Indonesia is one of the developing countries in South East Asia where the incidence of both communicable and non-communicable disease are rapidly increasing. One of the non-communicable diseases that have raised many concerns is Diabetes Mellitus. Based on the Indonesian Department of Health annual report (2009), diabetes is identified as one of the major diseases that had caused 5.7% of deaths in 2007. People with diabetes mellitus often have other diseases as comorbid whether it is biological or psychological which aggravating their health condition and wellbeing. As a form of psychological disorder, depression has been identified to have bidirectional relationship with diabetes and adversely associated as one of the major risk factors of diabetes (Golden et al 2008 cited in Katon 2010, p. 323, Eriksson et al 2008). In addition, depression itself has been acknowledged as one of the factors that causes disabilities and altered the sufferer’s role functioning in life (Lecrubier 2001).
As a community nurse in Indonesia, the author is responsible in organizing health promotion activities or programs in the community settings and, thus, facilitating the community to adapt healthy behaviours. In particular, the author is also responsible in supporting patients with diabetes mellitus in the community dwelling to achieve best quality of life and wellbeing. As health is identified beyond physical impairments (WHO 1974, p.1 cited in McMurray 2007, p. 6), psychological condition is acknowledged as one of the components that determine ones quality of life and wellbeing (Labonte 1998 cited in Victorian Department of Health 2011). Therefore, obtaining more knowledge on the association of psychological health disorders; depression, and diabetes mellitus is essential for the author. Not only it will enhance the author’s knowledge and stakeholders but it may also be utilized in designing health promotion activities or programs in the community that may reduce the burdens of diabetes and depression.
Through utilizing the concepts of epidemiology, this essay is aimed to further examine the association between diabetes mellitus and depression from three studies as the primary source of information and supported by other literatures. The overview and epidemiological aspects from the studies are described in the first section. Then, discussion of the issues obtained from the studies and their implications to the author’s area of practice is done in the second section. Lastly a conclusion is presented in the last section. Searching processes of the articles and other references are conducted through search engines and databases such as PubMed, OVID, ScienceDirect, Google Scholar, and Wiley InterScience. The keywords used in the searching process are ‘diabetes mellitus’, ‘depression’, ‘epidemiology’, ‘prevalence’, ‘diabetes management’ and ‘health promotion’.
Summary of the studies
‘Symptoms of depression in people with impaired glucose metabolism or Type 2 diabetes mellitus: The Hoorn study’
The study conducts a cross-sectional data from previous population-based cohort study; The Hoorn Study (Adriaanse et al 2008, pp. 843-849). It is aimed to examine the frequency and risk factors of depression in an elderly group (n = 550, men = 276, women = 274) and it is also comparing participants with impaired glucose metabolism (IGM) or Type 2 diabetes mellitus (DM2) and those with normal glucose metabolism (NGM). Secondary goals of the study are to investigate the association of age and education with depression on people with IGM and DM2 and to examine the association of IGM or DM2 and depression with cardiovascular risk factors. Statistical analyses done in the study are χ2 – tests, analyses of variance and logistic regression analyses.
The results of the study confirm that women with IGM and DM2 have higher prevalence of depressive symptoms, 23.1%and 19.7%, respectively. In contrast, the prevalence of depressive symptoms in men with IGM and DM2 are lower than in women. However, both man and women who have NGM have similar prevalence of depressive symptoms, 7.7%. The risk factors of depression is stated to be higher in women with IGM (OR = 3.60, 95% CI = 1.57-8.28) or DM2 (OR = 3.18, 95% CI = 1.31-7.74) than in men with DM2 (OR = 2.04, 95% CI = 0.75-5.49). In addition, the association between depression and IGM or DM2 with age and education both in man in women is not statistically significant. The same results are also occurred in the association between depression and IGM or DM2 with cardiovascular risk factors.
As the first population-based study that utilize cross-sectional data to examine the prevalence of depressive symptoms in men and women who are grouped in three different categories, the study presents essential information and data that can be further utilized in analysing and developing depression prevention programs in people with IGM and DM2 (Bonita et al 2006, p. 44). It is also provides further information on the association of cardiovascular risk factors with depression and DM2 that may better enhanced health promotion programs for people with DM2. However, the weaknesses of the study which are also acknowledged by the researchers can be identified as the disadvantages of the study. As an instance, causality between depression and diabetes cannot be inferred because of the cross-sectional design utilized in the study.
