|Year : 2011 | Volume
| Issue : 1 | Page : 56-63
Mood dysfunction and health-related quality of life among type 2 diabetic patients in Oman: Preliminary study
Masoud Y Al-Maskari1, Karin Petrini2, Ibrahim Al-Zakwani3, Sara S.H. Al-Adawi4, Atsu S.S. Dorvlo5, Samir Al-Adawi4
1 Department of Medicine, College of Medicine and Health Sciences, sultan Qaboos University, P. O. Box 35, Al-Khoudh 123, Muscat, Oman
2 Department of Psychology, University of Glasgow, Glasgow, United Kingdom
3 Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Sciences, sultan Qaboos University, P. O. Box 35, Al-Khoudh 123, Muscat, Oman
4 Department of Behavioral Sciences, College of Medicine and Health Sciences, sultan Qaboos University, P. O. Box 35, Al-Khoudh 123, Muscat, Oman
5 Department of Mathematics and Statistics, College of Science, Sultan Qaboos University, P. O. Box 35, Al-Khoudh 123 Muscat, Oman
|Date of Submission||10-Dec-2010|
|Date of Acceptance||23-Dec-2010|
|Date of Web Publication||11-Mar-2011|
Department of Behavioral Sciences, College of Medicine and Health Sciences, Sultan Qaboos University, P.O. Box 35, Al-Khoudh 123, Muscat
Source of Support: The economic and social research council (RES-060-25-0010), Conflict of Interest: None
| Abstract|| |
Aim: A temporal relationship exists between the presence of affective disturbance, poor glycaemic control and complications in people with type-2 diabetes. The objective of this study is to compare the performance of patients diagnosed with type-2 diabetes and normoactive group on indices of mood functioning and indices of health-related quality of life. Materials and Methods: In 2006-2007, for a six-month period, diabetics from Oman were screened for the presence of propensity towards psychiatric distress using Self-Reporting Questionnaire during their routine consultation at the diabetic clinic at a tertiary care hospital in an urban area of Oman. Those who fulfilled presently operationalised criteria for subclinical propensity towards affective disorders were further screened for affective functioning (Hospital Anxiety and Depression Scale) and indices of general well-being or health-related quality of life (Nottingham Health Profile). The age- and sex-matched controls group (n=40) underwent the same procedure. Results: Both measurement scales used in the present study indicated that the diabetic group had significantly poorer quality of life and higher distress level than the non-diabetic group, with the exception of emotional reaction for which the non-diabetics showed poorer health than the diabetics. Additionally, no difference between groups was found when compared for social isolation. Conclusions: In agreement with previous studies from different populations, people with diabetes in Oman appear to have marked affective functioning and impairment based on the indices of quality of life. The present finding is discussed within a sociocultural context that has a direct bearing on the situation in Oman.
Keywords: Diabetes, health-related quality of life, mood
|How to cite this article:|
Al-Maskari MY, Petrini K, Al-Zakwani I, Al-Adawi SS, Dorvlo AS, Al-Adawi S. Mood dysfunction and health-related quality of life among type 2 diabetic patients in Oman: Preliminary study. Int J Nutr Pharmacol Neurol Dis 2011;1:56-63
|How to cite this URL:|
Al-Maskari MY, Petrini K, Al-Zakwani I, Al-Adawi SS, Dorvlo AS, Al-Adawi S. Mood dysfunction and health-related quality of life among type 2 diabetic patients in Oman: Preliminary study. Int J Nutr Pharmacol Neurol Dis [serial online] 2011 [cited 2020 Jan 25];1:56-63. Available from: http://www.ijnpnd.com/text.asp?2011/1/1/56/77533
| Introduction|| |
Social, medical, and economic ramification of non-communicable diseases such as diabetes mellitus (DM) account for 80% of the total burden of chronic disease in many parts of the world. , There is increasing awareness that the rate of type-2 diabetes, unless concerted efforts are contemplated, is likely to become one of the fastest growing public health problems worldwide, with 366 million individuals to be affected by 2030. 
DM is characterised by hyperglycaemia and disturbances of carbohydrate, fat, and protein metabolism, which are associated with absolute or relative deficiencies of insulin action and/or insulin secretion.  Shortage of glucose in the brain triggers neuroglycopenic symptoms, , including unremitting affective disorder associated with adrenaline release in response to the declining blood glucose level. The incidence of affective disorder is much higher in diabetic populations than in other clinical populations.,,,,,, Conversely, there are some indications that affective disorder increases the risk of the onset of type-2 diabetes and vice versa.  Individuals with emotional distress have been shown to have poor compliance to hypoglycaemic therapy and other relevant lifestyle adjustments essential for managing diabetes.  Affective disorder may aggravate diabetes complications such as microvascular and macrovascular complications. Understanding of co-morbidity between diabetes and affective disorder is essential since this has implications for prognostic indication, quality of life, and health education. Despite the fact that diabetes is a global challenge, there is a dearth of studies examining the relationship between emotional distress and DM from developing countries like those in Arab Islamic countries, with a few exceptions. 
