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Association of psychosocial factors with anxiety and depressive symptoms in Chinese patients with type 2 diabetes
diabetes research and clinical practice 79 (2008) 523–530
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Association of psychosocial factors with anxiety and depressive symptoms in Chinese patients with type 2 diabetes Cai-Xia Zhang, Yu-Ming Chen, Wei-Qing Chen * Department of Biostatistics and Epidemiology, School of Public Health, Sun Yat-sen University, 74, Zhongshan Road 2, Guangzhou, China
article info
abstract
Article history:
Objective: To investigate association of psychosocial factors with anxiety and depressive
Received 18 March 2007
symptoms in Chinese type 2 diabetes patients.
Accepted 5 October 2007
Methods: Three hundred and four type 2 diabetes patients were inquired with a structured
Published on line 19 November 2007
questionnaire about socio-demographic characteristics, psychological stress, coping styles, social support, and anxiety and depressive symptoms. Multiple regression analysis was
Keywords:
performed to assess the association of these psychosocial factors with anxiety and depres-
Depression
sive symptoms after controlling for potential confounding factors of sex, age, educational
Anxiety
level, etc.
Type 2 diabetes
Results: After adjusting for the potential confounding factors, multiple stepwise regression
Psychosocial factors
analysis found that anxiety symptoms were significantly positively associated with ‘‘worrying about to be harmed by the disease’’, ‘‘social/family crisis caused by the disease’’, ‘‘worrying about declining in body/physical function’’, ‘‘declined economic condition caused by the disease’’ and ‘‘negative coping styles’’; and depression symptoms were significantly positively associated with ‘‘worrying about to be harmed by the disease’’, ‘‘worrying about declining in body/physical function’’, ‘‘social/family crisis caused by the disease’’, ‘‘declined economic condition’’, ‘‘negative coping styles’’, but negatively with ‘‘active coping styles’’ and ‘‘subjective social support’’. Conclusion: Our findings show that perceived stress from disease, coping styles, social support are the independent determinants of anxiety and depressive symptoms among Chinese patients with type 2 diabetes. # 2007 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Diabetes mellitus is a devastating chronic, progressive disease and especially poorly controlled diabetes is associated with multiple long term complications and has important implications for a patient’s well-being and social life. Anxiety and depression are common occurrence among diabetes patients and often debilitate them [1–3]. In a recent meta-analysis, the
prevalence of depression among people with diabetes was about twice as high as that among those without diabetes [4]. Depression is associated with poor self-management, metabolic control [5,6], and low compliance with therapy among diabetic patients [7,8], which, in turn, result in more diabetesrelated complications [5,6], particularly cardiovascular diseases and retinopathy [9,10] and worse health-related quality of life [11]. Improvements in depression or treatment of depression
* Corresponding author. Tel.: +86 20 87332199; fax: +86 20 87330446. E-mail address: [email protected] (W.-Q. Chen). 0168-8227/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.diabres.2007.10.014
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can lead to clinically significant improvements in glycaemic control [4,12]. To prevent depression and anxiety in the diabetic patients, a clear understanding about the determinants of and risk factors for mental disorders is necessary. It is believed that depression and anxiety in patients with diabetes is caused by multiple factors. Women patients with diabetes are at much greater risk of having depressive symptoms than men [4,13,14]. Patients are of poorer health and lower levels of education and socioeconomic status have higher rates of depression than patients without these characteristics [13– 15]. Other factors associated with depression symptoms include unmarried, unemployed, ethnic minorities, low income, presence of diabetes complications, higher nondiabetic medical co-morbidity, and poor glycemic control [11,12,14,16–20]. Besides these socio-demographic and clinical factors, some studies showed that psychosocial factors have also been shown to play important role in the development of depression and anxiety. Important psychosocial factors included childhood adversity, vulnerable personality styles, experience negative life events or other chronic stresses, poor quality of life, limited social support [21–24]. But, these earlier studies have methodological limitations that may affect the ability to generalize their findings to the adults with diabetes. For instance, these factors have been explored across some studies but usually only a few at a time, which has provided disjoined evidence of their association with depression and/ or anxiety. In addition, some studies used minority populations. Furthermore, many of these earlier studies did not simultaneously control for several socio-demographic and health variables which may account for relationships between the analytic variables. Therefore, we conducted a cross-sectional survey in 304 Chinese patients with type 2 diabetes, the purpose of the present study was to comprehensively examine associations of perceived stress from the disease, personal coping style and social supports with depression and anxiety after controlling for potential confounding factors.
2.
Patients and methods
2.1.
Study subjects
Type 2 diabetic patients were recruited for the study from out- or inpatients in the three affiliated hospitals of Sun Yatsen University, Guangzhou, China from November 2004 to March 2005. Subjects were required to be (i) aged 18 years or older; (ii) confirmed type 2 diabetes for at least 1 year according to WHO criteria; and (iii) free of other non-diabetes chronic health problems, including hypertension, chronic obstructive pulmonary disease (COPD), arthritis, asthma. Trained staff screened the potential subjects for eligibility via structured face-to-face interview to ensure that they met the criteria. Written informed consent was obtained from all the participants prior to enrollment after a detailed explanation on the study objective and requirements of the survey. The Ethical Committee of the Sun Yat-sen University approved the study.
2.2.
Measurements
Individual information on age, educational level, marital status, perceived stress from the disease, coping styles, and social support were collected using a structured questionnaire by well-trained interviewers via face-to-face interview. Diabetes status and the method of the treatment (hospitalization or medication) were identified from medical records. Subjects were also asked a series of questions on medical history, including whether they had been diagnosed suffering from diabetic-specific complications, such as retinopathy, nephropathy, neuropathy, cerebrovascular, peripheral vascular, cardiovascular, and metabolic diseases. If the patients reported that they have one or more complications, we would record them and then search medical record to confirm this information.
2.2.1.
