ORIGINAL ARTICLE

Factors associated with depression, anxiety and

stress among patients with diabetes mellitus
in primary health care: Many questions, few
answers
Fisekovic Kremic MB
Fisekovic Kremic MB. Factors associated with depression, anxiety and stress among patients with diabetes mellitus in primary health care: Many
questions, few answers. Malays Fam Physician. 2020;15(3);54–61.

Abstract
Keywords:
diabetes mellitus, risk factors, Introduction: People with diabetes mellitus (DM) may have concurrent mental health disorders
cognitive disorders, general and have been shown to have poorer disease outcomes.
practice Objective: The aim of this study to determine the prevalence of DASS in patients with diabetes
mellitus without mental disorders, aged 20 years or more, in primary health care, and to determine
any association between DASS and patients’ sociodemographic and clinical attributes.
Authors: Methods: This was a cross-sectional study conducted in a primary health care center, in the
department of general practice. Patients with DM who visited the doctor and agreed to fill in the
Marina B. Fisekovic Kremic questionnaire were included in the study. Data were collected using the questionnaire DASS-21.
(Corresponding author) Descriptive statistics, the Pearson chi-square test, and logistic regression analysis were used to analyze
PhD the data.
Primary Health Centre New Belgrade, Results: Out of a total of 102 respondents with DM, 29 (28.4%) had some form of psychological
Belgrade, Serbia symptoms. The prevalence of DASS was 16.7%, 16.6%, and 23.5%, respectively. There was no
Email: [email protected] significant difference between sociodemographic variables according to stress status. Respondents
aged 40–49 years more often showed emotional states of depression and anxiety. There was a
significant association between emotional status of DASS and HbA1c values. Logistic regression
analysis indicated that age (OR=2.57, 95% CI: 1.59-4.13) was a predictor of depression and anxiety.
Conclusion: Unpleasant emotional states DASS are common in patients with DM, depression
(16.7%), anxiety (16.6%), and stress (23.5%). Age is the strongest predictor of DASS status.
The screening and monitoring of unpleasant emotional states in people with diabetes should be
performed from a young age.

Introduction In this country, approximately 600,000

persons (8.2% of the population) suffer from
The incidence of diabetes mellitus is increasing. diabetes. In Serbia, as in developed countries
It is recognized that many person with chronic worldwide, diabetes is the fifth leading cause
illnesses also have undiagnosed comorbidities, of death5 and also the fifth cause of disease.6 In
including depression, anxiety, and stress this country, approximately 3,000 persons die
(DASS).1 People with diabetes mellitus may from this disease each year.5 The World Health
have concurrent psychological symptoms and Organization projected that 438 million people
are shown to have poor disease outcomes.2 will fall ill from diabetes by 2030. Although the
Mental illness or mental health disorders, highest incidences are recorded in developed
which refer to a wide range of mental health counties, the largest increase in diabetes
conditions, affect mood, thinking, and diagnoses is expected in developing countries
behavior.3 Some mental illnesses include like this one.7 More studies have been done to
depression, anxiety disorders, schizophrenia, determine the prevalence of depression, anxiety,
eating disorders, and addictive behaviors. Signs and stress (DASS) in patients with diabetes.2,8-10
and symptoms of mental illness can vary and Adverse socioeconomic circumstances early
can affect emotions, thoughts, and behaviors. in life increase the risk of diabetes mellitus
Sometimes mental health disorder symptoms and late-life cognitive disorders.11 DM often
present as physical problems, such as headaches, appears as a co-morbidity of a more psychiatric
back pain, stomach pain, or other unexplained illnesses, complicating its outcome. People with
pains.3,4 diabetes are 1.5 times more likely to develop