Emotional challenges tend to exacerbate physical illness and which, in turn, are likely to create a problem of health-related quality of life. Quality of life could be dented by various reasons including procedures inherent in diagnosis, difficulty in living with diabetes, long-term threat of decline and shortened life expectancy, necessary lifestyle changes that are necessary for living with diabetes as well as complicated therapeutic regimes and aversive symptoms that are inherent complications of DM. One useful paradigm to tease out the psychosocial impact is to examine health-related quality of life for people with diabetes. , This is pertinent with the view that many health problems, which were previously thought of as primarily medical, and hence demanding conventional medical intervention, are in fact more appropriately disentangled by understanding the psychosocial challenges they create.  The subjectively perceived emotional, social, and physical health problems have been variously quantified in reference to chronic illnesses.  However, very few studies have examined the indices of quality of life among patients with DM. Recognition of such a relationship is essential since many health campaigns tend to have only modest success because psychological variables are often untreated.
Examination of emotional disorders and other psychosocial variables as co-morbid in chronic illness in non-western countries has been hampered by cultural patterning. First, it is widely known that 'complaints about fear or sadness are not encouraged in the Arab/Muslim culture and these emotions are alleged to be expressed in 'somatopsychic' rather than 'psychological' ways, a communication style that has been often thought to reflect the communal nature of Arabs/Muslims, for example, in Omani society.  According to Dwairy,  traditional Omani society, like other non-western counterparts, is oriented towards group affiliation and interdependence, rather than competition. Cultural patterning with emphasis on enhancing sense of communalism, development of self-hood as perceived in Western psychology, may not overtly take place. According to Dwairy,  "…in the absence of a distinct domain for the self, somatic complaints are sometimes the only expression of distress" (p. 84). Second, overtly expressed subjectively perceived emotional, social, and physical health problems, as an indicator of quality of life, may be seen as lack of resoluteness in facing challenges in life, one of the essential pillars of social-culture teaching. It is therefore possible that emotional disorders and its counterpart, poor quality of life, may be hidden or expressed only via culturally acceptable channels in order to thwart off any perceived social stigma equated with emotional and psychological conditions. Studies are needed to explore mood dysfunction and health-related quality of life in such cross-cultural populations. The literature on affective disorder has been largely limited to psychiatric populations.  Thus, further studies are needed to explore the presence of affective disorders in other clinical populations. Such an undertaking would have implications for understanding how distress is experienced in different populations as well as audit emerging evidence from mostly Western populations that there is a temporal relationship between affective disorders and diabetes. Studies are needed to examine whether patients with type-2 diabetes have a worst quality of life and related mood dysfunction when compared to non-diabetic populations. This may shed some light on whether DM affects the quality of life of patients in very different cultural environments.
Despite strong associations between diabetes, affective disorder, and the quality of life, scant attention has been paid to these factors in Arab/Islamic countries like Oman where recent epidemiological data suggest that the burden of non-communicable diseases like DM is increasingly outstripping traditional 'enemies' like communicable diseases and malnutrition.  Oman, a country located in the southern part of the Arabian Peninsula, presents an interesting and fertile ground for such undertaking. Oman has witnessed a rising tide of type-2 diabetes at a staggering rate., The objective of this study is to compare the performance of patients diagnosed with type-2 diabetes and a normoactive group on indices of mood functioning, by using the Hospital Anxiety and Depression Scale and indices of health-related quality of life, by means of the Nottingham Health Profile. 
| Materials and Methods|| |
The sampling plan for this study was a convenience sampling procedure among consecutive patients, who came for consultation at the diabetic outpatient clinic either to refill their medication or have their regular checkups.
Sultan Qaboos University Hospital (SQUH) serves an ethnically diverse community. Being the only teaching hospital in Oman, it also caters to referrals from all regions of the country. The annual patient-visit volume per year for SQUH is in excess of 100,000.
