Volume 9, Issue 8, August – 2024 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24AUG927

Prevalence and Risk Factors of Psychiatric Symptoms

among Type 2 Diabetes Mellitus Patients in South
India: A Cross-Sectional Study.
Suguna Utchimahali1; S. Kannan2 Kumaravel Velayutham3
Ph.D. Research Scholar1; MD., MSc. Diab(Lond), DNB(Endo), MNAMS,
Ph.D. Professor, Head & Chairperson 2 Director & Consultant Endocrinologist,
Department of Environmental Studies, School of Energy, Alpha Hospital & Research Centre Institute
Environment and Natural Resources, Madurai Kamaraj of Diabetes and Endocrinology,
University, TN, India. TN, India.

Abstract:- Keywords:- Type 2 Diabetes Mellitus, Uncontrolled

Diabetes, Depression, Anxiety, Stress, Statistical Analysis.
 Background:
Type 2 diabetes mellitus poses a momentous I. INTRODUCTION
challenge when accompanied by psychiatric symptoms
like depression, anxiety, and stress, adding to the Diabetes mellitus (DM) is a severe and chronic inherited
complaint's threat. Research on these factors in patients metabolic disorder affecting 530 million people globally,
with uncontrolled chronic illnesses in India, particularly with a significant prevalence of three in every four adults
in Tamil Nadu, is limited. Hence, this study aims to living in low and middle-income countries.[1] In 2019,
determine the prevalence and risk factors of these diabetes caused 4.2 million deaths and accounted for at least
psychiatric symptoms among Type 2 diabetes patients. 10% of the global health expenditure, amounting to USD 760
billion.[2] According to the World Health Organization
 Methods: (WHO) 2022, India ranks second globally, with 74.9 million
A cross-sectional study was conducted in Alpha adults (aged 20-79) living with diabetes, and this number is
Hospital and Research Center in Madurai, South India, expected to rise to 124.8 million by 2045.[3] In Tamil Nadu,
from April 2020 to March 2021, enrolling 614 participants the prevalence of diabetes is notable, accounting for 21.9%,
(307 with Type 2 diabetes mellitus and 307 general 20.3%, and 13.4% in cities, towns, and peri-urban villages,
population). Data were collected using Hamilton respectively.[4]
Depression Rating Scale, Hamilton Anxiety Rating Scale
and Perceived Stress Scale. The IBM SPSS version 23 was Type 2 diabetes mellitus (T2DM) is the most common
used for statistical analysis. form of diabetes in India. It is characterized by chronic
hyperglycemia resulting from insulin resistance or
 Results: insufficient insulin production.[5] Persistent hyperglycemia
Two-thirds of youth women with type 2 diabetes in uncontrolled diabetes mellitus can cause several
have higher fasting blood sugar levels than men when complications such as cardiovascular disease, hypertension,
compared to general population. 82.61% of patients with chronic kidney disorder, neuropathy, nephropathy, and
uncontrolled diabetes developed severe stress, surpassing retinopathy.[6] People with T2DM have higher risks of
those with well-controlled and pre-diabetes. Severe morbidity, mortality, [7] and increased healthcare costs
depression is most prevalent among patients with compared to the general population.[2]
neuropathic foot ulcers (54.76%) and nephropathy
(61.54%). Predominant mental health risk factors include Comorbid psychiatric symptoms like depression,
being single, high school education, poor glycemic control, anxiety, and stress (DAS) can make managing type 2 diabetes
comorbid hypertension, and family history. Interestingly, (T2DM) extremely difficult. These symptoms are the most
lifestyle factors like alcohol use and smoking positively common mental illnesses in current times, and they can either
impact mental health outcomes. contribute to the progression of the disease or increase the risk
of developing diabetes [8]. Prolonged exposure to this
 Conclusion: circumstance makes it an integral part of the patient's life.
This study shows the intricate connection between These symptoms have several detrimental effects on the
Type 2 diabetes and mental health problems in Madurai, patient's health, including medication non-adherence, rapid
emphasizing the necessity for a multidisciplinary strategy disease progression, and a generally poor prognosis.[9]
to enhance outcomes and reduce financial burden. Future
research in nursing has to focus on implementing and
assessing therapies aimed at reducing patients' stress,
anxiety and depression.

