Kingdom of Saudi Arabia
Joint Program of Family Medicine, Taif
Predictors of depression among diabetes mellitus outpatient attending King Abdul-Aziz specialist hospital in Taif, Saudi Arabia (2018)
Prepped by:
Dr. Ibrahim Sulaiman Alasiri
M.B.B.S, R2, joint program of Family Medicine, Taif, 2017
Academic Supervisor
Dr. Fwaz Alotibi
CONSULTANT OF FAMILY MEDICINE
Proposal submitted in partial fulfillment of the requirement of the Saudi Board in Family Medicine
TABLE OF CONTENTS
PAGE
SUBJECT
CHAPTER
4
4
7
8
8
Introduction
o BACKGROUND
o RATIONALE
o AIM OF THE STUDY
o SPECIFIC OBJECTIVES
CHAPTER-1
9
15
15
15
15
16
16
16
17
17
19
19
20
21 LITERATURE REVIEW
Methodology
o STUDY DESIGN
o STUDY AREA AND SETTING
o TARGET POPULATION
o INCLUSION CRITERIA
o EXCLUSION CRITERIA
o SAMPLE SIZE
o SAMPLING TECHNIQUE
o DATA COLLECTION TOOLS:
o PILOT STUDY
o ADMINISTRATIVE AND ETHICAL CONSIDERATIONS
o DATA ENTRY AND STATISTICAL ANALYSIS
o BUDGET CHAPTER-2
CHAPTER-3
22 REFERENCES
CHAPTER-4
28 APPENDICES
o THE QUESTIONNAIRE
‘
List of abbreviations
Abbreviation Description
BDI Beck Inventory depression scale
PHQ Patient Health Questionnaire
BMI body mass index
JPFCM Joint Program of Family and Community Medicine
T2DM Type 2 Diabetes mellitus
SPSS Statistical Package for Social Sciences
X2 Chi-Square test
KSA Kingdom of Saudi Arabia
HBA1C Glycosylated hemoglobin
SD Standard deviation
CI Confidence interval
OR Odds ratio
CHAPTER-1 INTRODUCTION
-Background
Diabetes is a chronic disease which affects virtually every organ in the human system. The World Health Organization projected that 300 million people will suffer from diabetes by 2025. (1) In the Kingdom of Saudi Arabia; the number of people with diabetes is increasing due to population growth, aging, urbanization, and increasing prevalence of obesity and physical inactivity. The overall prevalence of diabetes was 23.7%, with 26.2% being males and 21.5% females. The calculated age-adjusted prevalence for Saudi population for the year 2000 was 21.9%. Diabetes mellitus is more prevalent among Saudis living in urban areas 25.5% compared to rural areas as 19.5%. (2)
Depression is a mental disorder that presents commonly with depressed mood, decreased energy, feelings of guilt or low self-worth, loss of interest or pleasure, poor concentration, and disturbed sleep or appetite. Depending on the number and severity of symptoms, it can be categorized as mild, moderate, or severe. (3)
The lifetime prevalence of major depression in adults is estimated to be 7 to 12 percent in men and 20 to 25 percent in women. The prevalence of depression in patients in primary care settings ranges from 5 to 10 percent. The rates are significantly higher in persons with certain medical conditions, including obesity, diabetes mellitus, cancer, and a history of myocardial infarction. (4)
Diabetes is a major contributor to the global burden of disease and a growing number of studies show links between depression and diabetes. (5’8) The rate of depression in people with diabetes is much higher than in the general population. (9) A meta-analysis including 20 controlled studies found that the risk of depression in the diabetic groups was two-fold higher than that in the non-diabetic comparison groups. (10) This relative risk of depression is greater than found in most other chronic diseases. (11) The risk of depression increases in women with diabetes. (9) The prevalence of depression is higher in patients with diabetes who have long-term complications. (12, 13)
Compared with patients with diabetes alone, patients with depression and diabetes have been shown to have poorer self-management and poor adherence to antidiabetic, lipid-lowering and antihypertensive treatment. (14) They are more likely to have higher cardiovascular risk factors like smoking, obesity, sedentary lifestyle, and uncontrolled hyperglycaemia. (13) Depression may be an important barrier to effective diabetes management. Patients with depression and diabetes are more likely to have higher macrovascular and microvascular complications (9) and higher mortality rates.(15)
At any given time, most people with diabetes do not have depression, but studies showed that people with diabetes have a greater risk of depression than people without diabetes. There are no easy answers about why this is true, the stress of daily diabetic management can build. (9) Despite numerous investigations, the underlying patho-physiologies of the metabolic abnormalities are poorly understood. A possible role play the increases counter-regulatory hormone release involved in glucose homeostasis, alterations in the glucose transport function and increased inflammatory activation triggered by depression. (11) Psychiatric disorders could affect patients’ quality of life. Such effects may be due to alterations in diet, constant dependence on medication, short and long-term side effects and the burden of costs. (16)
Previous studies have shown individuals who are insulin-resistant may have higher serotonin concentrations and may be more prone to depression and even suicide. (9)
While depression may contribute to poor diabetes-related outcomes, diabetes and its complications may also contribute to poor depression outcomes. (11, 14, 17)
In the absence of systematic screening, family physicians miss at least 50% of cases of major depression. (18, 19)
-Rationale
‘ Saudi Arabia has one of the highest prevalence of type 2 diabetes in the world. Nearly one-fourth of adult Saudi population is suffering from type 2 diabetes mellitus. (2)
‘ It is documented that depression may contribute to poor diabetes-related outcomes.
