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Table of Contents
SYSTEMATIC REVIEW
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 99-108

Glycemic control among patients with diabetes and comorbid depression in gulf countries: A systematic review


1 WHO Collaborating Centre for Public Health Education and Training, Department of Primary Care and Public Health, Imperial College London, London, UK; Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 WHO Collaborating Centre for Public Health Education and Training, Department of Primary Care and Public Health, Imperial College London, London, UK; Department of Family and Community Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
3 WHO Collaborating Centre for Public Health Education and Training, Department of Primary Care and Public Health, Imperial College London, London, UK

Date of Submission05-Nov-2020
Date of Decision30-Dec-2020
Date of Acceptance05-Jan-2021
Date of Web Publication13-Apr-2021

Correspondence Address:
Saad Mohammad Alsaad
Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsm.jnsm_139_20

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  Abstract 


Background: People with diabetes suffering from depression are at greater risk of suffering from an episode of diabetic burnout which can have adverse outcomes on their health. Objectives: The primary objective is to review the relationship between depression and glycemic control among patients with diabetes in the Gulf Cooperation Council (GCC) countries. Methods: MEDLINE, EMBASE, PsychINFO, and GLOBAL HEALTH databases were systematically searched without language restriction to identify relevant studies that examined the relationship between glycemic control and depression among patients with diabetes in (GCC) countries. Reference lists and Google Scholar were also searched for additional studies. Research was conducted by two reviewers independently and disagreements were resolved by discussion. Results: Our search revealed nine studies were published between 2004 and 2018 and a total of 2199 subjects with diabetes. Majority of the participants were diagnosed with type 2 diabetes mellitus (DM). Out of the 9 articles included in the synthesis, only five of them have reported a significant association between depression and glycemic control; on the other hand, four articles showed nonsignificant association. The prevalence rates of depression among diabetic patients ranged from 12.5% to 61.8%. Conclusion: Depression was associated with poorly controlled HbA1c. However, this association was not significant across all studies. Considering the high rates of DM in these countries, better quality studies are needed to assess the depression comorbidity and its impact on glycemic control for better cost-effective treatments and to inform practice.

Keywords: Depression, diabetes mellitus, glycosylated hemoglobin, Gulf Cooperation Council


How to cite this article:
Alsaad SM, Binmoammar TA, Hassounah S, Mokdad AH, Rawaf S. Glycemic control among patients with diabetes and comorbid depression in gulf countries: A systematic review. J Nat Sci Med 2021;4:99-108

How to cite this URL:
Alsaad SM, Binmoammar TA, Hassounah S, Mokdad AH, Rawaf S. Glycemic control among patients with diabetes and comorbid depression in gulf countries: A systematic review. J Nat Sci Med [serial online] 2021 [cited 2021 Jul 30];4:99-108. Available from: https://www.jnsmonline.org/text.asp?2021/4/2/99/313643




  Introduction Top


The Gulf Cooperation Council (GCC), also known as the Cooperative Council for the Arab States of the Gulf, is a political and economic union consisting of the following six countries: Bahrain, Kingdom of Saudi Arabia (KSA), Kuwait, Qatar, the United Arab Emirates (UAE), and Oman. With a population of around 52 million, the GCC countries have witnessed socioeconomic changes in the last decades.[1] This has brought with it changes in lifestyles and accelerated growth in the pattern of non-communicable diseases, in particular, diabetes mellitus (DM).[2],[3],[4] One in 10 people living in the Middle East and North Africa region have diabetes: this number is expected to double in the next two decades.[5] According to the International Diabetes Foundation, in 2014, diabetes prevalence was 21.9% in Bahrain, 23.1% in Kuwait, 14.5% in Oman, 19.8% in Qatar, 23.9% in Saudi Arabia, and 19.0% in the UAE.[5]

