Psychosocial contributing factors that affect mental well being in diabetic patients

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Authors: 
Behshid Garrusi, Mohammad Reza Baneshi, Samaneh Moradi
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0106
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Abstract: 
The rate of diabetes as a cause of disease burden has increased over time. Psychological well being could be considered as an important factor in improving of chronic disease management and decrease of mortality and morbidity of disease. Despite, increasing of Diabetes and its burden in Iran, there is a few researches about psychological aspects of treatment. The aim of this study was identifying of psychological contributing factors in determination of psychological well being in Iranian diabetic patients. Methods – This cross-sectional study was done in 350 diabetic patients that hospitalized for diabetes or related problems. The questionnaire`s survey was assessed presence of depression and anxiety (Hospital Anxiety Depression Scale – HADS), family behaviors (Diabetes Specific Family Support – DSFS), quality of life (Iranian Diabetes QOL), self care (Diabetes Self-Care Activities Questionnaire) and mental health (General Health Questionnaire -GHQ). For analysis of data, we used Descriptive statistics, correlation and Two-way Analysis of Variance (ANOVA). P-value less 0.05 was considered to be significant. Results – About 2/3 of participants had depression and anxiety. Anxiety, depression and non supportive behaviors had negative correlation with well being, quality of life and self care. Increasing of anxiety and depression was decreased the well being about 50% and 65%, respectively. Being single would be decrease the mental well being about 2.5 times. Conclusion – The results of recent study support the recommendation to assess psychological well-being in patients with diabetes as one part of diabetes management.
Cite as: 
Garrusi B, Baneshi MR, Moradi S. Psychosocial contributing factors that affect mental well being in diabetic patients. Russian Open Medical Journal 2013; 2: 0106.

Introduction

Diabetes mellitus as a chronic disease that will be affect about 333 million in world by 2005 [1].The prevalence of diabetes   is  estimated about 5.5 – 7.7%, in Iranian Adult Population [2, 3]. Diabetes increase the risk of long-term complications.  The  most important  complications are cardiovascular disease, neuropathy, nephropathy, retinopathy (blindness). Such functional disabilities, treatment costs, dependency to others especially families, could be affect psychological well being in diabetic patients. The American Diabetes Association ‘Standards for Medical Care’ 2006 clearly states that emotional well-being is part of diabetes management, and recommends ‘to incorporate psychological treatment into routine care rather than waiting for identification of a specific problem or deterioration in psychological status’ [4].

Psychological well being have mutual effect in diabetic patients. Impairment in psychological well being is associated with   insufficient glycemic control, lower rate of self control and  increasing of diabetic complications [5]. On the other hand, the worsening of diabetes complications could be due to lower quality of life, depression and anxiety [6]. It is not surprising that association of psychological disorders and diabetes could be result to more severe of both complications such as higher work disabilities, insufficient treatment and lower regime or activity adherence [7].

Researchers are argue that psychosocial factors are the most important factors that could be intervene in well being of diabetic patients [8, 9].

Psychological well being is affected by many of psychiatric  problems. Depression and anxiety have been associated with chronic disease such as diabetes. Anxiety and depression are  common emotion in reaction to stressful  issues, such as family and social problems. Moreover, some of factors such as illness  may trigger anxiety. Symptoms of depression and anxiety may be fluctuating [5]. Depression and anxiety is associated with severe reduction of person`s function and disease comorbidities [10].

One of the psychosocial factors that may be consider in diabetic  patients`  ell being is  supportive environment  that  could be result to better metabolic management, therapeutic adherence and  better quality of life [11, 12]. One  important aspect of  social   support is family support. Management of diabetes or its complication requires to change of lifestyles. These changing in lifestyles will be need helping from others especially near relatives. Some of researches are argue that not of all social or family supports may be useful [13].

Despite  the number of studies regarding  diabetes in Iran,  considering to  psychological aspects and related matters  in these studies are low. Therefore, we decide to explore some if these factors in Iranian populations. Understanding these factors can help to better therapeutic approach and management of diabetes.

 

Material and Methods

This cross-sectional  study was done in  Kerman, the center of largest provinces in Iran as a doctorate thesis. The study was confirmed by the Ethics Committee at Kerman University of Medical Sciences.

