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South Asian Journal of Psychiatry (volume 3:2, March 2015) 10

Introduction

Diabetes represents a major public health

burden, both locally and globally (Wild, Roglic,

Green, Sicree, & King, 2004). An estimated 285

million people corresponding to 6-8% of the adult

population lived with diabetes in 2010. The

number is expected to increases to 438 million by

2030. With an estimated 50.8 million people living

with diabetes, India has the world’s largest

population followed by china with 43.2 million

people (International Diabetes Federation, 2009).

The prevalence of psychiatric morbidity among

insulin-dependent patients is 18% and consists of

depression, anxiety, and attendant symptoms

(Wilkinson et al., 1988). In contrast the incidence

of diabetes mellitus in psychiatric patients has

been found to be two to eight times higher than in

the general population (Blanz, Rensch-Riemann,

Fritz-Sigmund, & Schmidt, 1993; Cassidy,

Ahearn, & Carroll, 1999; Mukherjee, Decina,

Bocola, Saraceni, & Scapicchio, 1996). Diabetics

are twice as likely as the general population to

suffer from depression, with the risk higher in

RESEARCH PAPER

Psychiatric morbidity in patients with Diabetes Mellitus: A hospital based study in Kashmir

Sheikh Shoib1, Mohammad Maqbool Dar1, Haamid Bashir2, Tasleem Arif1

1 Department of Psychiatry, SMHS Hospital Srinagar 2 Department of Biochemistry, University of Kashmir

Abstract:

Background: Diabetes mellitus (DM) is an illness that in addition to its physical consequences

has psychological and social impairments. The association between DM and psychiatric disorders

are considered bidirectional and this study looked at the pattern of psychiatric morbidity in

patients with DM.

Methodology: We conducted a cross-sectional study over a period of one year in SMHS

Government medical college associated Hospital in Srinagar. We selected every alternate patient

with DM attending the endocrinology outpatient clinic. A semi structured interview was

conducted along with the administration of the Mini International Neuropsychiatric Interview –

Plus (MINI - Plus) for evaluation of psychiatric symptoms and diagnosis. An age and sex matched

control group (n = 200) was selected from among non-diabetic patients.

Results: Out of total 200 subjects 87 were males (43.5 %), and 113 were females (56.5 %). The

mean age was 45 ± 15 years. 71% were married and 11.5% were unmarried. 57% of patients

with DM had significant psychiatric morbidity. Only 25.5% of the control group had psychiatric

problems (p=<0.005). Depressive disorder (13.5%) was the most common presentation,

followed by Adjustment disorder (7.5%), Premenstrual dysphoric disorder (6.5%), Panic disorder

(6%), Generalized anxiety disorder (5.5%), Dysthymia (4.5%), Suicidality (4%), Mixed anxiety

(1.5%) and OCD and agoraphobia (1.5%) each.

Conclusion: The increased frequency of psychiatric morbidity among patients with DM raises the

need for early diagnosis and treatment.

Key words: Diabetes mellitus, psychiatric morbidity.

Research Paper Psychiatric morbidity in patients with Diabetes Mellitus: A hospital based study in Kashmir


women than in men. During 5 year follow up, up

to 80% of diabetics have recurrence of depressive

episodes (P. J. Lustman, Griffith, Freedland, &

Clouse, 1997; Robinson, Fuller, & Edmeades,

1988). Diabetics suffering depression have a

higher incidence of suicidal ideations (Goldston et

al., 1997). Depression and anxiety in particular, are

more frequent in diabetic patients, compared to the

general population (P. J. Lustman et al., 2000; Pita

et al., 2002). Psychological stress factors play an

active role in both the etiology and the metabolic

control of DM (Cox & Gonder-Frederick,

1992).Other contributing factors in type 2 DM

pathogenesis include environmental and lifestyle

factors (Bener, Zirie, Musallam, Khader, & Al-

Hamaq, 2009; Bener, Zirie, Janahi, et al., 2009;

Kriska et al., 2003), positive family history

(Erasmus et al., 2001), ethnicity (Abate &

Chandalia), and genetics (Bener, Zirie, Musallam,

et al., 2009; Bener, Zirie, Janahi, et al., 2009; Sesti,

Federici, Lauro, Sbraccia, & Lauro).

The adverse influence of depression on the

course of diabetes has been discussed extensively

(P. Lustman & Anderson, 2002). Screening leads

to high stress among those with a positive result,

or false reassurance in those with a negative result

where the subjects are less likely to take

appropriate corrective action (Madhu & Sridhar,

2005).

Patients with mental health disorders receive

even less intensive medical care for DM (Desai,

Rosenheck, Druss, & Perlin, 2002; Frayne et al.).