Diabetes, as a chronic illness, needs continuous medical care, adherence to treatment, education, and patient self-management to avoid acute complications and to decrease the risk of long-term complications. In addition, chronic medical problems have been shown to increase the prevalence of depression.[6] Diabetes, in particular, was found to double the odds of comorbid depression in a meta-analysis that included 39 studies.[7] Studies also showed that adults with diabetes and comorbid depression may have poor glycemic control, increased complications, higher rates in health-care utilization and cost, shortened quality of life, and greater mortality rates.[8],[9],[10],[11],[12],[13],[14],[15] Furthermore, research has yielded increasing evidence that depression is a modifiable risk factor, the treatment of which can enhance glycemic control and health outcomes, making efforts to identify and treat depression in patients with diabetes priority.[9],[13],[16] In the GCC countries, a large number of cases go underdiagnosed in primary care clinics where the majority of patients with diabetes receive care.[17]

Depression has been associated with poor glycemic control in both types I and II diabetes.[15] Recent comprehensive reviews on the existing evidence have explored the nature of this relationship in both types of diabetes; there was contradictory evidence whether or not depression is associated with poor glycemic control in case of type 2 DM, but this relationship seems to be convincing in case of type 1 DM.[18],[19] The relationship between depression and glycemic control is an important area of research. As such, the present study aimed primarily to review the relationship between depression and glycemic control among patients with diabetes in GCC countries. Secondary objectives include: the prevalence of depression among diabetic patients in the included studies and the relationship between depression and duration of diabetes or diabetes complications. By systematically mapping the evidence from GCC countries, we were able to identify key publications which could both inform practice and identify gaps in the existing research.


  Methods Top


Search strategy and study selection

The electronic online databases, Ovid Medline from 1946, Embase Classic + Embase from 1947, Global health from 1973 and PsychINFO from 1967, were searched for relevant studies in February 2018 without language restriction using the following medical subject headings (MESH) and keywords: (Diabetes or diabetes mellitus or glycemic control or glycemic level) AND (Depression or depressive disorder). This was combined with (gulf cooperation council or GCC or Saudi Arabia or KSA or kingdom of Saudi Arabia or Bahrain or kingdom of Bahrain or Qatar or UAE or the United Arab Emirates or Oman or Kuwait). Reference lists of included studies were screened and a Google scholar search was also carried out to identify any additional relevant studies.

Inclusion criteria

We considered observational study designs in any clinical settings (primary health-care clinics, secondary or tertiary care hospitals). Studies were selected if they included participants with DM (Type 1 or Type 2) and were screened for depressive symptoms using validated measurement tools such as Beck Depression Inventory Scale (BDI-II), Hospital Anxiety and Depression Scale (HADS) scale or Patient Health Questionnaire (PHQ-9) and assessed glycemic control as an outcome (determined by HbA1c).

Exclusion criteria

Studies were excluded if they did not provide sufficient information on depression levels and HbA1c levels, included participants with gestational diabetes, postpartum depression; or if they included participants <15 years of age. Two reviewers (SA and SH) performed the search and reviewed the results. EndNote X7 (Thomson Reuters) was used to organize articles and remove any duplicate studies during the initial screen for titles and abstracts. Studies that did not meet the inclusion criteria were removed. Independently, the two reviewers assessed all relevant studies and any disagreement were resolved by discussion.

Quality assessment

Two reviewers (SA and TB) independently assessed the quality of the included studies. Full critical appraisal was performed for each study, using the Newcastle-Ottawa Scale (NOS) adapted for cross-sectional studies.[20] Items reviewed included (1) representativeness of the sample; (2) sample size; (3) response rate; (4) validity of measurement tool, if validated and if non-validated; (5) study controls for the most important factor and additional factors; (6) assessment of the outcome; and (7) statistical test used. Any discrepancies in the quality assessments were resolved by a third reviewer (SH). After the data extraction form was developed, two reviewers (SA and TB) independently extracted the data from included studies, including the primary outcome (the relation between depression and glycemic control) and the secondary outcomes (the prevalence of depression and diabetes comorbidity; and the relationship between depression and diabetes duration/complications). We used P values to identify the magnitude of the effect.


