East Asian Arch Psychiatry 2016;26:77-82


Depression and Associated Factors in Patients with Type 2 Diabetes Mellitus
NA Hashim, S Ariaratnam, MR Salleh, MA Said, AH Sulaiman

Dr Nurul Azreen Hashim, MD, MPM, Psychological & Behavioural Medicine Unit, Universiti Teknologi Mara, Selangor, Malaysia.
A/Prof. Suthahar Ariaratnam, MBBS, MMed (Psych), Psychological & Behavioural Medicine Unit, Universiti Teknologi Mara, Selangor, Malaysia.
Prof. Mohd Razali Salleh, MPM, FAMM, Psychological & Behavioural Medicine Unit, Universiti Teknologi Mara, Selangor, Malaysia.
Prof. Mas Ayu Said, MBBS, MPH(Epidemiology), PhD, Julius Centre University of Malaya, Department of Social and Preventive Medicine / University of Malaya Centre for Addiction Sciences, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
Prof. Ahmad Hatim Sulaiman, MBBS, MPM, PhD, Professor, Department of Psychological Medicine, University of Malaya, Kuala Lumpur, Malaysia.

Address for correspondence: Dr Nurul Azreen Hashim, Faculty of Medicine, Universiti Teknologi Mara, Selangor, Malaysia.
Tel: (60) 0361264800 ext 4713; Fax: (60) 0361264888; Email: azreenhashim@yahoo.com

Submitted: 19 August 2015; Accepted: 28 January 2016

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Objectives: To determine the prevalence of major depressive disorder and its association with socio- demographic and clinical factors in patients with type 2 diabetes mellitus.

Methods: This was a cross-sectional study of patients with type 2 diabetes mellitus who attended the hospital-based primary care clinics at the University Malaya Medical Centre, Kuala Lumpur, Malaysia. The patients were interviewed using the Mini-International Neuropsychiatric Interview to diagnose depression based on the DSM-IV criteria. The socio-demographic and clinical data were obtained by interviewing the patients and subsequently verified against their respective case notes.

Results: A total of 204 patients were recruited. The prevalence of major depressive disorder was 15.7%. Major depressive disorder was significantly associated with younger age of patients (mean ± standard deviation, 57.8 ± 15.1 years, p = 0.04), younger age at diagnosis of diabetes mellitus (46.2 ± 13.0 years, p = 0.01), having secondary education (p = 0.02), and having a history of depression (p = 0.002). Multivariate analysis showed that current age (p = 0.04), duration of diabetes mellitus (p = 0.04), age at diagnosis of diabetes mellitus (p = 0.01), and secondary education (p = 0.01) were significant factors.

Conclusions: The prevalence of major depressive disorder was high among patients with type 2 diabetes mellitus. Screening of patients with type 2 diabetes mellitus for depression should be performed periodically or routinely, especially in the primary care setting.

Key words: Depressive disorder, major; Diabetes mellitus; Malaysia; Prevalence; Socioeconomic factors


Diabetes mellitus (DM) is a chronic and debilitating disease that affects millions of people globally. Its prevalence is rising in many countries and it is recognised as a global epidemic of the 21st century that is rapidly becoming rampant. According to the International Diabetes Federation, the global prevalence of DM is estimated to increase from 6.6% in 2010 to 7.8% by 2030. This represents an increase in number of diabetics from 285 million to an estimated 438 million people worldwide over 20 years.1 In Malaysia, a rising trend in the incidence of DM is also seen. The Third National Health and Morbidity Survey in 2006 showed that the overall prevalence of DM (known and newly diagnosed) was 11.6%,2 compared with 8.3% in the Second National Health and Morbidity Survey 10 years earlier.3 Diabetes mellitus is viewed as a multidimensional biopsychosocial problem. Its association with depression is well established.4-7

A meta-analysis of 42 studies worldwide by Anderson et al8 demonstrated that 11% of patients with DM fulfilled the criteria for a co-morbid major depressive disorder (MDD) and 31% experienced significant depressive symptoms. The prevalence of depression in patients with DM was significantly higher in women than men. Analysis of the controlled studies in the meta-analysis revealed that the odds of a diabetic patient having depression were twice that of their non-diabetic counterparts.8

Nichols and Brown9 conducted a large study involving 16,180 type 2 DM patients with the same number of controls matched for age and gender. The prevalence of diagnosed depression was greater in the DM group than the control group (17.6% vs. 11.9%). The associated factors with depression were younger age, female gender, higher body mass index, and presence of cardiovascular disease. Other documented associated factors with depression in DM are smoking status, perceived worsening of health status,10 more severe DM symptoms,11,12 poor glycaemic control, diabetic complications,13 and a depressive history.12 A lower level of education14 and lower income10 were also found to be implicated in depression.

