Health Related Quality of Life, Depression and Anxiety among People with

Type 2 Diabetes Mellitus in Bangladesh.

Abstract

Background

Mental health conditions are well documented to be associated with type 2 diabetes mellitus.

However, this has not been addressed adequately in Bangladesh. This study aims to explore the

association of health related quality of life, anxiety and depression with the various demographics and

clinical characteristics among people with type 2 diabetes.

Methods

A cross-sectional study was conducted in Bangladesh in 2017. A total of 1253 patients were recruited

from six diabetic hospitals located in the rural and urban areas. Depression, anxiety and health related

quality of life were measured using the GAD-2, PHQ-2 and the EQ-5D-5L scale respectively with

predefined cut-off points. The EQ-5D-5L were then transformed to a score which is expected to lie

between 0 and 1, where a higher score represents a better health. Information was collected using

face-to-face interviews and patients’ medical records. Univariate and multivariable regression

analyses with bootstrapping method were used to analyse the data.

Results

The average health related quality of life was 0.642 (±0.20) and the prevalence of depression and

anxiety were 37.35% and 10.38% respectively. Older age, low income, low education level, residing

in urban area, longer duration of diabetes, being physically inactive as well as presence of macro-

and/or microvascular complications, impaired cognitive function, being depressed and having anxiety

were related to low level quality of life. With respect to depression, being female, having low

income, urban location of residence, physical inactivity, longer duration of diabetes, vascular

complications, cognitive impairment and anxiety had higher odds (ranges from 1.5 to 3.0-fold) of

having depression. Furthermore, the variables low income, physical inactivity, presence of vascular
complications and being depressed were related to higher odds (ranges from 1.6 to 3-fold) of anxiety.

However, insulin mode of treatment was found to be protective of anxiety. (OR=0.5)

Conclusion

The study found that various demographic and clinical characteristics are related to depression,

anxiety and reduced quality of health among people with type 2 diabetes. In countries like

Bangladesh, where mental health conditions often go unrecognised, the finding of this study could be

useful to develop interventions for early and prompt diagnosis and treatment.

Key words: Type 2 diabetes mellitus, health related quality of life, depression, anxiety, Bangladesh

Introduction

Non-communicable diseases (NCDs) are preventable and yet every year they contribute 41 million to

the deaths worldwide. While coronary heart disease is the major contributor to NCDs, diabetes is

among the top 5 contributors, contributing to 1.6 million to this death toll.(1) Presently, 425 million

people are living with diabetes and are disproportionately spread in the middle and low income

countries.(2, 3) In 2017, diabetes contributed USD727 billion to the global expenditure on health.(3)

If the statistics were to be broken down further, type 2 diabetes mellitus (T2DM) contributes 90% to

all the diabetes cases. T2DM is when the body retains some of its insulin producing capacity but it

may not be utilised well or the cells in the body may have developed resistance to it. Overtime, there

is a preceding decrease in the insulin production and the patient will require insulin therapy.(4) While

genetic pre-disposition might be among the causes for T2DM, modifiable lifestyle risk factors further

add to the risk. The most common co-morbidities associated with T2DM is hypertension, obesity,

hyperlipidaemia, visual complications, chronic kidney disease and cardiovascular disease.(5) While

these are considered to be among the most heard and common complications, one often tends to

overlook the mental conditions associated with it. Depression, anxiety and a number of other

psychological conditions are witnessed on a very high prevalence among people with diabetes.(6, 7)

Depression is a major psychological condition that involves persistent feeling of sadness and

worthlessness that deters one from engaging in formerly pleasurable activities and affects their
physical and emotional aspect of life. Depression in its initial stages affects day to day activities and

in its most sever forms can lead to suicide. In 2012, depression affected 350 million people and by

2030 it is estimated to be the leading contributor to the burden of diseases.(8) The burden further

increases when depression occurs as a co-morbidity. Diabetes with depression as a co-morbidity

significantly increases morbidity, mortality and increases health care costs.(9-11) The T2DM

complications such as diabetic foot, retinopathy and erectile dysfunction had strong association with

developing depression.(12) One of the largest population based study conducted in 60 countries

across the world found that depression as a comorbidity with diabetes has severe detrimental effects

on health than the conditions alone.(13) The study was done to find the prevalence of co-morbid

depression with diabetes and found that the 1-year prevalence of diabetes alone was 2%, whereas

depression as a co-morbidity among these diabetes patients was 9.3%.(13) People with diabetes have

a 2 times higher prevalence of depression as opposed to those without.(14, 15) It was found in a

systematic review that 1 in 3 people in the low and middle income countries had the co-morbidity of