Adherence to treatment in DM was adversely

affected by the occurrence of natural calamities

(Ramachandran, 2005). A lesser degree of

psychological distress not amounting to

psychiatric morbidity is also more common

(Sridhar & Madhu, 2002). The quality of life of the

patient is adversely affected due to the knowledge

about the course of illness, restriction of diet and

activity, closely monitored management schedules

and the continued risk of acute and chronic life

threatening complications (Kovacs, Goldston,

Obrosky, & Bonar, 1997). “Diabetes burnout” and

“Diabetes overwhelmus” are the words used often

to describe the distress experienced by DM

patients (Balhara, 2011). The aim of the study was

to assess the pattern of psychiatric morbidity in

patients with DM.

Methodology

We conducted a cross-sectional study over a

period of one year in the SMHS Government

medical college associated Hospital in Srinagar.

Every alternate patient attending the

endocrinology outpatient clinic was included after

informed consent. A total of 200 patients were

included in the study. Demographic data and

psychiatric history were recorded using a semi

structured interview. Patients were subjected to the

Mini International Neuropsychiatric Interview -

Plus (MINI - Plus) for evaluation of symptoms and

diagnosis. The MINI-Plus is a DSM-IV based

diagnostic interview with high reliability and

validity. An age and sex matched control group

(n=200) was selected from non-diabetic patients

were also administered the same instruments.

Diabetes was diagnosed based on drug

treatment for diabetes (insulin or oral

hypoglycemic agents) and/or criteria laid by the

ADA in 2004 i.e. fasting plasma glucose (FPG)

126 mg/dl or 2 hour post-glucose value of 200

mg/dl. Impaired glucose tolerance (IGT) was

diagnosed if FPG was <126 mg/dl and 2 hour.

post- glucose value (140 mg/dl and <200 mg/dl

(American Diabetes Association, 2004). The

diabetics included both insulin dependent and non-

insulin dependent patients. Patients with past

history or family history of diabetes mellitus in

both the groups were not included in this study.

Similarly, patients suffering from other physical

disorders were also excluded, as were those who

were unwilling to participate. Ethical approval for

the study was obtained.

Results

Two hundred diabetic patients from the

endocrinological departments of Govt. Medical

College, Srinagar hospital were included in the

study. There were 87 males (43.5%), and 113

females (56.5%). Most of the participants were in

the 41-50 year age group (33.5%) followed by 51-

60 years (22.5%) (Table 1). Psychiatric co-

morbidity was significantly higher among females

than in the males (p=0.0097) (Table-2).

Psychiatric co-morbidity was also higher in the

rural population than in the urban population

(p<0.001). There was no significant difference in


12 South Asian Journal of Psychiatry (volume 3:2, March 2015)

the number of the patients in whom the psychiatric

co-morbidity was present and in those in whom it

was absent in the different socio-economic status

of patients. The p-value of the comparison is

0.0025 which is significant.

Of the diabetics, 57% were found to have

psychiatric morbidity in contrast to 25% in a non-

diabetic control group (p=0.0027). Depressive

disorder (13.5%) was the most common morbidity,

followed by adjustment disorder (7.5%),

premenstrual dysphoric disorder (6.5%), panic

disorder (6%), generalized anxiety disorder

(5.5%), dysthymia (4.5%), suicidality (4%), mixed

anxiety (1.5%), OCD and agoraphobia (1.5%) and

other disorders as tabulated. Among the control

group, the most common diagnoses were

depressive disorder and panic disorder (3.5%) and

adjustment disorder (2.5%).

Characteristic Present Absent p value

n % n %

Age (years)

≤ 25 8 53.3 7 46.7

0.0043

26 to 40 23 71.8 9 28.1

41 to 50 38 62.2 23 37.7

51 to 60 23 51.1 22 48.8

61 to 70 14 45.2 17 58.8

> 70 8 50 8 50

Gender Male 38 43.7 49 56.3

0.0097 Female 76 67.6 37 32.8

Dwelling Rural 71 62.2 51 44.7

p < 0.001 Urban 43 55.1 35 44.9

Marital status

Unmarried 11 47.8 12 52.2

1.257 Married 90 63.3 52 36.6

Widowed 13 37.1 22 62.9

Occupation

Household 68 63.6 39 36.4

0.0058

Unskilled 19 61.2 12 38.7

Semiskilled 17 51.5 16 48.4

Skilled 9 36 16 64

Professional 1 25 3 75

Family type

Nuclear 49 56.3 38 43.7

p < 0.005 Joint 21 43.8 27 56.2

Extended 44 67.7 21 32.3

Literacy status Illiterate 68 58.1 49 41.9

0.0016 Literate 46 55.4 37 44.6

Family Income (Rs)

< 5000 19 51.4 18 48.6

2.572 5000 to 10000 82 71.9 52 38.1

> 10000 13 44.8 16 55.2

Socioeconomic status (Kuppuswamy Scale)