Psychological stress
Psychological stress caused by type 2 diabetes was measured with the questionnaire developed from the scales, respectively, used in the studies by Leung et al. [25] and Lin and Zhang [26]. The questionnaire consisted of 30 items. Each item is scored on a 5-point Likert-type scale from 1 (never or rarely) to 5 (very often). The patients would choose one number from the scale as their responses. Factor analysis identified four factors explaining 53.0% of the total variance (see Appendix A). According to the nature and contents of the items included in each factor, the four factors were, respectively, defined as follows: ‘‘worrying about to be harmed by the disease’’, ‘‘social/family crisis caused by the disease’’, ‘‘worrying about declining in body/physical function’’, ‘‘declined economic condition’’. The Cronbach a of the four factors and the whole scale was 0.89, 0.87, 0.72, 0.79 and 0.94, respectively.
2.2.2.
Coping style
Coping style was measured using validated scale [27]. The scale consisted of 24 items. The patients were asked and a 4point Likert-type scale was used for each item, ranging from 1 (never do) to 4 (always do) (1 = never do, 2 = seldom do, 3 = often do, 4 = always do). Factor analysis of the 24 items of coping style yielded four factors, which explained 41.7% of the total variance. According to the nature and contents of the items included in each factor, the four factors were, respectively, defined as: ‘‘negative coping style’’, ‘‘active coping style’’, ‘‘self-relaxing’’ and ‘‘avoidance coping style’’. The Cronbach a of the four factors and the whole scale was 0.70, 0.71, 0.64, 0.53 and 0.77, respectively.
2.2.3.
Social support
Social support status was assessed using a well-validated social support rating scale designed by Xiao [28,29]. The scale is a 10-item measure of three dimensions of social support: subjective support, objective support, and support utility.
2.2.4.
Anxiety and depressive symptoms
Hospital anxiety and depression scale (HADS) was used to assess anxiety and depression [30]. It consists of 14 items, 7 items for anxiety and 7 for depression. Separate anxiety and depression subscale scores were then calculated. The score for each subscale ranges from 0 to 21. The higher the score, the
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worse the status with respect to a particular category. The Chinese version of HADS has been developed and validated by previous studies [31].
2.3.
Statistical analysis
Pearson correlation coefficients of the scores of anxiety/ depressive symptoms, each factor of psychological stress, coping style and social support were calculated and examined. Multiple forward stepwise regression analysis was used to test the independent determinants of the anxiety and depressive symptoms. The independent variables of multivariate analysis included each factor of psychological stress and other psychosocial factors with adjustment for sex (1 = male, 2 = female), age (treated as a continuous variable), marital status (1 = unmarried, 2 = married, 3 = divorce), educational level (1 = primary school or below, 2 = middle school, 3 = college or above), income (1 = <1000 yuan/month, 2 = 1000 yuan/month), employment (1 = cadre, 2 = worker, 3 = farmer/others), years since diagnosis of the disease (treated as a continuous variable), and presence or absence of diabetes complications(1 = no, 2 = yes). F-to-entry and remove criteria were 0.05 and 0.10. P < 0.05 (two-tailed) was regarded as statistically significant. All the analyses were performed with SPSS for Windows (Release 11, SPSS Inc., Chicago, USA).
3.
Results
3.1.
Demographic traits and physical variables of patients
Three hundred and four participants (M/F, 121/183) completed the survey. They had a mean (S.D.) age of 59.4 (13.7) years. Years since diagnosis of diabetes ranged between 1 and 62 years (mean 7.3 years). 71.4%, 6.9% and 21.7% of them were administrators or other white collar, blue collar and farmer/ others, respectively. 33.9%, 48.3% and 17.8% of them had formal education of primary school or below, middle school, college or above. Of the 304 patients, 41 (13.5%) had cardiovascular complications, 18 (5.9%) had cerebrovascular complications, 7 (2.3%) had retinopathy and neuropathy, 9 (3.0%) had nephropathy, and 18 (5.9%) had metabolic complications (hyperlipidemia, ketoacidosis, and gout). 32.2% patients treated by medication and 67.8% treated by hospitalization. Of all, 29.3% participants take insulin to control diabetes (Table 1).
3.2.
Anxiety and depressive symptoms
The mean (S.D.) scores of HADS-A and HADS-D subscales were 5.0 (4.2) and 4. 9 (4.3), respectively, 78 (25.7%) and 78 (25.7%) participants were, respectively, classified as possibly clinically relevant levels of anxiety and possibly clinically relevant levels of depression by Snaith and Zigmond’s criteria (HADS-A 8 or HADS-D 8) [32].
3.3. Correlations among psychosocial factors and anxiety/ depressive symptoms Anxiety and depressive symptoms were positively correlated with ‘‘worrying about to be harmed by the disease’’, ‘‘social/
Table 1 – Characteristics of subjects with type 2 diabetes Demographics
Number
%
Age (years) Years since diagnosis (years)
59.4(13.7) 7.3(6.2)
Sex Male Female
121 183
39.8 60.2
Marital status Unmarried Married Divorce Bereft of one’s spouse
15 258 3 28
4.9 84.9 1.0 9.2
Educational level Primary school or below Middle school College or above
103 147 54
33.9 48.3 17.8
Income <1000 yuan/month 1000 yuan/month
153 151
50.3 49.7
217
71.4
21 66
6.9 21.7
41 18 18 9 7 7
13.5 5.9 5.9 3.0 2.3 2.3
206 98 89
67.8 32.2 29.3
Employment status Administrator or other white collar Blue collar worker Farmer/others Diabetes complications Cardiovascular complications Cerebrovascular complications Metabolic complications Nephropathy Retinopathy Neuropathy Diabetes therapy Hospitalization Medication Insulin
Mean (S.D.)
family crisis caused by disease’’, ‘‘worrying about declining in body/physical function’’, ‘‘negative coping style’’, and negatively correlated with ‘‘objective social support’’. Other correlation coefficients among other factors of coping style, psychological stress caused by disease, and social support are also presented in Table 2.
3.4.
