ABSTRACT
Context:
Psychiatric disorders are common among people with diabetes but often go undiagnosed and untreated. Various factors increase the risk of mental disorders in diabetic patients.
Aims:
1. To estimate the prevalence of psychiatric disorders among adult patients with type II diabetes mellitus. 2. To identify sociodemographic factors associated with psychiatric comorbidity in the study population.
Settings and Design:
The present cross-sectional study was conducted under the Department of Community Medicine, JNMC (2023–2024), among the 390 randomly selected type II diabetes mellitus patients.
Methods and Materials:
Study tools included a predesigned structured questionnaire for collecting data on sociodemographic factors. The General Health Questionnaire (GHQ-12) was used to screen psychiatric disorders, and Diagnostic and Statistical Manual of Mental Disorder 5 Text Revision (DSM-5 Level 1) was used to confirm different psychiatric disorders.
Statistical Analysis Used:
Data were analyzed using IBM SPSS 20.0 software. For assessing the association of psychiatric disorders with sociodemographic factors, binary logistic regression was applied.
Results:
Among 390 patients, 177 (45.4%) were males and 213 (54.6%) were females, with a mean age of 56.49 ± 12.49 years. Psychiatric disorders were present in 120 (30.8%) patients, among which depression (27.6%) and anxiety (23.5%) were most common. Psychiatric disorders were more common in patients above 70 years of age, females, living alone, illiterate, presently not working, belonging to the Muslim faith, patients residing in semiurban areas, patients belonging to a 3-generation family, and the upper socioeconomic class. Significant associations were found between the presence of psychiatric disorders and gender, marital status, educational status, and occupational status.
Conclusions:
Psychiatric comorbidity is common among patients with type 2 diabetes. Sociodemographic factors such as gender, marital status, level of education, and occupational status are important determinants of psychiatric comorbidity among diabetic patients.
Keywords: Diabetes, psychiatric disorder, sociodemographic factors
Introduction
Diabetes mellitus is a prominent noncommunicable disease (NCD) globally, with an estimated prevalence of 9.3% in 2019.[1] Around 537 million adults aged 20 to 79 years are currently living with diabetes. This number is projected to increase significantly, reaching 643 million by 2030 and 783 million by 2045. Notably, India is home to approximately one-sixth of the world’s diabetic population.[2]
Psychiatric disorders also represent a significant public health issue. Worldwide, about 793 million people are affected by mental health problems, which corresponds to slightly more than 10% of the global population.[3] While diabetes and mental health disorders are often studied separately, there is a notable association between the two. Research, including systematic reviews, indicates a higher prevalence of mental disorders among individuals with diabetes compared to those without. The global prevalence of mental disorders among people with diabetes is estimated to range between 18% and 28%.[4] However, many psychiatric conditions in diabetic patients remain undiagnosed, with about half of these disorders going unrecognized and untreated. Psychiatric disorders commonly associated with diabetes are depression, anxiety, panic disorder, eating disorders, manic episodes, suicidality, obsessive-compulsive disorder, and so on.[5]
Sociodemographic factors have been identified as an essential determinant that increases the risk of psychiatric comorbidity among diabetic patients.[6] These factors include age, gender, type of family, marital status, religion, place of residence, educational status, occupational status, and socioeconomic status.
Despite the rising prevalence of psychiatric disorders among diabetic patients, these conditions are often overlooked and underdiagnosed, leading to adverse health outcomes and suboptimal treatment. There is a lack of comprehensive data on the prevalence of mental disorders among people with diabetes in our local setting. To supplement this knowledge gap and to estimate the magnitude of the problem and its contributing factors, the present study was conducted with the financial support of the Indian Council of Medical Research (ICMR) with the following objectives:
1. To estimate the prevalence of psychiatric disorders among adult patients with type II diabetes mellitus. 2. To identify sociodemographic factors associated with psychiatric comorbidity in the study population.
Subjects and Methods
This cross-sectional study was conducted in field practice areas of the Urban Health Training Centre (UHTC) and Rural Health Training Centre (RHTC) of the Department of Community Medicine, Jawaharlal Nehru Medical College (JNMC), Aligarh Muslim University (AMU), Aligarh from August 2023 to July 2024.
The sample size was calculated based on a similar study with a reported prevalence of 18% of psychiatric comorbidity among diabetic patients.[4]
Applying the formula, N = [(1.96) 2 × P (1 − P)]/L2
Where P = Expected prevalence of psychiatric disorder = 18%
L = Allowable error – 4%
N = 354.4 + 10% non-response rate (35.4%)
N = 389.7 rounded off to 390
Final sample size = 390
Listing of all households with adult patients with type II diabetes under each field practice area was done. The Probability Proportional to Size (PPS) technique was used to draw the required sample from rural and urban areas. One hundred forty-four (144) patients were selected from urban areas and 246 from rural areas. Households with diabetic patients were selected by simple random sampling using a random number table. From each household, all eligible diabetic patients satisfying the inclusion criteria were selected. Patients already diagnosed with type II diabetes mellitus and those consented were included in the study. Patients who had any other type of diabetes, that is, type I or gestational diabetes, had any comorbid conditions like hypertension, coronary artery disease, and so on, or had a previous history of any psychiatric disorder were excluded from the study. The following household was taken if no patient was available in the selected household. All the patients were informed about the nature of the study. Written informed consent was obtained from all the study patients.
Patients were interviewed using a predesigned and structured questionnaire by a resident doctor of the Department of Community Medicine. The interviewer had been trained in the psychiatry department before starting the data collection. All the diabetic patients were screened for the presence of psychiatric disorders using the General Health Questionnaire-12 (GHQ-12). It is a validated tool for adults, comprising 12 questions, each scoring from 0 to 3 on a Likert scale. A GHQ-12 score equal to or more than 12 was considered a cutoff score for screening out patients with a higher probability of having a psychiatric disorder.[7] Further diagnosis of psychiatric disorder was confirmed in all the GHQ-12 screened-out patients, using Diagnostic and Statistical Manual 5 of Mental Disorders Text Revision Level 1 Cross-Cutting Symptoms Measures (DSM-5 TR Level 1 CCSM).[8] The adult version of DSM-5 TR level 1 CCSM consists of 23 questions that assess 13 psychiatric domains. Out of the 13 psychiatric domains, the following eight domains (based on prevalence) have been considered for the present study: Depression, Anxiety, Sleep disturbances, Somatoform disorders, Mania, Obsessive Compulsive Disorders (OCD), Suicidal ideation, and Memory disturbances. Each question assessed the mental health condition over the past 2 weeks on a 5-point scale as given below:
0 = Not at all (None)
1 = Rare/less than a day or 2 (Slight)
2 = Several days (Mild)
3 = More than half the days (Moderate)
4 = Nearly every day (Severe).
Diagnosis of all the psychiatric disorders except suicidal ideation was confirmed by the highest domain score of 2 or more. For suicidal ideation, the highest domain score of 1 or more was considered confirmatory.
Data were analyzed using IBM SPSS 20.0 software. For assessing the association of psychiatric disorders with sociodemographic factors, binary logistic regression was applied. Initially, bivariate analysis was conducted to determine the crude association between each independent variable and the binary outcome, and crude odds ratios (CORs) with 95% confidence intervals were reported. Subsequently, all relevant variables—regardless of their statistical significance in the bivariate analysis—were included in the multivariate logistic regression model, after checking for its assumptions. This inclusive strategy was adopted to account for potential confounders. Adjusted odds ratios (AORs) were calculated to determine the independent effect of each variable on the outcome.
Ethical clearance was taken from the Institutional Ethics Committee, Jawaharlal Nehru Medical College and Hospital (Ref. No.: IECJNMC/817). Maintaining confidentiality was given utmost importance. Patients who were diagnosed with psychiatric disorders were counseled and referred to the appropriate health facility for further management.
Results
Sociodemographic profile of the study population
The mean age of the study participants was 59.21+/-10.7 years, with the minimum recorded age being 24 and a maximum of 90 years. More than one-third (36.7%) of patients were 60–69 years old, followed by the 50–59 age group (24.4%). More than half of the patients (54.6%) were female by gender. Most (54.6%) of the patients lived in 3-generation families, and only one-fourth (26.6%) were from nuclear families. More than three-fourths of the patients (75.4%) were married and living as a couple. More than half (56.9%) of the patients were Hindus by faith, followed by Muslims (40.8%). Almost two-thirds of patients (63.6%) were from rural areas, and more than half were illiterate or just literate (54.1%). Only 10% of the patients had education beyond high school.
Concerning occupation, almost half of the study patients (48.5%) were either not working or retired. This was probably because more than half of the population was beyond 60 years of age. The second largest group (18.3%) comprised female homemakers. The mean per capita income was 4130.9 ± 2149 ₹. The majority of the patients belonged to the middle socioeconomic class (37.4%), followed by the upper middle class (30.8%) and lower middle class (25.9%) (Mod. BG Prasad Classification-2023 April) [Table 1].
Table 1.
Sociodemographic profile of study patients (n=390)
| Characteristics | Frequency (n) | Percentage (%) |
|---|---|---|
| Age in years | ||
| <50 | 90 | 23.1 |
| 50 to 59 | 95 | 24.4 |
| 60 to 69 | 143 | 36.7 |
| 70 and more | 62 | 15.9 |
| Gender | ||
| Male | 177 | 45.4 |
| Female | 213 | 54.6 |
| Type of family | ||
| Nuclear | 104 | 26.6 |
| Joint | 73 | 18.7 |
| 3 Generation | 213 | 54.6 |
| Marital status | ||
| Single/Unmarried | 1 | 0.3 |
| Married | 294 | 75.4 |
| Divorced | 1 | 0.3 |
| Widow/Widower | 94 | 24.1 |
| Religion | ||
| Hindu | 222 | 56.9 |
| Muslim | 159 | 40.8 |
| Others | 9 | 2.3 |
| Place of residence | ||
| Rural | 248 | 63.6 |
| Semiurban | 142 | 36.4 |
| Educational status | ||
| Illiterate/Just literate | 211 | 54.1 |
| Primary | 68 | 17.4 |
| Middle school | 35 | 9 |
| Highschool | 37 | 9.5 |
| Post high school | 17 | 4.4 |
| Graduate/Post Graduate | 20 | 5.1 |
| Profession/Honors | 2 | 0.5 |
| Occupational status | ||
| Not working/retired | 189 | 48.5 |
| Unskilled | 12 | 3.1 |
| Semiskilled | 21 | 5.4 |
| Skilled | 19 | 4.9 |
| Clerical/Shop owners/farmers | 70 | 17.9 |
| Semiprofessional | 4 | 1 |
| Professional | 2 | 0.5 |
| Homemaker | 73 | 18.3 |
| Socioeconomic class (Modified BG Prasad, 2023, April) | ||
| Upper Class (≥8822) | 15 | 3.8 |
| Upper middle class (4411–8821) | 120 | 30.8 |
| Middle class (2647–4410) | 146 | 37.4 |
| Lower middle class (1323–2646) | 101 | 25.9 |
| Lower class (<1323) | 8 | 2.1 |
Screening of psychiatric disorders by the General Health Questionnaire (GHQ-12)
Study participants had a mean GHQ-12 score of 10.48 + 4.602, having a minimum score of 0 and a maximum score of 24. Out of 390 patients, 172 (44.1%) were screened out with a high probability of psychiatric disorder [Table 2].
Table 2.
Distribution of GHQ-12 scores among the study patients
| Distribution of GHQ-12 score | |||
|---|---|---|---|
|
| |||
| Mean (±SD) | Minimum | Maximum | Range |
| 10.48±4.602 | 0 | 24 | 24 |
|
| |||
| Categorisation of patients using GHQ-12 | |||
|
| |||
| GHQ-12 score | Frequency (n) | Percentage (%) | |
|
| |||
| <12 | 218 | 55. 9 | |
| ≥12 | 172 | 44.1 | |
| Total | 390 | 100 | |
Confirmation of psychiatric disorders by Diagnostic and Statistical Manual 5 of Mental Disorders Text Revision level 1 (DSM-5 TR level 1)
Out of 172 GHQ-12 screened-out study participants, 120 (69.7%) patients confirmed the presence of at least one of the eight psychiatric disorders. However, the remaining 52 (31.3%) patients did not show any evidence of psychiatric disorder [Table 3].
Table 3.
Results of DSM-5 TR level 1 questionnaire (n=172)
| DSM TR Level 1 | Frequency (n) | Percentage (%) |
|---|---|---|
| Positive | 120 | 69.7% |
| Negative | 52 | 31.3% |
| Total | 172 | 100 |
Overall prevalence of psychiatric disorders
DSM-5 TR level 1 questionnaire confirmed the presence of a psychiatric disorder in 120 patients among the 172 GHQ-12 positive patients.
Out of the total 390 diabetic patients, 120 (30.8%) had psychiatric disorders, and 270 (69.2%) did not have psychiatric disorders. Thus, the overall prevalence of psychiatric disorders among the study participants was 30.8% [Figure 1].
Figure 1.
Prevalence of psychiatric disorders in study patients
Among the eight different psychiatric disorders studied, depression was the most common disorder observed in 108 (27.6%) of the patients, followed by anxiety in 92 (23.5%). Sleep disturbances and somatoform disorders followed next, affecting 22% and 18.7% of patients, respectively [Figure 2].
Figure 2.
Frequency of different psychiatric disorders among the study patients
Out of the 120 diabetic patients who had psychiatric disorders, only 2 had one psychiatric disorder, while all others had more than one psychiatric disorder. 19 (15.8%) had two psychiatric disorders, while 99 (82.5%) patients had three or more psychiatric disorders [Table 4].
Table 4.
Distribution of multiple psychiatric disorders among the study patients (n=120)
| Number of psychiatric disorders | Frequency (%) |
|---|---|
| 1 | 2 (1.6%) |
| 2 | 19 (15.8%) |
| 3 or more | 99 (82.5%) |
Patients in the age group 70 or above had the highest prevalence of psychiatric disorder (37.1%), followed by the age group of 60 to 69 years. However, the difference was found to be statistically insignificant. Female patients had a higher prevalence of psychiatric disorder (33.3%) as compared to males (27.7%) (AOR 2.283, CI 1.209–4.314). Patients belonging to three-generation families had the highest prevalence of psychiatric disorder (35.2%), followed by patients from nuclear families (27.9%). Almost half of the patients who were widowed/unmarried/divorced (47.9%) had a psychiatric disorder, while only one-fourth (25.2%) of the married patients had a psychiatric disorder. Being widowed/unmarried/divorced led to significantly higher odds of occurrence of psychiatric disorder (OR 3.527, CI 1.842–6.753). Overall, Muslim patients (39%) had a higher prevalence of psychiatric disorders compared to patients of other faiths. However, the association between religion and psychiatric disorder was not statistically significant. Higher prevalence (39.4%) of psychiatric disorder was observed in diabetic patients of semiurban areas as compared to those who belonged to rural areas (25.8%). Higher prevalence of psychiatric disorder (40.3%) was noted among the illiterate diabetic patients (19.6%). Only 19.6% of the educated diabetic patients had a psychiatric disorder. A diabetic patient who was illiterate had a significantly higher chance of developing a psychiatric disorder (OR 2.423, CI 1.375–4.270). Patients who were homemakers had the highest prevalence (41.1%) of psychiatric disorder, followed by those presently not working/retired (36%). Concerning the working class, homemakers and those not working had statistically higher odds of developing psychiatric disorders (OR 3.623, CI 1.520–8.637; OR 2.364, CI 1.135–4.924, respectively). The upper class had the highest prevalence (46.7%) of psychiatric disorder, followed by the middle class (32.9%). However, the association of socioeconomic status with psychiatric disorder was statistically insignificant [Table 5].
Table 5.
Association of psychiatric disorders in diabetic patients with sociodemographic factors
| Variable | Category | Total | Psychiatric disorder | Crude OR (95% CI) | Crude (P) | AOR (95% CI) | Adjusted (P) | |
|---|---|---|---|---|---|---|---|---|
|
| ||||||||
| Present | Absent | |||||||
| Age (Years) | 50 or less | 90 | 27 (30%) | 63 (70%) | Ref. | Ref. | ||
| 50 to 59 | 95 | 25 (26.3%) | 70 (73.7%) | 0.833 (0.439–1.583) | 0.578 | 0.983 (0.472–2.047) | 0.964 | |
| 60 to 69 | 143 | 45 (31.5%) | 98 (68.9%) | 1.071 (0.604–1.899) | 0.813 | 1.753 (0.719–4.273) | 0.217 | |
| 70 or more | 62 | 23 (37.1%) | 39 (62.9%) | 1.376 (0.694–2.729) | 0.361 | 1.867 (0.659–5.289) | 0.240 | |
| Gender | Male | 177 | 49 (27.7%) | 128 (72.3%) | Ref. | Ref. | ||
| Female | 213 | 71 (33.3%) | 142 (66.7%) | 1.306 (0.845–2.019) | 0.229 | 2.283 (1.209–4.314) | 0.011 | |
| Type of family | Nuclear | 104 | 29 (27.9%) | 75 (72.1%) | Ref. | Ref. | ||
| Joint | 73 | 16 (21.9%) | 57 (78.1%) | 0.726 (0.360–1.463) | 0.370 | 0.873 (0.403–1.889) | 0.730 | |
| 3 Generation | 213 | 75 (35.2%) | 138 (64.8%) | 1.406 (0.842–2.347) | 0.193 | 1.009 (0.478–2.131) | 0.981 | |
| Marital status | Widowed/unmarried/divorced | 96 | 46 (47.9%) | 50 (52.1%) | 2.735 (1.694–4.417) | 0.000 | 3.527 (1.842–6.753) | 0.000 |
| Married | 294 | 74 (25.2%) | 220 (74.8%) | Ref. | Ref. | |||
| Religion | Hindu | 222 | 55 (24.8%) | 167 (75.2%) | Ref. | Ref. | ||
| Muslim | 159 | 62 (39%) | 97 (61%) | 1.941 (1.249–3.016) | 0.003 | 1.486 (0.789–2.799) | 0.220 | |
| Others | 9 | 3 (33.3%) | 6 (66.7%) | 1.518 (0.367–6.275) | 0.564 | 1.299 (0.278–6.076) | 0.740 | |
| Place of residence | Rural | 248 | 64 (25.8%) | 184 (69.2%) | Ref. | Ref. | ||
| Semiurban | 142 | 56 (39.4%) | 86 (60.6%) | 1.872 (1.205–2.909) | 0.005 | 1.438 (0.754–2.743) | 0.270 | |
| Educational status | Illiterate | 211 | 85 (40.3%) | 126 (59.7%) | 2.776 (1.751–4.399) | 0.000 | 2.423 (1.375–4.270) | 0.002 |
| Educated | 179 | 35 (19.6%) | 144 (80.4%) | Ref. | Ref. | |||
| Occupational status | Not working | 189 | 68 (36%) | 121 (64%) | 2.708 (1.567–4.679) | 0.000 | 2.364 (1.135–4.924) | 0.022 |
| Home maker | 73 | 30 (41.1%) | 43 (58.9%) | 3.362 (1.567–4.679) | 0.000 | 3.623 (1.520–8.637) | 0.004 | |
| Working | 128 | 22 (17.2%) | 106 (82.8%) | Ref. | Ref. | |||
| Socioeconomic status | Upper class | 15 | 7 (46.7%) | 8 (53.3%) | 1.930 (0.647–5.754) | 0.238 | 2.581 (0.722–9.229) | 0.145 |
| Upper middle class | 120 | 31 (25.8%) | 89 (74.2%) | 0.768 (0.432–1.3660) | 0.370 | 0.917 (0.467–1.798) | 0.800 | |
| Middle class | 146 | 48 (32.9%) | 98 (67.1%) | 1.080 (0.634–1.840) | 0.776 | 1.134 (0.627–2.051) | 0.677 | |
| Lower middle and lower class | 109 | 34 (31.2%) | 75 (68.8%) | Ref. | Ref. | |||
Discussion
Among 390 diabetic patients included in the study, the prevalence of psychiatric disorders was found to be 30.8%. Similar prevalence of psychiatric disorders in diabetes was detailed in other published studies. A two-stage evaluation on diabetes patients from the Endocrinology outpatient clinic of Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, found almost similar prevalence of psychiatric disorder (33.9%) among diabetes patients.[9] Similarly, the prevalence of psychiatric disorders among diabetic patients among Spanish adults was documented as 25%.[6] The global prevalence of psychiatric disorders, ranging from 18% to 28%, is consistent with the findings of the present study.[4] However, a cross-sectional study on diabetes patients of North India showed a higher prevalence of psychiatric disorders (58.1%).[10] The higher prevalence might be due to the different geographical setting of hilly areas and related contributory factors in this study. Similarly, a case-control study on diabetes patients of North India also found a higher prevalence of psychiatric disorders among diabetes patients as compared to general patients (67.5% vs. 37.5%).[11]
Among the eight different psychiatric disorders considered in this study, depression was the most common psychiatric disorder observed in 108 (27.6%) of the patients, followed by anxiety in 92 (23.5%). Depression followed by anxiety was also found to be the most common psychiatric disorder among people with diabetes in different studies.
One of the meta-analyses studying depression among type 2 diabetes patients documented an overall (pooled) prevalence of 38% (95% CI: 31%–45%).[12] Population-based studies noted a prevalence rate of depression, ranging from 19.70% to 40.68%.[13] Prevalence of depression in a community-based survey in Jammu was recorded as 38.9%.[14] Similar to the present study, the prevalence of anxiety was 20.0%.[15] However, a higher prevalence of anxiety was noted by other studies.[14] Varying rates of depression and anxiety in different studies can be attributed to the differences in methods of reporting and diagnosing these disorders. Another study found the prevalence of somatoform disorders to be 16.1% and panic/mania to be 7.9% among the diabetic patients.[9]
The prevalence of psychiatric disorders has been increasing with age, as confirmed by many studies.[6,10,14] This could probably be because older people have financial constraints, limited social interactions as compared to young individuals, together with feelings of loneliness and low self-esteem, which increases the risk of developing psychiatric disorders over underlying diabetes. Similar to the present study, the higher prevalence among females is supported by other studies.[9,10,12,14] This gender difference in rate of psychiatric morbidities is probably due to sociocultural factors, the role played by either gender in the family, and the way each gender copes with stress in daily life. Many authors also noted an increased risk of psychiatric disorder in a single spouse.[14,15] Married people are more likely to have emotional and psychosocial support from their partner, which may decrease their likelihood of getting the disease. Higher prevalence of psychiatric disorder in urban patients and among the uneducated group, similar to the present study, was also noted.[15] An educated person is more informed about disease, its complications, and how to care for oneself. They usually have positive health-seeking behavior, which might decrease their risk of developing psychiatric comorbidity. Being unemployed increased the risk of the development of psychiatric disorders among diabetic patients.[6] This was expected since being unemployed is a depressing factor, and its financial burden increases the risk manifold. Low-income people living in a nuclear family and belonging to the Hindu faith had higher rates of psychiatric disorders.[6] Family income can be an essential determinant in disease outcome as it influences access to healthcare and purchasing power. Another study supported that the extended family had a low prevalence of psychiatric disorders compared to the nuclear family.[11] This could be related to more stress in the nuclear family as fewer members are available to share responsibility. The differences in psychiatric disorders about religion are more due to the demographic composition of the study populations and do not bear any relationship to the outcome.
Conclusion
The study reveals a significant prevalence of psychiatric disorders among diabetic patients, with 30.8% of patients affected, with depression and anxiety being the most common. The problem warrants the need for integrated mental health care within diabetes management.
Correlates among sociodemographic factors like gender, living status, educational class, and working status significantly determined the chances of the development of psychiatric disorder among the patients.
Limitations
First, the subjective nature of questionnaire responses may lead to variability across different respondents, potentially causing underestimation or overestimation of the actual responses. Second, some patients might withhold information about their mental or psychiatric state due to social and cultural stigma, leading to an underestimation of the disorder. Finally, the present study could not incorporate all determinants and confounding factors which could have influenced the study results.
List of abbreviations
DSM-5 TR CCSM: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision Cross-Cutting Symptom Measure
GHQ 12: General Health Questionnaire 12
OCD: Obsessive Compulsive Disorders
SPSS: Statistical Package for Social Science.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Financial assistance received from ICMR for MD thesis 2022.
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