Lower 11 52.4 10 47.6

0.0025

Upper lower 7 36.8 12 63.2

Middle 81 63.8 53 41.7

Upper middle 10 41.7 14 58.3

Upper 5 55.5 4 44.5

Table 1 - Demographic characteristics of the studied patients



Characteristic n %

Age (years)

≤ 25 15 7.5

26 to 40 32 16

41 to 50 61 30.5

51 to 60 45 22.5

61 to 70 31 15.5

> 70 16 8

Mean ± SD 45 ± 15

Gender Male 87 43.5

Female 113 56.5

Dwelling Rural 122 61

Urban 78 39

Marital status

Unmarried 23 11.5

Married 142 71

Widowed 35 17.5

Occupation

Household 107 53.5

Unskilled 31 15.5

Semiskilled 33 16.5

Skilled 25 12.5

Professional 4 2

Family type

Nuclear 87 43.5

Joint 48 25

Extended 65 32.5

Literacy status

Illiterate 117 58.5

Primary 13 6.5

Secondary 22 11

Matric 27 13.6

Graduate 17 8.5

Postgraduate/Professional 4 2

Family Income (Rs)

< 5000 37 18.5

5000 to 10000 134 67

> 10000 29 14.5

Socioeconomic status (Kuppuswamy Scale)

Lower 21 10.5

Upper lower 19 9.5

Middle 127 63.5

Upper middle 24 12

Upper 9 4.5

Group Number of patients

with psychiatric comorbidity

Percentage of psychiatric

comorbidity p value

Index group (n=200) 114 57 p < 0.0027

Control group (n=200) 57 25.5

Table 2 - Psychiatric co-morbidity across socio-demography of the patients

Table 3 - Morbidity compared with control group



Major depressive disorder, dysthymia,

suicidality, panic disorder, social anxiety disorder,

OCD and mixed anxiety and depression were

significantly higher in the patients with DM.

Generalized anxiety disorder, dysthymia,

agoraphobia, specific phobia, alcohol and

substance dependence, adjustment disorder,

premenstrual dysphoric disorder and psychotic

disorders were not associated with DM (Table 4).

Discussion

This cross-sectional study found DM to be

associated with high psychiatric morbidity

including major depressive disorder. We found

twice the frequency of psychiatric disorders as

compared to non-diabetics which is comparable to

a study done by Kovacs M et al (1997) with had a

prevalence of 47.6% for psychiatric disorders in

DM. Another study carried by Sushil and Vyas

(1990), reported that 74% of those with DM had

psychiatric comorbidity. Our findings are also

consistent with a study done by Lloyd and Brown

(2002) who found that all psychiatric disorders and

especially depression was more common in DM.

Other studies too highlight a range of psychiatric

co-morbidity (Lloyd et al.). In DM, the

hypothalamic pituitary adrenal axis is implicated

in the aetiology of depression (Brown, Varghese,

& McEwen, 2004). Persons in all ages are at risk

of psychiatric morbidity in DM (Crooks,

Buckwalter, & Petitti, 2003; Dantzer, Swendsen,

Maurice-Tison, & Salamon, 2003). Some studies

show that treatment with hypoglycemic medicines

may also lead to severe anxiety (Carney, 1998).

The relationship between DM and psychiatric

morbidity is bidirectional. DM per se may result in

psychological distress and vice versa, psychiatric

illness may lead to poor lifestyle measures which

may lead to metabolic syndrome and DM

(Coclami & Cross, 2011).

Conclusions

Routine screening for psychiatric disorders

should be considered in DM, considering the high

morbidity shown in many studies including ours.

Psychiatric disorders Index group

% Control group

% p value

Major depressive disorder 27 13.5 7 3.5 0.0036

Dysthymia 9 4.5 4 2 0.0489

Suicidality 8 4 3 1.5 0.0185

Panic disorder 12 6 7 3.5 0.0256

Alcohol abuse and dependence disorder 3 1.5 2 1 0.448

Generalized anxiety disorder 11 5.5 6 3 0.859

PTSD 1 0.5 1 0.5 p < 0.001

Social anxiety disorder 2 1 1 0.5 p < 0.005

Mixed anxiety-depressive disorder 3 1.5 1 0.5 0.0285

Premenstrual dysphoric disorder 13 6.5 6 3 0.0789

Psychotic disorder 1 0.5 0 - 1.256

OCD 3 1.5 2 1.5 0.0111

Agoraphobia 3 1.5 2 2 0.458

Specific phobia 3 1.5 4 2 0.586

Adjustment disorder 15 7.5 5 2.5 0.789

Total psychiatric comorbidity 114 57 51 25.5 p < 0.005

Table 4 - Pattern of psychiatric morbidity



Early identification and treatment will improve the

outcome of both conditions. All health

professionals should be educated to intervene

appropriately.

Declaration of interest

None

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