Glycemic control of type 2 diabetics and associated depressive disorders spectrum - descriptive comparative study in Ismailia city -Egypt

Abstract

Background:

Depressive disorders are highly prevalent in the general population worldwide. Evidence suggests a longitudinal reciprocal   bi-directional relationship between depression and type 2 diabetes.  This study aims at detecting the relationship between diabetic control and spectrum of depressive disorders among patients with type II diabetes attending health insurance medical complex, between January and March 2022, Ismailia city, Egypt.

Methods:

This study recruited 105 patients with type II diabetes randomly selected from patients attending the specialized endocrinology and diabetes center, and matched on a regular basis with another 105 non-diabetic individuals randomly selected from new patients attending for general medical check up covered by the comprehensive medical insurance pilot in Egypt run in Ismailia Governorate. Brief medical history and examination was carried out for all participants including, duration of type 2 DM diagnosis, presence of diabetic complications, and smoking status, and BMI recording, followed by interview for self-completion of the “Beck Depression inventory II scale”. A venous blood sample, in a non-fasting state, was drawn for measuring the HbA1C% in the same session.

Results:

The means of HbA1c% in in diabetic group was 8.7% +2.1, compared with 5.3 + 0.44 in non-diabetic group. Assessment of the prevalence and grades of depression in the two study groups, showed a highly statistically significant difference in the prevalence of depression, with 55 subjects representing 52.4% in the diabetic group, compared with 11 subjects, representing 10.5% in the non-diabetic group. The grades of severity of depression between the two groups showed also a highly statistically significant difference with 33.3%, 15.2%, and 3.8% respectively for mild, moderate, and severe depression in the diabetic groups, compared with 8.6%, 1.9%, and 0% respectively for mild, moderate, and severe depression in the non-diabetic groups. High statistically significant difference in Beck ‘depression inventory Score (BDI-II) between the two groups was shown, with mean score of 14.2 + 7.6 in the diabetic group, compared with 9.8 + 3.3 in the non-diabetic group. A linear correlation manner was shown between HbA1c%, and BDI-II score in all of the study participants, and in the diabetic group a moderate correlation was shown between BDI-II and HbA1c% with r coefficient 0.37 that was highly statistically significant (P< 0.001). The results of binary regression analysis model for prediction of depression, showed among several independent factors selected, that smoking, and presence of diabetic complications were statistically significant predictors (P = 0.016, and 0.013, respectively), and glycemic control (HbA1c%) was highly statistically significant predictor (P < 0.001)

Conclusion:

In this study, poor glycemic control reflected in glycosylated hemoglobin percent (HbA1c%), was shown to be closely related to higher percentages of all grades of depressive disorders as assessed by BDI-II scale when comparing type 2 diabetic and non-diabetic patients, and among the type 2 diabetic patients. The correlation between glycemic control and the spectrum of depressive disorders was moderate, and depicted a linear relationship.  Glycemic control was shown to be the strongest predictor of depressive disorders, followed by presence of diabetic complications, and smoking.

Introduction

Depression is projected to become the leading cause of disability and was the second leading contributor to the global burden of disease by 2020 ⁽¹⁾. World Health Organization (WHO) ranked depression the fourth global burden of disease and found it to be the largest non- fatal burden of disease, with nearly 12% of total years lived with disability ⁽²⁾. Diabetes is a global health concern due to its increasing prevalence which was projected to rise from 2.8% in 2000 (171 million adults) to 4.4% in 2030 for all age-groups ^(3). (366 million adults). There were over 7.8 million cases of diabetes in Egypt in 2015 ⁽⁴⁾. Diabetes has been associated with an increased risk of certain psychiatric disorders, particularly depression and anxiety disorders ⁽⁵⁾. The complex interactions of biological, psychological, social and genetic factors that contribute to the association between diabetes and depression remain uncertain. Type II diabetic patients with poor glycemic control were more likely to have depression than those with good diabetic control. A conclusion that was confirmed across different cultural and ethnic groups ⁽⁶⁾. while others found no correlation between HbA1c and depressive disorders ^{(7). It} is currently unclear how and when depression develops after diagnosis of type II diabetes and results are equivocal. Recent studies have shown that coexisting depression increases synergistically the risk of death among people with diabetes ⁽⁸⁾.  Data suggest a bidirectional relationship; depression symptoms predict the onset of type 2 diabetes, and the diagnosis of type 2 diabetes is associated with increased depressive symptoms over time, with the first directional effect appearing to be more robust than the second. The presence of psychiatric comorbidity especially depression has been associated with medications non-adherence, suboptimal glycemic control, and the development of diabetes -related complications ⁽⁹⁾. Accordingly, in our study, we tried to study the relationship between depressive disorders in all grades of severity and status of glycemic control, and what factors can predict the occurrence of depressive disorder among a sample of type 2 diabetic patients attending the specialized endocrinology and diabetes center in Ismailia Medical Complex, Ismailia, Egypt.