‘ The available data regarding the prevalence of depression in diabetes patients in KSA are limited, particularly in Taif region.
‘ During residency period, I have seen many diabetics with depressive symptoms; despite of that they were not diagnosed or treated for depression.
Aim of the study
To investigate the prevalence and determinants of depression in patients with diabetes attending diabetic clinics, King Abdulaziz Specialist hospital, Taif, Saudi Arabia
Specific objectives:
1. To determine the prevalence of depression among diabetic patients attending diabetic clinics, King Abdulaziz Specialist hospital, Taif, Saudi Arabia
2. To identify the associated risk factors for depression among diabetic patients attending diabetic clinics, King Abdulaziz Specialist hospital, Taif, Saudi Arabia
‘
CHAPTER-2 LITERATURE REVIEW
In Saudi Arabia
With reviewing the literatures, only three local studies conducted recently in Saudi Arabia were cited in addition to one unpublished study conducted in Jeddah.
Trabulsi and Almasaodi (2013) carried out a study to determine the prevalence of depression among type 2 diabetic patients and its associated factors in Al-Eskan Avenue in Makkah. The study included 136 diabetic patients of type 2. The prevalence of depression regardless its severity was 41.9%. Approximately 13.2% and 26.5% of patients had mild and moderate depression respectively. Only 2.2% of them had severe depression. More than half of them (58.1%) had no depression. The prevalence of depression was significantly more reported among older, low-income, chronically diseased, complicated and uncontrolled diabetic patients. (20)
AL-Baik et al (2013) conducted a study to identify the diabetic patients at risk of depression and to explore the risk factors for depression in them. Patients with the two-item version of patients’ health questionnaire (PHQ-2) positive were constituted 45.8%. Depression was significantly associated with female gender, long standing diabetes, insulin use, and with other medical co-morbidities. (21)
Al-Muzien and Al-Sowielem (2014) conducted a study to assess the prevalence of depression and its associated factors in adult Saudi diabetics attending primary healthcare centers in the Qatif area. A total of 325 patients participated in the study. Prevalence of depression was found to be 14.5%. The prevalence of major depressive disorder was 6.2% and other depressive disorders were 8.3%. The presence of complications, co-morbidities and, in male patients, older age were found to be risk factors for depression in diabetics. The level of control was better in non-depressed patients while compliance with treatment had no relation with depression. (22)
One study unpublished done by Al Mouaalamy N (JPFCM) on 2004-2005 in Jeddah city about prevalence of depression among type 2 diabetic patients attending diabetic clinic at primary health care centers showed that 48% of type 2 diabetic patient had depression, however it was higher than that reported in studies conducted in other parts of the world. The prevalence of depression was higher among females (50%) than males (46%). Also it was noticed that depression was more prevalent among patients below 40 years and more than 60 years. Family history of psychiatric illness and use of insulin were significantly increasing the occurrence of depression. Taking more than 3 drugs or having more than 4 follow ups per year will increase the odds to have depression. The presence of complications in those patients was found to be significant factor in increasing the depression. Uncontrolled type 2 diabetic patients reported more depression than controlled patients. (23)
Regional studies
Almawi et al (2008) examined the association of depression, anxiety, and stress with Type 2 diabetes (T2DM) in Bahrain. Higher proportion of T2DM patients were found in the mild-moderate and severe- extremely severe depression (p=0.002), anxiety (p<0.001), and stress (p<0.001) groups. Chronic disease and disease duration were significantly associated with the 3 disturbances, while employment status was associated with anxiety and depression. Logistic regression analysis showed that anxiety, depression, and stress were associated with T2DM after adjusting for all variables, while age was the only significant variable associated with stress. These results suggested a positive contribution of T2DM to increased depressive and/or anxiety and/or stress disorders among the patients examined. (24)