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DASS, especially anxiety and depression, The sociodemographic data of the patients
regardless of age, ethnicity, or socioeconomic were recorded, including age, sex, marital
status.12 Although psychological and psychiatric status, education level, and occupation.
problems are frequently present in people with Factors that could affect DM severity
DM, in most cases these are neither diagnosed were also recorded, such as smoking
nor treated, to the patients’ detriment.13,14 status, presence of comorbidities, family
history of DM, DM duration, therapy,
This study was conducted to determine the number of doctor’s visits, HbA1c levels,
prevalence of DASS in primary care patients and blood sugar levels. The section on the
20 years or older with DM without DASS and detection of DASS was completed using
to determine any association between DASS the validated DASS-21 questionnaire.
and patients’ sociodemographic and clinical The DASS-21 questionnaire has 21
characteristics. items, a set of three self-reported scales
designed to measure DASS. The DASS-
Methods 21 questionnaire has been translated into
multiple languages, including Serbian,
1. Study Design which has been validated for its use.15
The DM patients were asked to estimate
This was a cross-sectional study conducted their experience of each symptom on
from December 2017 until February a 4-point severity scale ranging from 0
2018. This study was conducted in (“does not apply to me”) to 3 (“applies
the primary healthcare center in New to me most of the time”). These scores
Belgrade in the department of general were added up and categorized as normal,
practice. mild, moderate, severe, or extremely
severe, according to the manual. Values
This study included patients 20 years of DASS obtained were then transformed
or older with diabetes mellitus (DM), for further analysis. The DASS has no
without the presence of DASS, who direct implications for the allocation
visited the doctor for one reason or of patients to diagnostic categories
another. Patients diagnosed with mental postulated in classification systems, since
disorders were excluded from the study. it is predominantly aimed to measure
The prevalence of depression in the DASS symptoms in both clinical and
area studied ranged from 8 to 18%. nonclinical samples. Therefore, the DASS-
The minimum number of samples was 21 questionnaire is only a screening tool.16
calculated using Kish’s formula: Sample
size = z2 (p (1-p)/c2), where z = 1.96 for 3. Statistical Analysis
95% confidence interval (CI)
All questionnaires were checked and
In this equation, p = prevalence (of entered into the statistical software SPSS
depression for DM based on Andreoulakis 20. Data were expressed as frequencies
study: 8-18%),10 and c = desired level of (%) for categorical variables, and all
precision. The minimum sample size was the continuous variables were expressed
113 DM patients but without mental as mean and standard deviations. The
disorders. Pearson chi-square test was used to
measure the differences between the
2. Study Variables variables. Significant associations were
found, with a p-value <0.05.
Data were collected using the
questionnaire DASS-21.15 Patients with All variables that were significantly
DM who visited the doctor and agreed to associated with the outcome measure
fill out the questionnaire were included (p < 0.05) were entered into a logistic
in the study. This self-administered regression model and were identified as
questionnaire consisted of three sections: outcome predictors. Finally, the odds
sociodemographic information, DM ratios (OR) and confidence intervals (95%
severity, and DASS detection, and it CIs) were also calculated.
was given to the patients when visiting a
doctor of general practice.

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Results

A total of 102 patients who visited a PHC doctor successfully completed the questionnaire. Out
of a total of 102 respondents with DM, 29 (28.4%) displayed psychological symptoms. The
prevalence of depression, anxiety, and stress was 16.7%, 16.6%, and 23.5%, respectively. The
mean patient age was 50 ± 7.86 years. Almost 52% of the respondents had secondary education.
Approximately 77.5% of respondents were employed. More than half of the respondents had a
positive family history of DM (55.9%), and more than two-thirds of the respondents (67.6%)
had concurrent co-morbidities, and a majority of the patients received only oral medication
(72.5%), whereas 10.8% received a combination of both oral medication and insulin. The
average blood sugar level was 7.2 and HbA1c 6.4%. The sociodemographic characteristics of the
respondents are shown in Table 1.

Table 1. Frequency distribution of respondents by sociodemographic and clinical characteristics

Sociodemographic and clinical characteristics N (%)
Sex
Male 49 (48.0)
Female 53 (52.0
Marital status
Single 21 (20.6)
Married 78 (76.5)
Widow/er 3 (2.9)
Age (years)
≤29 1 (1.0)
30-39 8 (7.8)
40-49 38 (37.3)
50-59 41 (40.2)
≥60 14 (13.7)
Education
Primary school 3 (2.9)
Secondary school 53 (52.0)
University 46 (45.1)
Occupation
Employed 79 (77.5)
Unemployed 23 (22.5)
Family history of DM
No 45 (44.1)
Yes 57 (55.9)
Smoking
Smokers 51 850.0)
Nonsmokers 51 (50.0)
Comorbidity
No 33 (32.4)
Yes 69 (67.6)
DM therapy
Oral 74 (72.5)
Insulin 17 (16.7)
Oral + insulin 11 (10.8)
DM duration (years)
≤1 16 (15.7)
1 – 4.9 44 (43.1)
5 – 9.9 33 (32.4)
10 – 14.9 6 (5.9)
≥ 15 3 (2.9)