depression with diabetes. This prevalence on an average was 35.7% which was higher than those in

the high income countries (25%).(16) A study conducted in Ethiopia found that those with diabetes

had a 1.5 fold increased risk of depression. A number of reasons such as poor quality of diabetes care,

level of education and accuracy of the measurement tools used may be attributed to it. (17) Similar

results were also found in India where a 2-fold higher prevalence of depression was found in those

with diabetes compared to those without.(18) In Bangladesh, this association was remarkably higher

with depression being 7-fold more likely to be present in people with diabetes.(19) Another study

conducted in Bangladesh concluded that female gender, age (>=60 years), 1-3 complications, higher

waist-hip circumference, social factors like major conflicts, deaths, divorce, etc. had a higher

prevalence of depression among T2DM patients.(20) (21)

Diabetes coupled with depression would most evidently affect one’s Health Related Quality of Life

(HRQoL).(22) A HRQoL is more than just an absence of sickness. It is more so based on a person’s

perception of wellbeing. The Centre for Disease Control and Prevention views it as a

multidimensional concept that involves the evaluation of the positive and negative aspects of a
person’s life.(23) In the 1980’s, the term Health related quality of life (HRQoL) was introduced that

focused on the perceived physical and mental health of people. It focused on effect quality of life had

on an individual’s physical and mental health.(22, 24) Studies done in China, Russia and Turkey all

found similar results where diabetics had a poor HRQoL as opposed to non-diabetics.(25)(26) Even

the mere diagnosis of T2DM leads to patient reporting a decrease in his/her HRQoL. (27) Age, sex,

economic status of a region, glycemic control, duration of diabetes, lack of adherence to treatment and

positive attitude had a huge role to play in the HRQoL of T2DM patients.(28, 29) Furthermore, a

multinational study done to analyze the factors related to HRQoL in T2DM found that use of three

oral agents or insulin or the use of insulin alone had negative impacts on HRQoL. (30) A cross

sectional study conducted in the Bangladeshi population found that pain/discomfort,

anxiety/depression, mobility, duration of diabetes, treatment prescribed and glycemic status had

effects on the HRQoL.(31) Furthermore, it was found that the impact of T2DM on HRQoL was much

higher in Bangladesh as compared to the western world.(32)

Being anxious is a normal feeling which one experiences when put in situations that are stressful and

uncomfortable. However, when this feeling continues to last even when the stimulus has been

removed or exists for long durations of time for no apparent reason, the person suffers from a mental

health condition called anxiety. Anxiety can have many forms, mainly being, generalized anxiety

disorder (GAD), social anxiety, specific phobias and panic disorders.(33) GAD is the most common

amongst them all.(33) People with GAD usually worry about prospective hazards and are usually

described as “worrywarts”. They experience severe debilitating psychiatric illnesses and severe

impairment like constant tiredness, irritable, difficulty concentrating and muscle tension.(34-36) The

global prevalence of anxiety in 2015 was 3.6%.(37) Studies have shown that the prevalence of anxiety

in those with diabetes is higher than the general population.(38, 39) A systematic analysis done to find

the prevalence of anxiety among those with diabetes found a 4% prevalence of GAD and a 40%

prevalence of elevated symptoms of anxiety. (40)(41) In T2DM patients who have anxiety, sex and

BMI play a major role in its prevalence.(42) According to the World Health Organization, anxiety

prevalence in the general population in Bangladesh was 4.4% in 2012.(37)

It is evident that while studies have been conducted in Bangladesh with respect to diabetes and its co-

morbidities, not many studies have explored the mental health conditions associated with it. There has

been extensive research done in the western world, which could not be translated well to South Asian

countries given the differences in the economic status and lifestyle characteristics of these countries.

Also, T2DM, anxiety, depression and HRQoL are all inter-related.(43) However, not many studies in

Bangladesh adequately addressed this complex relationship. Thus, the aim of this study was to assess

the mean HRQoL and the prevalence of depression and anxiety in our study population. Furthermore,

it also explored the various demographic and clinical risk factors associated with HRQoL, anxiety and

depression.

Methodology

Study Design and Population

The participants were recruited from March-September 2017 through a cross sectional survey done

across 6 hospitals in Bangladesh. The hospitals were affiliated with the Diabetic Association of

Bangladesh and were located in different metropolitan and outside metropolitan areas, mainly

recruiting patients residing in rural, semi-urban and urban areas. The hospitals in the metropolitan

areas provide primary to tertiary healthcare all in the same hospital, whereas those hospitals that were

located outside the metropolitan areas provide only primary to secondary healthcare. Thus, this study

ensured that there was a heterogeneous group of patients that were recruited.