Multiple regression findings
Multiple stepwise regression analysis shows that anxiety and depressive symptoms were significantly associated with the psychological stress caused by type 2 diabetes, coping styles and social support after controlling for potential confounding factors (Table 3). Psychological stress of ‘‘worrying about to be harmed by the disease’’, ‘‘social/family crisis caused by the disease’’, ‘‘worrying about declining in body/physical function’’, ‘‘declined economic condition’’ and ‘‘negative coping style’’ were significantly and independently associated with anxiety symptoms. These factors explained 48.9% of the variance in HAD anxiety symptoms score among Chinese patients with type 2 diabetes (Table 3). Patients with higher perceived stress from ‘‘worrying about to be harmed by the disease’’, ‘‘worrying about declining in
526
1
2
3
4
5
6
7
8
9
10
11
12
Psychological stress 1. Worrying about to be harmed by the disease 2. Social/family crisis caused by the disease 3. Worrying about declining in body/physical function 4. Declined economic condition Coping styles 5. Negative coping style 6. Active coping style 7. Self relaxing 8. Avoidance coping style
0.279** 0.211** 0.048 0.012
0.388** 0.071 0.035 0.125*
0.316** 0.030 0.148* 0.006
0.067 0.022 0.060 0.043
Social support 9. Objective social support 10. Subjective social support 11. Support utility 12. Anxiety 13. Depression
0.065 0.059 0.130* 0.384** 0.146*
0.122 0.178* 0.027 0.323** 0.286**
0.023 0.143* 0.095 0.328** 0.340**
0.054 0.124* 0.008 0.211** 0.104
* **
P < 0.05. P < 0.01.
0.185** 0.122* 0.013 0.491** 0.391**
0.084 0.166** 0.248** 0.010 0.291**
0.148* 0.152* 0.073 0.009 0.042
0.014 0.033 0.066 0.060 0.060
0.407** 0.187** 0.154* 0.215**
0.315** 0.106 0.314**
0.068 0.241**
0.646**
diabetes research and clinical practice 79 (2008) 523–530
Table 2 – Correlations of psychosocial factors with anxiety and depressive symptoms
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Table 3 – Associations of psychosocial factors with anxiety and depressive symptoms Independent variables
Beta
SE of Beta
Standardized beta
t value
p value
Partial correlation
Anxiety, R = 0.700, R2 = 0.489 Worrying about to be harmed by the disease Worrying about declining in body/physical function Social/family crisis caused by disease Declined economic condition Negative coping styles
1.476 1.175 0.986 0.916 1.037
0.226 0.221 0.226 0.217 0.251
0.328 0.268 0.225 0.207 0.239
6.533 5.323 4.365 4.217 4.141
<0.000 <0.000 <0.000 <0.000 <0.000
0.387 0.323 0.270 0.261 0.257
Depression, R = 0.657, R2 = 0. 432 Worrying about declining in body /physical function Social/family crisis caused by disease Worrying about to be harmed by the disease Declined economic condition Active coping style Negative coping style Subjective social support
1.194 0.890 1.101 0.482 1.131 0.629 0.162
0.238 0.251 0.245 0.234 0.233 0.270 0.045
0.271 0.201 0.243 0.108 0.263 0.144 0.199
5.019 3.553 4.491 2.059 4.864 2.330 3.635
<0.000 <0.000 <0.000 0.041 <0.000 0.021 <0.000
0.308 0.224 0.278 0.132 0.300 0.149 0.228
Multiple regression analysis with adjustment for sex, age, marital status, educational level, income, employment, years since diagnosis of the disease, and presence or absence of diabetes complications. The adjustment factors were entered in step 1 (enter) and the psychosocial factors were then selected into the model using the forward stepwise approach in step 2.
body/physical function’’, ‘‘social/family crisis caused by the disease’’, ‘‘declined economic condition’’, lower ‘‘subjective social support’’ and those taking more ‘‘negative coping style’’ had higher depressive symptoms score. Whereas patients taking ‘‘active coping style’’ had lower depressive symptoms score. These predictors accounted for 43.2% of the variance in HAD depressive symptoms score in this population (Table 3).
4.
Discussion
The aim of the present study was to examine the relationships of psychosocial factors, including psychological stress caused by type 2 diabetes, coping styles and social support, with anxiety and depression in Chinese patients with type 2 diabetes after controlling for potential confounding factors. Our findings showed that a significantly positive relationship between the psychological stress and anxiety and depressive symptoms; negative coping style was positively related to anxiety and depressive symptoms, whereas the active coping style and subjective social support were negatively associated with depressive symptoms. As the same as other chronic diseases, type 2 diabetes patients may also experience a variety of stressors brought about by the illness and its treatment. These stressors include pain, disfigurement, impaired physical functioning, lifethreat, permanent changes in lifestyle, dependency, selfmanagement tasks, threats to dignity, diminished selfesteem, disruption of normal life transition, decreasing resources, and changes in future perspectives [33]. It has been observed that these disease-related stressors may play an important role in the development of anxiety and depression among chronic diseases patients [33]. It has also been found that unfavorable childhood events and negative life events such as arguments within the household, financial problems, illness, and worsening marital difficulties were positively associated with depressive symptoms and/or anxiety among patients with type 2 diabetes [22,34–36]. Consistent with previous studies, our results showed that
psychological stress caused by type 2 disease was significantly related to the anxiety and depressive symptoms. Perceived stresses of ‘‘worrying about to be harmed by the disease’’, ‘‘social/family crisis caused by the disease’’, ‘‘worrying about declining in body/physical function’’, ‘‘declined economic condition’’ were significantly associated with the anxiety and depressive symptoms. These suggest that perceived stressors would predict and propel the onset of the depression and anxiety state. Also, this highlights that when developing interventions, it is very important to address perceived stress from disease. Coping strategies are defined as a set of behavioral and cognitive responses to stress by Lazarus and Folkman [37]. Previous studies reported that the type of coping strategy of an individual affects both physical and mental health [38,39]. We also observed that ‘‘negative coping style’’ was significantly positively associated with anxiety and depressive symptoms. ‘‘Negative coping style’’ and anxiety/depression might have a reciprocal causal relationship. ‘‘Negative coping style’’ may damage mental health and increase the risk of anxiety and depressive symptoms. Patients with anxiety and depression symptoms, in turn, may be more inclined to take a negative coping style. Therefore, it would be important to break such an infernal circle in the diabetes care and management. ‘‘Active coping style’’ was significantly and negatively associated with depressive symptoms. Stimulating the use of this functional coping style may prevent developmental problems in depression. Other coping styles, ‘‘self-relaxing’’, ‘‘avoidance coping style’’ did not have an independent effect on anxiety and depressive symptoms in our study after adjusting for the potential confounders. Social support can be defined as information from others that one is loved and cared for, esteemed and valued, and part of a network of communication. Social support is important not only to provide an opportunity to share each other’s problems and feelings, but also to gain encouragement and strength. That utilization from social support seems to determine whether an individual has had actual contact with other social groups or other individuals. It has been reported
