Detection and prevalence of depression among adult type 2 diabetes mellitus patients attending non-communicable diseases clinics in Lilongwe, Malawi

(2020) 14:79 Udedi et al. Int J Ment Health Syst https://doi.org/10.1186/s13033-020-00413-3 International Journal of Mental Health Systems Open Access RESEARCH Detection and prevalence of depression among adult type 2 diabetes mellitus patients attending non‑communicable diseases clinics in Lilongwe, Malawi Michael Udedi1,2,3* , Brian W. Pence5, Robert C. Stewart1,6,7 and Adamson S. Muula3,4 Abstract Background: Depression is associated with chronic physical illnesses and negatively affects health outcomes. However, it often goes undiagnosed and untreated. We investigated the prevalence of depression among adult type 2 diabetes mellitus (T2DM) patients attending non-communicable diseases (NCD) clinics in Lilongwe, Malawi, and estimated the level of routine detection by NCD clinicians. This study set out to determine the prevalence of major depression and its detection among adult type 2 diabetes mellitus (T2DM) patients attending NCD clinics in Lilongwe, Malawi. Methods: In a cross-sectional study design, 323 T2DM patients aged ≥ 18 years were screened for depression with the Patient Health Questionnare-9 (PHQ-9) followed by diagnostic assessment with the Structured Clinical Interview for DSM-IV (SCID). We analysed the association between presence of major depression and sociodemographic factors using logistic regression. Results: Three quarters of the participants (76%) were females. The participants’ ages ranged from 21–79 years. Of the 323 participants, 58 (18%) met criteria for DSM-IV major depression. None of the cases of major depression had been identified by the NCD clinicians. Major depression was found not to be significantly associated with any of the sociodemographic factors. Conclusions: We found that depression is common among NCD clinic attendees with T2DM in Malawi, and poorly detected by NCD clinicians. Given the high prevalence and challenges in clinical identification, integration of depression screening with a standardized validated tool should be a high priority so as to link patients to appropriate services. Keywords: Depression, Type 2 diabetes mellitus, Malawi Introduction Depression is associated with chronic physical illnesses and negatively affects health outcomes [1, 2]. Few affected people access appropriate treatment as *Correspondence: 1 Department of Mental Health, College of Medicine, University of Malawi, Chichiri, P/Bag 360, Blantyre 3, Malawi Full list of author information is available at the end of the article depression is often undiagnosed. Diabetes mellitus is a common chronic disease, and in Malawi, the prevalence of raised fasting blood glucose or being currently on medication for diabetes based on the 2009 STEPS survey was 5.6% [3]. A systematic review shows that the prevalence of depression in patients with diabetes mellitus ranges between 6 and 43% [4]. The wide range of reported prevalence estimates may be due to differences in assessment tools and variation in the types of patients © The Author(s) 2020. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Udedi et al. Int J Ment Health Syst (2020) 14:79 in the studies cohorts. Depression in patients with diabetes is often associated with poor glycaemic control, poor adherence to medication, and rapid development of complications [5–7]. For instance a diabetic complication such as diabetic neuropathy is associated with reduced quality of life, poor sleep, depression and anxiety [8]. Comorbid depression is associated with a decrease in metabolic control, poor adherence to medication and diet regimens, a reduction in quality of life, and an increase in health care expenditures. Consequently, poor metabolic control may exacerbate depression and diminish response to depression treatment [9]. Evidence indicates that depression complicate diabetes management, increase the length of hospital stays, and almost doubled the cost of diabetes management [10]. Literature also suggests that duration of diabetes influences depressive symptoms [11]. Furthermore, depression is often undiagnosed and untreated in this patient population [12–16]. Despite the high prevalence and its impact on diabetes, the potential for depression treatment to improve diabetes care outcomes has received little attention in both low and middle income countries (LMIC) [17–19], and high income countries. In LMIC this lack of attention is partly because of limited capacity in depression management and the absence of any routine practice to identify and manage depression in NCD care. Malawi is facing a growing challenge of non-communicable diseases (NCD), including diabetes mellitus [20–23]. Furthermore, Malawi has a large treatment gap for common mental disorders including depression with a limited number of mental health professionals serving a population of > 18 million. Prevalence of depression between 19 and 30% has been reported among adult primary care attendees in Malawi [24, 25]; none of these cases of depression were identified by clinicians in routine care [24, 25]. There are no published data regarding the prevalence of depression among patients with diabetes attending NCD clinics, or of levels of detection by clinic staff. Currently, there is no routine screening for depression in the NCD clinics in the country. Therefore, the aim of this study was to determine the prevalence of major depression and its detection by clinicians among adult type 2 diabetes mellitus (T2DM) patients attending NCD clinics in Lilongwe, Malawi. Materials and methods Setting and participants We carried out a cross-sectional study from December 2017 till April 2018 among patients suffering from diabetes mellitus. We conducted the study at two diabetes clinics in two facilities within Lilongwe district. The catchment population of the two clinics and the Page 2 of 8 staffing levels have been described elsewhere [26]. The patients attending to the clinics are not routinely screened for any mental health problems. We included adult patie (...truncated)