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Volume 9, Issue 8, August – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24AUG927
The World Health Organization highlights the two-way II. MATERIALS AND METHODS
relationship between physical and mental health. However, in
India, the focus on treating diabetes often prioritizes the A. Research Design
physical complications of type 2 diabetes (T2DM), with little A cross-sectional study was carried out from December
attention to the mental well-being of these patients. Factors 19, 2020, to December 30, 2021, with 614 participants,
contributing to DAS vary across study populations and have consisting of 307 patients with T2DM and 307 individuals
not been adequately studied together using standard from the general population. The process that was followed
psychological tools in the population of South India, for the study is shown in Fig. 1. Using the probability
particularly in Tamil Nadu. [10,11] Additionally, there is a selection method, the participants were chosen from the
lack of studies investigating the prevalence of DAS in diabetic and endocrinology-focused Alpha Hospital and
individuals with T2DM compared to the general population. Research Centre in Madurai, Tamil Nadu, India. People had
The current study aims to analyze the prevalence and risk to be willing to participate in order to meet the inclusion
factors associated with these conditions at a tertiary care requirements, and the study was not open to anyone with a
center in the Madurai district of Tamil Nadu. history of serious illness or mental health disorders. As a
comparison group, a general population group with
comparable sociodemographic and clinical characteristics
(FBS levels) was gathered. The majority of the people in this
category were the patients' healthy relatives.

Fig 1: Selection Process Followed for the Studied Participants

B. Data Collection alcohol consumption, and difficulty sleeping were also

investigated. Diabetes diagnosis followed the American
 Assessment of Socio-Demographic and Clinical Profile: Diabetes Association's guidelines, with patients considered
The study used a structured form to gather diabetic if they had HbA1c levels of 6.5% or higher [6], or
sociodemographic information from all participants through fasting plasma glucose levels of 126 mg/dL or higher in two
interviews. This included age, gender, marital status, separate tests.[13]
educational qualification, occupational status, monthly
income, and socioeconomic status based on Kuppuswamy's  Assessment of Depression, Anxiety and Stress:
modified Socioeconomic Status scales.[12] Biochemical test The assessment of Depression, Anxiety, and Stress
reports were obtained from the hospital database on the same utilized three scales, the Hamilton Depression Rating Scale
day of the patient’s visit. In addition to this, the researcher (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), and
collected the clinical profiles of T2DM participants through the Perceived Stress Scale (PSS).
the interview method. Lifestyle habits related to smoking,

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Volume 9, Issue 8, August – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24AUG927
HAM-D was employed to gauge the presence and D. Ethical Approval and Informed Consent Statements
severity of depression over the past week. This scale is widely This study was approved by the Internal Research and
acknowledged as the gold standard for assessing depression Review Board (IRB), Ethical Clearance (EC), Biosafety and
and has been extensively used in India. On the 17-item HAM- Animal Welfare Committee of Madurai Kamaraj University,
D scale, the scores between 0 and 7 suggest normalcy, 8-13 Madurai (Registration ID: EC/MKU/20-21/039) on 11th
indicate mild depression, 14-18 indicate moderate December 2020. All participants provided written informed
depression, and a score of 19 - 54 indicates severe depression. consent prior to enrolment in the study. This research was
A study by Dedeken., et al. found that Cronbach’s alpha for conducted ethically in accordance with the World Medical
the HAM-D 17 items was 0.92, indicating a high level of Association Declaration of Helsinki.
internal consistency.[14]
E. Statistical Analysis
The HAM-A is a tool used to measure anxiety The data was entered into Microsoft Excel, and IBM
symptoms through 14 different items. Scores on the scale SPSS Version 23.0.1.0 was used for data analysis. A
range from 0 to 56, with a score of less than 17 indicating descriptive statistical analysis was conducted for continuous
mild severity, 18-24 indicating mild to moderate severity, and and categorical variables. The normalcy was evaluated using
25-30 indicating moderate to severe conditions. The scale has the Shapiro-Wilk test. Non-parametric tests such as the
a high level of internal consistency, indicated by Cronbach's Kruskal-Wallis H test, Mann-Whitney U test, and Chi-square
alpha of 0.893.[15] test were used because it was discovered that the data was not
normally distributed. Binary logistic regression models were
Perceived Stress Scale (PSS) is used to assess perceived applied to examine associations between predictor variables
stress levels. This scale used a five-point Likert scale ranging and the risk of DAS. In the Multivariate logistic regression
from 0 (never) to 4 (very often) to gauge responses to model, severe depression and very severe depression cases
questions such as "In the last month, how often have you felt were grouped into a "severe depression" category, leaving the
upset?" Increases in perceived stress were correlated with other severity levels unaffected. Odds ratios (OR) with 95%
higher scores on the measure. The scale showed good internal confidence intervals were calculated to determine
consistency with a Cronbach's alpha of 0.85.[16] independent associations between T2DM and
depression/anxiety disorders. The P value of 0.05 was used
C. Sample Size Determination as the standard for statistical significance.
In an initial pilot study, 40 participants with T2DM were
(excluded from the main study) to determine the sample size. III. RESULTS
The prevalence of DAS symptoms among 11 out of the 40
T2DM patients was found to be 27.5%. Following the Central A cross-sectional study in Madurai, Tamil Nadu,
Limit Theorem by Hans Fischer [17], the sample size (n) was examined the prevalence of DAS and its risk factors among
calculated using the formula: N = (Z^2 x p x (1-p))/d^2. In T2DM patients. Out of 614 participants, 307 had T2DM, and
this formula, 'N' represents the desired sample size, 'Z' is the 307 were from the general population. The study highlighted
standard normal deviation at a 95% confidence interval the demographic, socioeconomic, mental health, and clinical
(1.96), 'p' is the prevalence value of DAS symptoms among factors affecting FBS levels in T2DM patients, unlike the
T2DM (0.275), and (1−p) represents the margin of error (5%). stable levels in general individuals.
The minimum sample size calculated was 306.24, rounded up
to 307 using this formula.