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Frequency of visits
Once a month 54 (52.9)
Once in two months 33 (32.4)
Once in three months 15 (14.7)
Blood sugar
≤ 6.0 12 (11.8)
≥ 6.1 90 (88.2)
HbA1c
≤ 5.6 14 (13.7)
5.7 – 6.5 52 (51.0)
≥ 6.6 36 (35.3)

Table 2 shows the differences between the DASS statuses and sociodemographic variables
of the respondents. There was no significant difference between sociodemographic variables
according to stress status, but there was a significant difference between sociodemographic
variables according to depression and anxiety statuses. Respondents aged 40–49 years more often
displayed depression or anxiety. However, anxiety was more prevalent among respondents who
were employed.

Table 2. Difference between DASS status and sociodemographic characteristics

Sociodemographic Depression Anxiety Stress
characteristic N (%) No Yes No Yes No Yes
Sex
Male 41 (48.2) 8 (47.1) 41 (48.2) 8 (47.1) 36 (46.2) 13 (54.2)
Female 44 (51.8) 9 (52.9) 44 (51.8) 9 (52.9) 42 (53.8) 11 (45.8)
Marital status
Single 19 (22.4) 2 (11.8) 19 (22.4) 2 (11.8) 18 (23.1) 3 (12.5)
Married 63 (74.1) 15 (88.2) 63 (74.1) 15 (88.2) 57 (73.1) 21 (87.5)
Widow/er 3 (3.5) 0 (0) 3 (3.5) 0 (0) 3 (3.8) 0 (0)
Age (years)
≤29 1 (1.2) 0 (0) 1 (1.2) 0 (0) 1 (1.3) 0 (0)
30-39 7 (8.2) 1 (5.9) 7 (8.2) 1 (5.9) 7 (9.0) 1 (4.2)
40-49 25 (29.4) 13 (76.5)* 26 (30.6) 12 (70.6)* 25 (32.1) 13 (54.2)
50-59 38 (44.7) 3 (17.6) 37 (43.5) 4 (23.5) 33 (42.3) 8 (33.3)
≥60 14 (16.5) 0 (0) 14 (16.5) 0 (0) 12 (15.4) 2 (8.3)
Educational
Primary school 3 (3.5) 0 (0) 2 (2.4) 1 (5.9) 2 (2.6) 1 (4.2)
Secondary school 45 (52.9) 8 (47.1) 45 (52.9) 8 (47.1) 41 (52.6) 12 (50.0)
University 37 (43.5) 9 (52.9) 38 (44.7) 8 (47.1) 35 (44.9) 11 (45.8)
Occupation
Employed 63 (74.1) 16 (94.1) 62 (72.9) 17 (100.0)* 58 (74.4) 21 (87.5)
Unemployed 22 (25.9) 1 (5.9) 23 (27.1) 0 (0) 20 (25.6) 3 (12.5)

There was a significant association between the emotional statuses of DASS and the HbA1c
values of the respondents, especially in pre-diabetic values. In addition, there was a significant
difference between anxiety status and positive family history and stress status and appearance of
higher blood sugar (Table 3).

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Table 3. Differences between DASS status and clinical characteristics