Based on calculations, recruiting 1253 patients with T2DM ensured 95% power and a 5% significance

level. To be eligible, participants had to meet the following criteria: patients were at least 18 years of

age and had a minimum one-year history of T2DM. Patients were excluded if they had any other form

of diabetes such as type 1 diabetes and gestational diabetes.

Data Collection

Data was collected from patients via face-to face interviews and patients’ record book. Questionnaires

that were pretested in a pilot survey done at the Bangladesh Institute of Health Sciences were used.

The questionnaire consisted of questions in three parts. The first part consisted of questions on the
socio-demographics and lifestyle characteristics. This extracted information was on age, gender,

education, marital status, profession, monthly household income, smoking status, eating habits and

physical activity. The second part focused on diabetes related questions like duration of diabetes,

family history of diabetes, periodicity of follow-up check-up and hypoglycaemic events. Patients

medical records were extracted using a data extraction checklist. This provided information on

laboratory test results, diagnosis, medication, co-morbidities and past complications. The third section

was used to gather information on known or purported factors affecting diabetes control. A number of

measurement tools were used with or without certain modifications made to them. Prior permission

was taken from the respective authorities to use these tools. The UK Diabetes and Diet Questionnaire

(UKDDQ)(44) was tailored with minor modifications to make it suitable for the Bangladeshi

population. The Global Physical Activity Questionnaire(45) was used to assess physical activity with

6 items selected. Besides this, the following questionnaires were used with no modifications made to

them- 1) EQ-5D-5L, Patient Health Questionnaire (PHQ-2)(46) , Generalised Anxiety Disorder Scale

(GAD-2)(47), Michigan Neuropathy Screening Instrument(48), and the Six-item Cognitive

impairment test (6CIT)(49). Body mass index (BMI) was calculated by weight being measured with

light clothes on and height measured with no shoes on. Waist to hip ratio (WHR) was calculated with

measurements taken against thin clothes. Patient health related quality of life was assessed using the

EQ-5D-5L scale. Data collection and management was done using Research Electronic Data Capture

(REDCap).(50)

Operational Definition

Glycaemic status recorded within the last three months was classified as good glycemic control:

Glycated Hemoglobin (HbA1c ) <7% (51) , fair control: HbA1c 7%-8%, poor control: HbA1c >8.0%

(52), and very poor control : HbA1c >=9.0% (53). BMI was defined as <18.50 = underweight, 18.50-

24.99 = normal, >25.00 = overweight and obese (54). The WHR cut off was >0.90 for men and >0.80

for women (55). Hypertension was defined either as known previous detection, patient on anti-

hypertensive medication or newly discovered BP reading with systolic>140mmHg and diastolic

>90mmHg (56). Dyslipidemia was defined as known previous diagnosis or if patient is presently on
lipid lowering medicine. A score of more than seven on the 6CIT (49) and more than or equal to

seven on the Michigan Neuropathy Screening Instrument (48) was defined as impaired cognitive

function and neuropathy, respectively. Visual detection of ulcers, amputations or previous

documented diagnosis of diabetic foot was defined as diabetic foot. More than 150 minutes of

walking per week was considered as physically active on the GPAQ. PHQ-2 scale was used to assess

depression and the GAD-2 scale was used to assess anxiety, where each of them have two Likert scale

questions with four options (0, 1, 2 and 3). A patient with a total score of 3 or more was identified as

having depression/anxiety. The HRQoL was assessed using the EQ-5D-5L, which consisted of 5

dimensions. The dimensions were mobility, self-care, activity, pain/discomfort and

anxiety/depression. Each dimension had 5 levels- no problem, slight problem, moderate problem,

severe problem and unable to move, which were coded 1 to 5 respectively. Based on the patients’

response, a 1-digit number was generated for each dimension which then generated a 5-digit number

for the 5 dimensions which described the patients’ overall health status. This 5- digit number had no

arithmetic properties and was then converted to a single index which presented in country specific

value sets. From the available value sets, value set for Zimbabwe was chosen because it was closest to

Bangladesh both economically and socially. The EQ VAS scale was also used where participants

were asked to state how their health felt on the day of the interview on a scale from 0-100.(57)

Ethical Approval

The study has been approved by the Monash University Human Research Ethics Committee, Ethical

Review Committee of the Bangladesh University of Health Sciences and Diabetic Association of

Bangladesh. The principles of the Declaration of Helsinki as revised in 2013 was used to carry out the

study procedures.

