Depression and anxiety among persons with type II diabetes mellitus and hypertension; A cross-sectional analytical study in the rural field practice area of a tertiary care center in Puducherry

INTRODUCTION

Hypertension (HTN) is one of the most frequent causes of death and disability across the globe. In India, HTN is prevalent in roughly 24% males and 21.3% females, according to the National Family Health Survey-5 2019–21 report.^[1] Diabetes mellitus (DM) affects an estimated 285 million people globally which may surpass 500 million by 2030, with Asia bearing the major brunt of the “diabetes epidemic.”^[4,20] India is now considered the “diabetes capital of the world,” reporting 72.9 million (8.8% of the adult population) cases of DM in 2017, according to the International Diabetes Federation.^[2] Mental health disorders lead in the fifth position among the causes of years of healthy life lost due to disabilities (YLDs) and disability-adjusted life years (DALYs), accounting for 22.9% and 7.4% respectively.^[6,20] People with DM and HTN are more likely to suffer from depression or anxiety.^[7] They tend to utilize more healthcare resources and have a poor quality of life (QOL) if their ailments are not properly managed.^[7] Depression affects an estimated 350 million individuals worldwide, with a lifetime risk of 7%.^[3] Anxiety is also prevalent as it is the sixth most common cause of disability when considering YLDs alone globally.^[6] The National Mental Health Survey (NMHS) of India (2015–16) showed the lifetime prevalence of depression and anxiety was 5.1% and 3.1% respectively.^[8]

Persons with mild or moderate depression/anxiety continue their daily lives without much disruption, thus being overlooked by healthcare systems. Studies on individuals seeking help from primary care settings have shown the anxiety prevalence varying from 15% to 44%, and 33 to 83% were suffering from depression.^[5,8] National program for prevention and control of cancer, diabetes, cardiovascular disease and stroke recently attempted to broaden the community’s understanding of successful non-communicable disease (NCD) prevention, detection, referral, and treatment measures. Although linking NCD care with ongoing interventions of the National Mental Health Program has been considered under primary healthcare infrastructure, we are very far from achieving it nationwide.^[1]

The presence of chronic multiple comorbidities has important implications for the QOL and patient well-being which is currently under-addressed in our primary healthcare settings.^[11,12] This study aims to determine the proportion of depression and anxiety disorders and their association with socio-demographic, NCD-related factors as well as the QOL among persons with DM/HTN residing in rural field practice areas and availing treatment at JIPMER Rural Health Centre (JIRHC), Puducherry.

MATERIALS AND METHODS

This is a facility-based cross-sectional analytical study done in JIPMER Rural Health Center, Puducherry providing services in four villages with around 10000 residents namely Ramanathapuram, Thondamanatham, Thutipet, and Pillayarkuppam.^[74] In September 2019, 704 people enrolled at the NCD clinic for treatment of diabetes, HTN, or both, all of them were approached for the study. The study was conducted on the NCD clinic days – Wednesdays and alternate Tuesdays.^[75] Persons showing symptoms of mental health problems were referred to the psychiatry clinic in JIRHC, held once fortnightly on Wednesdays which is attended by the Psychiatry faculty of JIPMER. All persons aged ≥30 years who were diagnosed with DM, HTN, or both, residing in rural field practice areas and getting treatment from JIRHC were included in the study. By the time a person reaches his/her thirties, if there is a higher risk of having an NCD like Type II DM or HTN, they would have been incorporated into the JIRHC NCD clinic by the healthcare workers. Anticipating a similar anxiety disorder prevalence of 19.1% among those with DM and HTN in a hospital-based study by Kulkarni et al., (2012), the sample size was calculated in OpenEpi Version 3.0 as 659 with 95% confidence interval (CI) and 3% absolute precision.^[10] Considering 5% non-response rate, 692 participants consented to participate in the study.

The 692 participants also include those with pre-existing psychiatric conditions. Those with severe psychiatric conditions while those with physical disabilities such as speech and hearing impairment were interviewed with the help of their relatives taking care of the person’s health needs. A proforma containing socio-demographic details and NCD-related history were collected following which Hospital Anxiety and Depression Scale (HADS) questionnaire containing 14 items was used to screen for depression and anxiety disorders among respondents within the last 1 week. A one-week assessment was done to identify and manage short-term fluctuations in depression and anxiety symptoms appropriately.^[87] The total score of HADS ranges from 0 to 21, with 0–7 indicating no depression or anxiety, 8–10 mild, 11–14 moderate, and 15–21 severe.

The 26-item scale, World Health Organization (WHO)-QOL-BREF questionnaire was used to assess the QOL where except for the first two questions assessing the overall QOL and general health satisfaction, the remaining items are divided into four domains-Physical, psychological, social, and environmental. Raw scores were transformed statistically to make them identical to the WHOQOL-100 scores. The revised scores were then used in the analysis.