Clinical Depression Anxiety Stress
characteristic N (%) No Yes No Yes No Yes
Family history of DM
No 40 (47.1) 5 (29.4) 42 (49.4) 3 (17.6) 38 (48.7) 7 (29.2)
Yes 45 (52.9) 12 (70.6) 43 (50.6) 14 (82.4)* 40 (51.3) 17 (70.8)
Smoking
Smokers 41 (48.2) 10 (58.8) 43 (50.6) 8 (47.1) 40 (51.3) 11 (45.8)
Nonsmokers 44 (51.8) 7 (41.2) 42 (49.4) 9 (52.9) 38 (48.7) 13 (54.2)
Comorbidity
No 26 (30.6) 7 (41.2) 27 (31.8) 6 (35.3) 27 (34.6) 6 (25.0)
Yes 59 (69.4) 10 (58.8) 58 (68.2) 11 (64.7) 51 (65.4) 18 (75.0)
DM therapy
Oral 59 (69.4) 15 (88.2) 59 (69.4) 15 (88.2) 57 (73.1) 17 (70.8)
Insulin 15 (17.6) 2 (11.8) 16 (18.8) 1 (5.9) 13 (16.7) 4 (16.7)
Oral + insulin 11 (12.9) 0 (0) 10 (11.8) 1 (5.9) 8 (10.3) 3 (12.5)
DM Duration (years)
≤1 15 (17.6) 1 (5.9) 15 (17.6) 1 (5.9) 15 (19.2) 1 (4.2)
1 – 4.9 36 (42.4) 8 (47.1) 35 (41.2) 9 (52.9) 33 (42.3) 11 (45.8)
5 – 9.9 26 (30.6) 7 (41.2) 27 (31.8) 6 (35.3) 24 (30.8) 9 (37.5)
10 – 14.9 5 (5.9) 1 (5.9) 5 (5.9) 1 (5.9) 3 (3.8) 3 (12.5)
≥ 15 3 (3.5) 0 (0) 3 (3.5) 0 (0) 3 (3.8) 0 (0)
Number of visits
Once a month 42 (49.4) 12 (70.6) 43 (50.6) 11 (64.7) 38 (48.7) 16 (66.7)
Once in two months 28 (32.9) 5 (29.4) 28 (32.9) 5 (29.4) 27 (34.6) 6 (25.0)
Once in three months 15 (17.6) 0 (0) 14 (16.5) 1 (5.9) 13 (16.7) 2 (8.3)
Blood sugar
≤ 6.0 11 (12.9) 1 (5.9) 12 (14.1) 0 (0) 12 (15.4) 0 (0)
≥ 6.1 74 (87.1) 16 (94.1) 73 (85.9) 17 (100.0) 66 (84.6) 24 (100.0)*

HbA1c
≤ 5.6 12 (14.1) 2 (11.8) 13 (15.3) 1 (5.9) 14 (17.9) 0 (0)
5.7 – 6.5 39 (45.9) 13 (76.5)* 38 (44.7) 14 (82.4)* 33 (42.3) 19 (79.2)*
≥ 6.6 34 (40.0) 2 (11.8) 34 (40.09 2 (11.8) 31 (39.7) 5 (20.8)

Logistic regression analysis (Table 4) indicated that age (OR=2.57, 95% CI: 1.59-4.13) was a
predictor of depression and anxiety statuses. Therefore, DM patients should be tested with the
DASS questionnaire at a young age. Other variables (occupation, family history of DM, blood
sugar, HbA1c) were not predictors of DASS status.

Table 4. Logistic regression model with DASS status as the dependent variable
Depression Anxiety Stress
Independent OR p OR p OR p
B B B
variable (95%CI) value (95%CI) value (95%CI) value
0.35 0.33 0.80
Age (years) -1.062 0.012 -1.104 0.023 -0.222 0.460
(0.15 - 0.79) (0.13 – 0.86) (0.44 1.44)
0.19 0.55
Occupation -1.619 0.182 -19.909 0 0.998 -0.597 0.408
(0.18 – 2.14) (0.13 2.27)
Family 1.72 3.43 2.09
0.545 0.384 1.233 0.089 0.739 0.157
history of DM (0.50 – 5.88) (0.83- 14.23) (0.75-5.82)
0.99 0.73 1.00
Blood sugar -0.006 0.968 -0.320 0.207 0.003 0.981
(0.75 – 1.31) (0.44-1.19) (0.78-1.28)
0.46 0.52 0.83
HbA1c -0.767 0.133 -0.652 0.231 -0.190 0.644
(0.17 – 1.26) (0.18-1.51) (0.37-1.85)