Another study done in Iran 2007 by Khamseh et al including a total of 206 participants; (54.9%) had diabetes (type 1 = 66 and type 2 = 140). Major depression was present among 71.8% of this sample with diabetes (both types; type 1 and type 2). Depression was more prevalent among women with diabetes than men (Adjusted OR = 2.1 (95% CI 1.4-3.2). Of the 375 participants, 135 (36%) had BDI scores lower than 11 and 240 (64%) had BDI scores indicating moderate to severe depression (>16). (25)
International studies
In Pakistan (2016), Arshad and Alvi have conducted a study in Mountain Medical Battalion, Bagh, Azad Kashmir to estimate depression and its determinants among type 2 diabetic patients. They used PHQ9 for depression screening. Depression was reported among 51 out of 133 diabetic patients (38.4%), of which depression was mild in 34 moderate in 12 moderately sever in 4 and severe in 1. Only shorter duration of diabetes had significant association to depression among diabetic patients.(26)
In the United States in 2001, Anderson et al showed that the prevalence of co-morbid depression was significantly higher in diabetic women (28%) than in diabetic men (18%), in uncontrolled (30%) than in controlled studies (21%), in clinical (32%) than in community (20%) samples, and when assessed by self-report questionnaires (31%) than by standardized diagnostic interviews (11%).(27)
In Berlin Germany, Regen et al carried out a study in 2005. It was a cohort study showed a high prevalence of depression in patients with diabetes mellitus. (28)
Egede and Ellis (2010) reviewed the literature on the prevalence, burden of illness, morbidity, mortality, and cost of co-morbid depression in people with diabetes as well as the evidence on effective treatments. Systematic review of the literature on the relationship between diabetes and depression was performed. Diabetes and depression are debilitating conditions that are associated with significant morbidity, mortality, and healthcare costs. Coexisting depression in people with diabetes is associated with decreased adherence to treatment, poor metabolic control, higher complication rates, decreased quality of life, increased healthcare use and cost, increased disability and lost productivity, and increased risk of death.(29)
Raval et al (2010) carried out a study to investigate the prevalence and determinants of depression in patients with established type 2 diabetes (T2DM) attending a tertiary care hospital in north India. Of the study patients, 23% met the criteria for major depression, 18% for moderate depression and the remaining 59% had no clinically significant depression. Depression was strongly associated with age >54 yr (OR 1.26, P<0.05), central obesity (OR 1.34, P<0.001), neuropathy (OR 1.94, P=0.002), nephropathy (OR 1.81, P=0.041), peripheral vascular disease (OR 6.08, P=0.042), diabetic foot disease (OR 2.32, P<0.001) and pill burden (>4) (OR 1.27, P=0.035). However, the likelihood of depression was not significant with duration of diabetes and insulin use. (30)
Another Indian study conducted by Joseph et al (2013) to find out the proportion and determinants associated with depression among patients with established type 2 diabetes mellitus (T2DM) in various tertiary care hospitals in Mangalore city of south India. Among the participants, 30.9% met the criteria for moderate depression, 33 14.3% for severe depression, and the remaining 54.8% had no clinically significant depression. Only 11.3% of patients were already aware that they were depressed, of whom just 3 had taken medical consultation. Among the risk factors, depression was found to be significantly associated with older age, female gender, low socioeconomic status, unskilled and retired employment status, having complications due to T2DM or co-morbidities like hypertension and coronary artery disease, being overweight and being on insulin syringe injections. (31)
CHAPTER-III METHODOLOGY
Study design:
Cross-sectional study design will be adopted
Study area and setting:
The study will be carried out in Taif city which is a city in the Maccah Province of Saudi Arabia at an elevation of 1700-2500 meter above sea level on the slopes of the Sarawat Mountains with total area 42750 km2 and more than 2000 villages with a total population of ‘ 1000000. Diabetic center at King Abdulaziz Specialist hospital will be the study setting. It was established on 15/7/1436 H and includes 12 clinics (4 for type 1 and type 2 diabetes, 1 for insulin pump, 1diabetic foot, 1 ophthalmology, 1 nephrology, 1 nutrition, 1 obesity and 2 health education)
Target population:
All diabetic patients (type 1, type 2) attending diabetic clinics of King Abdulaziz Specialist hospital throughout the study period (April to June, 2017) will constitute the target population for the study.
