In our study, we found high prevalence of depressive disorders including all grades of severity in 52.4% of the diabetic group while only 10.5 %of the non-diabetic patients had depression. It was mild in 33.3% moderate and severe in 19% of the diabetic group, compared with moderate and severe in 1.9% of the non-diabetic group. Comparing the findings of our study with others, in an Egyptian study carried out in 2012 to estimates the prevalence of depression among a sample size of 303 type 2 diabetics attending family health centers in Alexandria using Hamilton Depression Rating Scale (HAM-D), moderate to severe depression was present in 39.1% and 40.7% in males and females respectively, compared with 19% in the present study (13). In a cross-sectional Iranian study 2019 that included 514 type 2 diabetics patients, and used Beck Depression Inventory II scale to assess depression, depression was found in 46.3% of the study population, and there was no significant association between glycemic control expressed as HbA1c level and depression (OR: 1.11 95% CI: 0.87-1.57), by contrast , sex (OR: 2.03, 95% CI: 1.03-3.99), residence ( OR: 1.92, 95% CI:1.28-2.91), and sexual complications ( OR: 5.54, 95% CI: 1.07-27.87) have a significant statistical association with depression (14) . In a Tunisian study 2017 that recruited 100 type 2 diabetic patients to study the prevalence of depression using validated Arabic version of Hospital Anxiety and Depression Scale (HAD), the prevalence of depression was 31%, and poor glycemic control, presence of macro-angiopathy, irregular follow up, and poor treatment adherence were more common in depressed compared with no depressed patients (15).
In a descriptive study 2018 carried out in Northern Greece to investigate the role of self- efficacy, depression and glycemic control in a convenience sample of 170 adults with type 2 diabetes mellitus who completed the General Health Questionnaire-28 (GHQ-28), and the Diabetes Empowerment Scale- short form (DES) questionnaire, the overall rates of diabetic patients showing psychological distress was 50.6%, adults with low to moderate income compared with high economical status, and adults who graduated elementary education compared with those with a higher educational level, experienced higher levels of depression and anxiety. There was negative correlation between Body mass index (BMI), and self-efficacy scale, and negative correlation between depression and self-efficacy (16).
Comparing our findings with other studies done in other Arabic countries showed variable results, in a Bahraini study 2009 surveyed 264 type 2 diabetic patients using Beck Depression Inventory scale (BDI), 33.3% of the study participants showed score of 16 or more on BDI, with no significant association was found between BDI score and metabolic control, duration of diabetes, and presence of diabetic complications (17). In a Saudi study 2019 carried on 450 adults with T2DM to study the prevalence and predictors of depression, anxiety, and stress, using a validated depression, Anxiety, and Stress Scale (DASS-21), the prevalence of depression, anxiety, and stress was 33.8%, 38.3%, and 25.5% respectively, major predictors of psychological distress were age, sex, the presence of comorbidities, duration since t2DM diagnosis, and serum level of A1c. (18). In another Saudi observational study carried on 267 adults patients with type 2 diabetes seen at King Abdulla Medical City in Mecca, using the Arabic version of the Patients Health Questionnaire -9 (PHQ-9) to asses prevalence of depression, 73% suffered from different degrees of depression;36%, 19.9%, 8.6%, 5.2%, and 3.4% of the participants were suffering from minimal, mild, moderate, moderately severe, and severe depression, respectively, and only neuropathy was a significant risk factors of depression (odds ratio = 2.87, 95% CI 1.18-6.97. P = 0.02) (19).
The longitudinal, and reciprocal relation between depression and glycemic control has been investigated by some studies. In a prospective study carried out in Taiwan 2019 on a nationally representative sample of 398 patients with type 2 diabetes, followed for 3 years, and applied statistical method (cross -lagged structural equation model) to examine the reciprocal relationship between depressive symptoms and glycemic control, and the moderation effects of perceived family support, a stronger association was noted for higher depressive symptoms scores predicting worse glycemic control ( B = 0.22, critical ratio 3.0), as opposed to worse glycemic control predicting depressive symptoms scores, in patients wit low family and friend support , more depressive symptoms at baseline were associated with subsequent worse glycemic levels ( B = 0.36, critical ratio 4.03) (20) . In a systematic review and meta-analysis study included 37 eligible studies, six investigated the longitudinal association between self-reported depressive symptoms and HbA1c, and five the reverse longitudinal association, with a combined sample size of 48793 and mean follow up of 2 years, The pooled effect estimates were reported as partial correlation coefficients (rp) or odds ratio (OR), the study concluded that higher levels of baseline depressive symptoms were associated with subsequent higher levels of HbA1c (partial r = 0.07 (95% CI 0.03-0.12), whereas higher baseline HbA1c values were also associated with 18% increased risk of (probable) depression (OR = 1.18 (95% CI 1.12- 1.25) (21).
Depression itself has been associated with high levels of HbA1c in individuals with T2DM, the association between diabetes and depression suggests the usefulness of determining HbA1c as a biological marker of depressive symptoms as shown in a Meta-analysis of 34 studies with 68,398 participants to determine HbA1c levels in individual with T2DM with vs. without depression. Investigators used rigorous methodology to ensure the quality assessment using the Newcastle-Ottawa Assessment Scale (NOS), and the cut-off point of the studies included was determined with scores of six or higher on collected data up to January 2020 (22). The Meta-analysis used the ‘’d’’ statistic and 95% confidence interval (95% CI) to estimates the mean difference in HbA1c levels, and the pooled weighted mean difference with 95% CI was calculated thereafter, the heterogeneity among studies was evaluated using the Cochran Q test and inconsistency index (I2), that considered p < 0.10 as significant and indicative of heterogeneity, and the values of I2 < 25 were considered as absence of heterogeneity. The results showed that individuals with T2DM with depression showed significantly increased levels of HbA1c in comparison to individuals with T2DM without depression (d= 0.18, 95% CI: 0.12-0.29, p(Z)< 0.001; I2 = 85.00) , HbA1c levels also remained elevated in individuals with T2DM with depression who were taking talking hypoglycemic drugs, in individuals with less than 10 years of evolution, and in individuals with complications of the disease. The study postulates that there is a diabetes-HbA1c-depression connection, linked to negative moods and a greater risk of diabetes complications in general. These findings may be more or less consistent with the findings of our study.
The prevalence of mental disorders in Egypt has been estimated in back dated national household survey in 2009 including 14,600 adults aged 18-64 years in 5 regions in Egypt, the overall prevalence was estimated at 16.93% of the studied population, the main problems were mood disorders, anxiety disorders, and multiple disorders in 6.43%, 4.75%, and 4.72%, respectively. The effectiveness of antidepressant acceptance, and adherence in type 2 diabetics have been investigated in a study carried in Egypt between 2013-15 , and recruited 196 diabetics scored more than 20 on screening for Major Depression Inventory (MDI), of them, 86 (43.9%) accepted and were adherent to treatment with fluoxetine for 8 weeks, and decliners were matched as control via diabetologist visits, in comparison with control, there was reduction from baseline in MDI, fasting and glycosylated hemoglobin levels (p for all comparisons < 0.001) (24). The effectiveness of non-pharmacological interventions, like cognitive behavioral therapy (CBT) on glycemic control and psychological outcomes in adults with type 1, and 2 diabetes mellitus was investigated in a systematic review and meta- analysis of 12 RCTs in 2017, CBT was shown effective in reducing short term and medium term glycemic control, although no significant effect was found for long term glycemic control, it was also effective in improving short term and medium term anxiety and depression, and long-term depression, while mixed results were found for diabetes related distress and quality of life, although the findings were inconclusive (25).
These findings emphasize the important role played BY Family physicians in dealing with the complexity of chronic illnesses encountered in very day practice and the importance of working in multidisciplinary teams.
The limitations of the study: are mainly related to the type of design adopted, as cross-sectional studies do not establish a cause and effect relationship, more controlled studies including prospective and clinical randomized trials are needed. Despite these limitations, the results contribute to the expansion of knowledge regarding the bidirectional relationship between DM and depressive symptoms, and add to growing evidence regarding glycemic control and HbA1c level use as biomarker for depression screening in type 2 diabetics.