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ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
Health-related quality of life and its association with depression in type ii diabetes mellitus patients: A cross-sectional study from Delhi

1 South Delhi Municipal Corporation, New Delhi, India
2 Department of Community Medicine, Lady Hardinge Medical College, New Delhi, India

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Date of Submission20-Apr-2022
Date of Decision03-Jun-2022
Date of Acceptance25-Jun-2022
Date of Web Publication20-Oct-2022


Background: Diabetes mellitus is noncommunicable disease that in most cases affects the whole life after diagnosis with long-standing effects and debilitating complications. It is also one of the top five causes of mortality and contributes significantly to morbidity. Besides limitations and complications to physical health, it also significantly affects the mental health and affects the quality of life (QOL) among the patients. The current study aimed at finding the QOL among the patients living with diabetes. Methodology: A cross-sectional study was conducted among diabetic patients attending a diabetic clinic at a district hospital in East Delhi between December 2016 and March 2018. A total of 250 study subjects were included in the study. The Physical Health Questionnaire (PHQ 9) and the World Health Organization QOL-BREF questionnaire were used along with a pretested, semi-structured questionnaire for data collection. Data analysis was done on SPSS 23. Results: The prevalence of depression was found to be 17.6% as per the PHQ-9. Health-related QOL was highest for social domain (63.81 ± 12.74) and lowest among the psychological domain (40.83 ± 8.93) followed by environment (46.92 ± 8.34). The score of all the domains was lowest among depressed group as compared to nondepressed study subjects. Conclusion: Mental health can be adversely affected in the case of patients with diabetes which in turn can affect the QOL of the cohort. Hence, it is important to focus on mental well-being of the diabetics and timely intervention.

Keywords: Depression, diabetes mellitus, domains, quality of life

How to cite this URL:
Singh K, Acharya AS, Rasania SK, Khandekar J, Vaz RP. Health-related quality of life and its association with depression in type ii diabetes mellitus patients: A cross-sectional study from Delhi. Indian J Med Spec [Epub ahead of print] [cited 2022 Dec 5]. Available from: http://www.ijms.in/preprintarticle.asp?id=359347

  Introduction Top

Diabetes mellitus is a noncommunicable disease that is one of the leading causes of death and disability worldwide. Hence, it poses a major public health problem. The burden is especially high in low- and middle-income countries such as India and can further complicate the situation as it causes financial strain in the affected families. According to the recent estimates of the International Diabetes Federation, globally 537 million people had type II diabetes mellitus (T2DM) in 2013, which is expected to rise to 643 million by 2030 and 783 million by 2045 if action is not taken urgently.[1] India has the largest number of diabetic patients in the world as per the International Diabetes Federation 2015. Seventy million (9.3%) of adult population are suffering from diabetes in India in 2017. By 2030, India is expected to have around 79.4 million people with diabetes, most of them with T2DM.[2] Diabetes and depression generally tend to coexist and have a bidirectional relationship. Diabetes mellitus doubles the likelihood of depression as compared to normal individuals.[3] Both diabetes and depression are projected to be among the top five leading causes of the Global Disease Burden by 2030.[4] Globally, diabetic patients have a 24% increased risk of developing depression[5] and depressed adults have 37% higher risk of developing diabetes.[6] Diabetes also reduces the quality of life (QOL) among the affected individuals, and depression causes further negative impact on quality of life. A meta-analysis conducted by Mendenhall E et al. has shown the prevalence of depression in diabetics ranging from 16.9% to 84%.[7] In a meta-analysis of 10 randomly controlled trials on T2DM conducted by Ali S et al., a slightly higher prevalence of depression was found among diabetics as compared to nondiabetics (17.6 vs. 9.8%, odds ratio = 1.6, 95% confidence interval [CI]: 1.2–2.0).[8]

Indian studies conducted earlier have reported prevalence rates of depression that vary from 11.5%[9] to 63%.[9],[10],[11],[12] India is home to the second-largest number of diabetics in the world after China, yet there is a dearth of studies from India which have focused on the prevalence of depression in diabetics and their QOL. Therefore, this study was planned with the objective to measure the health-related QOL among the study subjects and to study the association of depression among study subjects with the World Health Organization QOL (WHOQOL).

  Methodology Top

This is a community-based cross-sectional study which was carried out from December 2016 to March 2018. Data collection was done from January 2017 to December 2017.

The study was conducted in the diabetic clinic of a district hospital run by the Delhi Government. The diabetic clinic is scheduled twice a week on Monday and Wednesday afternoons from 2 to 4 pm. It mainly caters to the patients that hail from the surrounding five localities within a radius of 5 km. Approximately one-fourth of the patients who come to the outpatient department are residents of nearby Kalyanpuri, a resettlement colony. The study population comprises the patients aged more than 30 years and residing in Kalyanpuri area. Permanent residents of Kalyanpuri (residing >1 year), diagnosed cases of type II diabetes attending diabetic clinic (>1 year), and patients of both sexes >30 years were included in the study. Patients with known psychiatric illness, serious illnesses, on antidepressants, or pregnant were excluded.