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that poorly perceived social supports was positively associated with depressive symptoms in community-based volunteers [36]; and general or diabetes-specific social support are associated with fewer depressive symptoms [21,40] or easier psychosocial adjustment to diabetes, including emotional well-being [41] in diabetic patients. Similar results were found in our study. The utilization of subjective social support was significantly correlated with lower depressive symptoms in this population. A reasonable explanation is that poor health status might limit an individual to develop and maintain his/her social relations, and therefore contribute to emotional depression. Our findings support the hypothesis that efficient social support could attenuate depressive symptoms in diabetic patients. We recognized that our findings were based on a clinical sample from three affiliated hospitals of our university. These hospitals are the top class hospital in this region. The patients of these hospitals usually have a relatively higher social economical status and/or a more serious or complicate condition than those from other smaller hospitals or clinics. Such a sample might thus limit the generalization of the results regarding the relationship between psychosocial factors and anxiety and depression in Chinese patients with type 2 diabetes. Second, it should be noted that we could not determine a causal relationship due to the limitation of the cross-sectional study design. Third, hemoglobin A1c (HbA1c) was not measured in the present study, so that we could not assess the associations of it with depression and/or anxiety and psychosocial factors, at the same time we also could not adjust its potential confounding effect. Despite these limitations, this is the first study in Chinese patients with type 2 diabetes and adds to the existing evidence that perceived sources of stress, coping style, social support are independent
determinants of depression and anxiety symptoms in diabetic patients, particularly in Chinese type 2 diabetes patients. Further longitudinal study needed to clarify whether the relationship is a unilateral or reciprocal causal relationship. Although drawn from cross-sectional data, our findings have some clinical implications. First, to decrease or relieve depression and anxiety in type 2 diabetes patients, some specific measures should be taken to manage patients’ perception of stress from the disease. Of course, it is very important to identify the sources of patients’ perceiving stress from the disease at first. Second, doctors should advise the patients to take active coping styles rather than negative coping methods for improving their physical and psychological well-being. Third, in clinical practice, doctors might mobilize more social support resources to reduce the risk of anxiety and depression in type 2 diabetes and to improve their quality of life. In conclusion, our findings show that perceived sources of stress, coping styles, social support are the independent determinants of depression and anxiety among Chinese patients with type 2 diabetes. Our findings support the need to address these psychosocial risk factors that precipitate and propel the depression and anxiety when treating the type 2 diabetes patients with depressive and/or anxiety symptoms.
Acknowledgements The authors would like to thank the following clinical settings: the First Affiliated Hospitals, the Second Affiliated Hospitals and the Third Affiliated Hospitals of Sun Yat-sen University. Other investigators in this research are Qiu Quan, Kang Min, Li Liquan, Sun Kangjian, Li Biao, and Liang Shixing.
Appendix A Factor analysis of the scale of the psychological stress. Item description (eigenvalues; variance proportion)
Factor loading
Factor1: worrying about to be harmed by the disease (10.708; 35.693%) 1. Worrying pain caused by the disease 2. Worryinging about treatment side effects 3. Wory about having no treatment of own illness 4. Worrying inaccuracy of diagnosis and therapy 5. Worrying about depending on doctors and nurses 6. Worrying discomfort 7. Worrying about death 8. Disruption of life plan 9. Worrying that illness will change one’s physical appearance 10. Feeling loneliness because of treatment in bed and convalesce
0.715 0.677 0.663 0.662 0.613 0.589 0.585 0.551 0.485 0.406
Factor 2: social/family crisis caused by the disease (2.267; 7.557%) 1. Feeling no future and no value because of no doing something on time 2. Worrying about the relationship between oneself and family caused by being chronically ill 3. Worrying about the stability of marriage and family caused by being chronically ill 4. Hiding one’s illness from others due to some causes 5. Worrying about being an useless person 6. Worrying about being treated as a sick person by relatives and friends 7. Reducing social activities and affect social position because of illness 8. Unfulfilled family roles
0.598 0.564 0.545 0.542 0.519 0.504 0.501 0.485
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Appendix A (Continued ) Item description (eigenvalues; variance proportion)
Factor loading
9. Be in bed and to convalesce, restrict getting-up and have the feeling of restriction because of the illness 10. Keeping from eating foods that one like and feel being deprived of freedom 11. Disruption of will
0.448 0.446 0.434
Factor 3: worrying about declining in body/physical function (1.682; 5.606%) 1. Slipped memory and attention 2. Feeling hypodynamic and tired 3. Weaken or lose the general physical function because of the longtime illness 4. Often insomnia
0.691 0.671 0.661 0.644
Factor 4: declined economic condition (1.250; 4.166%) 1. Worrying about loss of job 2. Worrying about being retired 3. Worrying about being unable to work 4. Economic burden 5. Family income influenced by disease
0.806 0.784 0.631 0.570 0.442
Conflict of interest The authors state that they have no conflict of interest.