The aim of this work

This study aimed at studying the relationship between degree of glycemic control in type 2 diabetics mellitus and the spectrum of depressive disorders prevalence among controlled and uncontrolled type 2 diabetics compared with non- diabetic patients. 

Subjects And Methods

Sample size calculation: The power of the study was estimated using G*Power 3.1.9.4, with a 95% confidence level (Z-score = 1.96), and a margin of error (confidence interval) of +/- 5%. Based on the study of Kalantari et al ⁽¹⁰⁾ that reported the prevalence of depression in patients with diabetes mellitus to be 37.8% compared to a prevalence of 16% in non-diabetic subjects, the sample size was estimated to include 105 subjects in each group. 

Subjects

105 patients with type II diabetes mellitus were randomly selected from patients attending the specialized endocrinology and diabetes center of the Medical Complex of Health Insurance, Ismailia City, and matched on a regular basis for another 105 non-diabetic individuals randomly selected from new patients attending for general medical checkup covered by the comprehensive medical insurance pilot in Egypt run in Ismailia Governorate. 

Inclusion Criteria: any type 2 diabetic/ non-diabetic adult and willing to participate in the study

Exclusion Criteria: 

-  Previous history or receiving treatment of any psychiatric conditions.

-  History of or on treatment for any non-diabetic co-morbid diseases.

Methods

Brief medical history and examination was carried out for all participants including, duration of type 2 DM diagnosis, presence of diabetic complications, and smoking status, and BMI recording. Measurement of glycosylated haemoglobin percent (HbA1c%).  was done by collecting non-fasting 5 ml of venous blood sample in EDTA tube by ion-exchange high-performance liquid chromatography (HPLC) for the automatic separation of HbA1c. EDTA blood is sampled directly from the primary tube, diluted in hemolyzing buffer and pumped via a pre-filter to the ion-exchange column. A series of three buffers are used to elute the hemoglobin from the column and the peak measurement achieved by dual wavelength detection. Quantitation is two-point calibrators. blood sample takes 3 minutes to elute and there is no pretreatment of the sample ⁽¹¹⁾ . the method was applied systematically for all of the study participants. This was followed by interview with all subjects for completion of the “Beck Depression inventory II scale” (BDI-II). The BDI-II scale is a scale that measures the existence and severity of symptoms of depression, it is self-administered questionnaire consists of 21 items that include 2 subscales, 13 items for somatic and 8 items for affective symptoms. Each item is scored on a scale of 0-3 in a list of four statements arranged in increasing severity about a particular symptom of depression, with 2 items 16 and 18, there are seven options to indicate either increase or decrease of appetite, and sleep. Total score of 0-13 is considered minimal range, 14-19 is mild, 20-28 is moderate, and 29-63 is severe. The BDI-II was proven a relevant psychometric instrument, showing high reliability, capacity to discriminate between depressed and non-depressed subjects with improved concurrent, content, and structural validity, and internal consistency was described as around 0.9 and the retest reliability ranged from 0.73 to 0.9. The BDI-II can be viewed as cost- effective questionnaire for measuring the severity of depression, with broad applicability for research and clinical practice worldwide. Substantial overlap between measures of depression and anxiety was reported ⁽¹²⁾.

Statistical design: The raw data coded and entered into SPSS system files (version 22), the following statistical measures were used when appropriate; Descriptive statistics were used including frequency; distribution, mean, median with interquartile range (IQR) and standard deviation to describe different characteristics. Univariate analyses, including Student t test, χ²   test, and Mann Whitney test, were used to test the significance of results of quantitative variables. Spearman’s rank correlation coefficient or Spearman’s rho was used to assess how well the relationship between two variables can be described using a monotonic function. Binary regression analysis model was used to predict different biosocial variables that predict change in BDI-II score.

