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 Table of Contents  
Year : 2018  |  Volume : 9  |  Issue : 1  |  Page : 19-24

Depressive symptoms among participants with type 2 diabetes in Southeast Asia: A systematic review

1 Center for Control of Chronic Diseases (CCCD), International Center for Diarrhoeal Disease Research, Dhaka, Bangladesh
2 School of Health Policy and Management, Faculty of Health, York University, Toronto, Canada
3 Center for Control of Chronic Diseases (CCCD), International Center for Diarrhoeal Disease Research, Dhaka, Bangladesh; Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Melbourne, Victoria; Cardiovascular Division, The George Institute for Global Health, University of Sydney, New South Wales, Australia

Date of Web Publication2-Apr-2018

Correspondence Address:
Dr. Sheikh Mohammed Shariful Islam
Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC 3131

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jod.jod_23_17

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Objective: Diabetes and depression are two major non-communicable diseases that have increased in epidemic proportion globally. Depression is common in participants with diabetes causing increased morbidity and mortality. This article aimed to review co-morbid depression in participants with type 2 diabetes (T2D) in Southeast Asia. Methods: We conducted a systematic review of published literature on the prevalence of depression among adult patients with T2D in Southeast Asia. A comprehensive search was performed using PubMed, Google Scholar and BanglaJOL for published studies between 1990 and 2014 with full text available in English. Study selection and data extraction were conducted independently by two researchers. A formal meta-analysis was not performed, and only summary findings of the relevant studies were presented. Results: A total of six studies including 3837 participants were included. The prevalence of depressive symptoms among participants with T2D ranged from 14% to 41%, with the highest prevalence of 60.8% among female T2D patients in Pakistan. The pooled prevalence of depressive symptoms in participants with T2D was 27.7% (95% confidence interval 21.4%–34.0%). Depressive symptoms were higher among females in four studies and associated with increasing age. Conclusion: Our review shows a high prevalence of depressive symptoms among participants with T2D in Southeast Asia. Further research is needed to clarify the association between depressive symptoms and diabetes in this population group, and efforts for prevention, early diagnosis and optimum management through innovative mechanisms of both conditions are warranted.

Keywords: Co-morbidity, depression, Southeast Asia, type 2 diabetes

How to cite this article:
Rezia R, Islam A, Shariful Islam SM. Depressive symptoms among participants with type 2 diabetes in Southeast Asia: A systematic review. J Diabetol 2018;9:19-24

How to cite this URL:
Rezia R, Islam A, Shariful Islam SM. Depressive symptoms among participants with type 2 diabetes in Southeast Asia: A systematic review. J Diabetol [serial online] 2018 [cited 2022 Dec 3];9:19-24. Available from: https://www.journalofdiabetology.org/text.asp?2018/9/1/19/229008

  Introduction Top

In recent years, non-communicable diseases have emerged as the leading cause of global burden of disease and adversely affects the developing countries.[1] Diabetes is one of the leading causes of death worldwide, and in 2014, an estimated 422 million adults were living with diabetes in globally.[2] The estimated number of people with diabetes is projected to rise to 552 million by 2030.[3] Most of the increase in diabetic population will occur in low- and middle-income countries, where around two-thirds of those affected by diabetes are currently living.[4],[5] In many South East Asian countries, diabetes is reported to an increasing trend in both urban and rural areas.[6] On the other hand, major depressive disorder is recognised as one of the leading causes of disability globally.[7] More than 350 million people of all ages are suffering from depressive symptoms worldwide.[8] Depression is one of the most common mental health problems affecting population around the world despite effective treatment. There is ample evidence that individuals who suffer from chronic diseases like diabetes are at more risk and have two times more prone to have anxiety disorders, especially depressive symptoms when compared with healthy people.[9]

Co-morbid depression is common in participants with type 2 diabetes (T2D). Individuals with diabetes have been reported to have almost two-fold increased risk of developing depressive symptoms, and people with depression also have an increased risk of developing diabetes.[10] The relationship between diabetes and depressive symptoms is strong and appears bidirectional as patients with depressive symptoms developing increased incidence of diabetes.[11] Although the association between diabetes and depression is well-documented, the nature of this relationships remains unclear.[12] Co-morbid depression and diabetes increases the burden of both illnesses and remains as a major public health problem and clinical challenge.[11]

Depression in patients with diabetes causes decreased adherence to treatment, poor quality of life, increased medical complications and higher mortality.[13],[14] At the same time, participants with depressive symptoms report poorer diabetes self-care, less glycaemic control and decreased medication adherence.[15] In spite of the huge impact of co-morbid depressive symptoms and diabetes on individuals and health systems, these problems have largely been ignored in Southeast Asia. The majority of studies have been carried out in the developed world. Data on the prevalence of depressive symptoms among diabetic participants in South Asian region are scarce. Therefore, we conducted this review to explore the prevalence of depressive symptoms in participants with T2D in South Asia.