Table 1: Characteristics of T2DM Patients and Healthy Individuals and their Association with Fasting Blood Sugar Levels
Descriptive statistics Healthy Group (n=307)
T2DM patients (n=307) Fasting Blood Sugar Levels
Fasting Blood Sugar Levels
Variables Category N (%) Median U/H N (%) Median U/H
(Q1, Q3) score (Q1, Q3) Score
Socio-demographic Profile
Age (years) 18-23 39 (12.7) 139.21 2.900 19 (6.18) 98.3 2.394
(125.31,218.92) (89.5,99)
24-40 134 (43.6) 162.56 22 (7.16) 98.3
(127.7,238.58) (89.5,99)
41-60 113 (36.8) 145.7 132 (43) 98.3
(127.86,229.12) (97.3,99.11)
61 and 21 (6.8) 157.3 114 (37) 98.2
above (127.88,218.92) (97,98.8)
Gender Male 107 (34.9) 144 10059.5 113 (36.8) 98.3 10447.5
(127.33,235) (97,99)
Female 200 (65.1) 157.2 194 (63. 1) 98.2
(127.33,235) (97.2,99)
Marital Unmarried 54 (17.6) 159.87 1.735 55 (17.9) 98.3 0.630

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Volume 9, Issue 8, August – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24AUG927
Status (126.48,238) (97,99)
Married 223 (72.6) 157.51 214 (69.7) 98.3
(127.91,235.61) (97.4,98.9)
Others 30 (9.8) 136 38 (12.3) 98
(126.64, (96.9,99)
218.21)
c
Educational No formal 87 (28.3) 188.13 5.510 77 (25) 98.11 1.713
Qualification Education (128.31,245.32) (95.52, 99)
to middle
school
High School 82 (26.7) 143.11 85 (27.6) 98.11
(126.4,181.55) (97.3,99)
Diploma 138 (45) 161 145 (47.2) 98.3
and above (126.94,238.58) (97.3,99)
Occupation Unemployed 193 (62.9) 143.33 1.181 75 (24.4) 98.3 0.024
(127.8,221.53) (96.9,99)
Daily Wage 48 (15.6) 147.87 114 (37) 98.2
and (127.58,223.5) (97,99)
Business
Others 66 (21.5) 160.27 118 (38.4) 98
(126.61,247.42) (97.6-99)
b
Income Housewife 135 (44) 160.27 7.295 125 (40.7) 98.3 0.770
(in Rupees) /Student (126.61,247.4) (97.3,99)
less than 72 (23.5) 157,42 141 (45.9) 98.2
18496 (126.52,237.16) (97.99)
18497 above 100 (32.6) 144.41 41 (13.3) 98.3
(128.17,221.88) (95.4, 99.3)
Economic Upper class 34 (11.1) 128.32 (118.13- 1.529 22 (7.16) 98.2 0.331
status 219) (95.6,98.8)
Middle class 78 (25.4) 160.20 141 (45.9) 98.3
(128.11,237.11) (97,99)
Lower class 195 (63.5) 147.92 144 (46.9) 98.3
(126.8,230.13) (97.3, 99)
Mental Health Risk Factors
Depression Mild 72 (23.45) 188 2.069 256 (83.3) 98.26 0.838
(127,255) (97,99)
Moderate 74 (24.1) 146 49 (15.9) 98.3
(125.8,237.9) (97.5,99)
Severe 160 (52.11) 145 2 (0.65) 95.5
(128,225.6) (92.7,99)
Anxiety Mild 35 (11.4) 231 3.211 202 (65.7) 98.3 1.729
(128,276) (97.3,99)
Moderate 39 (12.7) 158.4 96 (31.2) 98.26
(123.6, 235.6) (96.9,99)
Severe 233 (75.89) 147.9 9 (2.93) 98
(127.5,225) (94.5,98.5)
Stress Mild 16 (5.21) 128.98 3.275 147 (47.8) 98.2 1.065
(123.4,217) (97,99)
Moderate 152 (49.51) 160 156 (50.8) 98.3
(128,235.9) (97.3,99)
Severe 139 (45.27) 144.6 4 (1.3) 97.8
(127,225.8) (91.7,98)
Clinical Profile
Body Mass Normal 165 (53.74) 147 535.5
Index (BMI) (126.4,235)
Overweight 120 (39) 159.4
(127.9, 235)
Obese 22 (7.16) 150.6
(128,231.6)
Adherence to Yes 156 (50.8) 146.4 11559