‘Lifetime depression and diabetes self-management in women with Type 2 diabetes: a case-control study’
It is a case-control study that is aimed to investigate the association of lifetime history of major depressive disorder (L-MDD) and diabetes self-management in women with DM2 (Wagner et al 2010, pp. 713-717). Statistical analyses that are utilized in the study are ANOVA, ANCOVA and χ2 – tests. Compared with their control group (n = 90), women with L-MDD (n = 63) experienced more distress, higher score in the Measure of Invasiveness and Skipping SMBG (MISS) and Problem Areas in Diabetes (PAID) and has lower rate of visiting health care providers or settings within the past twelve months (χ2 = 5.87, P = <0.05). Women with L-MDD also identified to have lower self-efficacy on diabetes control which is projected through the Summary of Diabetes Self-Care Activities (SDSCA) score (r = 0.49, P = <0.05). Furthermore, by conducting bootstrapping test the study also indicates that self-efficacy is mediating the link between L-MDD and SDSCA scores.
As a case control study, the study has the advantages that increase the value of information which are provided as the results of the study. As an instance, multiple associations between DM2, depression, self-efficacy and self-management can be obtained through the study. Therefore, by identifying specific interventions that may enhance one of these variables such as self-efficacy, may significantly affect the outcomes and reduce the burden of DM2. However, as it only has quite small number of participants and limited only for women with DM2, the result of the study cannot be widely applied in general population. Furthermore, the depressive symptoms measured in the study may be affected by recall bias which often occurs in case-control study (Hassan 2006). Nevertheless, the study may provide benefits for healthcare providers in developing health promotion interventions that may also support people with DM2 in the community to increase their skill and knowledge in conducting self-care diabetes management.
‘Depression and advanced complications of diabetes’
It is a prospective cohort study which is aimed to investigate the association of depression among people with DM2 (n = 3,723) and the risk for further macrovascular and microvascular complications (Lin et al 2010, pp. 264-269). It is a five years longitudinal study which is initiated in 2000-2002 where baseline data obtained and finished in 2005-2007 where follow up or measurement of the outcomes are conducted. Within the study, the association of depression and the vascular complications is done by implementing the proportional hazards model. Furthermore, by utilizing the model and modify it into four models, the researchers examine the association of covariates of diabetes and depression and other variables; as mediator, that may affect the relationship between depression and adverse outcomes.
The result describes that people with DM2 who have major depression have 36% higher risk of developing microvascular diseases and 25% of macrovascular diseases as complications within five years duration. From the analyses of covariates, the association of major depression and severe adverse events is also confirmed to be significant. Furthermore, mediators such as diabetes self-care are confirmed to affect the relationship of both variables and altered the significance. As the advantages of the study, the information obtained from the study can be utilized in developing diabetes education programs that may support people with DM2 to adapt healthy behaviours to reduce the prevalence of depression and, moreover, to prevent the incidence of vascular complications both micro and macro. However, as a longitudinal study, there may be confounding factors that affect the outcomes during the time of the study that are not identified both by the participants and the researchers such as changes of medications and life events that may increase the risk and severity of depression and DM2 (Moon et al 2000, p. 72).
From the summary of the studies there are three identified issues that are indicating risk factors within the association of DM2 and depression. The identified issues are:
1) Women with IGM or DM2 are at higher risk (absolute risk) to have depression and that there is a possibility that cardiovascular risk factors or diseases and depression increased the risk of DM2.
2) L-MDD in women with DM2 increase the risk of lower self-efficacy which related with diabetes self-management and resulted to lower adherence to designed diet, blood glucose monitoring, lacking of initiative to visit healthcare provider and projected more diabetes-specific emotional distress.
3) People with DM2 with major depression are at higher risk of developing macrovascular complications (25%) such as Myocardial Infarction or Stroke and microvascular complications (36%) such as end stage renal disease (ESRD) or blindness.
Sedgwick (2001) asserts that by understanding the defined risks within epidemiological studies, a risk reduction strategy can be appropriately developed. As advanced information, these issues provide information to conduct risk reduction strategy in primary prevention through an effective health promotion strategy that is aimed to support and facilitate people with DM2 in the community.
Ganguli and Kukull (2010, p. 108) argue that a risk factor is a factor that has the potential to increase the probability of a disease, whereas, a protective factor lowers it. Within the studies summarized previously, the term of risk factors can be fitted to variables that may cause diabetes mellitus, DM2 in particular, and depression. As an instance, adverse health behaviours within sedentary lifestyle are identified to be the risk factors of type 2 diabetes (Tuomilehto et al 2001). Whilst, family history, childhood experiences, stress, alcohol and marital status are confirmed to increase the prevalence of depression (Haggerty 2011). On the other hand, protective factors for DM2 may include adequate health promotion, active lifestyle and healthy diet.