Data management and analysis

Univariate analysis (t-test, ANOVA, chi square, and simple logistic regression) were used to find the

potential risk factors for HRQoL, depression and anxiety. Following this, multivariable analysis with

bootstrapping method were carried out to select the potential risk factors for the outcome measures.
(58-60) Missing values were imputed using ICE chained equation method in STATA. (61) Data were

analyzed using the statistical software package STATA SE version 15.

Results

A total of 1253 people with T2DM were included in the study. Of them, 53.2% were male with an

overall mean age of 54 (±12.1) years and with a 9.9 (±7.2) years of mean duration of T2DM. The

prevalence of depression and anxiety in our study population was 37.35% and 10.38% respectively

and the average health related quality of life was 0.642 (±0.20).

Table 1, represents univariate analysis of the demographic characteristics for HRQoL, depression and

anxiety. Female gender, secondary or less education, unemployment, urban residence, increased

duration of T2DM and being physically inactive lead to a decreased HRQoL and an increased

prevalence of depression (p<0.001). Increasing age lead to decreased HRQoL (p<0.001) and

increased prevalence of depression (p= 0.008). Highest HRQoL and least prevalence of depression

was observed in the group with an income of 21,000tk to 60,000tk followed by >61,000tk and

≤20,000tk income group (p<0.001). While unemployment (p=0.017), income ≤20000tk (p=0.005) and

being physically inactive (p≤0.001) increased the likelihood of anxiety.

Table 2, represents univariate analysis of the clinical characteristics for HRQoL, depression and

anxiety. Combination therapy (Oral anti-hyperglycaemic agents+ insulin), presence of hypertension,

impaired cognitive function, having both micro- and macro-vascular complications and the presence

of anxiety were related to a decreased HRQoL and increased prevalence of depression (p<0.001).

Furthermore, HbA1c ≥7 lead to a decreased HRQoL (p=0.05) but did not significantly affect the

prevalence of depression (p=0.13). With anxiety, having both micro- and macro-vascular

complications (p=0.002), impaired cognitive function (p=0.01) and depression (p<0.001) had

association within increased prevalence of anxiety.

Table 3, presents multivariable analysis performed to find the association of various demographic and

clinical characteristics with HRQoL, depression and anxiety. Older age (>60 years) (b=-0.03; 95% CI
-0.05 to -0.001), income (<=20000tk) (b= -0.03; 95% CI= -0.06 to -0.015), urban residence (b=-0.04;

95% CI=-0.06 to -0.015), increased duration of T2DM (>10 years) (b= -0.03; 95% CI= -0.04 to -

0.012), physical inactivity (b= -0.08; 95% CI= -0.10 to -0.06), impaired cognitive function(b= -0.08;

95% CI= -0.10 to -0.06) and having either/both micro- and macro-vascular complications(b= -0.11;

95% CI= -0.13 to -0.09 ), depression (b= -0.11; 95% CI= -0.12 to -0.09 ) and anxiety (b= -0.37; 95%

CI= -0.65 to -0.01)were found to be related to a low HRQoL. Higher education was found to be

protective of HRQoL. (b=0.02; 95% CI=0.006 to 0.048)

Odds of depression was increased by 50% for both of being female (95% CI 1.1 to 1.9) and having a

duration of diabetes >10 years (CI 1.1 to 1.9). Having an income less than 20000tk (95% CI 1.4 to

2.8), being physically inactive (95% CI 1.4 to 2.4) and having micro-vascular complications (95% CI

1.1 to 2.7) each lead to a 1.9-fold increased odds of depression as opposed to income >61000tk, being

physically active and having no complication. Both having an urban location of residence (95% CI 1.0

to 2.0) and having macro vascular complications (95% CI 1.1 to 2.6) lead to a 1.7-fold increased

odds of depression as opposed to rural residence and no complication. Having both micro- and macro-

vascular complications related to a 2.8-fold higher odds (95% CI 1.9 to 4.0) of depression than no

complication. Being cognitively impaired lead to a 1.6-fold increased odds (95% CI 1.2 to 2.1) of

depression as opposed to intact cognition. Furthermore, presence of anxiety increased the odds of

depression by 3-fold (95% CI 1.9 to 4.4) compared to no anxiety.

With anxiety, both having an income ≤2000tk and being physically inactive lead to a 1.9 times higher

odds of anxiety than income >61000tk and being physically active. Having both macro- and micro-

vascular complications lead to a 2.1-fold higher odds (95% CI 1.2 to 3.7), however being treated by

insulin therapy reduced the odds of anxiety by 50% (95% CI 0.3 to 0.8), and having depression lead to

a 2.8-fold higher odds (95% CI 1.8 to 4.2) of developing anxiety as opposed to no complications, use

of only OHA and absence of depression respectively.