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Volume 9, Issue 8, August – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24AUG927
Healthy (128,228.9)
Diet (ADH) No 151 (49.2) 160
(126.5,237)
Medical T2DM 244 (79.5) 152.8 7515.5
Condition (127.9, 230.8)
T2DM + 63 (20.5) 156.7
HTN (125,237)
Adherence to Yes 60 (19.5) 143.9 6878
Physical (128,220.6)
Activity No 247 (80.5) 157.5
(APA) (127.2,236)
Family Present 120 (39.1) 136.4 9820
History (126, 227.5)
Absent 187 (60.9) 160
(128, 235.61)
Menstrual Present 15 (7.5) 188.2 347.24
Irregularities (126,243)
(n=200) Absent 185 (92.5) 152.3
(127.5,233)
a
Smoking Present 4 (1.3) 259 203.50
(228.8,296)
Absent 303 (98.69) 148.5
(127,233.5)
Alcohol use Present 46 (15) 177.9 5655.5
(126.8,236)
Absent 261 (85) 147.9
(127,231.47)
a
Insomnia Present 68 (22.1) 190.5 6523
(128.7,261)
Absent 239 (77.9) 145.7
(126.8,225)
On OHD 212 (69.06) 157 12.362
Medication (127.5,233)
IT 59 (19.21) 145.7
(126.5,255)
Both 36 (11.73) 148.2
(128.2,224.8)
Complication Present 177 (57.65) 165.57 445.429
(128.27-
245.41)
Absent 130 (42.34) 144
(126.77-
223.33)
Note: aP < 0.05, bP < 0.01, cP < 0.001 ( P = Significant Value)

Table 1 displays the sociodemographic profile, mental higher in T2DM patients compared to the general population
health well-being status, and comparison of FBS scores i.e. depression (23%, 24%, 52% vs. 83.3%, 16%, 0.65%),
between T2DM patients and the general population based on anxiety (11%, 13%, 78% vs. 65.7%, 31.2%, 2.93%), and
the descriptive analysis and Mann-Whitney U test stress (5%, 50%, 45% vs. 47.8%, 50.8%, 1.3%). In T2DM
respectively. The median FBS levels of T2DM patients aged patients, mild depression [188 (Q1: 127, Q3: 255)] and mild
24 to 40 years (44%) [162.56 (Q1: 127.7, Q3: 238.58)] and anxiety [231 (Q1: 128, Q3: 276)] are linked to increased FBS
females (65%) [157.2 (Q1: 127.33, Q3: 235)] are higher than levels, while FBS levels in healthy individuals remain consistent
those of their counterparts. General population without DM across mental health categories. Among T2DM patients, only 4
have constant median FBS levels across age groups and smoked, and 22.10% suffered from insomnia, both showing high
genders. In T2DM patients, FBS levels were statistically FBS levels [259 (Q1: 228.8, Q3: 296), p < 0.05] and [190.5 (Q1:
128.7, Q3: 261), p < 0.05], respectively. Other clinical factors
significant among the lowest income category, including associated with high median FBS levels included BMI (overweight
housewives and students (n=135) [160.27 (Q1: 126.61, Q3: 39%), diabetic complications (57.65%), oral hypoglycemic
247.4), p = 0.01], and those with no formal education up to medications (69.06%) and alcohol use (15%). Notably, 60.9%
middle school (n=28) [188.13 (Q1: 128.31, Q3: 245.32), p = of T2DM patients without a family history of diabetes
0.001]. The mild, moderate and severe levels of DAS were showed higher FBS levels [160 (Q1: 128, Q3: 235.61)].