 

Participants

Participants were included all of diabetic patients that hospitalized for diabetes or related problems from  March to June 2012. Inclusion criteria were following:

i)      age >18 years,

ii)     hospitalization for diabetes type 2  and 3- desire for participation.

About 350 patients were participated in this study. Anonymous questionnaire was completed by the respondents after informed consent.

 

Questionnaire

This questionnaire were included below parts:

1 – Demographic  variables such as gender, age, marital status (single, married, widowed), education (illiterate –elementary, high school, university), occupational status (unemployed, employed, housewife), economic status (fair-medium, good or excellent) and therapeutic agent (oral agents, insulin, both).

2 – Hospital Anxiety Depression Scale (HADS).

This instrument  was developed by Zigmond and Snaith in 1983.  HADS has been developed for detection of depression and anxiety in hospitalized patients, but that would be suitable for  using  in the general population. Psychometric properties of   this questionnaire in Persian was  assessed that  was acceptable.  This scale have 14 items (7 items for each subscales) on a 4-point Likert scale (range 0–3), the total score is ranging from 0 to 21 [14]. HADS score was divided to three categories (for both depression and anxiety): 0-7 is normal, 8-11 is borderline,  and >11 represents clinical subjects.

3 – Diabetes Specific Family Support (DSFS).

This  self reported likert type questionnaire was developed in 1986 by Schafer, that include 16 items, 9 items for positive or supportive  behaviors  and 7 items for negative or non supportive behaviors. This questionnaire is scored  from   1 (none) to 5 (a lot of), the total score is ranging from 16 to 80. Psychometric properties of this questionnaire in Persian was acceptable [15].

4 – Quality of life (Iranian Diabetes QOL).

 In this  questionnaire there  are  41 items  regarding general ad specific aspects of quality of life. There were 13 items for assessing general QOL. The possible score was 40–160, higher scores indicating better QOL.  This questionnaire had  acceptable  reliability and validity [16].

5 – Summary of Diabetes Self-Care Activities (SDSCA) Questionnaire.

The questions ask about diabetes self-care activities during the past 7 days. The SDSCA is a 25-item self-report measure of the frequency of performing diabetes self-care tasks over the preceding 7 days. This measure served as another index of patient self-care, to examine concurrent validity. Areas assessed include diet, exercise, glucose monitoring, medication taking, foot care, and smoking. Inter-item correlations ranged from r=0.20 to r=0.76 for four SDSCA subscales; 6-month test-retest reliability ranged from r=0.00 to r=0.58 across three studies [17].

6 – General Health Questionnaire (GHQ-12).

 This is a screening instrument to detect psychiatric disorders in community settings and non-psychiatric clinical settings, such as primary care or general practice. This instrument was developed by  Goldberg. Iranian version of the GHQ-12 has a good structural characteristic and is a reliable and valid instrument that can be used for measuring psychological well being in Iran [18].

 

Statistical analysis

Descriptive statistics were used to summarize the data, presentation of mean was mean (±SD). The correlation between  various variables was assessed by the Pearson correlation, Two-way Analysis of Variance (ANOVA) and last, linear regression analysis was performed to identify factors that influence mental health in a multi-factorial setting. All analyses were done using SPSS software. A P-value <0.05 was considered to be significant.

 

Results

About 72% of 351 participants  were female. The mean age of subjects was 48.5(±17.2) years. Demographic characteristics of participants were shown in Table 1.

 

Table 1. Demographic characteristics of participants

Variables

N (351)

%

Gender

·  Female

·  Male

 

253

98

 

72.1

27.9

Marital status

·  Married

·  Widowed

·  Single

 

291

42

18

 

82.9

12.0

5.1

Work status

·  Employee

·  Unemployed

·  Housewife

 

48

103

200

 

13.6

29.3

56.9

Economic status

·  Fair

·  Medium

·  Good or Excellent

 

101

210

40

 

28.8

59.8

11.4

Living  in

·  Big cities

·  Village

 

206

145

 

58.7

41.3

Kinds of treatment

·  Oral agent

·  Insulin

·  Both

·  No treatment

 

101

165

60

26

 

28.8

47.0

17.1

7.4

 

The mean score of variables and classification of psychiatric co-morbidities were shown in Table 2.

