Prevalence and determinants of depression among patients with Type 2 diabetes mellitus attending family medicine clinics in Qatar

Aims To assess the prevalence of depression and its associated factors among patients with Type 2 diabetes mellitus attending family medicine clinics in Qatar Methods A cross-sectional study was conducted from January to April 2021 where 683 adult patients with Type 2 diabetes mellitus were selected by cluster sampling technique using probability-proportionate to size sampling. Diabetes mellitus was defined as having HA1c of greater than or equal to 6.5%, and patients were assessed for depression using the Patient Health Questionnaire-9. The relationship between depression, glycemic control, and background characteristics was analyzed using Chi-square, and binary logistic regression analyses. Adjusted logistic regression models estimated the significant factors that were independently associated with depression. Results 20.1% of the study participants had depression with the vast majority of them having mild depression (70.8%). More than three-quarters had uncontrolled diabetes mellitus (81.5%). Male patients were at higher risk for developing depression (AOR =1.98, 1.25-3.14) when compared to female patients. On the other hand, being Qatari was associated with a lower risk for depression compared to non-Qatari patients (AOR =0.56, 0.34—0.90), and treatment with insulin-containing regimens was associated with a lower risk for depression as compared to treatment with non-insulin- containing regimens (AOR =0.49, 0.30-0.78). Conclusions Prevalence of depression among patients with Type 2 diabetes attending family medicine clinics in Qatar is high. Therefore, utilizing a multidisciplinary health care plan for screening and management of depression in patients with diabetes in a primary health care setting is highly recommended. Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.


Introduction
Diabetes mellitus (DM) is a common chronic non-communicable disease that is considered a leading cause for disability and mortality worldwide with around 12% of healthcare expenses in many countries dedicated to preventing and combating diabetes complications 1 .In addition to its associated health and economic burden, DM imposes social and psychological challenges that would ultimately increase the risk for depression. 2 According to the WHO, 265 million people worldwide have depression. 3Comorbid depression complicates the management of chronic diseases and it is associated with worse clinical outcomes com-pared to having depression alone, having any of the chronic diseases alone, or having a combination of other chronic diseases other than depression. 4Depression in patients with diabetes is often unrecognized and untreated leading to poor adherence to diabetes self-care plans and resulting in potentially negative health consequences including a higher risk for diabetic complications, functional impairment, and increased healthcare expenditure. 5 , 6epression is the second-leading cause of disability worldwide with a higher likelihood of occurrence in patients with diabetes. 7Katon estimated that 15%-20% of people with diabetes are struggling with depression, more likely having moderate to severe form of depression.He https://doi.org/10.1016/j.ajmo.2022.100014Received 16 September 2021; Accepted 24 May 2022 Available online 29 May 2022 2667-0364/© 2022 The Author(s).Published by Elsevier Inc.This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ ) also hypothesized that the relationship between diabetes and depression is bidirectional with one disease leading to the increased risk of having the other. 5The etiology of depression in diabetes is not known yet but it is probably due to the complex interaction of genetic, biological, and psychological factors.Vascular changes due to DM could be the biological basis for the development of depression among patients with diabetes.Several neurotransmitters and neuron-endocrine defects have been identified to be common for both depression and diabetes, adding to the etiological speculations. 8ven as separate entities, diabetes and depression are by themselves major health problems in the world.0][11] A worldwide survey conducted through 60 countries using the ICD-10 criteria found that the one-year prevalence of depressive episodes in people with diabetes was 9.3% as compared to 3.2% in people without diabetes. 4An earlier matched case-control study on adults attending primary health care in Qatar found that depression scores were significantly higher and more frequent in patients with diabetes in comparison to healthy controls.Using the short version of the Depression Anxiety Stress Scales (DASS)-21, 38.9% of diabetic patients had mild depression compared to 26.5% of controls (p < 0.001), and 13.6% of diabetic patients had severe depression compared to 5.9% of controls (p < 0.001). 10The high prevalence of depression among patients with diabetes had led to the term "diapression". 12t is likely that the complex interactions between diabetes and social and cultural dynamics affect the way people experience illness and health. 135][16][17][18][19][20][21][22][23] Hence, it is important to take a culture-centered approach to assess and address risk factors for developing depression in patients with diabetes.
Primary healthcare is the front door of healthcare services for the community.Therefore, it should participate actively in screening, case finding, and management of depression among people with diabetes.To date, there is a lack of data on the prevalence of depression and its associated sociodemographic and clinical features in patients with diabetes treated in primary health care clinics in Qatar.This study aimed to assess this prevalence and its associated factors among patients with Type 2 diabetes mellitus attending family medicine clinics in Qatar.This will help in planning structured and targeted patient care services in order to enhance metabolic control, improve the clinical outcomes and possibly reduce the health-related expenses of patients with diabetes.Due to the unique sociodemographic structure of Qatar population, we hypothesize that the prevalence and associated factors of depression among patients with diabetes could be different from studies done in other countries.