In the first study, it is confirmed that the prevalence of depression is increased in women with DM2 and, thus, depression is a risk factor that may increase the health burdens of women with DM2. It is also concluded that the presence of cardiovascular risk factors (genetic, environment and behaviour) or cardiovascular diseases and depression may become the risk factors of DM2. Therefore, by eliminating variables that may cause depression on people with DM2 and cardiovascular diseases, better health outcomes can be generated. However, Engum et al (2005) state that non diabetic people have the same possibility to have depression as people with DM2. Furthermore, people with cardiovascular disorders share similar biological impairments with people with depression that may progress to DM2 (Lustman et al 2007 and Golden 2007 cited in Lin et al 2010, p. 268). Thus, a comprehensive strategy is required to prevent depression.
In the second study, L-MDD in women with type 2 diabetes is identified as the risk factor of low self-efficacy in diabetes management. Therefore, by implementing interventions that may facilitate women with DM2 in overcoming their depression, better self-efficacy and adherence in diabetes self-management can be achieved. The same intervention can also be implemented in overcoming the identified risk factor within the third study. In other words, to prevent the incidence of macrovascular and microvascular complications on people with DM2, interventions that may prevent major depression may be implemented. However, it is also essential to acknowledge that lifetime major depression is strongly associated with metabolic changes that significantly affect the incidence of CAD and DM2 in middle-aged women (Goldbacher et al 2009). Consequently, comprehensive interventions that may address lifetime major depression and its impacts are imperative.
A further consideration in designing health promotion strategy to address depression in people with DM2 is to understand how they perceived depression as a risk factor that affecting their wellbeing and quality of life. Although depression has been associated as one of the most frequent comorbid in chronic diseases, there is still a lacking of specific study or research that investigates the perception of depression in people with diabetes. However, previous study done by Maddigan et al (2006) confirms that comorbidities, including depression, are significantly affecting the health-related quality of life and acknowledged by people with DM2. Furthermore, numerous research have been done and established the strong association between depressive symptoms and poor diabetic self-management (Ciechanowski 2000). Thus, it may be assumed that depression is also perceived by people with DM2 as an adverse factor and needs to be addressed and prevented.
Health promotion strategy to prevent depression on people with DM2
Based on the previous discussion and the assertion that non diabetic people has the same possibility to have depressive symptoms as people with DM2 (Engum et al 2005), health promotion strategy to facilitate and support people with DM2 in addressing depression may be the same as the general population. The Australian National Action Plan for Depression (Commonwealth Department of Health and Aged Care 2000) is one of the excellent frameworks that can be implemented for preventing depression. It proposes evidence-based strategies to prevent depression and the early interventions within the primary care. Through health education or health literacy about depression, supportive health policy, adequate information resource and support system, it is expected that the prevalence of depression can be decreased.
Other specific actions that can be implemented by the author as a community nurse in Indonesia in facilitating people with DM2 in preventing depression based on the examined studies are:
- Provides adequate resources of information on depression, signs and symptoms, preventions and treatments through pamphlets and posters in accessible areas in the community and health information-education sessions in the public health centres, public premises, schools or diabetes group meetings. Within this intervention, the targeted group may include the non diabetic population, adolescents and older adults.
- Increase the healthcare providers’ knowledge and skill in diagnosing depression in people with DM2. Utilization of The Patient Health Questionnaire (PHQ-9) is one of the effective efforts that can assist healthcare providers in diagnosing and managing type 2 diabetes (Acee 2010).
- Provide adequate resources and information on acquiring and maintaining healthy lifestyle and behaviours that particularly enhance the health of cardiovascular system for people with DM2.
- In collaboration with the local council, public health centre and other community support groups, initiate community based activities that may increase the adaption of healthy lifestyle, health literacy and behaviours in the community.
Depression has been strongly associated with diabetes mellitus, particularly in people with type 2 diabetes or DM2. From the three epidemiology studies examined by the author, it is also confirmed that depression is one of the risk factors that increased the health burdens of people with DM2. From the discussion of the studies, information related with the association of DM2 and depression is obtained. Furthermore, the information is increasing the comprehension on the topic and may be utilized by the author as a community nurse in developing health promotion strategies in supporting people with DM2 within the author’s area of practice. Nevertheless, the fact that there is a lacking of studies on how depression is perceived by people with DM2 is acknowledged as a factor that may creates a gap between the interventions (health promotion) and the outcomes of depression prevention activities or strategies. Thus, further investigation on the perception of depression by people with DM2 is required to provide supportive information in reducing the risk of depression and its impacts.