Inclusion criteria
‘ Saudi adults (18 years or above) diabetic patient attending diabetic center at King Abdulaziz Specialist hospital Both sexes
Exclusion criteria
‘ Patients <18 years of age.
‘ Illiterate
‘ Non-Saudi patients
‘ Any patient with sever psychosis or other form of sever co-morbidities.
‘ Gestational diabetes since they are followed up out of the center at obstetrics and Gynecology clinics.
Sample size:
Assuming that the prevalence of major depressive disorder among type 2 diabetic patients was 6.2%, (21)
According to the formula of sample size calculation:
N=T” x P(1-P)
M”
Where:
N = required sample size
T = confidence level at 95% (standard value of 1.96)
P = estimated prevalence of disease in the project area
M = margin of error at 5% (standard value of 0.05)
The sample size would be a minimum of 362 patients. This sample will be increased to 400 in order to compensate for drop-out.
Sampling technique:
The sample size (400 patients) will be chosen from different clinics in the diabetic center by applying a systematic random sampling technique to select 20 patients daily. Thus a total of twenty working days (almost one month) will be needed to complete sample recruitment.
Data collection tools:
Data collection questionnaire developed by the researcher composed of three parts will be utilized for data collection:
1- Personal characteristics: Age, sex, education, employment, marital status, number of children, presence of co-morbidity (e.g., hypertension, heart disease, bronchial asthma, renal disease, etc.), smoking and family history of depression.
II- Diabetes-related variables: duration of disease, insulin treatment, compliance with therapy, presence of complications. In addition to data collected from patient`s file (type of diabetes, number of follow-up visits over the last year, last fasting blood glucose level, last HBA1c, weight and height). Fasting blood sugar level (mg/dL) will be assessed for diabetic patients. The level of control of diabetes as indicated by fasting blood sugar control was determined according to Campbell and Braithwaite(32), as follows:
‘ Good (<126 mg/dL)
‘ Borderline (126-180 mg/dL)
‘ Poor (>180 mg/dL)
Glycosylated hemoglobin (HBA1c) Levels above 9% will be considered as poor control, and levels above 12% will be considered as very poor control.(33) Body mass index (BMI) was calculated by dividing the weight in kg by the square of the length in meter. Participants were categorized, based on their BMI values into four subgroups; normal (BMI from 18.5 to 24.9 kg/m2), overweight (BMI from 25 to 29.9 kg/m2), Obese (BMI from 30 to 39.9 kg/m2), and extremely obese (BMI ‘ 40 kg/m2).
III- The Beck Depression inventory scale (BDI-II), Arabic version,(34) will be used for the screening of depression amongst the study population. It is a 21-item self-report measure and considered as one of the most popular screening instruments for detecting symptoms of depression. It can be used to assess individuals with depressive disorders (13 years of age or older).(35) It is designed to document depressive symptoms experienced over a one week before testing. Responses to the 21 items are made on a 4-point scale, ranging from 0 to 3 (scores can range from 0 to 63). Traditional cut-off points used to estimate severity in adults are: 10’16 indicating possible mild depression, 17’29 likely moderate depression; and 30’63 probable severe depression. (36) A BDI score of 16 has been recommended as a cut off score to indicate a depressive disorder. (37)
Pilot study
A pilot study will be conducted at the diabetic center, King Abdulaziz Specialist hospital, Taif on 40 patients to test wording of the questionnaire in order to avoid inter-observer variation or bias. Data collection will be totally done by the researcher. Their results will be omitted in the final report.
Administrative and ethical considerations
All the necessary official permissions will be obtained before data collection.