Methodology
A cross-sectional study was conducted from January to April 2021.All adult patients (age ≥ 18), with Type 2 DM (defined as having a HA1c of greater than or equal to 6.5%) who were attending family medicine clinics at primary healthcare corporation (PHCC) in Qatar were invited to participate in this study.Patients who were younger than 18 years old, had type 1 DM or gestational diabetes, had a previous diagnosis of depression or other psychiatric disorder, or were not capable of independent communication were excluded from the study.
In Qatar, there are 27 publicly run health centers providing healthcare for patients with diabetes through family medicine clinics which are both appointment-based and walk-in clinics.Sample size calculation was based on the hypothesis that the prevalence of depression among patients with type 2 diabetes mellitus is 50% 23 + /-5% to get the maximum sample size with a 5% margin of error, and 95% level of confidence.The design effect for cluster sampling was 1.5.The sample size was 638, and cluster sampling technique was used in which PHCC centers were con-sidered the primary sampling units.The clusters were identified based on the number of registered diabetic patients in each health center.A simple random sample was conducted to select four health centers, and within each selected health center, all eligible patients were included in the study.The estimated sample size was distributed proportionately among the four selected health centers according to the size of the registered patients with Type 2 DM (probability-proportionate to size sampling).

Data collection
A face-to-face interview was conducted by well-trained nurses using a questionnaire that included: socio-demographic characteristics including age ( ≤ 60 years or > 60 years), gender (male or female), marital status (married or single), smoking (non-smoker, smoker, ex-smoker), family history of diabetes (yes or no), as well as health factors including diabetes control (HA1c > 7% or ≤ 7%), treatment modalities (lifestyle modifications only, insulin-containing regimens or use of oral hypoglycemic agents only), duration of diabetes ( < 5 years, 5-10 years or ≥ 10 years), and the presence of other co-morbidities (hypertension, dyslipidemia, hypothyroidism, obesity).Physical examination data within the last three months were obtained from the patient's medical record including BMI, blood pressure, fundoscopy and HbA1c.The instrument was adopted and translated to the Arabic language, and back to English to be tested for validity.Depression status of patients was ascertained at the time of recruitment by using the Patient Health Questionnaire 9 (PHQ 9) which is a 9-item questionnaire designed to correspond to the nine diagnostic criteria for major depressive disorder covered in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).In this questionnaire, a total score of 0 indicates no depression, 1-4 indicates minimal depression; 5-9 mild depression; 10-14 indicates moderate depression, a score of 15-19 signifies moderately severe depression, and a score 20-27 signifies severe depression. 24This questionnaire has been validated for use in primary care, 25 and it showed good internal (Cronbach's alpha = 0.85) and test re-test reliability (intraclass correlation coefficient = 0.92). 26n this study, a PHQ-9 score of 4 to 9 was used to define mild depression, 10-19 for moderate depression and more than 20 for severe depression.Glycemic status was categorized as a good glycemic control if HbA1c was equal to or less than 7% or poor glycemic control if HbA1c > 7%.Blood pressure less than 130/80, LDL less than 100 mg/dl and BMI less than 25 were considered normal, whereas BMI of 25 to < 30 is considered overweight and BMI of 30 or higher is considered obesity.

Data processing and analyses
Data were analyzed using SPSS version 20.The analysis was performed and presented as tables and figures that included frequency and percentages for categorical variables.Bivariate analysis using Chisquare test (X 2 ) was used to assess association (crude odds ratio) between the categorical dependent variable (depression) and independent variables (socio-demographic, clinical characteristics including BMI and HbA1c and smoking history).Binary logistic regression was performed to identify the most significant associated factors of the outcome variable (depression).We used enter method model in the regression analysis and selected the significant variables from bivariante analysis.An alpha (p) value of ≤ 0.05 was considered the cut-off level for statistically significant association.

Ethical considerations
Ethical approval was obtained from the Institutional Review Board (IRB) of the research department in primary care corporation in Qatar.Informed verbal consent was obtained from each study participant, where they were informed about the aim of the study and its nature and their right to interrupt the interview at any time.Patients' confidentiality and privacy were preserved at all levels of the study.Patients  with diabetes who were diagnosed with depression during the study were managed accordingly.