Discussion

Diabetes contributes greatly to the growing epidemic of NCD’s and is of substantial concern. While it

has been well established that psychological conditions are associated with chronic medical

conditions including type 2 diabetes mellitus, limited studies have been conducted in the low and

middle income countries including Bangladesh. Hence, our study aimed to explore the effect of social,

demographic and clinical characteristics have on HRQoL, depression and anxiety among people with

T2DM. The average health related quality of life was 0.642 (±0.20). Furthermore, the study showed

the prevalence of depression and anxiety were 37.35% and 10.23% respectively, which is well above

the global prevalence in the general population, and supports that T2DM is strongly related to

depression and anxiety. Besides, this study also identified demographic, social and clinical risk factors

for HRQoL, depression and anxiety for people with T2DM.(62)

The purpose of medicine is not only to save lives but to improve the quality of life. Contrary to olden

times where under the microscope findings defined a person’s health, the HRQoL helps us to know

how health status affects quality of life. Our study found new insights in the relationship between

HRQoL and the various risk factors. In our cohort, we found that in the univariate analysis women

demonstrated poor HRQoL as opposed to men. This was consistent with the studies conducted among

T2DM patients in China, Japan, and Korea.(29, 63, 64) Also, this gender difference has already been

established in the general population in Italy (65), India and Pakistan (66). A strong predictor for this

could be that a good majority of women in Bangladesh or in developing countries in general

experience unparalleled mental trauma associated with the social norms of the region. This could be

situations like forced marriages, fewer job opportunities, sexual harassment, child marriage and

restrictions in working outside the house.(67, 68) Such situations lead to them developing emotional

and behavioural problems. It is imperative that women feel safe and secure and that community based

tailored interventions are in place to provide social protection. However, female gender was no longer

significant in the multivariable analysis for HRQoL.

Education empowers people. It empowers them to take decisions with the treatment and to understand

its importance. It significantly would enhance the quality of care. Besides, in most cases, a good
education would mean a better income, which would increase the affordability of the treatment. Our

study found supporting evidence where higher education (graduate or more) lead to a better HRQoL

in the population.(69, 70)

Income and HRQoL are a part of a vicious cycle. In most cases health is not a priority for those with

low incomes. There are competing demands and thus spending on healthcare goods and supplies is

not top priority. Besides, there is low health related literacy rate which further worsens the condition.

Poverty can lead to poor mental health which will in turn affect the HRQoL. Our study found

supporting evidence where people with low income had poor HRQoL which is consistent with studies

done in Hong Kong and Japan.(71)(72)

Older individuals have poor health statuses and more prevalence of chronic diseases. This would have

an effect on their HRQoL. Besides, absence of spouses, body pain, restricted mobility, lack of

emotional support, lower income and lower education further adds to the risk. Our study found that

being over 60 years of age lead to a low HRQoL.(73)

Area of residence is a strong determinant for HRQoL. Although, strong information in support of

either rural or urban area remains scanty, most literature concluded urban residence protective of

HRQoL.(74, 75) However, our study showed that having a rural residence had better HRQoL. This

was consistent with the study done in Poland where rural residence had positive association with

mental health but negative association with physical health.(76) The results in our study could be

attributed to the fact that urban areas have larger populations which leads to higher population

mobility leading to less likelihood of knowing neighbours and people around. This would then lead to

social isolation and loneliness. Furthermore, higher crime rates, congestion, contagious diseases, lack

of cultural facilities, green spaces, air quality and public administration in the urban areas could

further add to the risk.(77, 78) Another theory suggests that people in rural areas have strong informal

ties as opposed to weak formal ties in the urban setup which could affect a person’s mental health

condition.(79)
Our study found that HRQoL was negatively associated with duration of T2DM (more than 5 years).

This finding was consistent with the previous study conducted with Farzana Saleh et al.(31) Chronic

diseases including diabetes are slow in progression and hence the longer the duration the more

deteriorating the condition gets. It will limit a person’s capacity to live life to the fullest and would

also limit his productivity. Besides, the longer the duration, greater would be the burden of the cost of

treatment and increased micro- and macro- vascular complications. Intervention should be targeted

towards palliative care that would help with enhancing life rather than sustaining it.

The effect physical activity (PA) has on HRQoL is greatly influenced by the cultural and social

factors and the level of development of a country. This implies that studies that have been conducted

around the world cannot be generalized.(80) Our study showed that being active was significantly

associated with better quality of life. This was similar to studies conducted by Pucci et al and Anokye

et al.(80-82). Thus our finding in Bangladesh could be successfully applied to most of the south Asian

countries which have a similar cultural and social set up.