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Association of psychosocial factors with anxiety and depressive symptoms in Chinese patients with type 2 diabetes Cai-Xia Zhang, Yu-Ming Chen, Wei-Qing Chen * Department of Biostatistics and Epidemiology, School of Public Health, Sun Yat-sen University, 74, Zhongshan Road 2, Guangzhou, China
article info
abstract
Article history:
Objective: To investigate association of psychosocial factors with anxiety and depressive
Received 18 March 2007
symptoms in Chinese type 2 diabetes patients.
Accepted 5 October 2007
Methods: Three hundred and four type 2 diabetes patients were inquired with a structured
Published on line 19 November 2007
questionnaire about socio-demographic characteristics, psychological stress, coping styles, social support, and anxiety and depressive symptoms. Multiple regression analysis was
Keywords:
performed to assess the association of these psychosocial factors with anxiety and depres-
Depression
sive symptoms after controlling for potential confounding factors of sex, age, educational
Anxiety
level, etc.
Type 2 diabetes
Results: After adjusting for the potential confounding factors, multiple stepwise regression
Psychosocial factors
analysis found that anxiety symptoms were significantly positively associated with ‘‘worrying about to be harmed by the disease’’, ‘‘social/family crisis caused by the disease’’, ‘‘worrying about declining in body/physical function’’, ‘‘declined economic condition caused by the disease’’ and ‘‘negative coping styles’’; and depression symptoms were significantly positively associated with ‘‘worrying about to be harmed by the disease’’, ‘‘worrying about declining in body/physical function’’, ‘‘social/family crisis caused by the disease’’, ‘‘declined economic condition’’, ‘‘negative coping styles’’, but negatively with ‘‘active coping styles’’ and ‘‘subjective social support’’. Conclusion: Our findings show that perceived stress from disease, coping styles, social support are the independent determinants of anxiety and depressive symptoms among Chinese patients with type 2 diabetes. # 2007 Elsevier Ireland Ltd. All rights reserved.
1.
Introduction
Diabetes mellitus is a devastating chronic, progressive disease and especially poorly controlled diabetes is associated with multiple long term complications and has important implications for a patient’s well-being and social life. Anxiety and depression are common occurrence among diabetes patients and often debilitate them [1–3]. In a recent meta-analysis, the
prevalence of depression among people with diabetes was about twice as high as that among those without diabetes [4]. Depression is associated with poor self-management, metabolic control [5,6], and low compliance with therapy among diabetic patients [7,8], which, in turn, result in more diabetesrelated complications [5,6], particularly cardiovascular diseases and retinopathy [9,10] and worse health-related quality of life [11]. Improvements in depression or treatment of depression
* Corresponding author. Tel.: +86 20 87332199; fax: +86 20 87330446. E-mail address: [email protected] (W.-Q. Chen). 0168-8227/$ – see front matter # 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.diabres.2007.10.014
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can lead to clinically significant improvements in glycaemic control [4,12]. To prevent depression and anxiety in the diabetic patients, a clear understanding about the determinants of and risk factors for mental disorders is necessary. It is believed that depression and anxiety in patients with diabetes is caused by multiple factors. Women patients with diabetes are at much greater risk of having depressive symptoms than men [4,13,14]. Patients are of poorer health and lower levels of education and socioeconomic status have higher rates of depression than patients without these characteristics [13– 15]. Other factors associated with depression symptoms include unmarried, unemployed, ethnic minorities, low income, presence of diabetes complications, higher nondiabetic medical co-morbidity, and poor glycemic control [11,12,14,16–20]. Besides these socio-demographic and clinical factors, some studies showed that psychosocial factors have also been shown to play important role in the development of depression and anxiety. Important psychosocial factors included childhood adversity, vulnerable personality styles, experience negative life events or other chronic stresses, poor quality of life, limited social support [21–24]. But, these earlier studies have methodological limitations that may affect the ability to generalize their findings to the adults with diabetes. For instance, these factors have been explored across some studies but usually only a few at a time, which has provided disjoined evidence of their association with depression and/ or anxiety. In addition, some studies used minority populations. Furthermore, many of these earlier studies did not simultaneously control for several socio-demographic and health variables which may account for relationships between the analytic variables. Therefore, we conducted a cross-sectional survey in 304 Chinese patients with type 2 diabetes, the purpose of the present study was to comprehensively examine associations of perceived stress from the disease, personal coping style and social supports with depression and anxiety after controlling for potential confounding factors.
2.
Patients and methods
2.1.
Study subjects
Type 2 diabetic patients were recruited for the study from out- or inpatients in the three affiliated hospitals of Sun Yatsen University, Guangzhou, China from November 2004 to March 2005. Subjects were required to be (i) aged 18 years or older; (ii) confirmed type 2 diabetes for at least 1 year according to WHO criteria; and (iii) free of other non-diabetes chronic health problems, including hypertension, chronic obstructive pulmonary disease (COPD), arthritis, asthma. Trained staff screened the potential subjects for eligibility via structured face-to-face interview to ensure that they met the criteria. Written informed consent was obtained from all the participants prior to enrollment after a detailed explanation on the study objective and requirements of the survey. The Ethical Committee of the Sun Yat-sen University approved the study.
2.2.
Measurements
Individual information on age, educational level, marital status, perceived stress from the disease, coping styles, and social support were collected using a structured questionnaire by well-trained interviewers via face-to-face interview. Diabetes status and the method of the treatment (hospitalization or medication) were identified from medical records. Subjects were also asked a series of questions on medical history, including whether they had been diagnosed suffering from diabetic-specific complications, such as retinopathy, nephropathy, neuropathy, cerebrovascular, peripheral vascular, cardiovascular, and metabolic diseases. If the patients reported that they have one or more complications, we would record them and then search medical record to confirm this information.
2.2.1.
