DIABETES RELATED EMOTIONAL DISTRESS AND DEPRESSION: A STUDY OF PATIENTS WITH TYPE 2 DIABETES MELLITUS

Urooj un Nisa and Dr. Humera Shafi. 1. Ph. D. Research scholar, Department of Psychology, University of Kashmir, Srinagar (190006). 2. Sr. Asst. Professor, Department of Psychology, University of Kashmir, Srinagar (190006). ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

The presence of depression or diabetes-specific emotional distress, or a combination of these, might comprise barriers to adequate self-management in persons with diabetes (Lloyd, Pambianco, and Orchard, 2010). The underrecognition of emotional problems, such as depression, anxiety, and diabetes-specific emotional distress, has been reported , and when such concerns are recognized, problems might be identified as depression, even in patients whose problems are directly related to diabetes and its treatment (Gonzales, Fisher, and Polonsky, 2011). Diabetes-specific emotional distress can be defined as a range of emotional responses and reactions to life with diabetes, especially those related to the treatment regimen and self-care demands. It is part of a person's experience of managing diabetes and its treatment in the social context of family and health-care personnel (Fisher, Hessler, Polonsky, and Mullan, 2012). In contrast, depression is more strongly related to an anhedonic state, in which an individual is markedly affected by feelings of sorrow and hopelessness (Watson et al., 1995;Zigmond and Snaith, 1983) Gonzales et al. (2008) suggested that depression and diabetes-specific emotional distress are independent constructs in type 2 diabetes, and later proposed that there can be confusion regarding what is actually addressed (Gonzales, Fisher, and Polonsky, 2011).  showed that despite some overlap, people with depression and those with diabetes-specific emotional distress did not constitute identical groups in patients within type 1 or type 2 diabetes. It has been shown that depression and diabetes-specific emotional distress are differently associated with diabetes-specific indicators, but this is mainly examined in persons with type 2 diabetes (Fisher, Glasgow, and Strycker, 2010;Fisher et al., 2007).
Chew, Vos, Mohd-Sidik, and Rutten (2016) further found that diabetes related distress and depression were correlated. Patients with higher diabetes related distress were younger and had higher scores on the patient health questionnaire.
Efficient psychological care such as cognitive behavioral therapy or medication is available (Pouwer, 2003). Unfortunately the detection rate of depression in patients with diabetes, which is an important condition for treatment, is still low . Given the importance of a timely diagnosis and treatment of psychosocial distress, and screening for depression and diabetes-related distress in patients with diabetes should be integrated in structural diabetes care (IDF, 2006;American Diabetes Association, 2006). To support the need for such screening, the aim of this study was to estimate the prevalence of depression and diabetesrelated emotional distress and to investigate relevant risk factors in patients attending a diabetes center.
Objectives:-1. To study the relationship between diabetes related emotional distress and depression among type 2 diabetes mellitus patients.

Methods:-Study population:-
In this cross-sectional study, 435 patients (selected purposively) with type 2 diabetes attending an outpatient diabetes clinic at Srinagar city of J&K comprised the sample of the study. Eligibility criteria were age > 18 years, diagnosis type 2 diabetes with or without comorbidity, and taking insulin and oral drugs for >1 year. All eligible patients were told about the study and were invited to participate. Patients who were willing to participate received both written and verbal information about the study, an informed consent form, and questionnaires.

Measurements:-
Demographic and clinical characteristics, including age (in years), gender, educational level (high education being defined as secondary school or university), and duration of diabetes were assessed by self-report. Information about co-morbidities (thyroidism, heart disease, hypertension and obesity) was obtained from the medical records.
Depression was measured using the Beck's Depression Inventory (BDI-II) (Beck, Steer, and Brown, 1996). It is a 21-item self-report instrument intended to assess the existence and severity of symptoms of depression. The test items are measured on a Likert scale of 0-3. People are asked to report feelings consistent with their own over the past 2 weeks. Interpretation of scores is accomplished through criterion-referenced procedures utilizing the following interpretive ranges: 0-13-minimal depression; 14-19-mild depression; 20-28-moderate depression; and 29-63-severe depression. The test was also shown to have a high one-week test-retest reliability (Pearson r =0.93). The test also has high internal consistency (α=.91).

