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Psychiatric morbidity in patients with Diabetes Mellitus: A hospital based study in Kashmir

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

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