  Results Top


The systematic literature review yielded 118 articles and 5 additional articles were retrieved from reference lists and Google scholar [Figure 1]. After excluding 32 duplicates records, two reviewers (SA and SH) independently screened 91 articles by title and abstract to identify relevant studies. A total of 22 articles were then examined by full-text assessment for eligibility, 13 of which were removed for the following reasons: 3 studies we could not retrieve the full texts for assessment because two are conference abstracts and one was an abstract of a master thesi;[21],[22],[23] 5 articles did not provide sufficient information on the relationship between depression and glycemic control;[24],[25],[26],[27],[28] 2 articles used fasting blood sugar (FBS), not HbA1c, to measure the glycemic control;[29],[30] 1 article looked at the prevalence of diabetes and depression comorbidity without further analyzing the association between depression and glycemic control;[31] and finally, 2 articles from Kuwait were removed because they had a research population under the age of 15.[32],[33] This resulted in 9 articles[34],[35],[36],[37],[38],[39],[40],[41],[42] included for analysis, with quality assessment results ranging from 5 to 9 out of 10 using the NOS.
Figure 1: PRISMA flow diagram of study search and selection

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Six of the included studies were conducted in KSA, two in UAE and one in Bahrain [Table 1]. All studies had a cross-sectional design and took place in an outpatient setting, except for one which was based in a hospital.[38] Articles were published between 2004 and 2016, with a total sample size of 2199 subjects with diabetes. Patients' age ranged from 15 to 90 years old. In general, the percentage of female participants was higher than male participants and the proportion of patients with Type 2 diabetes was also higher than those with type 1 diabetes. In fact, three articles included only patients with Type 2 DM.[35],[38],[41] Five different tools were used to screen for depression: Four studies used self-report BDI-II;[34],[39],[40],[42] Two studies used the PHQ-9;[35],[37] one study used the HADS;[38] one study used the (K6) scale;[41] and the last study interviewed the patients using PHQ-2.[36] The identification of poor glycemic control with HbA1c measurements also varied across the studies. For example, in Mirghani and Elbadawi Al Muzien and Al-Sowielem and Al-Ghamdi studies, patients were identified as having poor glycemic control if HbA1c >8%.[34],[37],[39] In the Hawamdeh et al. study[40] poor glycemic control was set at HbA1c >7.5% and in the Al-Baik et al., Al-Hayek et al. and Nasser et al. studies[36],[38],[42] poor glycemic control was set at HbA1c ≥7%. Five studies did not describe the response rate[34],[38],[39],[40],[42] and Five studies did not provide sufficient information to analyze the association between depression and duration of diabetes.[34],[35],[38],[40],[41] Similarly, five studies did not discuss the relationship between depression and diabetes complications.[34],[35],[36],[38],[40] The highest score of quality assessment was 9 points and the lowest score was 5 points, which demonstrates disparity in terms of quality of the included studies.
Table 1: Description of included studies

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Primary outcome

Relationship between depression and glycemic control

The results of the studies on the relationship between depression and poor glycemic control varied and they are summarized in [Table 2].
Table 2: Description of primary and secondary findings.

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In the Al-Ghamdi study, depressed patients with diabetes were found to have poorer HbA1c (10.4 ± 2.1%) as compared to non-depressed patients with diabetes where HbA1c was (9.2 ± 2.1%), with a significant difference between the two groups (P = 0.04).[39] Similarly, in the Badedi et al. and Al-Muzien and Al-Sowielem studies the level of blood sugar was higher in depressed patients with diabetes than non-depressed patients with diabetes and a significant difference was found (P > 0.001 and P = 0.021; respectively).[35],[37]