 

Table 2. The mean score of Variables and Classification of psychiatric co-morbidities

Variables

Mean

SD

Depression

9.48

2.55

Anxiety

9.39

4.53

Family behaviors

·  Supportive behaviors

·  Non-Supportive behaviors

 

28.14

11.86

 

8.08

4.98

Quality of life

56.88

1.61

Self control

25.06

13.29

 

Classification of psychiatric co-morbidities

N

%

Anxiety

·  Normal

·  Borderline

·  Clinical

 

129

95

125

 

36.9

27.1

35.7

Depression

·  Normal

·  Borderline

·  Clinical

 

69

168

111

 

19.7

48.0

31.7

 

The mean score of depression and anxiety  were 9.5(±2.6)     and 9.4(±4.5), respectively. The mean score of GHQ was 15.0(±7.7). Mean of supportive behaviors in family {28.1(±8.1)} was greater than non-supportive family behaviors {11.9(±5.0)}. Except the score of Anxiety, there was no differences between other factors in both gender (anxiety score in male and was  8.6(±4.3) and 9.8(±4.5), respectively, P=0.02). The mean score of some of predictive factors based on gender were shown in Table 3.

 

Table 3. The mean score of Variables based on gender

Variables

Gender

Mean

SD

P value

Mental Health

(GHQ)

Female

15.07

7.06

NS

Male

13.95

6.41

Quality of life

Female

60.94

14.69

NS

Male

60.61

13.17

Anxiety

Female

9.79

4.51

0.025

Male

8.60

4.29

Depression

Female

9.59

2.59

NS

Male

9.74

2.38

Family Behaviors

Supportive behaviors

Female

28.49

7.52

NS

Male

30.15

18.17

Non Supportive behaviors

Female

12.03

5.00

NS

Male

11.97

4.98

 

About 67% and 79% of diabetic patients had anxiety and depression, ordinary.

Table 4 is shown the differences of mean score of psychological variable based on marital status. The values of mental health, quality of life and non-supportive family behaviors were significantly different in various marital status.

 

Table 4. The mean score of Variables based on marital status

Variables

Marital status

Mean

SD

P value

Mental Health

(GHQ)

Single

11.83

5.90

0.008

Married

14.56

6.87

Widowed

17.40

6.80

Quality of life

Single

60.37

14.41

0.004

Married

59.88

1`3.89

Widowed

67.75

15.15

Anxiety

Single

8.11

4.01

NS

Married

9.32

4.47

Widowed

10.92

4.46

Depression

Single

9.50

3.12

NS

Married

9.75

2.54

Widowed

10.90

2.13

Family Behaviors

Supportive behaviors

Single

26.38

8.35

NS

Married

29.24

7.76

Widowed

28.04

7.08

Non Supportive behaviors

Single

11.33

3.91

0.002

Married

11.70

4.87

Widowed

14.50

5.67

 

There was negative correlation between anxiety ,depression  and non supportive family behaviors with mental health, quality of life and self care. Supportive family behaviors had negative  correlation with  depression and anxiety. The negative correlation was between non supportive behaviors and depression and anxiety (Table 5).

 

Table 5. Correlation between psychosocial variables

 

Mental Health

Quality of life

Self care

Anxiety

Depression

Supportive family behaviors

Non-supportive family behaviors

Mental Health

1

 

 

 

 

 

 

Quality of life

0.460**

1

 

 

 

 

 

Self care

0.113*

0.011

1

 

 

 

 

Anxiety

-0.51**

-0.450**

-0.027

1

 

 

 

Depression

-0.476**

-0.377**

-0.089

0.422**

1

 

 

Supportive family behaviors

0.137

0.430

0.184**

-0.022

-0.064

1

 

Non-supportive family behaviors

-0.233**

-0.254**

-0.005

0.106

0.026

-0.025

1

*P>0.05,** P>0.01
 
We used a multi factorial linear regression model to explore variables that influence mental health after adjusting for other variables. Results are given in Table 6. Anxiety, depression, family behaviors, education and marital status, were independently able to predict  mental health. Marital status was significance, being single could be increase the chance of poor mental health about 2.5 times.
 