Prior to data collection, the investigator will inform all participants regarding the objectives of the study. They will be assured that no harm is ever expected to occur if they decide to participate in the study. They will be also assured about the anonymity and full confidentiality of their responses. Their verbal consents to participate will be requested. All diabetic subjects who obtained scores >10 will be referred to a psychiatrist to establish the final diagnosis and to start management accordingly.
Data entry and statistical analysis
Statistical Package for Social Sciences (SPSS) software version 22.0 will be used for computerized data entry and analysis. Descriptive statistics (number, percentage for categorical variables and mean, standard deviation ( SD) and range for continuous variables) and analytic statistics using Chi Square tests (”2) to test for the association and/or the difference between two categorical variables will be applied. P-value equal or less than 0.05 will be considered statistically significant.
Depression, based on BDI (Arabic version) will be treated as dependent variable in multivariate logistic regression analysis. All significant associated factors from univariate analysis will be treated as independent categorical variables. The adjusted measure of association between associated factors and depression among diabetic patients was expressed as the odds ratio (OR) with 95% Confidence Interval (95% CI). Adjusted or crude ORs with 95% CI that did not include 1.0 will be considered significant.
Budget:
This study will be completely funded by the researcher himself.
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CHAPTER-4 REFERENCES
1. King H, Auburt RE, Herman WH. Global burden of diabetes 1. 1995-2025: prevalence, numerical estimates, and projections. Diabetes Care 1998; 21: 1414-31.
2. Al-Nozha MM, Al-Maatouq MA, Al-Mazrou YY, Al-Harthi SS, Arafah MR, Khalil MZ, et al. Diabetes mellitus in Saudi Arabia. Saudi Med J 2004;25:1603-1610.
3. World Health Organization. Depression. Fact sheet No. 369, 2015.
4. Sharp LK, Lipsky MS. Screening for Depression across the lifespan: a review of measures for use in primary care settings. Am Fam Physician. 2002 Sep 15; 66(6): 1001-1009.
5. Anderson RJ, Freedland KE, Clous RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care 2001; 24: 1069’1078.
6. Ali S, Stone MA, Peters JL, Davies MJ, Khunti K. The prevalence of co-morbid depression in adults with type 2 diabetes: a systematic review and meta-analysis. Diabet Med 2006; 23: 1165’1173.
7. Dunbar JA, Reddy P, Davies-Lameloise N, Philpot B, Laatikainen T, Kilkkinen A,, et al. Depression: an important co-morbidity with metabolic syndrome in a general population. Diabetes Care 2008; 31: 2368’2373.
8. Reddy P, Philpot B, Ford D, Dunbar JA. Identification of depression in diabetes: the efficacy of PHQ-9 and HADS-D. British Journal of General Practice, June 2010 e239-e245
9. American Diabetes Association. Depression. Available from: URL: http://www.diabetes.org.
10. de Groot M, Anderson R, Freedland KE, Clouse RE, Lustman 4. PJ. Association of depression and diabetes complications: a meta analysis. Psychosomatic Med 2001; 63 : 619-30.
11. Egede LE, Zheng D, Simpson K. Comorbid depression is associated with increased health care use and expenditures in individuals with diabetes. Diabetes Care 2002; 25 : 464-70.
12. Katon WJ, Simon G, Russo J, Von Korff M, Lin EH, Ludman E, et al. Quality of depression care in a population-based sample of patients with diabetes and major depression. Med Care 2004; 42: 1222-9.
13. Lin EH, Katon W, Von Korff M, Rutter C, Simon GE, Oliver M, et al. Relationship of depression and diabetes self-care, medication adherence, and preventive care. Diabetes Care 2004; 27 : 2154-60.
14. Katon WJ, Rutter C, Simon G, Lin EH, Ludman E, Ciechanowski P, et al. The association of comorbid depression with mortality in patients with type 2 diabetes. Diabetes Care 2005; 28 : 2668-72.
15. Regen F, Merkl A, Heuser I, Dettling M, Anghelescu I. Diabetes and depression. Dtsch Med Wochenschr 2005; 130 (17):1097-1102.
16. Braunwald E, Fauci AS, Kasper DL, Longo DL, Jameson JL. Harrison’s Principles of Medicine. 15thedition, New york: Mc Grow- Hill 2001.