There is growing evidence that depression and type 2 DM share a common biological pathway, particularly overactivation of innate immunity leading to a cytokine- mediated inflammatory response, and potentially through dysregulation of the hypothalamic-pituitary-adrenal axis. Over time, these pathways can lead to insulin resistance, cardiovascular disease, depression, increased risk of type 2 DM, and increased mortality. Proinflammatory cytokines are neurotoxic and can cause depressive symptoms.15 There is limited information regarding depression in type 2 DM patients in Malaysia despite extensive evidence of their co- morbidity. In addition, available data mainly focused on prevalence derived from a screening questionnaire, rather than diagnostic interview.16,17 This study aimed to determine the prevalence of MDD using a diagnostic tool and its association with socio-demographic and clinical factors among patients with type 2 DM in a hospital-based primary care clinic.


This was a cross-sectional study of patients diagnosed with type 2 DM who attended the General Outpatient Clinic and Family Clinic, hospital-based primary care clinics at the University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia. The study was conducted from January to June 2011. Informed and written consent was obtained from all participants. This study was approved by the Ethics Committee of UMMC.

Sample size was calculated using OpenEpi; by con- sidering the population size of 10,000, 80% power of study, frequency of outcome was 11% based on Anderson et al,8 and alpha set at 0.05, a sample size of 149 was required. Universal sampling method was used to select patients with type 2 DM who attended the clinic for follow-up of their DM during the study period. Inclusion criteria were patients who had agreed to give informed consent, age ≥ 18 years, and ability to communicate either in Malay or English language. Patients were excluded if they refused to give informed consent, had a physical disability such as being deaf, blind or too ill, and if they were unable to communicate due to factors such as dysphasia or severe dementia. During the recruitment period, patients were identified at the registration counter while they recorded their attendance. Subsequently, their case notes were scrutinised and those eligible for the study were approached to participate. These patients were then interviewed to collect socio-demographic data, their clinical profile, as well as personal and family history of depression.

The patients were interviewed using the Mini- International Neuropsychiatric Interview (MINI) to diagnose MDD. The MINI is a short structured diagnostic interview designed to diagnose DSM-IV and ICD-10 psychiatric disorders (lifetime and current). It is a relatively brief instrument and is fully structured to allow administration by non-specialised interviewers. For most modules, 2 to 4 screening questions are used to exclude the diagnosis when answered negatively. Positive responses to screening questions are explored by further investigation of other diagnostic criteria. The initial study found its inter- rater reliability to be high with kappa coefficient ranging from 0.88 to 1.0 and for MDD, the test-retest reliability was good with kappa of 0.83.18 Other studies have also reported excellent inter-rater and test-retest reliability for the English version of MINI19 and moderate validity of MINI versus Composite International Diagnostic Interview (CIDI)19 and Structured Clinical Interview for DSM-IV-TR Axis 1 Disorders Patients Edition (SCID-P).20 The MINI has been translated into many different languages including Malay. To date, no cross-cultural validity in Malay has been evaluated. Nonetheless, the Japanese version of MINI has shown good validity and reliability.21

Data were analysed using the Statistical Package for the Social Sciences Windows version 17 (SPSS Inc., Chicago [IL], US). The relationship between MDD as a dependent variable and socio-demographic and clinical variables as independent variables was analysed using cross-tabulation analysis. Categorical variables were analysed using Chi-square test and analysis of variance to test for statistical significance of difference. For continuous variables, the data were analysed using either independent sample t test or Mann-Whitney U test based on the result of the normality test. Regression analyses were carried out to study the strength of association between outcome and factors of interest with adjustment for covariates / confounders.


A total of 228 patients were approached to participate in the study and 24 patients failed to participate; 15 patients refused to give consent due to time constraints and 9 patients could not speak and read in the Malay or English language. The remaining 204 patients completed all the questionnaires required for the study.

The mean (± standard deviation) age of the sample was 61.3 ± 10.3 years and most (62.7%) were female. The majority of patients (75.5%) had been diagnosed with type 2 DM when they were aged 40 to 60 years; only 4.9% were diagnosed in the age-group 20 to 30 years. The socio-demographic and clinical profiles of the patients are summarised in Table 1.

Of 204 patients, 32 (15.7%) were diagnosed to have MDD. Univariate analysis of the socio-demographic, clinical, and disease variables revealed 4 variables that were significantly associated with MDD: patient age, age at diagnosis of DM, having secondary education, and having a history of depression (Tables 2 and 3).

Logistic regression analysis showed that 4 factors, including patient age, age at diagnosis of DM, secondary education, and duration of DM were significantly associated with MDD after controlling the confounders (Table 4).