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Volume 9, Issue 8, August – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24AUG927

Fig 2: Impact of DAS on the Diabetes Status among the T2DM Patients

Fig. 2 demonstrates the impact of DAS on the diabetes In Table 2, the fully adjusted logistic regression analysis
status among patients with Type 2 Diabetes Mellitus (Model 2), perceived stress was found to be significantly
(T2DM). It indicates that in patients with controlled type 2 associated with participants' Married status (AOR: 0.000, p =
diabetes, severe depression (54.76%), severe anxiety 0.02), FBS levels (AOR: 2943.3, p = 0.009), comorbid
(50.00%), and severe stress (80.95%) are highly prevalent; in conditions of T2DM and hypertension (AOR: 0.000, p =
pre-diabetes patients, there is significant difference in 0.04), APA (AOR: 0.000, p = 0.03), and family history (AOR:
moderate (52.38%) and severe (39.68%) depression, severe 17261.6, p = 0.03). Similarly, anxiety scores showed
anxiety (61.90%), and severe stress (79.37%); in patients with significant associations with participants' high school
uncontrolled type 2 diabetes, there is a higher likelihood of educational qualification (AOR: 6.185, p = 0.02), mode of
moderate (52.17%) and severe (47.83%) depression, severe treatment – “Both” with OHD and Insulin therapy (AOR:
anxiety (65.22%), and severe stress (82.61%). 0.209, p = 0.01) and smoking (AOR: 0.036, p = 0.03).
Furthermore, depression scores were found to be significantly
associated with participants' single status (AOR: 5.540, p =
0.03), high school educational qualification (AOR: 3.312, p =
0.01), and alcohol use (AOR: 0.382, p = 0.02).

Table 2: Mental Health Risk Associated with T2DM Patients

Stress Anxiety Depression
a c d
Personal COR Model Model 2 COR Model Model 2 COR Model Model 2
Background [95% 1 [95% CI] 1 [95% 1
e b
CI] AOR AOR AOR AOR CI] AOR AOR
[95% [95% CI] [95% [95% CI] [95% [95%
CI] CI] CI] CI]
Socio-Demographic Profile
Age 2.949 146.6 1.903 1.211 1.111 0.575
18-23 years f® [0.752- [0.004- [0.746- [0.262- [0.501- [0.171-
24-40 years 11.52] 587] 4.854] 5.599] 2.465] 1.932]

41-60 years 1.731 0.037 3.908 2.662 1.721 0.850

[0.478- [0.000- [1.313- [0.457- [0.741- [0.230-
6.265] 155.5] 11.628] 15.502] 4.00] 3.132]
61 years and 0.000 0.000 1.097 0.836 0.982 0.525
above [0.288- [0.101- [0.303- [0.104-
4.181] 6.940] 3.183] 2.652]
Gender Male® 0.886 5.097 1.283 2.341 0.756 1.707
Female [0.313- [0.001- [0.624- [0.426- [0.429- [0.459-
2.508] 34007.1] 2.639] 12.853] 1.332] 6.342]
m l m
Marital Status 0.218 0.000 0.345 0.404 0.778 0.969
Unmarried® [0.073- [0.000- [0.161- [0.124- [0.402- [0.383-