Diabetes-related emotional distress was measured with the validated Problem Areas in Diabetes-scale (PAID) by
Joslin Diabetes Centre, Boston. Its authors are Polonsky, Anderson, Lohrer, Welch, Jacobson, Aponte, and Schwartz (1995). It consists of 20 items that cover a range of emotional problems frequently reported in type 1 and type 2 diabetes. Each item is rated on a six-point Likert type scale. A total scale score is computed by summing the total item responses. Psychometric reports to date on the PAID have shown it to: (i) have consistently high internal reliability (i.e. a = 0.90); (ii) have sound (r = 0.83) 2-month test-retest reliability using a sample of stable patients. A cut-off score ≥ 30 is appropriate for detecting clinical and subclinical depression with a sensitivity of 79% and a specificity of 76% (Polonsky, Anderson, Lohrer, Welch, Jacobson, Aponte, 1995).

Ethical issues:-
To adhere the ethical considerations and to reduce biases the study was approved by Departmental Research Committee of University of Kashmir. To assist the subjects to understand the reason for the study, both the information sheet and the questionnaires will be written in two languages (English and Urdu). The information sheet describing the study in the language of subjects' choice and will be given to them to read or will be read to them by the researcher. Written consent will be taken from all the participants before taking the relevant information. Further the researcher will not take any such kind of information which will disclose the participant's identity.
Statistical Analysis:-Statistical analyses were performed using SPSS version-20. Pearson's correlation coefficient and stepwise multiple regression was used to investigate the relationship of diabetes-related distress with depression. A p-value of < 0.05 (two tailed) was considered to be statistically significant in all analyses.

Results and Interpretation:-
Results revealed that there is significant positive correlation between Depression and Diabetes related emotional distress as correlation coefficient (r = 0.733) is significant at p≤0.01 level of significance (Table 3).
Stepwise multiple regression analyses were carried out to predict depression among type 2 diabetes mellitus patients (Table 4). Diabetes related emotional distress explained 54% of variance in depression. Together with demographic and clinical variables, final model explaining the total variance of 59.4% in depression. In this model while controlling the demographic and clinical variables [educational status (beta= -.172, p < .001), comorbidity (beta= .111, p < .001), duration of diabetes (beta = .079, p = .010)], diabetes related distress (beta= .696, p < .001) emerged as significant predictor of depression in type 2 diabetes mellitus. 267 (61.37%) Note. SD (Standard Deviation); Co-morbidity (thyroidism, heart disease, hypertension and obesity); Low education is defined as no education or primary school; medium education is defined as vocational education; and high education is defined as secondary school and university.   Several limitations of this study need to be mentioned. First, the cross-sectional study design means that it is not possible to draw long-term conclusions. Second, the samples were recruited from a general hospital and could not represent all of the patients in Kashmir.
Despite these limitations, the results of the present study are potentially of clinical value. In this study, according to the informed consent of the participants, the investigator reports all patients who were having high levels of depression or distress to their physicians. Subsequently, the physicians offered a selection of these patients (i.e. who were not receiving psychological care yet), a referral to a psychologist.

Conclusion:-
The mean score of depression and diabetes related emotional distress were 10.80 ± 8.23 and 10.92 ± 10.80 respectively among subjects with type 2 DM in this study. Diabetes related distress, low educational status, comorbidity and short duration of diabetes were associated with the presence of depression. These findings support a recommendation for routine screening for depression in patients with diabetes mellitus, to reduce the number of the depressed or the misrecognized depressed diabetic patients and consequently offer them a better quality of life.