Results
Six hundred and eighty-three patients with Type 2 DM were enrolled in the current study.The majority were married (92.2%), two-thirds were males (61.1%), and almost half of them were Qatari and aged less than 50 years (48.8% and 48.2% respectively).Approximately threequarters of the studied subjects had a family history of diabetes (72.0%).More than two-thirds of the patients were on oral hypoglycemic medications (69.7%) and 67.2% of the total patients developed diabetic complications ( Table 1 ).The prevalence of depression among patients with Type 2 DM was 20.1 %, with the vast majority of them having mild depression (70.8%), while 4.7 % and 1.2% had moderate and severe depression respectively ( Figure 1 ).The association between various sociodemographic characteristics and depression showed that depression was found to be statistically significantly higher among patients who were females (p < 0.001), married (p = 0.018), Qatari (p < 0.001), their age more than 50 years (p = 0.013),and with family history of diabetes (p = 0.002) ( Table 2 ).However, the clinical characteristics of patients including blood pressure control, lipid panel level, TSH, and vitamin D status were not statistically significantly correlated with the prevalence of depression in diabetes ( Table 3 ).
Binary logistic regression analysis for depression (as a dependent variable) with multiple independent variables including gender, nationality, pharmacological treatment for diabetes and duration of diabetes mellitus showed that males were at a higher risk of depression (AOR = 1.98, 95% CI 1.25-3.15,p = 0.004), while being Qatari and treatment for diabetes with insulin were at lower risk for depression development (AOR = 0.56, 95% CI 0.34-0.90,p = 0.017, 0.49, 95% CI 0.30-0.78p = 0.003 respectively).Moreover, duration of diabetes for more than 10 years was also associated with a higher risk for having depression as shown in Table 4 (AOR = 3.25, 95% CI 1.89-5.58p < 0.001).

Table 2
Relationship of depression with sociodemographic characteristics, diabetes duration and control among patients with Type 2 diabetes mellitus at primary health care in Qatar.

