Background:
Diabetes is groups of metabolic disorders in which there is metabolic derangement leading to acumination of glucose in blood and resulting in several tissue and organs damage .
The diabetes can occur as result of pancreatic failure to release the insulin in response to high blood glucose level (type 1 diabetes ) or the defect In insulin action as result of either resistance at receptors or in appropriate insulin (type 2 diabetes) which represent 90%
The etiology of the disses unknown, but it might be thought the genetic factors play important role in both types of diabetes , additionally the familial factors , sedentary life style , obesity , unhealthy diet certain disses may lead to type2 diabetes.
The type 1 diabetes tend to present early in life and being more common among children and adolescents whereas the type 2 diabetes more commonly discovered in middle aged and elderly population with significant risk factors
Based on current data the prevalence of diabetes worldwide has been estimated to be around 150 millions and this might be increased to reach around double the existing number by 2025 more of this increased occur in devolving countries as result of increased prevalence of inappropriate lifestyle obesity growth , aging among them .
The study also mentioned that on 2025 the diabetic patient on developing countries between the 45 ‘ 64 years whereas those in developed countries aged around 65 years
Since 1890 the studies have shown that diabetes has increased in quadruple especially in countries with low income for many reason of which the sedentary lifestyle and obesity and unhealthy diet being important predictors
The diabetes(both type 1 and type 2) one of the major cause of death among dissed patient if not appropriately managed and control , the study found in 2012 that 1.5 million deaths has occurred among diabetic patient as a result of serious complication which can easily prevented by following the diabetic diet and compliance with treatment and avoid sedentary life style.
In 2016 the who , announce the population about the most important that should be taken seriously in order to prevent the occurrence of diabetes and measure that should be considered in diabetic patient to prevent complication , morbidly and increase the survival.
“Globally: According to the statistics of the International Diabetes Federation (IDF), there are over 400 million adults with diabetes and the figure is expected to be over 592 million in 2035, with 5 million deaths every year.”
“Locally: According to the statistics mentioned in the Saudi Health Information Survey Handbook 2013, there are about 1,851,080.00 diabetics, over the age of 15 years, and will increase to over 4,300,000.00 in 2030.”
Diabetes can affect any body systems when there is poor control ,among these system skin in which the diabetes can make the patient prone to recurrent fungal infection especially between the fingers , under nipple and wet areas , the diabetic patient may be more prone to another types of infection include bacterial infection . another skin problems that may also occurred in skin include diabetic dermopathy, necrobiosis lipoidica diabeticorum, diabetic blisters, and eruptive xanthomatosis. So careful monitoring of those patient to the skin should be considered impotently
The diabetes can affect the ocular system as well and range from minor illness to visual blindness. People with diabetes has affinity to developed glaucoma than those without diabetic by about 40% and affinity to developed cataract by 60% . the risk of glaucoma can also increased by aging, long duration of the disses and being uncontrolled . being diabetic have chance to developed cataracts faster and at young age .
The diabetes can affect kidney function and lead to impairment leading to abnormalities in electrolytes , acid base disturbance and abnormal controlled blood pressure , make the patient more debited and dialysis dependent
The nerve system also might be involved in diabetic patient leading to diabetic neuropathy that may be peripheral or autonomic. Result in many problems such as in digestive systems gastroparesis ,heartburn , vomiting of undigested meal ,nausea diarrhea , constipation lose defection control , indigestion. In urinary systems there may bel lost of urine control , frequent urination or fullness of bladder with no ability to urinate .in sex the men may have difficult to maintained erection and women may lose the arousal .in visual there may difficult to adjust the vision from moving from dark to light area or vise versa . in the skin there may be profuse seating or no sweeting despite being in hot climate or dry skin .there may be lose of response to hypoglycemia as a result of nuroadrenergic systems abnormalities . in heart there may be palpation or postural hypotension or poor prediction to serious disses like mi
In peripheral nerve , patient may complain of tingling , pain , or numbing and increased sensation
In addition to that the diabetic neuropathy include ; foot drop, focal neuropathy , thoracic/lumber radiculopathy cranial neuropathy, compression mononeuropathy ,Charcot joints
Macrovascular complication include stroke , heart attack higher in diabetic patient than in general population , being diabetic chance of having stroke about 1.5 times , in addition to that there 2 out of 3 diabetic patient die from macrovascular complication
Diabetes may lead to several mental health problems , that if present may complicate diabetes management further , among theses problems depression which is found to be associated with many diabetic complication in many studies .
If diabetic patient becomes depressed the liability to becomes uncontrolled more as a result of being the patient has no interest to diabetic self care , fatigue that make diabetes self check more difficult , lose of control to diet and finding that the treatment its time consumed without any result .