However, in the Al-Hayek et al. study, where only patients with Type 2 DM were included, 70.7% of the population had poor control HbA1c and the level of depression was higher among patients with poorly controlled diabetes as compared to well controlled (P = 0.0002).[38] Similar results found in the study by Hawamdeh et al. in the outpatient clinic across six emirates in UAE allowed good comparison between both groups as half of the participants with diabetes (92, 50.5%) and the other half of patients without diabetes (90, 49.5%). The study revealed a highly statistically significant relationship between depression level and diabetes status (P < 0.001).[40] The study also identified a positive relationship between poor glycemic control and higher levels of depression (P = 0.042). At least, half of the subjects with diabetes (n = 47, 51.1%) showed poor glycemic control.[40]

Another study from UAE done by Sulaiman et al., among 347 patients with type 2 DM, showed that the level of depression score was higher in those with poorer HbA1c level as compared to those with better HbA1c level, but it was not statistically significant (P = 0.07).[41] A similar study in four primary health-care (PHC) centers randomly selected in Bahrain by Nasser et al. revealed a higher percentage of depressive symptoms among people with uncontrolled HbA1c compared to controlled diabetes, but it also was not statistically significant (P = 0.810).[42]

Finally, a recently published article in 2016 by Mirghani and Elbadawi in Saudi Arabia, showed no statistically significant difference between depressed subjects with acceptable diabetes control versus poor control (P = 0.293).[34] A similar finding was published before by Al-Baik et al. in 2014 (P = 0 0.656) between the level of HbA1c control and depression symptoms score.[36]

Secondary outcomes

The prevalence of depression among diabetic patients

The percentage of the prevalence of depression among diabetic patients as evidence by the included studies from Gulf countries was as shown in [Table 2].

Studies from Saudi Arabia

Al-Hayek et al. study did not mention the prevalence.[38] Highest depression prevalence rate was reported by Mirghani and Elbadawi (61.8%) among subjects with diabetes versus (30%) of controls with highly significant difference (<0.001).[34] In the Al-Ghamdi study, depression in patients with diabetes was 34% versus 13% in subjects without diabetes (P < 0.001).[39] In the Al-Muzien and Al-Sowielem study, prevalence was 14.5%, and in the Al-Baik study, 45.8% of the patients with diabetes screened positive for depression.[36],[37]

Studies from UAE

In the Hawamdeh et al.'s study, the prevalence of mild/borderline to moderate depression among patients with diabetes was (60.6%), whereas (16.3%) showed severe or extreme depression.[40] In the Sulaiman et al.'s study, the prevalence was 12.5%.[41]

Studies from Bahrain

Only one study in this systematic review was found to be conducted in Bahrain, which showed that 33.3% of the participants had depression and diabetes comorbidity.[42]

The relationship between depression and diabetes duration

The relationship between depression and duration of diabetes was examined by four studies. In the Al-Ghamdi study, depressed patients with diabetes were found to have a longer duration of diabetes, which was 10.8 years (±7.9) compared to 8.6 years (±6.7) in non-depressed patients with diabetes (P = 0.03).[39] Another study, Al-Baik et al., found a significant association with long-standing diabetes (P = 0.035) among patients screened positive for depression symptoms.[36] However, the duration of diabetes had no significant association with depression in the Al-Muzien and Al-Sowielem study, where the mean duration of diagnosis of DM was 7.54 years (± 6.12).[37] Similarly, no statistically significant association was found in the Nasser et al. study.[42]

The relationship between depression and diabetes complications

The relationship between depression and diabetes complications can be analyzed by looking into microvascular diabetes complications (neuropathy, retinopathy, and nephropathy) and macrovascular diabetes complications.

Microvascular complications

A positive relationship between depression and retinopathy was demonstrated in the Al-Ghamdi study (P = 0.007) and in the Sulaiman et al.