Discussion
The current study aimed to assess the prevalence and associated factors of depression among patients with Type 2 DM attending family medicine clinics in PHCC, Qatar.The prevalence of depression in this study with a PHQ-9 cutoff value of more than 4 was (20.1%)where most of the cases had mild depression (70.8%).
Worldwide, the prevalence of depression among patients with Type 2 DM varied widely in different countries and studies.The reported prevalence of depression in Type 2 DM was 10.6% in Taiwan, 14 11.5% in Malaysia, 15 13% in Addis Ababa, 16 14.7% in Pakistan, 17 18.6% in Brazil, 18 19.7% in Jordan, 19 23.2% in Vietnam, 20 38.8% in India, 21 40% in Palestine, 22 and 48% in Saudi Arabia. 23The criteria used to determine depression in these studies varied according to different instruments used such as The Beck Depression Inventory (BDI), PHQ-9, Center for Epidemiologic Studies Depression Scale (CESD), Hospital Anxiety and Depression Scale (HADS) and the Depression, Anxiety and Stress Scale -21 Items (DASS-21). 27.Thus, the difference in the prevalence rate of co-morbid depression in patients with Type 2 DM among different studies could be explained by using different assessment tools for depression, sociocultural, and behavioral-related factors among study participants as well as using different cutoff scores for diagnosing depression even with the same instrument.
The study findings indicated a higher prevalence of depression in patients with Type 2 DM compared to another recent study in Qatar showing a prevalence of 15.4%. 28This could be explained by the fact that the earlier study included only Qatari adults who were younger than the age of 60 years, whereas in the current study only half of the participants had Qatari nationality and just more than half were aged more than 60 years.
In the current study, male gender was associated with developing depression, which is in line with study results from Ethiopia, where male patients had a 1.92 higher chance of developing comorbid depression in diabetes in comparison to female patients. 29However, other studies both locally and internationally showed that female patients with Type 2 DM had a higher incidence of depression. 22 , 23 , 28Another crosssectional study in Austria also found that women with Type 2 diabetes were twice as likely to be diagnosed with depression compared with men. 30However, a recent review by Lloyd et al. concluded that studies from around the world confirm that the prevalence of depression is increased in people with diabetes mellitus although the levels of depression vary between countries, between populations within the same country and between the sexes.Consequently, healthcare providers should manage mental health disorders in patients with diabetes in a culturecentered approach. 13lthough the current study showed a statistically significant correlation between being married and depression, marital status was not found to be an associated factor for developing depression in patients with Type 2 DM in other studies.Previous studies in Sir Lanka and Ethiopia suggested that the marital status of patients with DM plays a role with those being married having less rates of depression in contrast to those who were single/divorced or widowed. 29 , 31On the other hand, the result of the study conducted in Vietnam reported that marital status had no significant association with depression in people with diabetes. 20The increased prevalence of depression among married patients with diabetes in this study may suggest that lifestyle and social factors among this subgroup of patients could be involved.Notably, Qatar has a very distinctive population with 88% of the 2.9 million residents being expatriates, 75% are males with a population median age of 33 years. 32This could be associated with unique social and cultural dynamics affecting response to stress and health.
Regarding treatment with insulin, both our study and the recent study from Qatar 28 showed that patients with Type 2 DM who were treated with insulin had a lower risk for developing depression than other patients.On the contrary, other studies found a higher prevalence and severity of depression among patients who were on insulin. 33One possible explanation for this finding is that patients in our sample who received insulin might have had better control of their diabetes.The interpretation of potential risk factors for depression in diabetes is further complicated by the interaction between these factors.For example, using insulin in Type 2 diabetes might be associated with a longer duration of the disease and a higher risk of diabetes complications; however, patients in our study may not be able to afford insulin or were not receiving insulin for the appropriate reasons.Therefore, further research is needed to explore the underlying etiology behind this apparent association.
The correlation of age with comorbid depression in diabetes has been inconstantly reported.In the current study, depression was statistically significantly associated with patients' age.In the other study from Qatar, younger patients were more likely to report depressive symptoms. 28tudies conducted in Saudi Arabia showed a high prevalence of depression among patients older than 60 years. 23On the other hand, the result of the study conducted in Vietnam reported that the prevalence of depression was significantly high among patients under 60 years old. 20his study showed an association between obesity and depression among patients with Type 2 DM.Similar findings from previous studies reported such association as depression was documented to be strongly associated with obesity among Middle Eastern societies, including Qatar. 34pproximately two-thirds of the studied group had uncontrolled diabetes mellitus with HbA1cmore than 7%.In contrast to other study reports, we did not find a significant association between poor glycemic control and depression.Other studies have reported that depressed patients with Type 2 DM have higher HbA1c levels compared with nondepressed patients. 35 , 36However, this association has not been verified in all studies.In a systematic review and meta-analyses by Ismail, et al., depression was found to be weakly associated with the glycemic status. 37his study has several limitations.As a cross-sectional study, a causal relationship between diabetes and depression cannot be established; therefore, a longitudinal study design is needed to investigate this relationship.In addition, as it was only conducted in primary health care, the study results might not reflect the actual burden of depression among patients with Type 2 DM treated in the private sector or secondary care.Also, we did not collect data on substance use including alcohol, family history of depression, availability of social support or recent stressors which might have had affected the results.A future study highlighting these variables should be conducted in order to plan a comprehensive patient-centered care plan.Despite these limitations, our study included a representative sample of the diabetic population that is managed in primary health care including older ages, different nationalities and sociodemographic backgrounds.Patients were recruited prospectively and were assessed for multiple potentially confounding variables in order to reduce selection bias.Also, the diagnosis of depression was based on the PHQ-9 assessment tool which has been validated previously for diagnosing depression in primary care; therefore, self-reported diagnosis of depression was avoided.
Based on the study results, patients with Type 2 DM should be regularly screened for depression, and those diagnosed with depression should be referred to social workers and/or psychologists if appropriate.Managing depression in diabetes with a multidisciplinary approach would facilitate patient-centered care and optimize control of their interrelated risk factors.

Conclusion
Depression is prevalent comorbidity among people with diabetes who are treated in primary health care.The current study showed that a fifth of the studied population was depressed with male patients being at a higher risk of developing depression while being Qatari and treatment of diabetes with insulin were associated with a lower risk for developing comorbid depression in people with diabetes.

Figure 1 .
Figure 1.Prevalence of depression among type 2 diabetic patients attending family medicine clinics in Qatar.

Table 1
Sociodemographic & clinical characteristics of the studied group.

Table 3
Relationship of depression with clinical characteristics among patients with Type 2 diabetes mellitus at primary health care in Qatar.
* Statistically significant at p < 0.05

Table 4
Binary logistic regression analysis for depression (dependent variable) with multiple independent variables including gender, nationality, pharmacological treatment for diabetes and duration of diabetes mellitus.