Acee, A 2010, ‘Detecting and managing depression in type II diabetes PHQ-9 is the answer!’, MEDSURG Nursing, vol. 19, no. 1, pp. 32-38.
Adriaanse, M, Dekker, J, Heine, R et al 2008, ‘Symptoms of depression in people with impaired glucose metabolism or Type 2 diabetes mellitus: The Hoorn study’, Diabetic Medicine, vol. 25, pp. 843-849.
Bonita, R, Beaglehole, R and Kjellström 2006, Basic Epidemiology, 2ndedn, World Health Organization, Geneva.
Ciechanowski, P, Katon, W and Russo, J 2000, ‘Depression and diabetes: Impact of depressive symptoms on adherence, function and costs’, Arch Intern Med, vol. 160, pp. 3278-3285.
Commonwealth Department of Health and Aged Care 2000, The Australian National Action Plan for Depression, Mental Health and Special Programs Branch, Canberra.
Engum, A, Mykletun, A, Midthjell, K et al 2005, ‘Depression and diabetes: A large population-based study of sociodemographic, lifestyle, and clinical factors associated with depression in type 1 and type 2 diabetes’, Diabetes Care, vol. 28, no. 8, pp. 1904-1909.
Eriksson, A, Ekbom, A, Granath, F et al 2008, ‘Psychological distress and risk of pre-diabetes and Type 2 diabetes in a prospective study of Swedish middle-aged men and women’, Diabetes Medicine, vol. 25, pp. 834-842.
Ganguli, M and Kukull, W 2010, ‘Lost in translation: Epidemiology, risk, and Alzheimer disease’, Archives of Neurology, vol. 67, no. 1, pp. 107-111.
Goldbacher, E, Bromberger, J, Matthews, K et al 2009, ‘Lifetime history of major depression predicts the development of the metabolic syndrome in middle-aged women’, Psychosom Med, vol. 71, no. 3, pp. 266-272.
Hassan, E 2006, ‘Recall bias can be a threat to retrospective and prospective research designs’, The Internet Journal of Epidemiology, vol. 3, no. 3, viewed 12 June 2011, <http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ije/vol3n2/bias.xml>.
Haggerty, J 2011, Risk factor for depression, Psych Central, viewed 14 June 2011, <http://psychcentral.com/lib/2006/risk-factors-for-depression/>.
Indonesian Department of Health 2009, Indonesian Health Profile 2008, Indonesian Department of Health, Jakarta.
Katon, W 2010, ‘Depression and diabetes: Unhealthy bedfellows’, Depression and Anxiety, vol. 27, pp. 323-326.
Lecrubier, Y 2001, ‘The burden of depression and anxiety in general medicine’, Journal of Clinical Psychiatry, vol. 62, pp. 4-9.
Lin, E, Rutter, C, Katon, W et al 2010, ‘Depression and advanced complications of diabetes’, Diabetes Care, vol. 33, no. 2, pp. 264-269.
Maddigan, S, Feeny, D, Majumdar, S et al 2006, ‘Understanding the determinants of health for people with type 2 diabetes’, American Journal of Public Health, vol. 96, no. 9, pp. 1649-1655.
McMurray, A 2007, Community Health and Wellness, A socio-ecological approach, 3rdedn, Elsevier, New South Wales.
Moon, G, Gould, M, Brown, T et al 2000, Epidemiology: An Introduction, Open University Press, Buckingham.
Sedgwick, J 2001, ‘Absolute, attributable and relative risk in the management of coronary heart disease’, Heart, vol. 85, 491-492.
Tuomilehto, J, Lindström, J, Eriksson, J 2001, ‘Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance’, The New England Journal Of Medicine, vol. 344, no. 18, pp. 1343-1350.
Victorian Department of Health 2011, ‘The factors affecting health and wellbeing’, State Government of Victoria, Australia, viewed 12 June 2011, <http://www.health.vic.gov.au/healthpromotion/downloads/factors_hlth_wellbeing.pdf>.
Wagner, J, Tennen, H and Osborn, C 2010, ‘Lifetime depression and diabetes self-management in women with Type 2 diabetes: a case-control study’, Diabetic Medicine, vol. 27, pp. 713-717.