Psychological stress
Psychological stress caused by type 2 diabetes was measured with the questionnaire developed from the scales, respectively, used in the studies by Leung et al. [25] and Lin and Zhang [26]. The questionnaire consisted of 30 items. Each item is scored on a 5-point Likert-type scale from 1 (never or rarely) to 5 (very often). The patients would choose one number from the scale as their responses. Factor analysis identified four factors explaining 53.0% of the total variance (see Appendix A). According to the nature and contents of the items included in each factor, the four factors were, respectively, defined as follows: ‘‘worrying about to be harmed by the disease’’, ‘‘social/family crisis caused by the disease’’, ‘‘worrying about declining in body/physical function’’, ‘‘declined economic condition’’. The Cronbach a of the four factors and the whole scale was 0.89, 0.87, 0.72, 0.79 and 0.94, respectively.
2.2.2.
Coping style
Coping style was measured using validated scale [27]. The scale consisted of 24 items. The patients were asked and a 4point Likert-type scale was used for each item, ranging from 1 (never do) to 4 (always do) (1 = never do, 2 = seldom do, 3 = often do, 4 = always do). Factor analysis of the 24 items of coping style yielded four factors, which explained 41.7% of the total variance. According to the nature and contents of the items included in each factor, the four factors were, respectively, defined as: ‘‘negative coping style’’, ‘‘active coping style’’, ‘‘self-relaxing’’ and ‘‘avoidance coping style’’. The Cronbach a of the four factors and the whole scale was 0.70, 0.71, 0.64, 0.53 and 0.77, respectively.
2.2.3.
Social support
Social support status was assessed using a well-validated social support rating scale designed by Xiao [28,29]. The scale is a 10-item measure of three dimensions of social support: subjective support, objective support, and support utility.
2.2.4.
Anxiety and depressive symptoms
Hospital anxiety and depression scale (HADS) was used to assess anxiety and depression [30]. It consists of 14 items, 7 items for anxiety and 7 for depression. Separate anxiety and depression subscale scores were then calculated. The score for each subscale ranges from 0 to 21. The higher the score, the
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worse the status with respect to a particular category. The Chinese version of HADS has been developed and validated by previous studies [31].
2.3.
Statistical analysis
Pearson correlation coefficients of the scores of anxiety/ depressive symptoms, each factor of psychological stress, coping style and social support were calculated and examined. Multiple forward stepwise regression analysis was used to test the independent determinants of the anxiety and depressive symptoms. The independent variables of multivariate analysis included each factor of psychological stress and other psychosocial factors with adjustment for sex (1 = male, 2 = female), age (treated as a continuous variable), marital status (1 = unmarried, 2 = married, 3 = divorce), educational level (1 = primary school or below, 2 = middle school, 3 = college or above), income (1 = <1000 yuan/month, 2 = 1000 yuan/month), employment (1 = cadre, 2 = worker, 3 = farmer/others), years since diagnosis of the disease (treated as a continuous variable), and presence or absence of diabetes complications(1 = no, 2 = yes). F-to-entry and remove criteria were 0.05 and 0.10. P < 0.05 (two-tailed) was regarded as statistically significant. All the analyses were performed with SPSS for Windows (Release 11, SPSS Inc., Chicago, USA).
3.
Results
3.1.
Demographic traits and physical variables of patients
Three hundred and four participants (M/F, 121/183) completed the survey. They had a mean (S.D.) age of 59.4 (13.7) years. Years since diagnosis of diabetes ranged between 1 and 62 years (mean 7.3 years). 71.4%, 6.9% and 21.7% of them were administrators or other white collar, blue collar and farmer/ others, respectively. 33.9%, 48.3% and 17.8% of them had formal education of primary school or below, middle school, college or above. Of the 304 patients, 41 (13.5%) had cardiovascular complications, 18 (5.9%) had cerebrovascular complications, 7 (2.3%) had retinopathy and neuropathy, 9 (3.0%) had nephropathy, and 18 (5.9%) had metabolic complications (hyperlipidemia, ketoacidosis, and gout). 32.2% patients treated by medication and 67.8% treated by hospitalization. Of all, 29.3% participants take insulin to control diabetes (Table 1).
3.2.
Anxiety and depressive symptoms
The mean (S.D.) scores of HADS-A and HADS-D subscales were 5.0 (4.2) and 4. 9 (4.3), respectively, 78 (25.7%) and 78 (25.7%) participants were, respectively, classified as possibly clinically relevant levels of anxiety and possibly clinically relevant levels of depression by Snaith and Zigmond’s criteria (HADS-A 8 or HADS-D 8) [32].
3.3. Correlations among psychosocial factors and anxiety/ depressive symptoms Anxiety and depressive symptoms were positively correlated with ‘‘worrying about to be harmed by the disease’’, ‘‘social/
Table 1 – Characteristics of subjects with type 2 diabetes Demographics
Number
%
Age (years) Years since diagnosis (years)
59.4(13.7) 7.3(6.2)
Sex Male Female
121 183
39.8 60.2
Marital status Unmarried Married Divorce Bereft of one’s spouse
15 258 3 28
4.9 84.9 1.0 9.2
Educational level Primary school or below Middle school College or above
103 147 54
33.9 48.3 17.8
Income <1000 yuan/month 1000 yuan/month
153 151
50.3 49.7
217
71.4
21 66
6.9 21.7
41 18 18 9 7 7
13.5 5.9 5.9 3.0 2.3 2.3
206 98 89
67.8 32.2 29.3
Employment status Administrator or other white collar Blue collar worker Farmer/others Diabetes complications Cardiovascular complications Cerebrovascular complications Metabolic complications Nephropathy Retinopathy Neuropathy Diabetes therapy Hospitalization Medication Insulin
Mean (S.D.)
family crisis caused by disease’’, ‘‘worrying about declining in body/physical function’’, ‘‘negative coping style’’, and negatively correlated with ‘‘objective social support’’. Other correlation coefficients among other factors of coping style, psychological stress caused by disease, and social support are also presented in Table 2.
3.4.