Both HADS and WHO-QOL-BREF questionnaires were validated and pre-tested in the study setting prior to the study in the local language.^[76-87] The interview of each participant didn’t last for more than 45 min (15 min for HADS and WHOQOL-BREF questionnaire administration respectively).

RESULTS

A total of 692 persons with a mean age (standard deviation, SD) of 55.3 (12.9) years were interviewed. Around 58% of participants were females, 284 (41.1%) had no formal education, and 117 (16.9%) were widowed. About 222 (32.1%) had both DM and HTN. Among the 383 persons having DM, the median (interquartile range, IQR) duration since the diagnosis of DM was 6 (5,9) years, while in 531 persons having HTN, it was 6 (4,10) years. Around 105 (15.5%) persons were having any known complications of DM, HTN or both, and 301 (43.5%) were unaware of any DM/HTN family history. Around half of the individuals had first-degree relatives with a depression/anxiety history. The median (IQR) domain-wise scores in physical, psychological, social and environmental domains (WHO-QOL-BREF) were 56 (44,63), 50 (44,69), 56 (44,69), and 56 (44,69) respectively [Table 1]. Nearly 123 (17.8%) persons had symptoms of depression, with 84 (12.2%) having mild, 26 (3.8%) having moderate, and 13 (1.9%) having severe depression, whereas 88 participants had symptoms of anxiety (12.7%), of which 73 (10.6%) had mild, 12 (1.7%) had moderate, and 3 (0.4%) had severe anxiety [Table 2]. Of all the participants interviewed, 12 of them had both depression and anxiety.

In the univariate analysis, factors associated with depression included age in years, gender, education, occupation, monthly income, marital status, comorbidities managed by NCD clinic, duration of DM in years, duration of HTN in years, complications caused by DM or HTN or both, number of comorbidities, family history of DM/HTN or depression/anxiety, current tobacco use, and current alcohol use, as well as all QOL domains. Further, in the multivariate regression analysis, the associated factors for depression were persons with increasing age with an odds ratio of 0.97 (95% CI: 0.95–0.99), depression/anxiety family history with an odds ratio of 2.58 (95% CI: 1.26–5.26), reduction in overall QOL with an odds ratio of 0.76 (95% CI: 0.67–0.97), and decrease in social domain with an odds ratio of 0.98 (95% CI: 0.97–0.99) [Table 3]. Meanwhile, for multivariate analysis, the factors associated with anxiety were those who are not educated with an odds ratio of 10.84 (95% CI: 4.54–25.86), homemakers with an odds ratio of 3.49 (95% CI: 1.29–9.42), DM/HTN family history with 1.51 higher odds ratio (95% CI: 0.66–1.54), and decrease in psychological domain score (aOR: 0.97; 95% CI: 0.95–0.99) as well as environmental domain score (aOR: 0.96; 95% CI: 0.94–0.98) [Table 4].

All 216 persons who got HADS scores ≥8 were referred to the psychiatry clinic for further evaluation. About 191 (88.42%) of them were diagnosed with depression/anxiety disorders and started on clinical management. The median number of visits (IQR) done in RHC after diagnosis was 4 (2, 5), though some participants had to rely on other nearby healthcare facilities providing psychiatric services owing to the COVID-19 restrictions [Table 5].

DISCUSSION

In the NCD clinic, 17.8% of respondents who have had depressive symptoms (95% CI: 13.8–22.4%). Studies done in various primary healthcare centers showed depression prevalence between 21% and 40.5% suggesting that one-fifth of the patients were depressed as found in the present study^{.[11,13-16,25,41,43,53,55,59]} The depression prevalence among Puducherry’s general population was lesser to the proportion reported in this study.^[8,72]

The proportion of anxiety reported at 12.7% (95% CI: 9.5–16.7%) was lesser than in other studies done in a similar setting in India^{.[6,8,11,15-16,35-38]} Anxiety prevalence ranged from 3% to 60% of people with DM, HTN, or both in multicentric studies, indicating a huge heterogeneity^{.[6,8-9,11,25,28-34,36,38,41,51,57]} This heterogeneity across various studies could be due to the variation in assessment tools, population characteristics, sampling variability, and methodological variations.

In this study, individuals with depression had a higher average age of 53 years (SD = 13.8) compared to those without depression. Studies on older people have shown that depression is the most prevalent Common Mental Disorder.^{[6,17,21,61,66]} Further, studies conducted outside India suggest older people are more prone to developing depression compared with younger people.^{[19,30,31,51,66]} Of those with anxiety, 17.1% were homemakers, adding to the evidence from various studies done in India and elsewhere, likely due to the inherent high risk for female gender among anxiety disorders^{.[9,24,26,27,38,44-45,52]} Statistically, no association between gender and depression was noticed in this study; though depression is twice as common among women with DM/HTN than in males.^[3,18,30] Female endocrinological peculiarities, societal pressures, and gender-restricted work roles might explain this association.^[11,16,25]