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0.650] 0.276] 0.741] 1.324] 1.502] 2.453]
Married
k l
Others 0.454 0.47 0.000 0.000 4.583 5.540
[0.090- [0.13, [1.058- [1.097-
2.293] 1.64] 19.864] 27.990]
l k m l
Education 1.975 14155.0 4.626 6.185 2.903 3.312
Qualification [0.571- [0.640- [1.267- [1.310- [1.294- [1.252-
No formal 6.826] 313042.2] 16.887] 29.210] 6.514] 8.765]
Education
to middle school
®
High School
Diploma and 3.392 51.130 1.100 1.305 1.061 0.883
above [ 0.990- [0.496- [0.513- [0.412- [0.585- [0.389-
11.630] 526.8] 2.359] 4.133] 1.926] 2.0]
l
Occupation 1.297 0.052 1.900 6.185 2.56 2.739
Unemployed® [0.240- [0.000- [0.647- [1.310- [1.062- [0.677-
Daily Wage and 6.998] 1617.6] 5.577] 21.210] 6.179] 11.080]
Business
Others 1.017 0.009 1.632 1.305 1.171 1.491
[0.210- [0.000- [0.597- [0.412- [0.530- [0.298-
4.926] 1001.7] 4.466] 4.133] 2.587] 7.468]
Economic status 0.000 1.326 1.979 1.172 1.087 0.397
Upper class® [0.000] [0.204- [0.068- [0.115- [0.029-
Middle class 19.197] 20.294] 10.261] 5.484]
Lower class 0.000 0.005 1.966 2.010 0.688 0.233
[0.000] [0.210- [0.093- [0.075- [0.014-
18.388] 43.460] 6.293] 3.801]
Clinical Parameters
Duration of 2.196 3.589 0.718 1.221 1.330 1.499 0.814 0.837 0.732
Treatment [0.692- [0.684- [0.002- [0.590- [0.593- [0.545- [0.479- [0.466- [0.363-
6.973] 18.817] 259.146] 2.525] 2.983] 4.124] 1.382] 1.504] 1.478]
HbA1c 1.259 0.789 18.378 1.298 1.023 0.559 1.035 1.015 0.740
[0.395- [0.155- [0.072- [0.616- [0.433- [0.194- [0.580- [0.534- [0.356-
4.012] 4.011] 4683.9] 2.736] 2.415] 1.608] 1.848] 1.931] 1.540]
l l l
FBS 3.414 9.73 2943.3 1.224 1.175 1.520 1.179 1.484 1.723
[1.217- [1.975- [7.075- [0.526- [0.418- [0.461- [0.620- [0.686- [0.749-
9.571] 48.414] 122455.9] 2.848] 3.301] 5.008] 2.242] 3.209] 3.964]
SBP 2.695 1.821 59.321 1.166 1.145 0.936 1.119 1.109 0.634
[0.891- [0.404- [0.389- [0.455- [0.400- [0.272- [0.547- [0.499- [0.254-
8.149] 8.211] 9056.1] 2.983] 3.273] 3.216] 2.288] 2.465] 1.580]
m l k
Medical 0.233 0.167 0.000 0.855 0.792 0.835 0.728 0.695 0.523
Condition T2DM [0.084- [0.043- [0.000- [0.368- [0.310- [0.280- [0.390- [0.352- [0.240-
® 0.648] 0.647] 0.739] 1.987] 2.025] 2.484] 1.357] 1.375] 1.138]
T2DM + HTN
T2DM 0.604 0.330 0.264 0.783 0.849 0.877 0.935 0.983 0.766
Complications [0.205- [0.080- [0.004- [0.379- [0.391- [0.351- [0.548- [0.553- [0.396-
Absent® 1.782] 1.363] 16.279] 1.619] 1.844] 2.194] 1.594] 1.747] 1.479]
Present
Medicationmode 1.560 2.298 5478.9 0.547 0.598 0.800 0.600 0.538 0.514
OHD® [0.336- [0.379- [0.059- [0.233- [0.238- [0.266- [0.318- [0.269- [0.234-
Insulin Therapy 7.240] 13.940] 50678.0] 1.282] 1.499] 2.403] 1.132] 1.076] 1.128]
l l
Both 0.602 0.544 0.001 0.408 0.391 0.209 1.180 1.222 1.173
[0.159- [0.067- [0.000- [0.158- [0.141- [0.059- [0.486- [0.469- [0.400-
2.273] 4.432] 7.792] 1.055] 1.083] 0.745] 2.864] 3.185] 3.441]
BMI Normal ® 0.823 0.566 4.392 0.857 1.024 1.151 0.889 0.928 0.811
Overweight [0.290- [0.136- [0.039- [0.413- [0.466- [0.459- [0.516- [0.517- [0.427-
2.334] 2.353] 497.4] 1.778] 2.252] 2.887] 1.531] 1.665] 1.543]
Obese 1.070 1.844 0.022 1.224 1.416 1.067 1.960 2.190 2.444
[0.127- [0.108- [0.000- [0.264- [0.253- [0.163- [0.551- [0.576- [0.569-

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Volume 9, Issue 8, August – 2024 International Journal of Innovative Science and Research Technology
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8.988] 31.423] 55.121] 5.676] 7.923] 6.978] 6.977] 8.334] 0.495]
i k k
APA No ® 0.513 0.176 0.000 0.798 0.652 0.359 1.031 0.747 0.558
Yes [0.171- [0.029- [0.000- [0.343- [0.245- [0.111- [0.530- [0.347- [0.233-
1.536] 1.068] 0.579] 1.857] 7.923] 1.165] 2.007] 1.610] 1.339]
j k
AHD No® 1.035 3.184 281.7 0.855 1.031 1.032 1.672 1.795 1.815
Yes [0.378- [0.617- [0.702- [0.422- [0.453- [0.404- [0.982- [0.967- [0.906-
2.832] 16.428] 113114.2] 1.732] 2.347] 2.632] 2.848] 3.335] 3.636]
k k
Family History 2.914 4.918 17261.6 0.645 0.728 0.526 1.420 1.762 1.680
Absent® [0.813- [0.948- [1.797- [0.318- [0.333- [0.205- [0.817- [0.952- [0.835-
Present 10.44] 25.5] 165804.7] 1.308] 1.589] 1.353] 2.470] 3.256] 3.381]
k k
Smoking 0.000 0.058 0.000 0.1221 0.121 0.036 0.935 0.708 0.619
Absent ® [0.017- [0.11- [ 0.002- [0.096- [0.056- [0.041-
Present 0.897] 1.291] 0.808] 9.129] 8.912] 9.414]
k l k
Alcohol use 2.744 11.614 511293.5 0.548 0.628 0.774 0.466 0.404 0.382
Absent ® [0.354- [0.500- [0.232- [0.243- [0.251- [0.239- [0.194- [0.168-
Present 21.294] 269.9] 1.295] 1.627] 2.384] 0.909] 0.841] 0.867]
l k
Insomnia 0.341 0.211 0.051 0.578 0.641 0.660 0.684 0.700 0.879
Absent ® [0.122- [0.055- [0.002- [0.268- [0.279- [0.243- [0.374- [0.367- [0.426-
Present 0.953] 0.804] 1.164] 1.251] 1.474] 1.792] 1.252] 1.335] 1.814]
Note : a Crude Odds ratio, bAdjusted Odds ratio, c Partially adjusted regression model, d Fully adjusted regression model,
e
CI: Confidence Interval, f Reference, I Adherence to Physical Activity , j Adherence to Healthy Diet, Significant Value (P)
k
P < 0.05, l P < 0.01, m P< 0.001,