Contradictory to the study done by Safita et al and Farzana Saleh, our study showed that having

either/both micro- and macro-vascular complications lead to a lower HRQoL.(31, 32) They can cause

multi-organ dysfunction and lead to physical impairment. All of this would ultimately affect a

person’s quality of life.(83)

The study also found that impaired cognitive function lead to a decreased quality of life. This fining

was consistent with a study done in Zambia by Anne L. Nau et al and Stites et al where it was found

that people with cognitive impairment had a lower HRQoL.(84, 85)

Our study also showed a negative association of HRQoL with depression and anxiety. This was

consistent with studies conducted by Derakhshanpour et al in Iran.(86) A study done by Altinok et al

found that medical and sociodemographic factors have a role to play in the association of depression

and HRQoL.(87) A study conducted by Zurita-Cruz et al found that patients with T2DM and

depression had inadequate HRQoL. It affected their physical, emotional and mental health.

Furthermore, it also found that with older population, there could be a perceived poor HRQoL due to
poor care, motivation and exhaustion.(88) The co-relation between diabetes and depression is very

close knit where the diagnosis of diabetes leads to perception that there is loss of health leading to

depressed states which ultimately leads to a decreased HRQoL. T2DM when coupled with such

mental health conditions leads to an increased level of care. Evidence presented in our study and other

studies highlights that importance of developing interventions that better self-care and promote a

healthy mental and physical wellbeing.

Depression is the key cause of disability worldwide and yet the social stigma associated with it often

leads to a failure of interpretation of the magnitude of the problem. Consistent with the World Health

Organization findings in the general population and the study conducted by Sun et al on T2DM

patients in China, our study found that the female gender had a higher prevalence of depression as

opposed to the male gender.(89) A woman’s life is very different to a man’s life. Her genetic

composition, hormones, psychological and social experiences are very different than a man. While it

is now known that depression runs in the genes, with women, issues related to pregnancy, fertility,

menstrual cycles and menopause have a huge role to play in depression.(90, 91) Women often have

negative body images that usually develop at puberty and extend through adulthood.(92)

Our study showed that income had an inverse relationship with depression and anxiety. This was

consistent with studies done in Canada.(93) Income decides the socio-economic status of a person.

Low socio-economic status leads to comparisons with those with high SES which ultimately leads to

shame, frustration and lower self-esteem. Besides, difficulty in fulfilling the day-to-day requirements

which in case of T2DM patients would be medications and lifestyle modification costs, further leads

to increased depressive symptoms and anxiety.(94)

Similar to HRQoL, with depression too the findings with urban and rural location of living had mixed

findings. Our study presented that living in the urban areas lead to an increased prevalence of

depression. This finding was consistent with the studies conducted by Wand et al.(95) The urban way

of life is fast paced. Difficulty in coping with stresses associated with housing, child rearing and

security leads to an increased prevalence of depression. Besides, lack of social interaction and social

withdrawal further adds to this risk.

Longer durations of diabetes would lead to an increases level of distress. It would greatly affect one’s

mood and lead to greater stress. Longer durations usually would also mean the need of insulin therapy

which would then make it necessary to take painful injection resulting in an added source of stress.

(96) Similar results were found in our study where a duration of greater than 10 years of T2DM lead

to more risk of depression.

Our study found that being physically inactive lead to an increased prevalence of depression and

anxiety. The bi-directional relationship between physical activity and depression is still a matter of

debate. The inactivity trap by Elfrey et al, states that a person with depression is inactive as a

protective mechanism to avoid conflict and resorts to a sedentary lifestyle which only worsens the

situation and leads him/her to further severe depression.(97) A recent study done by Karmel Choi

found that physical activity is protective of depression and 15 minutes of rigorous exercise daily leads

to decreased risk of depression.(98) Tailored interventions need to be in place to meet the different

lifestyles of people to make them more physically active.

This study found that having both or either micro and micro- or macro-vascular complications lead to

an increased risk of depression. Our study was in line with the study conducted in Indonesia by

Handoko et al which also found that these complications were directly related to hyperglycemia,

where longer durations of T2DM lead to damaging organs which caused complications and increased

depressive symptoms.(99)

Our study also found that being cognitively impaired lead to an increased risk of depression.

Cognitive impairment leads to decreased levels of self-care and the condition only worsens with age.