  Methods Top

We conducted a systematic review of published literature using PubMed, Google Scholar and BanglaJOL for potentially relevant studies that focused on the prevalence of depressive symptoms among diabetic participants in Southeast Asia, published between 1995 and 2014. These databases were searched using the relevant keywords including 'Prevalence', 'Depression', 'Depressive Symptoms', 'Association', 'Diabetes' and 'Southeast Asia'. Study selection and data extraction were conducted independently by two researchers. We identified 12 articles and selected 6 articles for this review based on the inclusion criteria. The methodological framework is presented in [Figure 1]. However, there were no relevant online materials found on other five countries (Afghanistan, Bhutan, Maldives, Nepal and Sri Lanka).
Figure 1: Methodological frame

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  Results Top

Of the six studies [Table 1], three were from Pakistan, two from Bangladesh and one from India. The prevalence of depressive symptoms among participants with T2D ranged from 14% to 41%, with the highest prevalence of 60.8% among female participants with T2D in Pakistan. The pooled prevalence of depressive symptoms in participants with T2D was 27.7% (95% confidence interval [CI] 21.4%–34.0%).
Table 1: Summary of the studies included for systematic review

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A study in Bangladesh by Asghar et al. found a high overall prevalence of depressive symptoms (29%) in a rural population. Montgomery-Asberg Depression Rating Scale (MADRS) was used to measure the level of depressive symptoms in this study, and Hemocue glucose analyzer was used to measure fasting blood glucose. Participants with newly diagnosed diabetes were recruited. Of 952 study participants, 412 (43.3%) were male and 540 (56.7%) were female. About 16.5% had both diabetes and depressive symptoms and 2.8% had diabetes but no depressive symptoms. Participants with depressive symptoms had low monthly income, low body mass index and low waist–hip ratio. Among participants with diabetes, 29% male and 30.5% female had depressive symptoms. In participants without diabetes, 6% male and 14.6% female had depressive symptoms. Overall, 29.7% and 14.1% participants had depressive symptoms with and without diabetes, respectively. This study result demonstrated a significantly higher prevalence of depressive symptoms in female with T2D compared to men.[16]

Another study by Roy et al. also found that depressive symptoms were more common in T2D mellitus patients in Bangladesh. This study estimated the prevalence of depression among T2D participants using data collected through two different modes using standard assisted collection and audio questionnaire methods. This study was carried out at the outpatient department among 417 participants with T2D in 3 diabetic clinics across Bangladesh. The World Health Organisation (WHO)-5 well-being index and patient health questionnaire-9 (PHQ-9) were used to measure depressive symptoms. The prevalence of depressive symptoms was 34% with PHQ-9 score ≥5 and 36% with WHO-5 score <52. Age, income, gender, treatment intensity and co-morbid cardiovascular diseases (CVD) were the main predictors. Female gender, older age, low income, poorly controlled diabetes and complications of diabetes were reported as independent predictors of depression. This study showed that the prevalence of depressive symptoms was more than three times higher in female for the PHQ9 (odds ratio [OR]: 3.4) and more than two times higher in female for WHO questionnaires (OR: 2.7).[17]

A cross-sectional study in Pakistan conducted by Zahid and et al. published in 2008 in a rural area of Pakistan found 14.7% prevalence of depressive symptoms with diabetes. They also aimed to determine associated risk factors. A total of 1290 participants (aged 20 years and more) participated and MADRS scale was used to measure depression. 'WHO criteria 1999' was used for diabetes measurement. The prevalence of overall depressive symptoms was 5.4% and slightly higher in female than men. Age above 40 and female gender found as risk factors for depressive symptoms. The prevalence of depressive symptoms was higher in participants with diabetes compared to those without diabetes.[18]