In this study, the prevalence of current MDD determined by MINI was 15.7% (n = 32). The prevalence of depression among the general population in Malaysia was much lower, between 10.7% in 19963 and 11.2% in 2006.2

The prevalence in this study was within the range for uncontrolled studies of between 11% and 19.9%.22 The figure was also comparable with that of 17.9% demonstrated by Nichols et al9 in the large population-based controlled study. Nevertheless, their study relied exclusively on a medical record database rather than face-to-face interviews. It was noted that the prevalence of depression in our study was higher compared with figures reported by Anderson et al8 and Fisher et al23 of 11% and 9.9%, respectively. The plausible reason for this is that both studies used different diagnostic instruments to assess MDD.

The prevalence of MDD in this study was indeed lower compared with 3 other cross-sectional studies across Asia13,24,25 that have identified varying rates of 28%, 19.4% and 23.7%, respectively. These studies used questionnaires based on the DSM-IV criteria such as CIDI and SCID-P. The difference in the prevalence with previous studies could also be due to use of different diagnostic instruments.

In our study, univariate analysis revealed that 4 variables were significantly associated with depression: patient age, age at diagnosis of  DM,  having secondary education, and a history of depression. Multivariate analysis demonstrated that duration of DM was also significantly demonstrated that duration of DM was also significantly associated with MDD.

In this study, the mean age of patients who had MDD was significantly younger (57.8 ± 15.1 years) compared with patients without MDD (62.0 ± 9.0 years). This finding was similar to other studies9,26 that reported depression to be associated with age < 65 years. Nonetheless, other studies have documented conflicting results and advancing age was associated with depression.10,13  We theorise that the elderly are more prone to depression due to the presence of multiple medical illnesses and disabilities.

Depression was also found to be significantly associated with younger age at the time of diagnosis of DM. The mean age at diagnosis of depressed patients was 46.2 ± 13.0 years, while that for non-depressed patients was 51.2 ± 8.8 years. To the best of our knowledge, no such association has been previously documented in Malaysia. We hypothesise that being diagnosed with type 2 DM at a younger age may increase the risk of depression due to perceived negative impact of illness on normal daily life such as work and family as well as perceived threat of DM to general well-being.26

This study also showed that having secondary education was significantly associated with depression and concurs with another study26 among individuals with DM in the US that found a high school education level to be an independent factor of MDD. The supporting evidence proposed that as the number of years of formal education increased, the corresponding odds of having an affective disorder also increased, at the rate of 16% per year of education.27 The same trend was found in another study from Pakistan wherein depression in type 2 DM was associated with having schooling for more than 5 years.16

The only clinical factor to demonstrate a significant association with depression was a history of depression. This finding was consistent with a study that investigated factors associated with MDD during a 5-year follow-up of patients with DM.12 The risk of MDD among diabetics was increased in the presence of a history of depression. A reason proposed by Lustman et al28 was that MDD in DM is usually noted to be a chronic and highly recurrent disorder, whereby 70% of patients with DM and MDD relapse with a mean of approximately 4 episodes over a 5-year period.

Our study revealed an unexpected negative finding that DM complications were not associated with MDD. On the contrary, many studies have affirmed that DM complications are associated with depression.29-34 The plausible explanation for this difference is that the cross- sectional design of this study was unable to demonstrate the association. Moreover, the prevalence of MDD in this study did not reflect the true prevalence due to the non- randomisation sampling method. It is also possible there was poor detection and documentation of DM complications in the case notes as well as recall bias or under-reporting by the patients.


The design of this study was cross-sectional, thus it could not demonstrate a cause-and-effect relationship. The prevalence of MDD from this study did not reflect the true prevalence due to the non-randomisation sampling method. The study sample of 204 patients was relatively small compared with previous studies.7,8,22 This underpowered study led to no association of important clinical features with MDD, whereas other studies with larger sample size demonstrated positive findings and association of DM complications with depression.29,32-34 We also did not include a group of healthy subjects as controls. Finally, other confounding factors such as stressful life events, co-morbid psychiatric illnesses, and level of social support were not controlled.

Conclusions and Recommendations

A prospective study would be a better study design to determine the risk factors for depression in patients with type 2 DM. The future study should include a control group, who are non-diabetic persons matched for age and gender. Finally, in order to enable the findings to be generalised, a multi-centre study would have been better in recruiting samples that are representative of the Malaysian population. It is hoped that the results of this study will help health care providers plan appropriate services for these patients.


We would like to thank all the patients who participated in this study and thus made this study a success. Our appreciation also goes to the staff and doctors in the General Outpatient Clinic and Family Clinic, UMMC for their assistance. Finally, we would like to thank the Head of Department of Primary Care Medicine, Head of Department of Psychological Medicine of UMMC, and Ethics Committee of UMMC for their cooperation and permission to conduct the study.


The authors have no conflicts of interest to declare.


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