Depression is serious mental health problems that is conceded in those who meet the criteria for depression according to DSM-V criteria they include feeling sad most of the day for every day for 2 weeks or lose of interest to the events that’s bring enjoy to patient previously most of the day for every day for 2weeks plus 5 vegetative symptoms include ; changes in sleep patterns that either lead to excessive sleeping time or diminished sleep , appetite problems that make the patent eat more or have no appetite at al , difficult concentration and taken more time to finish simple task than before that may effect the patient job and lead to unemployment , lose of energy and feeling of tired most of the day despite good sleep time, sensation of guilt, suicidal attempts or thoughts and nervousness with retardation almost all the times
Depression has been associated with increase the risk of mortality from either suicide or other causes such as the diabetic complication that result in heart disses
In 2009-2012 , study found that among those above 12 years age 1 out of 20 have a depression moderate to sever in 2 week, with increase the prevalence among female patient almost 10% of adults aged 40-59 reported current depression
Literature review :
By reviewing the literature ; the researcher found that the shared decision making model have been studied in many researches internationally but unfortunately a little studies done locally.
In study done in 2016 in Mountain Medical Battalion, Bagh, Azad Kashmir, Pakistan , self- administered questioner using PHQ9 that has been translated in to Urdu according to the result score of more than 5 indicate depression and then depression classified into several categories of severity based on cut off value the questioner administered during face to face interview for patent with type 2 diabetes who are not already on anti-depressant or was diagnose with psychological problems with aim to determine if there is association between DM and depression and discover the predictors in case of positive association , the result of the study was out of 133 patient , 51 were depressed (38.35%) of which depression was mild in 34 moderate in 12 moderately sever in 4 and severe in 1 , with shorter duration of diabetes has significant prediction to depression among diabetic patient
In Al-Makhfiah primary healthcare center, Nablus, Palestine 2014 Swilh et al. 294 diabetic type 2 patient surveyed for presence of depression using Beck Depression Inventory (BDI-II) scale with additional information like age , sex, marital status, Body Mass Index (BMI), level of education, smoking status, duration of diabetes mellitus, glycemic control using HbA1C test, use of insulin, and presence of additional illnesses obtained by review the patient record . the patient medication adherence was also assessed by 8-item Morisky Medication Adherence Scale (MMAS-8).
The result of 164 of total sample were female and 216 were below 65 years old , 120 patient scored ‘ 16 on BDI-II scale .with female gender, low educational level, having no current job, having multiple additional illnesses, low medication adherence and obesity (BMI’30 kg/m2 significantly associated with high grade of BDI-II scale whereas there was no association with glycemic control duration of diabetes and other socioeconomic factors
In 2009 February , study conducted in Irland in order to attempt to find major determine of depression and anxiety in diabetic patient using hospital anxiety and depression scale among 2049 type 1 and 2 diabetes . there was high evidence of anxiety and depression on diabetic patient with 32.0% of them have mild to moderate anxiety and 22.4% have mild to moderate depression . the study also found that history of smoking diabetic complication uncertainty about glycemic control and being heavy drinker were risk factors of both anxiety and depression . in other hand female gender and poor glycemic control were risk factors only for anxiety whereas high socioeconomic status and older age protective factors for depression and anxiety there was no significate association between type of diabeties insulin use marital status and model of care with either anxiety nor depression
In 2013 august ,Madhu et al. published research about predictors of depression among patient with DM in southern India , the study aims to find both prevalence of depression and predictors to it among type 2 DM with self administered PHQ9 questioner in 100 patient attend diabetic clinic in tertiary care hospital the prevalence of depression was 49% with female gender elevated blood glucose level physical disability physician’s advice about life style modification being important predictors , with strong association between elevated blood glucose and depression.
In 2005 September , Noh Jh et at. Studied the relationship between diabetes type 2 and depression in patient with oral anti diabetic drug compared to those with insulin group, 204type 2 DM patient invited to complete questioner using TH BACK DEPRESSION INVONTRY SCALE, overall 32.4% have depression and there was significant higher rate of depression among insulin group in comparison to patient with oral anti-DM group with additional risk factors that can also contribute to high rate of depression include social factors , hypoglycemia and diabetic complication as well.