Study (P < 0.034).[39],[41] A positive correlation was also found between depression and neuropathy in the Al-Muzien and Al-Sowielem study (P < 0.001) and in the Sulaiman et al.'s study (P < 0.005).[37],[41] The Nasser et al.'s study showed a statistically significant difference in rates of nephropathy between depressed and non-depressed patients with diabetes (P = 0.011).[42]

Macrovascular complications

Macrovascular complications were found to be significantly associated with depression in the Al-Ghamdi study (P = 0.004).[39] Similar results were also found by the Nasser et al.'s study in relation to ischemic heart disease (IHD) in depressed patients with diabetes compared to non-depressed patients with diabetes (P = 0.46).[42]


  Discussion Top


There is a growing body of research on the comorbidity of depression and DM as well as the effect of depression on glycemic control. In this study, we aimed to review the literature published from GCC countries about the relationship of depression on glycemic control. It is worth mentioning that most of the included articles were published in the last few years, which denoted a growing interest in the subject matter. There were a small number of studies retrieved originating from GCC countries of variable quality according to the NOS scale. This, in fact, reflects the paucity of good quality literature examining the effect of depression on glycemic control among patients with type 1 or type 2 DM in the GCC. In addition, the retrieved studies had relatively small sample sizes compared to other studies with similar methodologies conducted in other parts of the world.[19]

In general, the results should be viewed with caution as the assessment tools and cut-off points varied across the included studies [Table 1]. Six studies used self-report instruments (BDI-II, PHQ-9) to assess the severity of recent depression symptoms, while three articles interviewed patients using a non-specific screening tool (K6, PHQ-2, and HADS). In some studies, threshold scores on these instruments (e.g., BDI or PHQ-9) were also used to categorize depression severity (mild, moderate, and severe). Other studies used instruments to screen for depression status (present or absent) and patients were then referred to psychiatry for further assessment. Even though it has been found that major as well as minor depression have adverse effects on quality of life and social and physical functions in patients with chronic diseases.[43],[44],[45] Another noticeable finding was that majority of the subjects in the included studies were patients diagnosed with type 2 diabetes. This may be because we excluded studies with a population under the age of fifteen, whom are mainly affected by type 1 DM.

Depression and poor glycemic control

HbA1c was used as a marker of the glycemic control outcome, which is recommended as the best measure of recent glycemic control and is used to guide clinical management. Two studies[27],[28] were excluded as they used FBS to define the control level. The present review indicates that those who are depressed have a higher HbA1c level, i.e., with hyperglycemia. This finding is similar to previously published reviews.[15],[46],[47] In our review, majority of patients enrolled in the included studies had uncontrolled HbA1c (77.5% in Al-Ghamdi study, 70.7 % in Al-Hayek et al study, 51% in Hawamdeh et al study, 85.5% in Nasser et al study, 71% in Al-Baik et al study) which can explain the higher level of depression we found. However, only five studies[35],[37],[38],[39],[40] showed positive significant association between HbA1c and depression. This variation of results regarding the nature of the relationship between glycemic control and depression has been explained by longitudinal research to help identify the independent effect of depression on diabetes outcome, including glycosylated hemoglobin (HbA1c). Two longitudinal studies demonstrated a high glucose level among people with diabetes and comorbid depression.[46],[48] In contrast, other longitudinal studies have found non-significant association between glycemic control and depression.[49],[50],[51]

Prevalence of depression

The prevalence of depression among patients with diabetes ranged from 12.5% to 61.8% [Table 2]. The Sulaiman et al.'s study demonstrated the lowest prevalence, and the highest rate was reported by the Mirghani and Elbadawi study. This variation in the reported prevalence may be explained by methodological differences such as: inclusion criteria, self-reported depressive symptoms versus interviewing patients, and diabetes complication.[52] It should be noted that the present study does not reflect the prevalence of depression comorbidity among patients with diabetes in GCC countries as the primary objective of the review was to assess the relationship between depression and glycemic control and studies looking only at the prevalence were excluded. These rates of prevalence should also be viewed with caution as they do not adjust for potential confounders in most of the included studies.