Fig. 3 projects the prevalence of severe depression, foot ulcers (50%), hypertension (61.90%), and retinopathy
anxiety, and stress in patients suffering from different T2DM (65.22%); and severe stress is alarmingly prevalent in all
complications. Across all complication categories, severe categories, especially among patients with neuropathic foot
depression is most prevalent among patients with neuropathic ulcers (80.95%), hypertension (79.37%), and retinopathy
foot ulcers (54.76%) and nephropathy (61.54%); severe (82.61%).
anxiety is particularly common in patients with neuropathic

Fig 3: Impact of DAS on T2DM Complications among T2DM Patients

IV. DISCUSSION et al. (2012), which reported higher FBS levels in older
working-age groups. Female patients had a higher median
A. Prediction of FBS Levels Status among T2DM Patients FBS (157.2 mg/dL) than males, but healthy individuals
and the General Participants maintained consistent FBS levels across all ages and genders.
The study examined the prevalence of fasting Lower education levels and lower income groups (such as
hyperglycemia in young adults (aged 24–40) with T2DM, housewives and students) were linked to higher FBS levels in
finding an average FBS level of 162.56 mg/dL, which is T2DM patients, in line with studies in Taiwan and Korea.
higher than in other age groups. This finding contrasts with [18,19]
previous studies by Chandrupatla., et al (2021) and Rajput.,