In 2012 august , Roy T et al. study in Bangladesh of 417 type 2 diabetic patient was selected randomly in 3 out patient clinics , assessment of depression based on to types of questioner : the PHQ9 and culturally standardized Bengali and Sylheti versions of the World HealthOrganization-5 Well Being Index (WHO-5) , the prevalence of depression was 34% (PHQ-9 score’5) and 36% (WHO-5 score'<’52) with audio questionnaire delivery method. The prevalence rates were similar regardless of the type (PHQ-9 vs. WHO-5) and language (Sylheti vs. Bengali) of the questionnaires, and methods of delivery (standard assisted vs. audio methods). The predictors of depression using either one of questioner are income , age ,gender, treatment intensity, co-morbid cardiovascular diseases , poor glycemic control and no. of co-morbid condition
In 2012 0ct , cross-sectional study conducted in morocco included 187 diabetic patient , average age was 53”14 years and the percentage of females was high: 71.2%. Diabetes type 2 was the most representative (85.6%), diabetes type 1 (11.8%) and gestational diabetes (2.7%). Half of diabetics were treated with an association of healthy dietary measures (MHD) and oral anti-diabetics; 31.6% were under MHD and insulin therapy; 33.2% of patients had acute complications and 43.5% had degenerative complications. Only 11 patients (5.9%) had antecedents of depression
Self -administered Hamilton questioner and mini international psychiatric interview has been used for detection of depression The prevalence of major depressive episode was 41.2%; 27.8% of patients suffered from dysthymia and 21.9% from double depression. Hamilton’s depression scale indicates that all depressed patients had mild depression (total of 17 items from 8 to 17). The dysthymia was predominate in patient age 46 to 55 with rate of dysthymia higher in type 2 DM In compare to type 1 dm and gestational DM . the study found that DM and depression can complicate each other , and patient with depression have increased the risk to DM in compere to subject with no depression.
In 2013 0ct, in UAE AL-hawamdh et al. conducted study among 182 subjects in order to determine the prevalence of DM and assess the relationship between the diabetes , sociodemographic characteristic and poor glycemic control with depression then after , cross-sectional study with THE BACK DEPRESSION INVONTRY SCALE,, sociodemographic questioner include age, national status, economic status , level of education , employment status . the level of control was assessed by using hba1c . the result found that 92 subjects was diagnosed with DM with significate association between DM especially type 1 and depression in addition to that the study also found that patient with poor glycemic control have higher level of depression , they found also positive relationship between depression and national status
Wang Y et al. measure the prevalence of depression among type 2 patient from 2005 -2012 of the civilian, non-institutionalized US population , and estimate the predictors for depression among them including those whose already on antidepressant using PHQ9qustinere with score of ‘ 10 indicate clinically relevant depression and score of ‘ 15 indicate clinically significant depression. The result of correctional survey of 2182 patient with type 2 DM found the prevalence of clinically relevant depression 10.6 % and clinically significant depression 4.2 %. The combined burden of depressive symptoms and antidepressants may be as high as 25.4 %. The clinically significate depression was associate with age of less than 65 low income of lower than 130 % of poverty level education below college, smoking , BMI of (’30 kg/m(2 sleep problems , hospitalization in last year total cholesterol of ‘200 mg/dl. Whereas the clinically significant depression was associated also with cardiovascular problems and physical activity level below the recommended guidelines
In Netherlands , Pouwer F et al. conducted cross-sectional study with aim to find the prevalence of both type 1 and type 2 DM and relation with depression in 3 outpatient clinics of 2055 who were selected randomly using the World Health Organization-5 Well Being Index (WHO-5), the Centre for Epidemiologic Studies-Depression scale (CESD) using predefined cut-off scores, and depressive disorder with the Composite International Diagnostic Interview (CIDI). The result was about. 772 patient completed the questionnaire of depression and about one third of patient with type 1 DM and 37-43% of patient with type 2 have depression based on (WHO-5). Whereas 25% and 30% for men and women with type 1 DM and 35% and 38% for men and women with type 2 DM . according to the Composite International Diagnostic Interview (CIDI) the patient with type 1 dm have depression in 8%of them no gender differences and 2% of men and 21% of women with type 2 DM have depression , there was also positive relationship between type 1 DM and poor glycemic control and proliferative retinopathy while the obesity and non-Dutch descent correlate with type 2 DM
In Addis Ababa , Ethiopia , 2016 , Habtewold td et al. assess the sociodemographic , clinical, psychological factors associated with comorbid depression among typ2 DM in outpatient clinic in black lion general specialized hospital . cross-sectional study conducted throughout 276 type 2 DM who were selected randomly with response rate 95.6% to self- administered phq9 questioner . the study found that Lowe family income , diabetic complication , diabetic nephropathy negative life events and poor social support significantly increased the risk of depression .