In a controlled study by Al-Ghamdi A, a significant difference was found in the prevalence of depression among patients with diabetes (34%) as compared to patients without diabetes (13%) (P < 0.001), which supports the high prevalence of depression among patients with diabetes.[19],[53] Similarly, in another controlled study by Hawamdeh et al., statistical analysis revealed that a highly statistically significant relationship exists between depression level and diabetes status (P < 0.001). This correlates with previous findings that chronic diseases, including DM, doubles the odds of comorbid depression.[7] It is not clear, however, whether prevalence rates differ according to the type of diabetes and more research should be conducted on this matter.

Depression and duration of diabetes

In contrast to glycemic control, there is a paucity in the evidence regarding the duration of diabetes and its relation to the development of depression. In this review, 4 articles studied the relationship between depression and the duration of diabetes. In the Al-Ghamdi study, longer duration of diabetes was found in depressed groups as compared to non-depressed groups. A similar significant finding was demonstrated in other published studies from different countries, where the mean duration of diabetes was higher in depressed patients with diabetes as compared to non-depressed patients with diabetes. However, these associations became non-significant after adjustment for clinical characteristics.[50],[54]

The length of diabetes in the Al-Muzien et al. and Nasser et al. studies, had no significant association with depression. This finding has been illustrated in a cohort study that assessed the factors associated with major depression among patients with diabetes.[55] Although the research on diabetes and depression comorbidity is expanding, the duration of diabetes per se and its relation to depression needs further evidence to explore the significant effect.

Depression and diabetes complications

A large meta-analysis has reviewed the association between depression and (micro and macro) diabetes complications. The result of that meta-analysis reported a consistent, statistically significant relationship between depression and diabetes complications, including both micro and macro vascular.[8] In the present review, four articles have assessed the relationship between depression and diabetes complications. Retinopathy was significantly associated with depression in the Al-Ghamdi study and the Sulaiman et al. study, while neuropathy had a positive correlation with depression in the Al-Muzien et al. and the Sulaiman et al. studies. Only one study showed significant association between depression and nephropathy (Nasser et al.). In terms of macrovascular complications, a significant association was found in the Al-Ghamdi study and the Nasser et al. study. However, the assessment of complications in some of the included studies was done by self-reporting rather than from medical records, which may not be entirely reliable.

Theoretically, a bidirectional relationship can exist between depression and diabetes complications. On one hand, depression, which influence the glycemic control, may increase the likelihood of diabetes complications, an example of this relationship can be seen in the Al-Ghamdi and the Al-Muzien et al. studies, depression was found to be associated with uncontrolled HbA1c, while at the same time, there was a positive association between depression and diabetes complications. On the other hand, severe diabetes complications may play a role in the development of depression.

Limitations

Our review excludes population <15 years old, which can be avoided in future literature reviews as this may help understand in depth the relationship between depression and poorly controlled type 1 diabetes. We found that the prevalence of depression among diabetic patients was between 12.5% and 61.8% and this should be interpreted with caution. Because our primary objective was to review the relationship between depression and glycemic control measured by HbA1c; as a result, we excluded studies that did not report the effect on glycemic control and focused only on the prevalence of depression. One last thing worth to mention is not all included articles were of good quality, so this should be considered when interpreting the results of our review.


  Conclusion Top


The present study is aimed primarily to review the relationship between depression and glycemic control among diabetic patients in the GCC area. Taking in consideration, the high prevalence rates of DM in these countries our review found that depression was associated with poor glycemic control and this conclusion necessitate the early recognition of depressive symptoms. Because effective treatment of depression can help to improve compliance, glycemic control, and decrease risk of diabetes complications. Future studies from these countries should consider cohort design studies to explore the longitudinal relationship between depression and glycemic control.

Acknowledgements

The Department of Primary Care and Public Health at Imperial College London is grateful for support from the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Scheme, the NIHR Biomedical Research Centre scheme, and the Imperial Centre for Patient Safety and Service Quality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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