Multiple regression findings
Multiple stepwise regression analysis shows that anxiety and depressive symptoms were significantly associated with the psychological stress caused by type 2 diabetes, coping styles and social support after controlling for potential confounding factors (Table 3). Psychological stress of ‘‘worrying about to be harmed by the disease’’, ‘‘social/family crisis caused by the disease’’, ‘‘worrying about declining in body/physical function’’, ‘‘declined economic condition’’ and ‘‘negative coping style’’ were significantly and independently associated with anxiety symptoms. These factors explained 48.9% of the variance in HAD anxiety symptoms score among Chinese patients with type 2 diabetes (Table 3). Patients with higher perceived stress from ‘‘worrying about to be harmed by the disease’’, ‘‘worrying about declining in
526
1
2
3
4
5
6
7
8
9
10
11
12
Psychological stress 1. Worrying about to be harmed by the disease 2. Social/family crisis caused by the disease 3. Worrying about declining in body/physical function 4. Declined economic condition Coping styles 5. Negative coping style 6. Active coping style 7. Self relaxing 8. Avoidance coping style
0.279** 0.211** 0.048 0.012
0.388** 0.071 0.035 0.125*
0.316** 0.030 0.148* 0.006
0.067 0.022 0.060 0.043
Social support 9. Objective social support 10. Subjective social support 11. Support utility 12. Anxiety 13. Depression
0.065 0.059 0.130* 0.384** 0.146*
0.122 0.178* 0.027 0.323** 0.286**
0.023 0.143* 0.095 0.328** 0.340**
0.054 0.124* 0.008 0.211** 0.104
* **
P < 0.05. P < 0.01.
0.185** 0.122* 0.013 0.491** 0.391**
0.084 0.166** 0.248** 0.010 0.291**
0.148* 0.152* 0.073 0.009 0.042
0.014 0.033 0.066 0.060 0.060
0.407** 0.187** 0.154* 0.215**
0.315** 0.106 0.314**
0.068 0.241**
0.646**
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Table 2 – Correlations of psychosocial factors with anxiety and depressive symptoms
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Table 3 – Associations of psychosocial factors with anxiety and depressive symptoms Independent variables
Beta
SE of Beta
Standardized beta
t value
p value
Partial correlation
Anxiety, R = 0.700, R2 = 0.489 Worrying about to be harmed by the disease Worrying about declining in body/physical function Social/family crisis caused by disease Declined economic condition Negative coping styles
1.476 1.175 0.986 0.916 1.037
0.226 0.221 0.226 0.217 0.251
0.328 0.268 0.225 0.207 0.239
6.533 5.323 4.365 4.217 4.141
<0.000 <0.000 <0.000 <0.000 <0.000
0.387 0.323 0.270 0.261 0.257
Depression, R = 0.657, R2 = 0. 432 Worrying about declining in body /physical function Social/family crisis caused by disease Worrying about to be harmed by the disease Declined economic condition Active coping style Negative coping style Subjective social support
1.194 0.890 1.101 0.482 1.131 0.629 0.162
0.238 0.251 0.245 0.234 0.233 0.270 0.045
0.271 0.201 0.243 0.108 0.263 0.144 0.199
5.019 3.553 4.491 2.059 4.864 2.330 3.635
<0.000 <0.000 <0.000 0.041 <0.000 0.021 <0.000
0.308 0.224 0.278 0.132 0.300 0.149 0.228
Multiple regression analysis with adjustment for sex, age, marital status, educational level, income, employment, years since diagnosis of the disease, and presence or absence of diabetes complications. The adjustment factors were entered in step 1 (enter) and the psychosocial factors were then selected into the model using the forward stepwise approach in step 2.
body/physical function’’, ‘‘social/family crisis caused by the disease’’, ‘‘declined economic condition’’, lower ‘‘subjective social support’’ and those taking more ‘‘negative coping style’’ had higher depressive symptoms score. Whereas patients taking ‘‘active coping style’’ had lower depressive symptoms score. These predictors accounted for 43.2% of the variance in HAD depressive symptoms score in this population (Table 3).
4.
Discussion
The aim of the present study was to examine the relationships of psychosocial factors, including psychological stress caused by type 2 diabetes, coping styles and social support, with anxiety and depression in Chinese patients with type 2 diabetes after controlling for potential confounding factors. Our findings showed that a significantly positive relationship between the psychological stress and anxiety and depressive symptoms; negative coping style was positively related to anxiety and depressive symptoms, whereas the active coping style and subjective social support were negatively associated with depressive symptoms. As the same as other chronic diseases, type 2 diabetes patients may also experience a variety of stressors brought about by the illness and its treatment. These stressors include pain, disfigurement, impaired physical functioning, lifethreat, permanent changes in lifestyle, dependency, selfmanagement tasks, threats to dignity, diminished selfesteem, disruption of normal life transition, decreasing resources, and changes in future perspectives [33]. It has been observed that these disease-related stressors may play an important role in the development of anxiety and depression among chronic diseases patients [33]. It has also been found that unfavorable childhood events and negative life events such as arguments within the household, financial problems, illness, and worsening marital difficulties were positively associated with depressive symptoms and/or anxiety among patients with type 2 diabetes [22,34–36]. Consistent with previous studies, our results showed that
psychological stress caused by type 2 disease was significantly related to the anxiety and depressive symptoms. Perceived stresses of ‘‘worrying about to be harmed by the disease’’, ‘‘social/family crisis caused by the disease’’, ‘‘worrying about declining in body/physical function’’, ‘‘declined economic condition’’ were significantly associated with the anxiety and depressive symptoms. These suggest that perceived stressors would predict and propel the onset of the depression and anxiety state. Also, this highlights that when developing interventions, it is very important to address perceived stress from disease. Coping strategies are defined as a set of behavioral and cognitive responses to stress by Lazarus and Folkman [37]. Previous studies reported that the type of coping strategy of an individual affects both physical and mental health [38,39]. We also observed that ‘‘negative coping style’’ was significantly positively associated with anxiety and depressive symptoms. ‘‘Negative coping style’’ and anxiety/depression might have a reciprocal causal relationship. ‘‘Negative coping style’’ may damage mental health and increase the risk of anxiety and depressive symptoms. Patients with anxiety and depression symptoms, in turn, may be more inclined to take a negative coping style. Therefore, it would be important to break such an infernal circle in the diabetes care and management. ‘‘Active coping style’’ was significantly and negatively associated with depressive symptoms. Stimulating the use of this functional coping style may prevent developmental problems in depression. Other coping styles, ‘‘self-relaxing’’, ‘‘avoidance coping style’’ did not have an independent effect on anxiety and depressive symptoms in our study after adjusting for the potential confounders. Social support can be defined as information from others that one is loved and cared for, esteemed and valued, and part of a network of communication. Social support is important not only to provide an opportunity to share each other’s problems and feelings, but also to gain encouragement and strength. That utilization from social support seems to determine whether an individual has had actual contact with other social groups or other individuals. It has been reported