In the west of Ireland ,Foran e et al . conducted cross-sectional study to assess the prevalence of depression among type 2 diabetic patient age above 50 years old and to assess whether the depression is considered independent variable of diabetic control , the depression assessed with hospital and anxiety scale and hba1c was used to measure diabetic control , the result of 9698 patients over 50 years found that there is higher prevalence of sever depression among type 2 DM patients whereas there was no association between depression and poor diabetic control , the study found that presence of multi-morbidity considered predictors for depression either in diabetic or not diabetic patient , and finally the study considered the depression as one of comorbidly of diabetic patient not solely affect diabetic control
In French , Sebbani m et al. studied the prevalence of type 2 DM among depressed patient using cross-sectional study among 73 patient with depression data collected using questioner and blood sample taken to measure blood glucose level . the mean age 53 ” 15 years with female to male ratio 1.35 , the prevalence of type 2 DM 69.9% the result showed the heredity and lifestyle measure strongly corollate with diabetes and no association between diabetes type 2 with gender , smoking ,treatment regimen and remaining associated dieses.
From march to June 2014 , in Al-Solimania Primary Health Care Center, Al-Olaya, Riyadh, Kingdom of Saudi Arabia., Esmat m et al. conducted cross-sectional study among 100 male and female patient ( 27 type 1 diabetes , 29 type 2 diabetes , and 44 gestational diabetes ) the patient interviewed personally to questioner developed by researcher and using Back depression scale inventory for assessment of depression the result found that 37 % of those type 1 diabetes and 37.9 % of those type 2 diabetes diagnosed with depression while only 13.6 % of gestational diabetes have depression the result also showed that half of subject do not follow the diabetic diet and no regular care .
In eastern province Saudi Arabia 2013 , AA ELmahlli . conducted cross-sectional study among 260 patient with type 2 diabetes in outpatient clinics of governmental hospital using systemic random sample and 2 types of self administered questioner to assess both social factors and depression , the result have shown that fifty percent of patient with diabetes have depression among those the poor diabetic control and being unmarried considered the most important predictors for depression in diabetic patient
Rational :
Despite the real association between depression and diabetes based on previous study no research in Taif area with aim to conduct the most important predictors of depression among diabetic patient and to find of there is really the depression lead to poor compliance and poor diabetic control
To establish greater concern among our diabetic patient early upon the presence the real predictor to depression that has been conducted in our study and making great effort to prevent those factors
Aim of the study;
The aim of this study to estimate the prevalence of diabetic patient and to detect the most important predictors to depression among diabetic patient
Objectives :
1- To detect the factors that make the diabetic patient more vulnerable to be depressed
2- To estimate the prevalence of diabetes in our conducted area
3- To measure the degree of compliance in diabetic patient
4- To enhance the patient knowledge about the possibilities of depression in the presence of this factors and help them to help seeking behavior
5- To limit the number of comorbidity that affect good glycemic control
Methodology :
Study design:
Cross-sectional study design will be adopted
Study Area :
Taif city is a city in the Maccah Province of Saudi Arabia at an elevation of 1700-2500 m above see level on the slopes of the Sarawat Mountains. Total area 42750 km2 .it has more than 2000 veliiages . It has a population of ‘ 1000000
STUDY POPULATION AND SELECTION CRITERI
The target populations are those who are attending the diabetic clinics in KING ABDULAZIZ SPECIALIST HOSPITAL ( diabetic senter ) in Taif and accepted the invitation to participate in the study .
Inclusion criteria
‘ Attendees of diabetic clinics in diabetic center in KING ABDULAZIZ SPECIALIST HOSPITAL .
‘ Both genders.
‘ Age above 15 years attendees .
‘ All nationalities.
‘ Arabic speakers.
‘ Type 2 diabetics patient
Exclusion criteria:
‘ Illiterate.
‘ Younger than 18 .
‘ Non-Arabic speakers.
‘ Patient who already depressed or on antidepressants medication
Sample size:
Based on the statistics of the patients’ affairs in diabetic center in KING ABDULAZIZ SPECIALIST HOSPITAL in Taif the researcher found that the average number of daily attendees in male and female clinics (with type 2 diabetes) in diabetic center department is 16 patients/day. Multiplying this average by the number of working days during the period of study(20 days ) ; the estimated population of the study found to be 320 subjects .
With expected frequency of diabetes = 50%. Worst acceptable result = 5% with 95% confidence interval; sample size are 175 .
Data collection tool:
The tool of the study will be a Arabic language self-administered questionnaire with a cover letter explaining the purpose of the study without mentioning names to ensure confidentiality.
The questionnaire consists of 2 parts ; the first part includes a questions about demographical data including age, sex, marital status , job , occupation , economic and educational level , hba1c , BMI
The second part contains 21 questions for determination if the patient relay have depression or not and classification of depression into either mild , moderate , sever , very sever depression .each questions has scale from 0 to 3
Questionnaire Validity :
Valid and reliable
Data entry and analysis:
Ethical considerations:
Budget: