Abstract
Purpose
Adherence to treatment is of great importance in patients with diabetes mellitus due to its necessity and benefits. The purpose of this study was to evaluate the relationship between personality disorder, depression and eating disorder with appropriate treatment acceptance and follow-up in patients with type 2 diabetes.
Methods
This cross-sectional study was performed in Imam Ali Medical Education Center in Karaj city of Alborz province of Iran. A total of 1320 patients were evaluated and were screened according to the inclusion criteria, including type 2 diabetes and those over 18 years of age. Finally, considering the exclusion criteria, 600 patients with type 2 diabetes were included in the study. Patients were divided into 4 groups. 150 patients with type 2 diabetes in the control group, 150 patients with type 2 diabetes with major depressive disorder, 150 patients with type 2 diabetes with personality disorder and 150 patients with type 2 diabetes and eating disorder were studied. Questionnaires used in the study included Hamilton Depression Rating Scale(HAM-D) for depression, Minnesota Multiphasic Personality Inventory II (MMPI II) questionnaire for personality disorders and Eating Disorder Diagnostic Scale(EDDS) for eating disorder. The Murisky questionnaire also assessed adherence to treatment in patients, which included 8 questions. Scores measure the degree of adherence to treatment.
Results
600 patients with type 2 diabetes were studied. Patients were divided into 4 groups (each group consisting of 150 patients) of control, depression, personality disorder and eating disorder. Mean age, sex, marital status and duration of diabetes were not significantly different in the study groups (P > 0.05). The mean Murisky score in patients with depression and personality disorder was significantly lower than the control group (P < 0.05) but the mean Murisky score in patients with eating disorder was not significantly different (P > 0.05). Patients with depression, paranoid, schizotypal, antisocial, borderline, avoidant and dependent personality disorder had less adherent to treatment than the control group.
Conclusions
Early psychiatric evaluation of patients with diabetes and identification of possible disorders can help improve diabetes control.
Keywords: Personality disorder, Depression, Eating disorder, Diabetes mellitus
Introduction
Diabetes mellitus is a group of diseases in which elevated blood glucose levels are caused by impaired insulin release, insulin action, or both. Hyperglycemia is due to insulin deficiency. The World Health Organization reports that the prevalence of diabetes among adults worldwide doubles from 4.7% in 1980 to 8.8% in 2016, and in 2016 the prevalence of diabetes was 10.3% among adult women and men. [1–3] Diabetes mellitus is divided into two major groups, type I and type II diabetes. [4] Type 2 diabetes accounts for more than 90% of cases of diabetes, and according to the National Survey of Non-Communicable Diseases in Iran in 2005, the prevalence of diabetes mellitus in Iranian citizens aged 25–64 years was 7.7% (2 million persons). [5, 6] Lack of control and elevated blood glucose usually results in disability, early death, and systemic complications for patients, which should be considered appropriate treatment for patients with diabetes and respond to treatment and acceptance. [7]
Despite advances in the treatment of this disease in recent years, many diabetic patients still have fatal and devastating complications [8]. Studies show that cognitive, behavioral, personality, mood, emotional and social factors play a role in regulating and controlling diabetes. [9] Diabetes, on the other hand, is often associated with mental disorders and problems, which undermine the patient’s ability to self-manage the disease and reduce the patients’ ability to control diabetes, exacerbating their psychological problems and causing patients to fall into a faulty cycle. These problems may even be exacerbated by the psychological reactions of patients who have a negative impact on their experience of diabetes. [10] Therefore, it seems important to investigate psychiatric disorders in patients with diabetes, including personality disorder, eating disorder and depression. On the other hand, some studies have suggested an increased risk of and complications of diabetes in patients with personality disorders who recommended the need for further studies. [11] Eating disorders are also associated with serious medication problems and high rates of hospitalization, suicide attempts and death. On the other hand, some studies show an increase in morbidity and mortality in diabetic patients with eating disorders, which is very important. [12] Rapid diagnosis and treatment of depression along with diabetes is also important, as some studies suggest a link between depression and worsening diabetes [13].
On the other hand, adherence to treatment means a person’s consistent with health care recommendations. Meanwhile, non-adherence to treatment, especially in the field of chronic diseases, in addition to the negative effects on health including increasing comorbidities and increasing related care costs, is also associated with negative financial consequences for the individual and society. [14, 15] Various factors such as the status of the drug regimen, drug combination, frequency of drug use, costs, drug side effects and other factors affect the therapeutic adhesion. [16]
We designed this study according to the high prevalence of type 2 diabetes in the community and the complications of this disease that can be largely controlled by appropriate treatment, the association of psychiatric illnesses with this disease and the lack of sufficient studies to link these diseases with evaluation of the course of disease and acceptance of treatment by patients. The purpose of this study was to evaluate the relationship between personality disorder, depression and eating disorder with appropriate treatment acceptance and follow-up in patients with type 2 diabetes.
Methods
Study design and patients
This cross-sectional study was performed in Imam Ali Medical Education Center in Karaj (Iran). In a one-year period of time, all patients with a history of type 2 diabetes who had a medical record and were treated as diabetic patients under the care of this center were evaluated. Inclusion criteria included diagnosis of type 2 diabetes and over 18 years of age. Exclusion criteria included type 1 diabetes, reluctance to participate in the study, diabetic ketoacidosis, life-threatening comorbidities such as heart failure, respiratory failure and cancer, impaired consciousness, and inability to communicate. The type of treatment regimen used had no effect on the selection of patients between different groups and patients could be included in the study based on available sampling and inclusion criteria and also, if there were no exclusion criteria. Regarding the underlying comorbidity, only the points mentioned as exclusion criteria were involved in determining the patients to be considered for the study. In other situations, patients were selected based on available sampling. Adherence to treatment has also been evaluated based on the status of use of prescription drugs used to treat diabetes. In this study, the purpose of adherence to treatment is to follow the therapeutic care recommendations related to the control of chronic diabetes among patients with diabetes referred to the diabetes control clinic.
The researcher first described the study and asked patients to complete a written consent if they agreed to participate in the study. Demographic data were collected from patients, including baseline information such as age, sex, marital status, history of onset of disease and years of diabetes. Patients with type 2 diabetes were screened for depression, personality disorder, and eating disorder based on the questionnaires in order to be placed in four equal groups of patients that were considered for maximum statistical comparison. Patients were also interviewed by an expert psychiatrist for other psychiatric disorders or medications. If there was a psychiatric disorder or the concomitant use of psychiatric medication, the patient would be excluded from the study. Patients who were diagnosed with a psychiatric disorder during the assessment for entrance to the study based on the questionnaires or an interview with an expert psychiatrist, if desired, were consulted for related treatment free of charge.
Cases of identified diabetic patients with comorbidity between two or three of the above (depression, personality disorder and eating disorder) were also excluded from the study. Patients were assigned to one of the four groups, respectively. A total of 1320 patients were evaluated and screened initially and each patient was assigned to one of four study groups, up to 150 patients in each one. If the number of target groups in each group was completed, screening continued to complete the subsequent groups up to 150 individuals in each one. Finally, 4 groups of 150 patients with diabetes including a total of 600 patients were evaluated. They were grouped in the following order:
150 patients with type 2 diabetes in the control group, 150 patients with type 2 diabetes with depression, 150 patients with type 2 diabetes with personality disorder and 150 patients with type 2 diabetes and eating disorder were studied. No patients with concomitant comorbidity between the two or three disorders were included in the study. In other words, patients with diabetes mellitus were included in the study only if they had only one of these disorders.
Instruments
Diagnosis of depression
One of the most widely used tools for identifying and following up of patients with depression worldwide is the Hamilton Depression Rating Scale (HDRS). [17] A 17-item Hamilton Questionnaire (0–54 Score) was used to diagnose depression, with a score of 7 and above being considered as a diagnosis of minor to major depression. [18] The validity of this tool in Iran, through correlation with Beck Depression Scale and Dysfunctional Attitudes Scale, is equal to 0.55 and 0.39 and the reliability between evaluators is 0.95. [19]
Diagnosis of personality disorder and eating disorder
Diagnosis of personality and eating disorders was made according to DSM-5 clinical criteria and according to psychiatrist interview and also Minnesota Multiphasic Personality Inventory II (MMPI II) questionnaire for personality disorders and Eating Disorder Diagnostic Scale(EDDS) for eating disorder.
The Minnesota Multiphasic Personality Inventory (MMPI) is a global standard tool for assessing personality disorders. The adult version has been widely used for many years as MMPI II. [20] Psychometric properties of this tool have been evaluated in Iran and its related satisfactory internal and test-retest reliability has been reported. [21]
Eating Disorder Diagnostic Scale as a valid questionnaire has test-retest reliability (r = .87) and internal consistency (mean α = .89) and has convergent validity with extant eating-pathology scales. [22] The validation of eating disorder diagnostic scale has been evaluated in Iran. In a study by Khabir et al., the internal consistency coefficients, Spearman-Brown and Guttmann splithalf correlations were 0.84, 0.82 and 0.83, respectively. Thus, appropriate validity and reliability of this questionnaire were emphasized. [23]
Assessment of adherence to treatment
The Murisky questionnaire was used to assess treatment adherence in patients, which included 8 questions, the lowest score being 0 and the highest score being 10, with the highest score indicating greater adherence to treatment. [24] This tool is a simple questionnaire to assess adherence to treatment despite the complexities involved in this condition. [25] This tool has been used to examine adherence to treatment in different countries and in different studies. [26, 27] Moharamzad et al. evaluated the reliability and validity of this questionnaire among a group of Iranian patients. Its internal consistency was reported to be acceptable and its overall Cronbach’s α coefficient was 0.697. Also, its test-retest reliability showed good reproducibility (r = 0.940). [28]
Statistical analysis
SPSS software version 22 was used. At first, Kolmogorov-Smirnov test was used to determine the normal distribution of the data. Independent T, Mann-Whitney, Chi-square and Fisher’s exact tests were used.
Ethical considerations
Participation in the study was voluntary. Patients were not charged for participating in the study. They could leave the study whenever they wished. Ethics code and study permission were obtained from the Ethics Committee of Alborz University of Medical Sciences. (Ethics code: IR.ABZUMS.REC. 1398.143).
Results
In the present study, 600 patients with type 2 diabetes were studied. Patients were divided into 4 groups (each group consisting of 150 patients) of control, depression, personality disorder and eating disorder. The mean age of the patients in the groups compared with the control group is shown in Table 1 that there was no significant difference in Independent T test (P > 0.05).
Table 1.
Comparison of the mean age of the patients in the groups with the control group
| Groups / Average Age | Mean (SD) | Control group | P value |
|---|---|---|---|
| Depression disorder group | 53.55 (11.79) | 56.79 (12.55) | 0.072 |
| Personality disorder group | 59.48 (11.74) | 56.79 (12.55) | 0.077 |
| Eating disorder group | 55.83 (12.27) | 56.79 (12.55) | 0.956 |
The comparison of sexual frequency of patients in groups with control group is shown in Table 2 that there was no significant difference in Fisher’s exact test (P > 0.05). The comparison of marital status of the patients in the groups with the control group is shown in Table 3 which showed no significant difference in Fisher’s exact test (P > 0.05). The mean duration of type 2 diabetes in the groups compared with the control group is shown in Table 4 that there was no significant difference in Mann-Whitney test (P > 0.05).
Table 2.
. Comparison of sex frequency of groups with control group
| Control group | |||||
|---|---|---|---|---|---|
| Groups / Gender | Male(%) | Female(%) | Male(%) | Female(%) | P value (Male- Male/Female-Female) |
| Depression disorder group | 62 (41.3%) | 88(58.7%) | 67(44.7%) | 83(55.3%) | 0.072/0.064 |
| Personality disorder group | 84(54%) | 69(46%) | 67(44.7%) | 83(55.3%) | 0.830/0.893 |
| Eating disorder group | 38(25.3%) | 112(74.7%) | 67(44.7%) | 83(55.3%) | 0.864/0.823 |
Table 3.
. Comparison of marital status of patients in groups with control group
| Control group | |||||
|---|---|---|---|---|---|
| Groups/ Marriage Single(%) | Married(%) | Single(%) | Married(%) | P value (Single-Single/ Married-Married) | |
| Depression disorder group | 56(37.3%) | 94(62.7%) | 10(6.7%) | 140(93.3%) | 0.832/0.989 |
| Personality disorder group | 26(17.3%) | 124(82.7%) | 10(6.7%) | 140(93.3%) | 0.671/0.720 |
| Eating disorder group | 25(16.7%) | 125(83.3%) | 10(6.7%) | 140(93.3%) | 0.949/0.987 |
Table 4.
Comparison of mean duration of type 2 diabetes in patients in groups with control group
| Groups / mean duration of infection | Average (SD) | Control group | P value |
|---|---|---|---|
| Depression disorder group | 8.10 (4.38) | 8.53 (4.00) | 0.514 |
| Personality disorder group | 9.22 (3.94) | 8.53 (4.00) | 0.062 |
| Eating disorder group | 8.28 (4.01) | 8.53 (4.00) | 0.963 |
Comparison of the mean of Murisky scores in the groups with the control group is shown in Table 5 which depression and personality disorder groups were significantly different from the control group in Mann-Whitney test (P <0.05). Comparisons of the mean Murisky score of personality disorder group by type of disorder and control group are shown in Table 6 which the mean score of Murisky score in patients with paranoid, schizotypal, antisocial, borderline, avoidant and dependent personality disorders were significantly lower in the Mann-Whitney test than the control group (P < 0.05). In addition, the mean Murisky score in the Eating disorder group was compared with the control group, which is shown in Table 7. On the other hand, Pearson correlation test was used to determine the correlation between the severity of depression and acceptance of treatment in patients with r value of 0.82 but not significant (P = 0.316).
Table 5.
Comparison of mean Murisky group with the control group
| Groups / Morisky | Average (SD) | Control group | P value |
|---|---|---|---|
| Depression disorder group | 4.87 (3.25) | 7.00 (2.82) | <0.0001 |
| Personality disorder group | 4.56 (2.74) | 7.00 (2.82) | <0.0001 |
| Eating disorder group | 6.40 (3.02) | 7.00 (2.82) | 0.087 |
Table 6.
Comparison of mean Murisky score in personality disorder group and the control group
| Type of personality disorder | Number(%) | Average (SD) | Control group | P value |
|---|---|---|---|---|
| Paranoid | 44(29.3%) | 3.07 (2.05) | 7.00 (2.82) | <0.0001 |
| Schizoid | 16(10.7%) | 6.19 (2.23) | 7.00 (2.82) | 0.209 |
| Schizotypal | 12(8%) | 4.33 (1.72) | 7.00 (2.82) | 0.001 |
| Anti-social | 6(4%) | 1.00 (0.89) | 7.00 (2.82) | <0.0001 |
| Narcissistic | 12(8%) | 6.00 (2.04) | 7.00 (2.82) | 0.182 |
| Hysterical | 13(8.7%) | 7.08 (2.18) | 7.00 (2.82) | 0.837 |
| Borderline | 18 (12%) | 2.61 (1.85) | 7.00 (2.82) | <0.0001 |
| Avoidance | 14 (9.3%) | 5.57 (1.28) | 7.00 (2.82) | 0.039 |
| Dependent | 5(3.3%) | 2.80 (2.49) | 7.00 (2.82) | 0.005 |
| Obsessive- Compulsive | 10(6.7%) | 8.90 (0.99) | 7.00 (2.82) | 0.090 |
Table 7.
Comparison of mean Murisky eating disorder group and the control group
| Type of eating disorder | Number (%) | Average (SD) | Control group | P value |
|---|---|---|---|---|
| Bulimia | 117(78%) | 4.18 (2.66) | 7.00 (2.82) | 0.212 |
| Binge | 33(22%) | 5.91 (2.64) | 7.00 (2.82) | 0.065 |
Discussion
The purpose of this study was to determine the relationship between personality disorder, depression and eating disorder with appropriate treatment acceptance and follow-up in patients with type 2 diabetes. In this study 600 patients were studied. Results showed that patients with depression had significantly less adherence to treatment than the control group but there was no significant relationship between treatment adherence and severity of depression. In a similar study conducted in 2013, the results showed that depressive disorder in patients with type 2 diabetes reduced the acceptability of treatment and poor control of blood glucose in these patients, [29] which confirms the results of the present study. On the other hand, another study conducted in 2015 showed that depressive disorder in patients with type 2 diabetes reduced adherence to treatment and increased blood glucose levels, [30] which is in line with the results of the present study. Also in a meta-analysis of 47 cohort studies, depression was associated with poor self-care and non-adherence to drug therapy in patients with type 2 diabetes, [31] which confirms the results of the present study.
Some parameters of non-adherence to diabetes treatment in other studies have been conditions such as increasing the number of prescription drugs, the number of drug use, and starting new medications. [32] Also, the relationship between psychological distress and the diabetes care process is not well understood. [33] While people with depression experience less diabetes-related medications, and as the number of medications prescribed increases, we see a greater reduction in therapeutic adhesions in them. [34] Maeda et al. cited low self-efficacy as an important and effective factor in reducing adherence to treatment in patients with depression. They cited self-efficacy as one of the main predictors of promoting self-care behavior in chronic diseases. [35]
On the other hand the mean score of Murisky score in patients with paranoid, schizotypal, antisocial, borderline, avoidant and dependent personality disorders were significantly lower than the control group. In this context, a 2014 study showed that unconscientious - a cognitive behavior - is associated with increased risk of diabetes and mortality from diabetes and basic mechanisms may include unhealthy behaviors such as weight gain, physical inactivity, and failure to follow medical advice. [11] According to the personality characteristics of patients with personality disorders mentioned, including distrust in patients with paranoid personality disorder, being superstitious in patients with schizotypal personality, lack of conscience in patients with antisocial personality, behavioral instability in patients with Borderline personality, shyness in patients with avoidant personality disorder and inability to make decisions in patients with dependent personality disorder [36] may justify a reduction in adherence to treatment in these patients. Similarly, in a 2005 study, borderline personality disorder was associated with poor glycemic control in patients with type 1 diabetes. [37] High neuroticism in some groups of women and low conscience in some groups of men with personality disorders have been described as other causes associated with decreased adhesion to treatment in some clinical settings. [38]
On the other hand, in the present study, there was no significant difference in adherence to treatment in patients with eating disorder with the control group. In the present study, patients with eating disorders included Bulimia nervosa and Binge eating disorder, and patients with type 2 diabetes and Anorexia nervosa were not identified. Similarly, in a meta-analysis study conducted in 2017, Anorexia nervosa was reported to be a protective factor for type 2 diabetes. [39]
In our study, there was no statistically significant relationship between the severity of depression and adherence to treatment. This is in contrast to other studies in which increasing the severity of depression is associated with decreased adherence to treatment. [40] In this regard, it is important to note that what is emphasized more than anything else is the effect of depression with the depressed mood or anhedonia in reducing compliance and therapeutic adhesions. [41] The ineffectiveness of the severity of depression in the therapeutic adhesion status obtained in our study requires further evaluation in larger studies or other multicenter studies.
What can be seen in this study is the effect of some psychiatric disorders such as depression and some personality disorders in reducing treatment adherence in patients with type 2 diabetes. Due to the necessity and importance of accurate control of this disease, appropriate screening at the first opportunity along with the continuation of follow-up care in terms of psychiatric disorders in patients with type 2 diabetes, with the aim of improving the psychiatric status of patients, may play an effective role in improving treatment adherence.
Limitations
One of the limitations of this study is its cross-sectional design. It is recommended that a study with similar goals be conducted in an interventional manner to resolve the referred disorders and to evaluate them comparatively. Another limitation in this study is the lack of use of a structured interview such as SCID-II to diagnose personality disorders.
Conclusion
Results of the present study showed that patients with depression, paranoid, schizotypal, antisocial, borderline, avoidant and dependent personality disorder had less adherent to treatment than the control group. Early psychiatric evaluation of patients with diabetes and identification of possible psychiatric disorders can help improve diabetes control. Larger multicenter studies are recommended to evaluate the relationships mentioned.
Acknowledgements
We thank all the patients who collaborated to carry out this study. We also thank the officials of Imam Ali Medical Education Center.
Authors’ contributions
All authors had the same role in the various stages of preparing this article.
Funding
This study was conducted with the financial support of Alborz University of Medical Sciences. (IR.ABZUMS.REC. 1398.143).
Compliance with ethical standards
Conflicts of interest/competing interests
There is no conflict of interest.
Availability of data and material
All study data and materials are available.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Contributor Information
Negar Jalali, Email: Negar_jalali@yahoo.com.
Habibeh Taghavi Kojidi, Email: Dr.taghavi76@yahoo.com.
Rahim Badrfam, Email: rbadrfam@gmail.com.
Atefeh Zandifar, Email: zandifaratefe@gmail.com.
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