value |
Major depressive disorder |
27 |
13.5 |
7 |
3.5 |
0.0036 |
Dysthymia |
9 |
4.5 |
4 |
2 |
0.0489 |
Suicidality |
8 |
4 |
3 |
1.5 |
0.0185 |
Panic disorder |
12 |
6 |
7 |
3.5 |
0.0256 |
Alcohol abuse and dependence disorder |
3 |
1.5 |
2 |
1 |
0.448 |
Generalized anxiety disorder |
11 |
5.5 |
6 |
3 |
0.859 |
PTSD |
1 |
0.5 |
1 |
0.5 |
p < 0.001 |
Social anxiety disorder |
2 |
1 |
1 |
0.5 |
p < 0.005 |
Mixed anxiety-depressive disorder |
3 |
1.5 |
1 |
0.5 |
0.0285 |
Premenstrual dysphoric disorder |
13 |
6.5 |
6 |
3 |
0.0789 |
Psychotic disorder |
1 |
0.5 |
0 |
- |
1.256 |
OCD |
3 |
1.5 |
2 |
1.5 |
0.0111 |
Agoraphobia |
3 |
1.5 |
2 |
2 |
0.458 |
Specific phobia |
3 |
1.5 |
4 |
2 |
0.586 |
Adjustment disorder |
15 |
7.5 |
5 |
2.5 |
0.789 |
Total psychiatric comorbidity |
114 |
57 |
51 |
25.5 |
p < 0.005 |
Table 4 - Pattern of psychiatric morbidity |
Major depressive disorder, dysthymia, suicidality, panic disorder, social anxiety disorder, OCD and mixed anxiety and depression were significantly higher in the patients with DM. Generalized anxiety disorder, dysthymia, agoraphobia, specific phobia, alcohol and substance dependence, adjustment disorder, premenstrual dysphoric disorder and psychotic disorders were not associated with DM (Table 4).
Discussion
This cross-sectional study found DM to be associated with high psychiatric morbidity including major depressive disorder. We found twice the frequency of psychiatric disorders as compared to non-diabetics which is comparable to a study done by Kovacs M et al (1997) with had a prevalence of 47.6% for psychiatric disorders in DM. Another study carried by Sushil and Vyas (1990), reported that 74% of those with DM had psychiatric comorbidity. Our findings are also consistent with a study done by Lloyd and Brown (2002) who found that all psychiatric disorders and especially depression was more common in DM. Other studies too highlight a range of psychiatric co-morbidity (Lloyd et al.). In DM, the hypothalamic pituitary adrenal axis is implicated in the aetiology of depression (Brown, Varghese, & McEwen, 2004). Persons in all ages are at risk of psychiatric morbidity in DM (Crooks, Buckwalter, & Petitti, 2003; Dantzer, Swendsen, Maurice-Tison, & Salamon, 2003). Some studies show that treatment with hypoglycemic medicines may also lead to severe anxiety (Carney, 1998).
The relationship between DM and psychiatric morbidity is bidirectional. DM per se may result in psychological distress and vice versa, psychiatric illness may lead to poor lifestyle measures which may lead to metabolic syndrome and DM (Coclami & Cross, 2011).
Conclusions
Routine screening for psychiatric disorders should be considered in DM, considering the high morbidity shown in many studies including ours. Early identification and treatment will improve the outcome of both conditions. All health professionals should be educated to intervene appropriately.
Declaration of interest
None
References
Abate, N., & Chandalia, M. The impact of ethnicity on type 2 diabetes. Journal of Diabetes and Its Complications, 17(1), 39–58.
American Diabetes Association. (2004). Diagnosis and classification of Diabetes Mellitus. Diabetes Care, 27(1), S5–S10.
Balhara, Y. P. S. (2011). Diabetes and psychiatric disorders. Indian Journal of Endocrinology and Metabolism, 15(4), 274–83. http://doi.org/10.4103/2230-8210.85579
Bener, A., Zirie, M., Janahi, I. M., Al-Hamaq, A. O. A. A., Musallam, M., & Wareham, N. J. (2009). Prevalence of diagnosed and undiagnosed diabetes mellitus and its risk factors in a population-based study of Qatar. Diabetes Research and Clinical Practice, 84(1), 99–106. http://doi.org/10.1016/j.diabres.2009.02.003
Bener, A., Zirie, M., Musallam, M., Khader, Y. S., & Al-Hamaq, A. O. A. A. (2009). Prevalence of metabolic syndrome according to Adult Treatment Panel III and International Diabetes Federation criteria: a population-based study. Metabolic Syndrome and Related Disorders, 7(3), 221–9. http://doi.org/10.1089/met.2008.0077
Blanz, B. J., Rensch-Riemann, B. S., Fritz-Sigmund, D. I., & Schmidt, M. H. (1993). IDDM is a risk factor for adolescent psychiatric disorders. Diabetes Care, 16(12), 1579–87.
Brown, E. S., Varghese, F. P., & McEwen, B. S. (2004). Association of depression with medical illness: does cortisol play a role? Biological Psychiatry, 55(1), 1–9.
Carney, C. (1998). Diabetes mellitus and major depressive disorder: an overview of prevalence, complications, and treatment. Depression and Anxiety, 7(4), 149–57.
Cassidy, F., Ahearn, E., & Carroll, B. J. (1999). Elevated frequency of diabetes mellitus in hospitalized manic-depressive patients. The American Journal of Psychiatry, 156(9), 1417–20. http://doi.org/10.1176/ajp.156.9.1417
Coclami, T., & Cross, M. (2011). Psychiatric co-morbidity with type 1 and type 2 diabetes mellitus. Eastern Mediterranean Health Journal La Revue de Santé de La Mediterranean Orientale, 17(10).