A sample size of 250 subjects was calculated for this study taking the prevalence of depression as 40% based on the study by Thour et al.,[12] 2015, Chandigarh, with 15% relative error.

Diabetic clinic was visited once a week. Four hundred and seventeen study subjects who were registered at the diabetic clinic were screened for eligibility in the study. Two hundred and ninety-seven study subjects who fulfilled the exclusion and inclusion criteria were enrolled from the diabetic clinic. They were interviewed at their residence at Kalyanpuri. Out of 297 study subjects, 27 (9.09%) had given incorrect addresses and hence could not be traced. Ten (3.36%) were not available on three consecutive visits and hence were excluded. The remaining 120 patients did not fulfill the inclusion criteria. Thus, 250 study subjects were enrolled in the study. All the study subjects who were found suffering from depression were referred to the department of psychiatry in a secondary or a tertiary-level hospital for further workup.

The study tools used for measuring depression were the Physical Health Questionnaire-9 (PHQ-9) and the WHOQOL-BREF questionnaire for assessing their QOL which have been described below.

A questionnaire for depression scale (Physical Health Questionnaire-9)

PHQ-9 is a screening questionnaire containing nine questions which assesses major depressive disorders according to Diagnostic and Statistical Manual of Mental Disorders IV edition criteria. The questions are concerning fatigue, concentration, depressive complaints, thoughts of death, etc., on a five-point Likert scale: not at all, various days, more than half the days and almost every day Zero, one, two, and three points were scored respectively for these categories and a sum score of the nine questions were calculated. The score was classified into different grades of severity using standard cutoff values [Table 1]: 5–9 was classified as mild depression, 10–14 as moderate depression, 15–19 as moderately severe depression, and 20–27 as severe depression. The time frame of questions was last fortnight. It is validated and available in Hindi and used in other studies.[5]
Table 1: Summary of Physical Health Questionnaire-9 components and scoring of depression

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Questionnaire for quality of life (World Health Organization-Quality of Life-BREF)

WHOQOL-BREF questionnaire includes 26 items in Likert scale ranging from 1 to 5. The questions evaluate emotions and behavior of patients in the past 2 weeks in domains of hygiene and physical health, psychology, social relations, and social environment. For each domain, raw scores from 4 to 20 can be achieved, representing the worst and the best conditions, respectively. These raw scores can be converted into transformed scores ranging from 0 to 100 for each of the four domains.

Ethical committee clearance was taken prior to the commencement of the study. Data collection was done once a week from the diabetic clinic. Study subjects were consecutively selected fulfilling inclusion and exclusion criteria. After selection, interview was taken by the investigator by house-to-house visit. Informed consent was taken after explaining about the study to the subjects either by signature or by thumb impression for illiterate individuals. Following this, the questionnaire was administered and anthropometric measurements were taken. Data were analyzed using the Statistical Package for the Social Sciences version 23 (SPSS 23, IBM).

  Results Top

A total of 250 diabetic patients were enrolled in the study with 79 (31.6%) males and 171 (68.4%) females with a mean age of 55.17 ± 11.11 years. The prevalence of depression was found to be 17.6% (95% CI, 13.6–22) as per the PHQ-9. Mild depression was seen in 22 (8.8%) study participants, moderate depression in 12 (4.8%) study participants, and moderately severe and severe depression in 6 (2.4%) and 4 (1.6%) participants, respectively [Figure 1]. Majority (82.4%) of the study participants did not have depression. Health-related QOL was studied in all the study subjects, and it was found that the overall QOL score was highest for social domain (63.81 ± 12.74) which was seen in both males (64.88 ± 11.72) and females (64.88 ± 11.72), respectively. The total score was lowest among the psychological domain (40.83 ± 8.93) followed by environment (46.92 ± 8.34). However, there was no statistically significant difference in physical, psychological, social, and environment domains among males and females. QOL was seen worse with increase in age, being widow/widower, in illiterate/just literate, unskilled/unemployed study subjects, and lower socio-economic status. However, there was no statistically significant difference in mean score of all the domains with respect to occupation status of the study subjects. There was no statistically significant difference in all domains with respect to type of family [Table 2]. The score of all the domains was lowest among depressed group as compared to nondepressed study subjects. There was a highly statistically significant difference in mean score of all domains in respect to depression status of the study subjects. The mean score among those with depression as opposed to those without was seen, respectively, as 46.22 ± 8.06 vs. 54.91 ± 7.7 in physical domain, 31.02 ± 8.64 vs. 42.92 ± 7.50 in psychological domain, 48.50 ± 8.90 vs. 67.12 ± 10.91 in social domain, and 38.50 ± 8.63 vs. 48.72 ± 7.10 in environmental domain (P<0.01) [Table 3].
Figure 1: Magnitude of depression in the study subjects as per PHQ-9 (n = 250). PHQ-9: Physical Health Questionnaire-9