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that poorly perceived social supports was positively associated with depressive symptoms in community-based volunteers [36]; and general or diabetes-specific social support are associated with fewer depressive symptoms [21,40] or easier psychosocial adjustment to diabetes, including emotional well-being [41] in diabetic patients. Similar results were found in our study. The utilization of subjective social support was significantly correlated with lower depressive symptoms in this population. A reasonable explanation is that poor health status might limit an individual to develop and maintain his/her social relations, and therefore contribute to emotional depression. Our findings support the hypothesis that efficient social support could attenuate depressive symptoms in diabetic patients. We recognized that our findings were based on a clinical sample from three affiliated hospitals of our university. These hospitals are the top class hospital in this region. The patients of these hospitals usually have a relatively higher social economical status and/or a more serious or complicate condition than those from other smaller hospitals or clinics. Such a sample might thus limit the generalization of the results regarding the relationship between psychosocial factors and anxiety and depression in Chinese patients with type 2 diabetes. Second, it should be noted that we could not determine a causal relationship due to the limitation of the cross-sectional study design. Third, hemoglobin A1c (HbA1c) was not measured in the present study, so that we could not assess the associations of it with depression and/or anxiety and psychosocial factors, at the same time we also could not adjust its potential confounding effect. Despite these limitations, this is the first study in Chinese patients with type 2 diabetes and adds to the existing evidence that perceived sources of stress, coping style, social support are independent
determinants of depression and anxiety symptoms in diabetic patients, particularly in Chinese type 2 diabetes patients. Further longitudinal study needed to clarify whether the relationship is a unilateral or reciprocal causal relationship. Although drawn from cross-sectional data, our findings have some clinical implications. First, to decrease or relieve depression and anxiety in type 2 diabetes patients, some specific measures should be taken to manage patients’ perception of stress from the disease. Of course, it is very important to identify the sources of patients’ perceiving stress from the disease at first. Second, doctors should advise the patients to take active coping styles rather than negative coping methods for improving their physical and psychological well-being. Third, in clinical practice, doctors might mobilize more social support resources to reduce the risk of anxiety and depression in type 2 diabetes and to improve their quality of life. In conclusion, our findings show that perceived sources of stress, coping styles, social support are the independent determinants of depression and anxiety among Chinese patients with type 2 diabetes. Our findings support the need to address these psychosocial risk factors that precipitate and propel the depression and anxiety when treating the type 2 diabetes patients with depressive and/or anxiety symptoms.
Acknowledgements The authors would like to thank the following clinical settings: the First Affiliated Hospitals, the Second Affiliated Hospitals and the Third Affiliated Hospitals of Sun Yat-sen University. Other investigators in this research are Qiu Quan, Kang Min, Li Liquan, Sun Kangjian, Li Biao, and Liang Shixing.
Appendix A Factor analysis of the scale of the psychological stress. Item description (eigenvalues; variance proportion)
Factor loading
Factor1: worrying about to be harmed by the disease (10.708; 35.693%) 1. Worrying pain caused by the disease 2. Worryinging about treatment side effects 3. Wory about having no treatment of own illness 4. Worrying inaccuracy of diagnosis and therapy 5. Worrying about depending on doctors and nurses 6. Worrying discomfort 7. Worrying about death 8. Disruption of life plan 9. Worrying that illness will change one’s physical appearance 10. Feeling loneliness because of treatment in bed and convalesce
0.715 0.677 0.663 0.662 0.613 0.589 0.585 0.551 0.485 0.406
Factor 2: social/family crisis caused by the disease (2.267; 7.557%) 1. Feeling no future and no value because of no doing something on time 2. Worrying about the relationship between oneself and family caused by being chronically ill 3. Worrying about the stability of marriage and family caused by being chronically ill 4. Hiding one’s illness from others due to some causes 5. Worrying about being an useless person 6. Worrying about being treated as a sick person by relatives and friends 7. Reducing social activities and affect social position because of illness 8. Unfulfilled family roles
0.598 0.564 0.545 0.542 0.519 0.504 0.501 0.485
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diabetes research and clinical practice 79 (2008) 523–530
Appendix A (Continued ) Item description (eigenvalues; variance proportion)
Factor loading
9. Be in bed and to convalesce, restrict getting-up and have the feeling of restriction because of the illness 10. Keeping from eating foods that one like and feel being deprived of freedom 11. Disruption of will
0.448 0.446 0.434
Factor 3: worrying about declining in body/physical function (1.682; 5.606%) 1. Slipped memory and attention 2. Feeling hypodynamic and tired 3. Weaken or lose the general physical function because of the longtime illness 4. Often insomnia
0.691 0.671 0.661 0.644
Factor 4: declined economic condition (1.250; 4.166%) 1. Worrying about loss of job 2. Worrying about being retired 3. Worrying about being unable to work 4. Economic burden 5. Family income influenced by disease
0.806 0.784 0.631 0.570 0.442
Conflict of interest The authors state that they have no conflict of interest.
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