Another study by Perveen et al. found that depressive symptoms was significantly associated with newly diagnosed patients with T2D aged between 25 and 60 years in Karachi, Pakistan. In this case–control study using Siddiqui Shah Depression Scale for measuring depression, the researchers found significant association of depression with newly diagnosed T2D. In case of mild depression, it was 3.86 times higher among cases than control (OR: 3.86; 95% CI: 2.22–6.71) and for moderate-to-severe depression, it was 3.41 times higher in cases than controls (OR: 3.41; 95% CI: 2.07–5.61). This study did not provide any prevalence data but focused on the association of depressive symptoms with diabetes and found that all other factors including family history of diabetes, gestational diabetes, nuclear family and high body mass index (BMI) also has the association but not as strong as depressive symptoms. Participants with newly diagnosed T2D had more than three times the odds of depressive symptoms compared to those without diabetes.[19]

Another cross-sectional study by Zuberi et al. at the Aga Khan University hospital mainly focused on the associations of depression with treatment outcome in adult patients of 31–60 years with T2D in Pakistan. Hospital anxiety depression scale tool was used for measuring depression. Mean glycated haemoglobin in participants with depressive symptoms was 8.5% and 7.7% in non-depressed participants that clearly gives an impression of strong association between diabetes and depression. Again, similar to other studies, depression was significantly higher in female than men (60% vs. 39.2%). More depressed patients reported to have higher diabetic-related complication (87%) than non-depressed patients (77%). Adult with T2D who had depression reported poor glycsemic control and low compliance of self-care activities.[20]

A cross-sectional study in India by Raval et al. reported the overall prevalence of depression of 41% in patients with T2D in a tertiary care hospital in North India. Diabetes patients were identified according to the American Diabetes Association (1997) criteria and were examined consecutively for depression using PHQ-9. The prevalence of depressive symptoms was strongly associated with age ≥54 (OR: 1.26, 95% CI: 1.02–1.67). Depression was also strongly associated and significant with central obesity (OR 1.34), neuropathy (OR 1.94), nephropathy (1.81) and diabetic foot (2.32). In this study, depression was not significantly associated with gender, retinopathy and CVD.[21]

  Discussion Top

The results of the present review show that there is a high prevalence of depressive symptoms among T2D participants in South Asian countries. The prevalence of depressive symptoms is higher in female compared to male. The findings are similar from all the five studies, except from one study in India. A recent study in patients with T2D in Bangladesh reported higher prevalence of depressive symptoms among females (70.9%) compared to males (50.6%).[22] The reasons for difference in male and female prevalence are unclear. However, this higher rate in female may be due to their perceived lower social and economic status in Southeast Asia.[16],[23]

Higher age was significantly associated in both the 'depressive symptoms' and 'diabetes and depressive symptoms' groups. In a study by Asghar et al., BMI was also higher in the group with diabetes who has depressive symptoms, so this involves risk factors such as age, gender and BMI. A recent systematic review of the risk factors for T2D reported that Bangladeshi adults had had higher diabetes risk at a lower BMI compared to Western population.[24] In the other study in Bangladesh, more than one-third of the patients showed poor emotional well-being using the WHO-5 questionnaire and similar higher prevalence of depressive symptoms in patients with T2D using the PHQ-9.[17] The independent risk factors are similar to other studies in Bangladesh which reported older age, female gender, low income, poorly controlled T2D and complication of diabetes.[16] A recent study in Bangladesh reported that participants with T2D had earlier onset on several diabetes-related complications which could explain the higher prevalence of depressive symptoms in these patients.[22]

A study by Zahid et al. reported 14.7% prevalence of depressive symptoms among patients with diabetes in a rural area in Pakistan.[18] A recent study in Bangladesh showed that moderate-to-severe depressive symptoms was significantly associated with diabetes (OR = 6.4; 95% CI 3.4–12.3).[25] Results from a systematic review showed that the prevalence of depressive symptoms was significantly higher among participants with T2D (17.6%) compared to those without diabetes (9.8%). The study also reported higher prevalence of diabetes among females (23.8%) compared to male with diabetes (12.8%).[9] Higher prevalence of depressive symptoms in patients with T2D was found in the Indian study,[21] but this is the only study which does did not show any significant association between depressive symptoms and gender, whereas in all other studies female gender showed higher prevalence of depressive symptoms in both diabetics and non-diabetics.