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Table 2: World Health Organization Quality of Life domain mean score in relation to sociodemographic factors (n=250)

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Table 3: World Health Organization Quality of Life domain mean score by depression status (n=250)

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  Discussion Top

The prevalence of diabetes mellitus has long shown a steady increase in developed countries and has in recent times affected the population in developing countries as well. Owing to high burden of diabetes in India, it is important to know the physical as well mental health effects in the patients for better management and policy formulation. The disease has high propensity to affect the mental health of the patients, with effects ranging from mild stress to major depressive episodes based on the disease severity as well as its effects on daily activities of self and family. The QOL is also known to be lowered in such patients significantly. The present study carried out in the community studied the magnitude of depression as well as QOL among the known diabetics.

Screening for depression using the PHQ-9 scale as the community-based screening for depression can help as mainstay for early diagnosis and administering necessary early interventions. In case depression is found, the treatment can also be administered in the patients with established benefits and also preventing future sequelae. Moreover, differentiating asymptomatic individuals at risk of depression can help increase the QOL with necessary interventional measures. The prevalence of depression in the current study was seen in 17.6% of the individuals (44 out of 250). This overall reflects that 1 in every 5 patients of diabetes can be at a risk of developing depression in long run. The presence of depression also depends on various risk factors such as socio-economic status, cost of treatment, and other physical illnesses that can negatively affect the mental health.[13] Furthermore, in the study, females were found to be three times more affected with depression as opposed to males and the chance increased with age. This signifies the need for more importance to be given to mental health in the said cohort for better outcome.[14]

QOL can be affected to a great extent among the diabetics owing to the chronicity of the illness.[15],[16],[17],[18] Adverse mental health, including depression, is also a cause for lowering of the QOL among diabetics. In the current study, the WHOQOL-BREF questionnaire was used for assessment of QOL, and mean scores of all four domains were calculated. Overall, the highest QOL score was seen for social domain as seen in other leading studies. However, the study showed a lower QOL score when seen overall. This can be because of the lower scores in other domains. Although the scores varied in the study between the domains, the difference was not statistically significant in between the domains. Marital status affected the QOL scores with respect to social domain significantly. The scores among all domains were lower among the unmarried as opposed to married individuals. Since it is known that mental health is adversely affected among unmarried individuals due to reduced social interactions, the finding suggests better QOL among married individuals, but the issue of separation or divorce might show a different scenario. [17,18] Moreover, the significant difference in the social domain of QOL score also substantiates the finding. Better social rehabilitation henceforth can lead to a better outcome with respect to the QOL among the patients when this is considered. A better social life among the patients can also have a positive impact with respect to mental health of the individuals.

Education level also affected the scores of QOL in all domains with lower scores seen among illiterates or just literates as opposed to those who had at least completed primary education. Even though scores were lower among illiterates, social domain showed a statistically significant difference. Education level can alter the coping mechanisms used during the illness, especially when the illness is chronic in nature as seen in diabetes mellitus. Furthermore, the economic status and financial stability will depend on the occupation which in turn is dependent on the education level of the individuals. Poor education level has multiple modes through which it can affect the mental health and QOL of the patients both directly and indirectly making it an important determinant. Furthermore, in terms of occupation, all domains except the environment were lower among unskilled/unemployed as opposed to other higher-ranking occupations but showed no statistical difference among the domains and occupational groups.

Education and occupation can influence the socio-economic status of the individuals and scores of all domains were found to be lower in lower socio-economic status' individuals.[18] Socio-economic status is known to have a huge impact on QOL among the study subjects, though at times subjective perception can affect the actual scores. Largely, lower socio-economic status adversely affects the scores showing lower values in the cohort. The same was observed in the current study and was as per the available evidence of QOL. In terms of statistical relevance, only the environmental domain was significant.

Depression among the study subjects has an important bearing on QOL which was shown in the current study with all domains showing lower scores among the depressed individuals as opposed to nondepressed individuals. Hence, enhancement of various factors affecting the QOL can have a positive effect in terms of mental health among the diabetics.

  Conclusion Top

The current study showed low QOL scores among the diabetes patients across almost all dimensions with some being statistically significant. There was a statistically significant association between QOL and the presence of depression. Furthermore, poor mental health is known to affect physical health and may lead to self-harm. Hence, it is imperative that timely evaluation of the mental health of the patients of diabetes mellitus is to be stressed upon when it comes to patient management.

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Conflicts of interest

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Correspondence Address:
Rodney Preetham Vaz,
Upper Ground Floor, R24, Khirki Extension, Malviya Nagar, Delhi - 110 017
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_47_22


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  [Table 1], [Table 2], [Table 3]


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