17. Black SA, Markides KS, Ray LA. Depression predicts increased incidence of adverse health outcomes in older Mexican Americans with type 2 diabetes. Diabetes Care 2003; 26 : 2822-8.
18. Arroll B, Goodyear-Smith F, Crengle S, Gunn J, Kerse N, Fishman T, Falloon K, Hatcher S. Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Ann Fam Med. 2010;8(4):348-53.
19. Nease DE Jr, Maloin JM. Depression screening: a practical strategy. J Fam Pract. 2003;52(2):118-124.
20. Trabulsi FA, Almasaodi KA. Depression among type 2 diabetic patients in Al-Eskan Avenue in Makkah, 2010. American Journal of Research Communication. 2013; 1(10): 49-68
21. AL-Baik MZ, Moharram MM, Elsaid T, Al-Baik S, AlDahan S, Alkhadhrawi N, et al. Screening for depression in diabetic patients. Int J Med Sci Public Health 2014; 3:156-160.
22. Al-Muzien NA, Al-Sowielem LS. Prevalence of depression in diabetics attending primary healthcare centers in the Eastern Province of Saudi Arabia. J Bahrain Med Soc 2014;25(1): 14-18
23. Al Mouaalamy NA. Prevalence of depression among type 2 diabetic patients atteding diabetic clinic at primary health care centers in Jeddah 2004-2005 [dissertation]. Joint Programme of Family and Community Medicine, Jeddah ‘ KSA, 2005.
24. Almawi W, Tamim H, Al-Sayed N, Arekat MR, Al-Khateeb GM, Baqer A, et al. Association of comorbid depression, anxiety, and stress disorders with type 2 diabetes in Bahrain: a country with a very high prevalence of type 2 diabetes. J Endocrinol Invest. 2008; 31(11): 1020-4.
25. Arshad AR, Alvi KY. Frequency of depression in type 2 diabetes mellitus and an analysis of predictive factors. population. 2016;6:7.
26. Khamseh ME, Baradaran HR, Rajabali H. Depression and diabetes in Iranian patients: a comparative study. Int J Psychiatry Med. 2007; 37(1): 81-86
27. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care 2001; 24(6): 1069-1078
28. Regen F, Merkl A, Heuser I, Dettling M, Anghelescu I. Diabetes and depression. Dtsch Med Wochenschr 2005; 130 (17):1097-1102.
29. Egede LE, Ellis C. Diabetes and depression: Global perspectives. Diabetes Research and Clinical Practice 2010;87:302’312
30. Raval A, Dhanaraj E, Bhansali A, Grover S, Tiwari P. Prevalence & determinants of depression in type 2 diabetes patients in a tertiary care centre. Indian J Med Res. 2010 Aug;132:195-200.
31. Joseph N, Unnikrishnan B, Babu YPR, Kotian MS, Nelliyanil M. Proportion of depression and its determinants among type 2 diabetes mellitus patients in various tertiary care hospitals in Mangalore city of South India. 2013;17(4):681-688
32. Campbell KB, Braithwaite SS. Hospital Management of Hyperglycemia. Clinical Diabetes 2004; 22 (2): 81-88.
33. Gallagher EJ, Bloomgarden ZT, Le Roith D. Review of hemoglobin A1c in the management of diabetes. Journal of Diabetes, 2009, 1:9-17.
34. Abdel-Khalek AM. Internal consistency of an Arabic Adaptation of the Beck Depression Inventory in four Arab countries. Psychol Rep 1998; 82(1):264-266
35. Beck A, Steer R, Brown G. BDI-II Manual. San Antonio: The Psychological Corporation, Harcourt Brace; 1996.
36. Lasa L, Ayuso-Mateos JL, Vazquez-Barquero JL, D”ez-Manrique FJ, Dowrick CF. The use of Beck Depression Inventory to screen for depression in the general population: a preliminary analysis. J Affect Disord 2000; 57: 261’265.
37. Jami F Young JF, Miller MR, Khan N. Screening and managing depression in adolescents. Adolescent Health, Medicine and Therapeutics 2010:1 87’95
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Appendix 1
The Questionnaire (first part)
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Information from patient file:
*Type of diabetes Type I ( ) Type II ( ) Unknown ( )
*number of follow up over the last year ”
*last fasting blood sugar ”
*last level of HbA1C ”
*height ‘
*weight ”..
*body mass index (BMI ) ”.
BDI (Arabic version)