Results

Comparison of the sociodemographic characteristics between the two study groups showed no statistically significant difference in any of sociodemographic data compared. The mean age of participants in diabetic group was 52 years, and 53 years in non-diabetic group. Female patients represented 54% in diabetic group, and 53% in non-diabetic group (table1). Statistically significant difference in the means of glycosylated hemoglobin percent (HbA1%) was evident between the two study groups, with a mean 8.7% + 2.1 in diabetic group, compared with 5.3 + 0.44 in non-diabetic group (figure 1). The mean duration of disease in diabetic group was 5.7 +3 year. Twenty patients in the diabetic group, representing 19% have been previously diagnosed with diabetic complications, and 18 patients representing 17.1% was controlled, while 87 patients representing 82.9% was uncontrolled (table2). 

Comparing the sociodemographic characteristics between controlled and uncontrolled patients in the diabetic group showed no statistically significant differences in all variables compared including, educational level, and employment status. The mean age was 51.7 years in controlled diabetic patients versus 52.2 years in uncontrolled diabetic patients, BMI (mean + SD) was 28.7 + 4.6 in controlled patients, versus 29.7+ 4.8 in uncontrolled patients (table 3).  

Assessment of depression prevalence in the study groups, showed a high statistically significant difference between the two study groups, with 55 subjects representing 52.4% in the diabetic group, compared with 11 subjects, representing 10.5% in the non-diabetic group.  A High statistically significant difference in Beck ‘depression inventory Score (BDI-II) was shown between the two study groups, with mean score of 14.2 + 7.6 in the diabetic group, compared with 9.8 + 3.3 in the non-diabetic group.  The grades of severity of depression between the two groups showed also a highly statistically significant difference with 33.3%, 15.2%, and 3.8% respectively for mild, moderate, and severe depression in the diabetic groups, compared with 8.6%, 1.9%, and 0% respectively for mild, moderate, and severe depression in the non-diabetic groups (table 4). Moderate and severe depression constituted 19% in the diabetic group, compared with 1.9% in the non-diabetic groups (table 4, figure 2).

The comparison between patients with controlled and uncontrolled glycemia in the diabetic group regarding  clinical data, showed no statistically significant difference between the groups including occurrence of diabetic complications, means of disease duration that was 5.2+ 2.7 years in the controlled patients versus 5.7 + 3.1 in the uncontrolled patients  and mode of treatment, where, 77.8% on oral antidiabetics and 22.2% on insulin therapy in the controlled patients versus 78.3% on oral antidiabetics and 21.8% on insulin therapy in the uncontrolled patients, while HbA1c% levels were highly statistically significantly different between the two groups with a mean (SD) 5.6 + 1.1, representing 17% in the controlled patients, compared with a mean (SD) of 9.4 + 1.6, representing 83%  in  the uncontrolled patients (table 5, figure 3). Based on BDI-II score, depression was diagnosed in 22.2% in the controlled diabetic patients, compared with 58.6% in the uncontrolled patients, that was statistically significant (P < 0.022), with the mean score of BDI-II, 11.2 + 5.7 in the controlled patients, compared with a score of 14.8 + 7 in the uncontrolled patients, that was statistically significant difference (P < 0.033).  The percentages of severity grades of depression in the controlled, compared with uncontrolled group was alike highly statistically significantly different with percentages 16.8%, 5.6%, and 0%, respectively for mild, moderate, and severe depression in the controlled patient, compared with percentages 36.8%, 17.2%, and 4.6%, respectively for mild, moderate, and severe depression in the uncontrolled group (table5, figure 4).

The correlation between BDI-II score and data of the study participants showed a moderate correlation with HbA1c% with r coefficient 0.37 that was highly statistically significant (P< 0.001) (table 6). A linear correlation manner was shown between HbA1c%, and BDI-II score in all of the study participants (figure 5).

The results of binary regression analysis model for variables that predict depression in all of the study participants, showed among several independent factors selected that, smoking, and diabetic complications were statistically significant (P = 0.016, and 0.013, respectively), and HbA1c%, and DM control was highly statistically significant (P < 0.001) (table 7).

Discussion

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.

Conclusion

This study concluded that depressive disorders in all grades of severity were much common in type 2 diabetics compared with non-diabetics, and in uncontrolled diabetics compared with controlled patients. factors that were shown to predict depression in regression analysis model used was smoking, presence of diabetic complications, and the status of glycemic control, with the last predictor showing a moderate linear correlation. Family physicians have a crucial role in caring for diabetics by the virtue of the holistic approach they utilize with the patients and their families incorporating elements like life style counselling including, weight control, smoking cessation advice, and exercising and improving family support and self-efficacy to help control glycemic status and associated high rates of depressive disorders. 

Declarations

1- Ethical Approval and consent to participate:

Approval for conducting the study was officially obtained from the Medical Research Ethics Review Board of Ministry of Health and Population (DOHP) authorities, an informed consent was obtained from all subjects/ and or their legal guardian(s) in case of illiterate participants in the study. All methods were carried out accordance with relevant guidelines and regulations. 

2- Availability of data and materials:

All Raw data generated or analyzed during this study are included in the published article as a supplementary information file- SPSS spread sheet. 

3- Consent to publish: 

All authors of this study are consenting for publishing of this research and the participants as well were consenting for scientific publication of the research following appropriate explanation given with obtaining the consent. 

4- Funding:

No institutional or any other forms of funding for carrying out this research to be declared. 

5- Conflict of interest:

No competing or conflicting interests in any form were involved in this research.  

6- Author contribution: 

Dr. Seham A. Ibrahim; reviewed the results of the study, shares in editing the discussion part, and final conclusions of the study. Dr. Hassan A. Shora; wrote the protocol of this study, providing the raw data for the statistical analysis. Dr Ashraf Eltantawy; did the subjects and methods section, give his guidance for research in psychiatry and monitoring every step in the research. Dr. Ismail Dahshan; did the results part of the study, literature review part, and shared in editing the discussion part, and final review and preparation of this research manuscript.  

Acknowledgement: 

Special thanks should be given to professor D. Ashraf Eltantaway, head of psychiatry department, faculty of medicine, Suez Canal University for the time, expertise, he offered to all and the review of every section until final version of this manuscript submitted.

References

1. World Health Organization. Mental health: a call for action by world health ministers. Geneva. Who Int. 2001:16
2. Ustün TB, Ayuso-Mateos JL, Chatterji S, Mathers C, Murray CJL. Global burden of depressive disorders in the year 2000. Br J Psychiatry. 2004 May; 184:386–92.
3. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004 May;27(5):1047–53.
4. Egypt | International Diabetes Federation. IDF Diabetes Atlas - 7th edition. 2015 (4):79
5. Collins MM, Corcoran P, Perry IJ. Anxiety and depression symptoms in patients with diabetes. Diabet Med. 2009 Feb;26(2):153–61.
6. El-Shafie, T.M., El-Saghier, E.O., Ramadan IK. Depression among type 2 diabetic patients. Egypt J Hosp Med. 2011;3(July):258–71.
7. Joshi A, Joshi A, Maseeh A, Jha PK, Bhatt M, Vyasa B. A Study of Prevalence of Depression in Diabetes Mellitus: Analysis from Urban India. Indian J Psychiatry. 2013;55(2):135–9.
8. Zhang X, Norris SL, Gregg EW, Cheng YJ, Beckles G, Kahn HS. Depressive symptoms and mortality among persons with and without diabetes. Am J Epidemiol. 2005 Apr 1;161(7):652–60.
9. Gonzalez JS, et al, In: Coeie Cc, et al editors. Diabetes in America. 3^rd edition. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases (US); 2018 Aug. Chapter 33.
10. Kalantari S, Jafarinezhad A, Zohrevand B. Association of depression with type 2 diabetes and relevant factors. Adv Biomed Res 2014; 3:244.
11. Jeppsson J-O, Kobold U, Barr J, Finke A, Hoezel W, Hoshino T et al. Approved IFCC reference method for the measurement of HbA1c in human blood. Clin Chem Lab Med 2002; 40(1): 78-89.
12. Yuan-Pang Wang, Clarice Gorenstein . Review article. Psychometric properties of Beck Depression Inventory -II:a comprehensive review. Revista Brasileira de Psiquiatria. 2013; 35: 414-431.
13. A Rady A, et al. Epidemiological estimation of depression among type II diabetes mellitus in primary family health care centers in Alexandria: a cross sectional study. European Psychiatry. 2012; 27: Suppl 1. P1.
14. Mansori K, et al. Association between depression with glycemic control and its complications in type 2 diabetes. Diabetes Metab Syndr.2019 Mar-Apr; 13 (2): 1555-1560. Doi: 10.1016/j.dsx.2019.02.010. Epub 2019 Feb 5.
15. Ellouze F, et al. Depression in Tunisian type 2 diabetic patients: prevalence and association to glycemic control and to treatment compliance. Tunis Med. 2017 Mar; 95 (3): 210-214.
16. Sympa P, et al. Depression and self -efficacy in patients with type 2 diabetes in Northern Greece. Endocr Metab Immune Disord Drug targets. 2018; 18(4): 371-378. Doi: 10.2174/1871530317666171120154002.
17. Jameel Nasser, et al. Prevalence of depression among people with diabetes attending diabetes clinics at primary health settings. Bahrain Medical Bulletin. Vol.31. No.3, September 2009.
18. Alhussain Alzahrani, et al. Prevalence of and predictors of depression, anxiety, and stress symptoms among patients with type ii diabetes attending primary healthcare centers in the western region of Saudi Arabia: a cross sectional study. Int J ment Health System (2019) 13:48. http://doi.org/10.1186/s13033-019-0307-6.
19. Prevalence of depression among patients with type 2 diabetes at King Abdulla Medical City. Wasayf AlJohani, et al. Cureus. 2012 Oct; 13(10): e 18447. Doi: 10.7759/cureus.18447.
20. Institute of Gerontology, college of Medicine, National Cheng Kung University, Tainan, Taiwan, and Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University, Tainan, Taiwan. Longitudinal investigation of the reciprocal relationship between depressive symptoms and glycemic control: The moderation effects of sex and perceived support. J Diabetes Investig.2019 May; 10 (3): doi: 10.1111/jdi.12969.Epub 2018.
21. Magdalena Beran et al. "The bidirectional longitudinal association between depressive symptoms and HbA1c: A systematic review and meta‐analysis." Diabetic Medicine 39, no. 2 (2022): e1467.
22. Genis-Mendoza AD, González-Castro TB, Tovilla-Vidal G, Juárez-Rojop IE, Castillo-Avila RG, López-Narváez ML, Tovilla-Zárate CA, Sánchez-de la Cruz JP, Fresán A, Nicolini H. Increased Levels of HbA1c in Individuals with Type 2 Diabetes and Depression: A Meta-Analysis of 34 Studies with 68,398 Participants. Biomedicines. 2022 Aug 8;10(8):1919. doi: 10.3390/biomedicines10081919. PMID: 36009468; PMCID: PMC9405837.
23. M Ghanem, et al. National survey of prevalence of mental disorders in Egypt – preliminary survey. Eastern Mediterranean health journal.2009; 15 (10:65-75). Doi: 10.26719/2009.15.1.65.
24. Fawzi MH, et al. Psychiat4ric referral and glycemic control of Egyptian type 2 diabetes mellitus patient with depression. Gen Hosp Psychaitry.2016 May-June; 40:60-7. Doi: 10.1016/jgenhosppsych.2016.01.002.Epub 2016 Jan 14.
25. C Uchendu al . Effectiveness of cognitive-behavioural therapy on glycemic control and psychological outcomes in adults with diabetes mellitus: a systematic review and meta-analysis of randomized controlled trials. Diabet Med. 2017; 34:328-339. https://doi.org/10.1111/dme.13195.

Tables

Table 1: Sociodemographic characteristics of the study groups

Group 1: diabetic group, group 2: non-diabetic group, χ²: Chi-square test, t: student-t test 

Table 2: Comparison of type 2 diabetes mellitus related data in the study groups

U: Mann-Whitney, *: Statistically significant at p ≤ 0.05

Table 3: Comparison of sociodemographic characteristics between controlled and uncontrolled diabetics patients

χ²: Chi-square test, t: student-t test.

Table 4: Assessment of depression in the study groups

χ²Chi- U: χ²: Chi-square test Mann-Whitney, *: Statistically significant at p ≤ 0.05

Table 5: Comparison between patients with controlled and uncontrolled DM regarding clinical data

χ²: Chi-square test, U: Mann-Whitney, *: Statistically significant at p ≤ 0.05

Table 6:  Correlation between BDI-II score and the study participants’ data

r: Pearson coefficient, *: Statistically significant at p ≤ 0.05

Table 7: Binary logistic regression analysis for the prediction of presence of depression

B: Regression coefficient; SE: standard error; * Significant