A study done by Zhand Da et al found that controlling depression would lead to a decline in cognitive

impairment.(100)

Anxiety in people with T2DM is often associated with fear of hypoglycemia and invasive self-care. In

our study we found that the presence of both micro- and macro- vascular complications leads to an

increased risk of anxiety. The biological explanation could be the psychosocial stressors increases the

catecholamine in the circulation which increases the risk of vascular complications.(101)

Our study found that using insulin is protective of anxiety. The possible explanation for this could be

due to better control of diabetes with insulin use. Besides this, a study also found that those with

anxiety are less likely to start insulin therapy, which could be a possible explanation for our results.

(102) Our study found that people with anxiety are 4 times more likely to have depression than those

without and vice versa. With depression and anxiety there is no clear evidence as to which causes

which, but there is evidence that they both can be presented at the same time. Stronger studies are

needed that can establish temporal relationship.(103, 104)

Strengths and limitations

This study has the strength of having a population that is representative of the Bangladeshi population

and hence the findings can be generalized among all T2DM patients under the Diabetic Association of

Bangladesh. The study investigated depression, anxiety and HRQoL which covers a wide array of

mental health conditions and its effect on general wellbeing, which further adds strength to the study.

However, the study is cross sectional in nature which does not help establish temporal relationship.

Conclusion

The patterns uncovered in our study demonstrate that HRQoL, depression and anxiety were related to

various demographic and clinical characteristics of people with T2DM in Bangladesh. In a country

like Bangladesh where mental health conditions often go unrecognized, it is imperative that these

findings will be useful to help people with timely diagnosis and prompt treatment. The identified risk

factors in this study will further help with the development of tailored strategies that would help in

reducing the burden from depression and anxiety and help to improve the HRQoL of those with

T2DM.
References

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Table 1: Univariate analysis of HRQoL, Depression and Anxiety with patients’ demographics

Variables HRQoL Depression Anxiety

Mean±SD P-value n(%) P-value n(%) P-value
Yes No Yes No
Age
<=40 years 0.728±0.141 55 (31.2) 121 (68.7) 18 (10.2) 158 (89.7)
41-60 years 0.652±0.195 <0.001 237 (35.4) 432 (64.5) 0.008 74 (11.0) 595 (89) 0.658
>=61 years 0.581±0.216 176 (43.1) 232(56.8) 38 (9.3) 370 (90.6)
Gender
Male 0.662±0.207 <0.001 220 (32.3) 461 (67.6) <0.001 69 (10.1) 612 (89.8) 0.758
Female 0.619±0.192 248 (43.3) 324(56.6) 61 (10.6) 511 (89.34)
Education
Up to Secondary 0.6200±0.207 295 (40.8) 571(59.1) 108 (11.1) 858 (88.8)
Graduate and above 0.717±0.162 <0.001 73 (25.4) 214(74.5) <0.001 22 (7.6) 256 (92.3) 0.086
Employment
Unemployed 0.563±0.230 138 (46.6) 158(53.3) 41 (13.8) 255 (86.1)
Homemaker 0.610±0.193 <0.001 240 (44.1) 304(55.8) <0.001 59 (10.8) 485 (89.1) 0.017
Employed 0.740±0.145 90 (21.9) 321(78.1) 30 (7.3) 381 (92.70)
Income
61000 and above tk 0.640±0.188 107 (34.6) 202(65.3) 21 (6.8) 288 (93.2)
21000-60000 tk 0.672±0.175 <0.001 164 (33.0) 333(67) 0.001 47 (9.4) 450 (90.5) 0.005
<=20000 tk 0.610±0.231 197 (44.0) 250(55.9) 62 (13.8) 385 (86.1)
Physical Activity
Active 0.722±0.131 <0.001 161 (26.3) 451 (73.6) <0.001 40(6.5) 572 (93.4) <0.001
Inactive 0.566±0.22 307 (47.8) 334 (52.1) 90 (14.0) 551 (86.0)
Waist Hip Ratio:
Normal 0.733±0.171 0.002 33 (31.7) 71 (68.2) 0.700 14 (13.4) 90 (86.5) 0.036
Abnormal 0.689±0.145 270 (29.9) 633 (70.1) 68 (7.5) 835 (92.4)
Area of residence
Rural 0.724±0.142 <0.001 84 (25) 252 (75) <0.001 36 (10.7) 300 (89.2) 0.812
Urban 0.612±0.212 384 (41.8) 533 (58.1) 94 (10.2) 823 (89.7)
Duration
<=5years 0.705±0.178 111 (30.1) 257 (69.8) 39 (10.6) 329 (89.4)
6-10 years 0.662±0.200 0.020 112 (32.2) 235 (67.7) <0.001 39 (11.2) 308 (88.7) 0.745
>=11 years 0.586±203 245 (45.5) 293 (54.4) 52 (9.6) 486 (90.3)
Table 2: Univariate analysis of HRQoL, Depression and Anxiety with clinical characteristics.
Variables HRQoL Depression Anxiety
Mean± SD P-value n(%) P-value n(%) P-value
Yes No Yes No
Mode of treatment
OHA 0.699±0.175 0.001 129 303 (70.1) 50 (11.5) 382
Insulin 0.683±0.226 (29.8) <0.001 8 (9.2) (88.4) 0.591
Combination 0.604±0.203 482 (58.7) 72 (9.8) 79 (11.5)
339 662
(41.2) (90.1)
HbA1c
<=6.9 0.7001±0.182 0.055 47 (25.8) 135 (74.1) 0.132 15 (8.2) 167 0.337
>=7 0.676±0.182 258 561 (68.5) 87 (10.2) (91.7)
(31.5) 732
(89.3)
Hypertension:
No 0.706±0.170 <0.001 128 318 (71.3) <0.001 44 (9.8) 402 0.660
Yes 0.607±0.209 (28.7) 467 (57.8) 86 (10.6) (90.1)
340 721
(42.1) (89.3)
Cognitive function
Intact 0.701±0.162 <0.001 246 583 (70.3) <0.001 74 (8.9) 755 (91) 0.019
Impaired 0.527±0.222 (29.6) 202 (47.6) 56 (13.2) 368
222 (86.7)
(52.3)
Micro and macro vascular complications
No complication 0.746±0.122 100 358 (78.1) 31 (6.7) 427
Micro complication 0.636±0.169 <0.001 (21.8) 152 (58.6) <0.001 24 (9.2) (93.2) 0.002
Macro complication 0.644±0.195 107 119 (63.9) 23 (12.3) 235
Both 0.509±0.231 (41.3) 156 (44.5) 52 (14.6) (90.7)
67 (36.0) 163
194 (87.6)
(55.4) 298
(85.1)
Depression
No 0.716±0.149 <0.001 46 (5.8) 739 <0.001
Yes 0.518±0.217 84 (17.9) (94.1)
384
(82.0)
Anxiety
No 0.654±0.189 <0.001 384 739 (65.8) <0.001
Yes 0.536± 0.265 (34.1) 46 (35.3)
84 (64.6)
 Table 3: Multiple logistic regression analysis for HRQoL, Depression and Anxiety