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Discussion in diabetes have been conflicting, with

some studies reporting age as a risk factor
The present study has shown that depression, for depression and other studies showing
anxiety, and stress are commonplace in patients that younger age was related to depressive
with DM. The prevalence of DASS in our study symptoms in DM patients.30,31 Our study
was 16.7%, 16.6%, 23.5% respectively. Many shows that DM patients should be tested
studies showed the prevalence of depression with the DASS questionnaire at a young
among diabetic patients to be within the range age, preferably at the onset of the disease.
of 8.5–27.3%. This was similar compared with Research has shown an increasingly clear
other studies using the DASS-21 assessment relationship between DM and a variety of
tool.2,9,10,17-19 mental health issues, which indicates that
DM patients should be tested as early as
This study found that an elevated HBA1c possible.32,33 In light of the prevalence of
level was an independent risk factor of DASS.9 DM with psychiatric comorbidities and the
Several studies, including ours, have shown a negative impacts of these factors, individuals
positive association between HbA1c levels and with diabetes should be regularly screened
DASS status.20,21 In a study in the Netherlands, with validated questionnaires or clinical
several individual depressive symptoms interviews.33-35
were related to higher HbA1c levels in DM
outpatients, and these associations persisted Various social and clinical factors, such as
over time.22 This explained the increase in gender, marital status, level of education, DM
glycemia, enhanced inflammation, and insulin duration, smoking status, number of doctor’s
resistance.23-25 Furthermore, DASS status was visits, DM therapy, and comorbidities,
also linked with poorer behavioral management were predicted to be associated with DASS
of diabetes and glycemic control.26 A number of status, but our study failed to prove such an
studies have shown that depression is associated association.20 The high prevalence of DASS
with poor perceived control of diabetes and and the limited number of predictors imply
poor self-care behaviours.27 In addition, that all patients with diabetes should be
measurement of HbA1c might provide patients screened for DASS. Some researchers have
with reassurance; as a result, these patients suggested screening for depression in patients
were less depressed. Stress status has been also with chronic diseases, such as DM.17,36
associated with glucose levels in DM patients.
Those sick from both depression and diabetes Several limitations may restrict broader
also tend to have higher primary healthcare application of our study. The findings of this
costs. Depression among diabetics is associated research are limited to the PHC center in
with poor glycemic control, which is one of Belgrade and therefore reflect only one main
causes of diabetic complications.28 This not only city in Serbia and an even smaller sample size.
puts a great burden on the healthcare system but For better representation and associations,
also directly affects quality of life for patients.12 we recommend that future studies involve
a larger number of samples. Since this was
Our study also found that occupation appears a cross-sectional study, it did not allow for
to be a predictor for anxiety symptoms. cause-and-effect relationships to be studied.
Patients who were working were more likely to Second, the DASS-21 questionnaire is
experience anxiety compared with those who only a screening tool and not diagnostic of
were unemployed. Those employed may have specific psychiatric disorders. Finally, there
been too busy to understand their illness and remains the possibility of recall biases from
thus did not have time to focus on their health, respondents.
which may explain their lack of DM control.
Conclusion
Our study revealed that a family history of DM
was also a predictor of anxiety. These findings Clearly, our results show that unpleasant
were consistent with other studies, which emotional states, DASS, are common in
showed that family history was a predictor of DM patients in Belgrade, with 16.7%
DASS among patients with diabetes.9,15,18,29 experiencing depression, 16.6% experiencing
anxiety, and 23.5% experiencing stress. Age
Along the same lines, age was associated with is the strongest predictor of DASS status.
symptoms of depression and anxiety. Findings The screening and monitoring of DASS in
for the relationship between age and depression people with DM should be performed from

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 ORIGINAL ARTICLE

a young age. These findings also suggest that Ethical approval: The study was approved
the healthcare system must evolve to better by the Ethics Committee of the Primary
address the psychological burdens associated Health Care Center New Belgrade no. 29/5.
with diabetes. It is essential that health Participation in the research was voluntary.
professionals conduct early assessments and Anonymity, confidentiality, and privacy of data
identify DASS states in people with DM. were explained and guaranteed. Verbal consent
was obtained from participants after explaining
Acknowledgements the research aims and the confidentiality of data.

We are very grateful to the PHC center New Conflicts of interest: I declare that I have no
Belgrade and the patients who took part in financial or personal relationship(s) which may
the research and who devoted their time to have inappropriately influenced me in writing
completing the questionnaires. this paper.

How does this paper make a difference to general practice?

• The incidence of diabetes mellitus is increasing.

• People with diabetes have a greater risk of developing unpleasant emotional states,
depression, anxiety, and stress.
• DASS among diabetics is associated with poor glycemic regulation.
• This puts a great burden on the healthcare system but also directly affects quality of life in
patients.
• The screening and monitoring of unpleasant emotional states in people with diabetes
should be performed as soon as possible, preferably at the onset of the disease.

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