Cox, D. J., & Gonder-Frederick, L. (1992). Major developments in behavioral diabetes research. Journal of Consulting and Clinical Psychology, 60(4), 628–38.
Crooks, V. C., Buckwalter, J. G., & Petitti, D. B. (2003). Diabetes mellitus and cognitive performance in older women. Annals of Epidemiology, 13(9), 613–9. http://doi.org/10.1016/S1047-2797(03)00059-0
Dantzer, C., Swendsen, J., Maurice-Tison, S., & Salamon, R. (2003). Anxiety and depression in juvenile diabetes: a critical review. Clinical Psychology Review, 23(6), 787–800.
Desai, M. M., Rosenheck, R. A., Druss, B. G., & Perlin, J. B. (2002). Mental disorders and quality of diabetes care in the veterans health administration. The American Journal of Psychiatry, 159(9), 1584–90. http://doi.org/10.1176/appi.ajp.159.9.1584
Erasmus, R. T., Blanco Blanco, E., Okesina, A. B., Mesa Arana, J., Gqweta, Z., & Matsha, T. (2001). Importance of family history in type 2 black South African diabetic patients. Postgraduate Medical Journal, 77(907), 323–5.
rayne, S. M., Halanych, J. H., Miller, D. R., Wang, F., Lin, H., Pogach, L., … Berlowitz, D. R. Disparities in diabetes care: impact of mental illness. Archives of Internal Medicine, 165(22), 2631–8. http://doi.org/10.1001/archinte.165.22.2631
Goldston, D. B., Kelley, A. E., Reboussin, D. M., Daniel, S. S., Smith, J. A., Schwartz, R. P., … Hill, C. (1997). Suicidal ideation and behavior and noncompliance with the medical regimen among diabetic adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 36(11), 1528–36. http://doi.org/10.1016/S0890-8567(09)66561-8
International Diabetes Federation. (2009). IDF Diabetes Atlas. International Diabetes Federation. Retrieved from https://www.idf.org/sites/default/files/IDF-Diabetes-Atlas-4th-edition.pdf
Kovacs, M., Goldston, D., Obrosky, D. S., & Bonar, L. K. (1997). Psychiatric disorders in youths with IDDM: rates and risk factors. Diabetes Care, 20(1), 36–44.
Kriska, A. M., Saremi, A., Hanson, R. L., Bennett, P. H., Kobes, S., Williams, D. E., & Knowler, W. C. (2003). Physical activity, obesity, and the incidence of type 2 diabetes in a high-risk population. American Journal of Epidemiology, 158(7), 669–75.
Lloyd, C. E., Zgibor, J., Wilson, R. R., Barnett, A. H., Dyer, P. H., & Orchard, T. J. Cross-cultural comparisons of anxiety and depression in adults with type 1 diabetes. Diabetes/metabolism Research and Reviews, 19(5), 401–7. http://doi.org/10.1002/dmrr.394
Lustman, P., & Anderson, R. (2002). Depression in adults with diabetes. Psychiatric Times, 19(8), 45–48.
Lustman, P. J., Anderson, R. J., Freedland, K. E., de Groot, M., Carney, R. M., & Clouse, R. E. (2000). Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care, 23(7), 934–42.
Lustman, P. J., Griffith, L. S., Freedland, K. E., & Clouse, R. E. (1997). The course of major depression in diabetes. General Hospital Psychiatry, 19(2), 138–43.
Madhu, K., & Sridhar, G. R. (2005). Stress management in diabetes mellitus. Int J Diabetes, 25(7), 7–11.
Mukherjee, S., Decina, P., Bocola, V., Saraceni, F., & Scapicchio, P. (1996). Diabetes mellitus in schizophrenic patients. Comprehensive Psychiatry, 37(1), 68–73. http://doi.org/10.1016/S0010-440X(96)90054-1
Pita, R., Fotakopoulou, O., Kiosseoglou, G., Zafiri, M., Roikou, K., Simos, G., … Karamitsos, D. (2002). Depression, quality of life and diabetes mellitus. Hippokratia, 6(1), 44–47.
Ramachandran, A. (2005). Experiences of the WHO Collaborating Centre for Diabetes in India in managing tsunami victims with diabetes. Pract Diabetes Int, 22, 98–99.
Robinson, N., Fuller, J. H., & Edmeades, S. P. (1988). Depression and diabetes. Diabetic Medicine : A Journal of the British Diabetic Association, 5(3), 268–74.
Sesti, G., Federici, M., Lauro, D., Sbraccia, P., & Lauro, R. Molecular mechanism of insulin resistance in type 2 diabetes mellitus: role of the insulin receptor variant forms. Diabetes/metabolism Research and Reviews, 17(5), 363–73.
Sridhar, G., & Madhu, K. (2002). Psychosocial and cultural issues in diabetes mellitus. Curr Sci, 83, 1556–1564.
Wild, S., Roglic, G., Green, A., Sicree, R., & King, H. (2004). Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care, 27(5), 1047–53.
Wilkinson, G., Borsey, D. Q., Leslie, P., Newton, R. W., Lind, C., & Ballinger, C. B. (1988). Psychiatric morbidity and social problems in patients with insulin-dependent diabetes mellitus. The British Journal of Psychiatry : The Journal of Mental Science, 153, 38–43.