HRQoL Depressi Anxiety

on
Variables β 95% CI P-value OR 95% CI P-value OR 95% CI P-value
coefficient
Age(ref- <=40 years)
41-60 years
>=61 years -0.030 -0.059 to -0.001 0.039
Gender (ref: male)
Female -0.001 -0.019 to -0.016 0.901 1.5 1.1 to 1.9 0.004
Education (ref: Up to
secondary)
Graduate and above 0.027 0.006 to 0.048 0.012
Income (ref: >61000 and above
tk)
21000-60000 tk
<=20000 tk -0.038 -0.0620 to - 0.001 1.9 1.4 to 2.8 <0.001 1.9 1.1 to 3.4 0.01
0.015
Location (ref: rural)
Urban -0.042 -0.062 to -0.023 <0.001 1.7 1.0 to 2.1 0.01
Duration (ref:<=5 years)
6-10 years
>=11 years -0.030 -0.048 to -0.012 0.001 1.5 1.1 to 1.9 0.007
Physical activity (ref: active)
Inactive -0.084 -0.101 to -0.673 <0.001 1.9 1.4 to 2.4 <0.001 1.9 1.2 to 2.9 0.002
Mode of Treatment (ref: OHA)
Insulin 0.5 0.3 to 0.8 0.008
Complications (ref: No)
Micro complications -0.043 -0.066 to -0.019 <0.001 1.9 1.13 to 2.7 <0.001
Macro complication -0.054 -0.080 to -0.028 <0.001 1.7 1.1 to 2.6 0.006
Both -0.115 -0.139 to -0.091 <0.001 2.8 1.9 to 4.0 <0.001 2.1 1.2 to 3.7 0.006
Cognitive impairment (ref:
intact)
Impaired -0.083 -0.102 to -0.063 <0.001 1.6 1.2 to 2.1 0.001
Depression (ref: No)
Yes -0.110 -0.128 to -0.091 <0.001 2.8 1.8 to 4.2 <0.001
Anxiety (ref: No)
Yes -0.37 -0.065 to -0.010 0.007 3.0 1.9 to 4.4 <0.001