Characteristics like educational status, occupation, monthly income, and marital status are associated with depression in multiple studies done in India and elsewhere, although not in present study^{.[6,8,11,18,23,25,35,36,38,50,56,67]} Of those reported with anxiety, 38.2% never had formal education, supporting studies done worldwide and in India suggest persons with a lower educational status were more likely to have anxiety^{.[16,22,25,40,42,44,48,75]} Based on the above studies it is likely that people with low educational levels may have fewer employment and income opportunities, resulting in financial insecurity and anxiety. With their limited health literacy, which can further lead to anxiety about understanding and managing their health. Less than half of the study participants reported having a DM/HTN family history, suggesting a lack of knowledge about NCDs. Over 53.4% of people without a DM/HTN family history feel anxious, according to Indian studies, contrary to the current study’s suggestion of an association between having no DM/HTN family history and anxiety.^[3,44] However, a Nepal study indicated anxiety was associated with a family history of NCDs.^[42] This disparity may be due to differences in the healthcare systems across nations and methodological variations.^[42]

Depression was not associated with the DM/HTN duration in this study, as Raval et al. (2010) reported.^[68] However, a Bahrain study identified a correlation between anxiety and depression with duration of NCDs.^[37] In RHC, those who require a longer duration of DM/HTN management will be followed up in a higher facility; thus, most regular patients attending the NCD clinic at the center are recently diagnosed cases of DM/HTN. Although current tobacco and alcohol usage was not significantly associated with depression or anxiety in this study, DM/HTN patients consuming tobacco or alcohol are more likely to develop depression and anxiety than those who do not (Katon et al., 2004; Saleh et al., 2014; Hassan et al., 2019).^[69-71] Although these studies show tobacco and alcohol use may not independently contribute to depressive or anxiety symptoms, their duration, frequency, or severity of use can make persons suffering from type II DM or HTN more likely to develop these mental health problems. Meanwhile, family history of depressive symptoms or anxiety was under-reported because of a lack of knowledge or stigma since literature suggests depression or anxiety are more common in those with a family history.^[18,42,63] Although the present study has not shown significance, comorbidities managed in the NCD clinic, complications due to DM/HTN or both, and presence of multiple comorbidities were associated with depression in various studies in India and countries like Bangladesh, Pakistan, and United Kingdom^{.[6,11,25,35,36,38,39,51,52,54,61]}

Both depression and anxiety led to lower QOL scores in our study [Tables 3 and 4]. Other studies had lower scores across all the domains under the QOL when assessed using the WHO-QOL-BREF questionnaire.^{[16,54,62,64]} Studies outside India also had low QOL scores among persons with depression.^[7,49,65,69] DM duration and QOL were not associated with each other in the CODE-2 trial.^[54,61,65] Another study using the EQ-5D-5L instrument reported anxiety/depression among 35% of respondents, whereas pain or discomfort was indicated by 53%.^[54]

Compared with other studies, our study population had a better median follow-up visits (IQR) of 4 (2,5) clinics due to better mobilization of patients by Accredited Social Health Activists and healthcare facilities’ proximity.^{[47,58,60,73]} Patients who suffer from common mental disorders such as depression or anxiety are more likely to be non-compliant with their treatment.^{[46,49,60,61,65]} The study’s strengths include the following: (i) the prevalence of depression and anxiety disorders among participants was assessed using a comprehensive screening tool, and (ii) data entry via a mobile application with inbuilt checks minimizes data entry errors. The limitation of the study was not gathering data from a comparison group of healthy individuals, and medical conditions (e.g., treatment status, drugs taken, etc.) and glycemic status (as well as blood pressure) were not assessed objectively.

CONCLUSION

Nearly one-fifth of participants have depression and more than one-tenth of anxiety among persons with DM, HTN, or both in this study. Therefore, regular screening of common mental disorders is required, along with prompt referral to a psychiatry clinic for those diagnosed. In conclusion, our study highlights the complex interplay between chronic diseases like type II DM, HTN, and mental illness such as depression and anxiety, leading to a significant impact on an individual’s QOL. Our findings suggest that the co-occurrence of chronic diseases and mental illnesses, like depression and anxiety, can lead to a range of physical and psychosocial impairments that ultimately affect the QOL. This underscores the importance of taking a more holistic, patient-centered approach to healthcare that addresses both physical and psychological health needs to improve outcomes. In particular, our study highlights the need for healthcare providers to be aware of the potential deleterious effects of chronic diseases and mental illness on QOL and to incorporate screening and assessment tools, such as the HADS and the QOL (WHOsQOL-BREF) questionnaire, into routine clinical practice. Better screening and identification of mental illness, in conjunction with effective management of chronic diseases, can help reduce the negative impact on QOL and improve overall outcomes in these patients. Therefore, integrated care that takes into account both physical and mental health should be prioritized in clinical practice and public health initiatives to address the burden of chronic diseases and mental health disorders.