In Southeast Asian countries, the prevalence of depressive symptoms is increasing, and also, there is lack of proper attention, care and pre-counselling of patients. A previous study showed that depressive symptoms are influenced by mainly by social and cultural factors.[10] Even though the meaning of depression may be similar across culture, its prevalence and association to risk factors may be different between cultures.[17] A number of studies revealed that the incidence of depressive symptoms is increased in T2D [26] and depressive symptoms are a risk factor for T2D.[11] In developed countries like North America and Europe, the availability of self-management for new diabetes patients makes thing much better and implementing such approaches among patients with co-morbid diabetes and depressive symptoms in Bangladesh may be a good idea. In Bangladesh, clinicians can assume the preliminary role of counselling a diabetes patient on depressive symptoms and may also refer him or her to relevant mental counsellors for therapy and monitor his/her mental side regularly.[17] However, in Bangladesh and other Southeast Asian countries, there is lack of trained human resources for mental health, especially in rural areas.[23],[27],[28] Therefore, there is a need to develop effective policies for improving human resources for prevention, early detection and management of both diabetes and depression, for example, training healthcare providers at primary healthcare for screening depressive symptoms, especially among those at higher risks, developing a referral system, allocating additional resources to develop, train, support and integrate depressive symptoms screening and management and health systems reform at the primary care level.[27],[29],[30],[31]

Mental health has long been underrecognised and ignored by physicians and policymakers. Depression is the most common form of mental diseases and is often ignored and mostly remains a taboo and stigma. In Southeast Asian region, depressive symptoms are commonly overlooked and often not considered as a medical condition requiring treatment.[32] Although it is normal to have depression in one or two phases of life, prolonged depressive symptoms can have serious adverse effects, and when depression is tagged along with diabetes, it effects far more and creates a co-morbid condition. Most of the patients with diabetes and their family and peers focus on the physical illness of diabetes and tend to ignore depressive symptoms that a patient goes through even though it can certainly be fatal. Depression can have a serious impact on patients with diabetes well-being and their ability to motivate themselves in self-care management.[33] Both diabetes and depression are a costly condition and prevention could be a cost-effective measure for these diseases.[34],[35]

This review indicates a clear need for providing adequate health education and counselling for depressive symptoms at primary healthcare settings in Southeast Asian region. Participants with diabetes have shown to have limited knowledge about their disease in Bangladesh.[36],[37],[38] However, the challenge would be to improve the physicians' recognition of mental disorder rate under the backdrop of high patient loads and lack of training in this area. Just providing blood sugar report and medication plan in outpatient service may not improve the matter. More importantly, an awareness program needs to be scaled out for overcoming therapeutic inertia and low diabetes health literacy. Media contents such as articles, bulletins among others may help in making a point of this. There is a need to educate and inform patients, general practitioners and psychiatrists about the burden of depressive symptoms in newly diagnosed patients, and therefore, immediate counselling of the participants must be started through coordination between the healthcare teams. Diabetes patients should be considered for depressive symptoms screening through a government program. Medicines for depressive symptoms should be available in all primary care settings.[39] Efforts should be taken to consider the use of innovative information technology and mobile phones as an adjunct to clinical services in the hospitals and primary healthcare settings.[40],[41] Previous studies in Bangladesh have reported that text messaging improved glycaemic control in participants with T2D [42] and that participants were willing to pay a moderate amount of fees to receive diabetes-related short message service through mobile phones.[43]

This study has a number of limitations. First, we did not review papers and reports published in non-peer reviewed journals, such as thesis papers, government reports and those published in other languages. Second, we could not perform a meta-analysis of the data because of the different methods used to determine depressive symptoms and diabetes among the study population. Third, this review is based on mostly cross-sectional data, so it was not possible to identify any patterns of causation or direction of relationship. Moreover, none of the studies used standard psychiatric diagnostic interviews such as Composite International Diagnostic Interview which can confirm the presence of clinical depression.

  Conclusion Top

This study highlights the high prevalence of depressive symptoms in participants with T2D in Southeast Asian countries. Depression was higher among female participants with T2D. Co-morbid diabetes and depression impose a huge burden on the health systems and might increase the healthcare costs. There is a need to develop cost-effective policies and programs for prevention, early detection and management of both diabetes and depression in Southeast Asia.


We would like to thank all the Faculty, Course on Advanced Research Methodology at the Centre for Control of Chronic Diseases at ICDDR, B for supporting this study. ICDDR, B acknowledges with gratitude the commitment of its donors for their generous support to its research efforts. The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of their employing institution.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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