Table 6. Regression analysis of factors that influence mental well being in diabetic patients

 

Beta

SD

P value

Anxiety

-0.530

0.075

>0.01

Depression

-0.657

0.126

>0.01

Supportive family behaviors

0.118

0.036

>0.01

Non-supportive family behaviors

-0.219

0.058

>0.01

Marital status

-2.559

1.220

>0.05

 

Discussion

The aim of medical care in chronic disease such as diabetes is not only   physical treatment, but also to ameliorate of quality of life and decrease of mental health consequences. Some of researches were focused on gender differences in health consequences of disease. These researches, often reported lower quality of life and mental health in females [19]. This health consequences were in different age groups [20]. Despite of previous results, in recent study, there was no gender differences in mental health status. Except of  biological factors that could be result to gender differences in reaction to disease, this difference was probably due to the effects of social factors [12].

The result of this study showed  that self care in diabetes was affected negatively by depression and anxiety. Despite, prevalence of depression and anxiety in both gender is different for example women have twice the risk for most anxiety disorders as men [10, 20], but in this study among psychosocial variables, only anxiety is higher in women than men. In traditional Iranian families, the men are breadwinner and other family responsibilities such as child rearing  and housekeeping duties, are expected from women.  Constraints arising from diabetes such as specific regimen, taking  medication, regular blood control and complication of disease could be induce higher stress in women.

Also, depression in diabetic patients are present about twice of general population [21]. Association between depression and diabetes could be affect the course of disease, health consequences, quality of life and even mortality [21].  Regression  results showed both anxiety and depression will be increase  chance of poor mental health.

 

Another  factors that could be affect the mental health was supportive behaviors from family. Some of behaviors from relatives or family could be harmful or negative. Cole found that negative  family interactions may be induce  lower daily self care and therapeutic  compliance in diabetic patients [22]. Lake of  family support  or negative family support   such as  nagging about disease or treatment could be associate with poor glucose control [23]. Emotional well being and decrease of psychiatric co morbidities such as depression or anxiety would be decrease patients` distress, strain and increase of owns confidence. Self confidence could be resulting to better self care, quality of life and relation of family. Family behaviors such as communication, life styles and dynamic of family interaction could be influence of health out come such as depression, anxiety and perception of quality of life [22, 24].

As above mentioned, social network will be decrease adverse health consequences of chronic disease [22]. Marriage and marital life are considered  as one of  important  social  network. Some of researches are argue that more prolonged survival times and better health outcomes are associated with marriage [25]. Some of studies are focused on marital satisfaction  as a predictor of   poor metabolic control and elation of HbA1c [24]. In Iran, family is considered the most important and basic social group, therefore the role of family must be intentioned  seriously. Except marriage, other demographic variables even duration of disease had no effect on well being.

The results of this study  were consistent with findings  regarding of  researches that focused on relation between good socio-emotional support  and  improving of mental health well-being.

 

Limitations

For assessment  of psychosocial  predictive factors in chronic disease, studying the micro-cultures of a society may enhance our understanding of the social attitude towards disease, management and consequences.

 

Conclusion

Despite, mutual effects of mental well being and diabetes, attention to family dynamic and psychiatric co-morbidities especially anxiety and depression must be seriously considered. For  obtaining of better results, it is expected, psychosocial factors are mentioned in diabetes management programs.

 

Acknowledgment

This research was financially supported by Neurosciences Research Center of Kerman University Medical Sciences  as  doctorate thesis. The authors sincerely thank  Dr. Toobert and Dr. Alavi for giving us the opportunity of using  questionnaires and their cooperation. Also we thank Dr. Neuzar Nakhaee for his guidance and cooperation.

 

Conflict of interest: none declared.

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About the Authors: 

Behshid Garrusi – MD, Associate Professor of psychiatry, Neuroscience research center, Kerman University of Medical Sciences, Kerman, Iran;

Mohammad Reza Baneshi – PhD, Assistant Professor of Statistics, Research Center for Modeling in Health, Institute of Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran;

Samaneh Moradi – MD, Student Research Center, Kerman University of  Medical Sciences, Kerman, Iran.

© 2012, Garrusi B., Baneshi M.R., Moradi S.
© 2012, Russian Open Medical Journal

Received 19 November 2012, Revised 5 December 2012, Accepted 25 December 2012.

Correspondence to Dr. Behshid Garrusi. Tel: +98-341-3224613. Fax: +98-341-3221671. E-mail #1: bgarrusi@kmu.ac.ir. E-mail #2: behshidgarrusi@gmail.com.

DOI: 
10.15275/rusomj.2013.0106

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