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Volume 9, Issue 8, August – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24AUG927
Among clinical parameters, complications (165.57 studied population.[33] Patients with a family history have
mg/dL) and use of oral hypoglycemic medications (157 higher likelihood of experiencing stress. Managing diabetes in
mg/dL) were linked to higher FBS levels in type 2 diabetes individuals with a family history requires constant monitoring
patients, while healthy individuals showed stable FBS levels. and lifestyle adjustments, leading to ongoing stress.[34]
These findings are consistent with earlier studies conducted Regular physical activity and adherence to a healthy diet,
by Bin Rakhis., et al. (2022) and Lorenzati., et al. (2010). generally have protective effects against mental health
Lifestyle factors, such as smoking and insomnia, were issues.[35] Lifestyle risk factors like alcohol use and smoking
significantly associated with the highest median FBS levels, have a complex relationship. They may initially reduce
similar to a 2015 study done by Bhaskar et al. linking depression and anxiety due to self-medication effects, but
insomnia to a 33% higher risk in adult T2DM patients. long-term use is generally harmful. [36]
Interestingly, individuals without a family history of diabetes
had higher FBS levels (160 mg/dL) compared to those with a D. Impact of DAS on the T2DM Complications among the
family history (136.4 mg/dL), possibly due to better lifestyle T2DM patients
adjustments among those aware of their genetic risk.[20] The study shows a high incidence of stress, anxiety, and
depression among patients with diabetic complications. This
B. Prevalence of DAS among T2DM Patients highlights the significant mental health burden associated
The prevalence of severe DAS in our sample is notably with the condition. Previous research conducted by Tapp, R.
higher than in previous studies among T2DM patients in J., et al. (2006) and Ali Ahmad., et al. (2014), also supports
Qatar (13.6%, 35.3%, and 23.4%) [21], Bahrain (11.9%, this outcome.
41.3%, and 21%) [22] and Kathmandu, Nepal (10.8% and
4.7%)[2]. In North India, the rates were 26.3%, 27.6%, and E. Limitation and Strength of the Study
21%, respectively.[23] In South India, specifically Tamil The research was limited to one healthcare institute, so
Nadu, the prevalence of depression was 15.1% in Chennai the results may not apply to larger groups of people.
[24], 6.3% for depression and 10.4% for anxiety in Madurai Furthermore, most participants had serious health issues, such
district[9] and high perceived stress in both genders in as severe complications of T2DM, which could have affected
Perambalur district.[25] Limited data, especially with all the observed DAS. Despite its limitations, the study is notable
three DAS disorders from Tamil Nadu contrasts with a study for its thorough methodology and valuable insights into the
by Alzahrani., et al (2019) in Saudi Arabia, showing mild, T2DM-DAS connection. It effectively compares health
moderate, severe, and extremely severe depression in 9.3%, outcomes between T2DM patients and the general population
14.0%, 7.1%, and 3.3% of T2DM patients, respectively. The and includes diverse samples from a tertiary care hospital for
possible reason for the high prevalence of DAS among T2DM accuracy. In the future, it is imperative for diabetes research
patients in this study could be due to a combination of cultural to incorporate samples from different geographical locations
stigma and limited awareness about mental health, and conduct a meta-analysis to definitively determine the
socioeconomic challenges, inadequate access to quality prevalence of DAS in individuals with type 2 diabetes. Future
healthcare and the complexity of diabetes management. [26] research in nursing have to focus on implementing and
assessing therapies aimed at reducing patients' stress, anxiety,
C. Mental Health Risk Factors Associated with T2DM and depression.
Patients
This groundbreaking research is the first to investigate V. CONCLUSION
the risk factors associated of depression, anxiety, and stress
among T2DM patients, using standard tools HAM-D, HAM- T2DM and mental health disorders often coexist due to
A and PSS available in the public domain. The study found biological, psychological, and social factors. This study
that being married is linked to lower stress, highlighting the examined how socio-demographic, mental health (DAS), and
mental health benefits of social support. [27] Conversely, clinical factors relate to T2DM, comparing these aspects with
single status individuals are five times more likely to the general population to evaluate the prevalence of DAS risk
experience depression due to a lack of social support.[28] among T2DM patients in Madurai. The study highlights that
Patients with only a high school education are six times more two-thirds of young women with type 2 diabetes have higher
likely to develop anxiety and three times more likely to suffer FBS levels than men when compared to the general
from depression, suggesting that limited health literacy makes population. There is a notably high prevalence of severe
diabetes management more challenging.[29,30] Patients with depression, anxiety, and stress among patients with Type 2
high FBS levels have very high to develop stress[2] and the diabetes mellitus when compared to the general population.
presence of comorbidity with hypertension alongside T2DM 82.61% of the patients with uncontrolled diabetes developed
is significantly associated with stress[31] whereas combined severe stress, more than those with well-controlled and pre-
mode of treatment (Both OHD and Insulin therapy) is diabetes status. Among the T2DM complications, severe
positively associated with anxiety.[7] Lower health literacy depression is most prevalent among patients with neuropathic
has been associated with worse health outcomes and higher foot ulcers (54.76%) and nephropathy (61.54%). Factors such
rates of depression among chronic disease patients.[32] as marital status (single), high school education, poor
Moreover, the study found that the duration of treatment, glycemic control, comorbid conditions of type 2 diabetes with
HbA1c, blood pressure levels, menstrual irregularity, and BMI hypertension and family history are the predominant mental
show no significant association with DAS, indicating that they health risk factors in patients with type 2 diabetes.
might not directly impact these mental health outcomes in the Interestingly, lifestyle factors such as alcohol use and

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Volume 9, Issue 8, August – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24AUG927
smoking have a significant positive impact on mental health [6]. Minchala Urgiles, R. E., Tigasi Pastuña, J. A., Estrella
outcomes, possibly due to adaptive coping mechanisms and González, M. A., Ramírez-Coronel, A. A., & Romero
changes in perception. Effective diabetes management is Sacoto, L. A. (2020). Type 2 diabetes mellitus and
crucial in reducing mental health risks. The study underscores chronic complications. International Journal of
the need for comprehensive care in T2DM, emphasizing a Innovative Science and Research Technology, 5(5),
multidisciplinary approach that includes psychological 1906. Available from:
support, lifestyle modifications and effective clinical https://www.ijisrt.com/assets/upload/files/IJISRT20
management to enhance overall well-being and quality of life. MAY828.pdf
[7]. Wambugu, F. K., Nyamai, J. J., & Mogere, D. (2020).
ACKNOWLEDGMENT Knowledge on risk factors of diabetes mellitus 2
among students in selected universities in Rwanda.
We sincerely thank the Department of Environmental International Journal of Innovative Science and
Studies, Madurai Kamaraj University, Madurai (Tamil Nadu) Research Technology, 5(8), 1598. Available from:
India, the members and staff of Alpha Hospital and Research https://www.ijisrt.com/assets/upload/files/IJISRT20A
Center, Institute of Diabetes and Endocrinology, Madurai UG452.pdf
(Tamil Nadu), India and all the participants involved in this [8]. Rahmania, F. A., Rahmayanti, F. D., Hutami, P. T., &
study. Muslaini, R. (2020). Emotional regulation and
psychological well-being in patients with diabetes
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