For patients who consented to participate in the study and fulfilled the inclusion criteria (eg, Omani national, no persistent cognitive impairment that would render them unable to undergo psychological testing) were requested to fulfill preliminary screening, a Self-Reporting Questionnaire (SRQ-20).  SRQ-20 consists of 20 short questions concerning key phenomena related to mental disorders. The SRQ required only a simple 'yes' or 'no' answer to each question. Designed by the World Health Organization, the SRQ has been validated in various developing countries, including Oman,  to determine the prevalence of 'conspicuous psychiatric morbidity' without specific diagnoses. For the present analysis, a composite score higher than or equal to 10 was considered to indicate 'psychiatric caseness'. These subjects were then invited to answer other assessment measures as described below.
A total of 40 subjects, previously diagnosed as having type-2 diabetes and who subjectively endorsed the presence of psychiatric caseness as well as consented to proceed to the next phase of this study, were required to fill the assessment measures. They also were required to bring their spouses, neighbours, and friends in a subsequent visit. The spouses, neighbours, and friends, subjects without diabetes (n=40) were recruited as control participant in the present study. Non-diabetic subjects were recruited in this way to overcome some confounding factors such as socioeconomic and educational differences. 
As shown in [Table 1], approximately 12 of the 40 participants were diagnosed with diabetes less than one year before this study had started. The majority of participants (30/40) were diagnosed with diabetes for longer than one year, and of these, 50% have had diabetes for more than three years. The clinical and demographic characteristics of diabetics and non-diabetics are shown in [Table 1]. The study was approved by local IRB (Medical Research Committee and Ethics Committee, MREC#286).
|Table 1: Clinical and demographic characteristics of diabetics and non-diabetics|
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Various demographic characteristics were sought as shown in [Table 1]. In addition to demographic information such as age, gender, marital status, education, employment and income, some clinical variables such as body mass index were also sought and categorised as reported elsewhere.  The number of cigarettes smoked is also reported in agreement with previous literature. ,
Hospital anxiety and depression scale
One of the most frequently used measures of affective functioning is the Hospital anxiety and depression scale (HADS),  which is a portable, easy-to-use measure of an individual's current anxiety and depression levels. The most important feature of the HADS is that it enables clinicians to establish the presence and severity of both anxiety and depression simultaneously while giving a separate score for each. The HADS provides cut-off scores to indicate one's anxiety/depression level as normal, mildly, moderately, or severely disordered.  HADS consist of two subscales (anxiety and depression), each including seven items, and each item scores from 0 (no distress) to 3 (maximum distress). Psychometric properties of HADS have been established in Arabic speaking populations.  As described elsewhere,  each subscale score ranges from 0 to 21, with higher scores representing poorer emotional well-being. Scores of 0-7 on either subscale are considered to represent 'normal' level of anxiety and depression. The score higher than 7 for each subscale was operationalised as having propensity towards affective dysfunction.
Nottingham Health Profile (NHP)  consists of 38 statements on health problems, making up six dimensions of subjective health: physical mobility, pain, sleep, energy, emotional reactions, and social isolation. The respondent is requested to answer in 'yes' or 'no' to each statement. Scores for each item are weighted and added together to give a final score for each subscale that ranges between 0 (no problems or absence of limitations) and 100 (all potential problems are present). Therefore, higher scores indicate higher psychological burden. The psychometric property of NHP has been established in various linguistic and cultural groups, and its performance has been found to be adequate ,, across a range of clinical populations, , including diabetics. ,,, However, to our knowledge, there are no reports of NHS on an Arabic speaking population. Therefore, for brevity it was deemed essential to compare performance of diabetics and normoactive groups in Oman. The protocol for adopting the instrument, which was applied in the present study, in Arabic, has been reported elsewhere. 
| Statistical Analysis|| |
For categorical variables, frequencies and percentages were recorded. For continuous variables, means and standard deviations (SD) as well as median and 95% confidence interval (CI) were calculated. Differences between groups (diabetics, non-diabetics) were analysed using the non-parametric Wilcoxon (Mann-Whitney) test. Correlations between the different domains of the Nottingham Health Profile and Hospital Anxiety and Depression Scale were performed using the Spearman's correlation coefficient. A prior two-tailed level of significance was set at 0.05. Statistical analyses were performed using SPSS 17.0.
| Results|| |
As shown in [Table 1], a majority of subjects were older than 40 years, with males constituting 65% of participants for the diabetics group and 50% for the non-diabetics group. A majority of diabetic group's participants were married (92.5%), while most non-diabetic group's participants were single (98%). In terms of BMI, both groups showed a majority of 'overweight' (diabetics: 52.5%; non-diabetics: 55%) or 'obese' (diabetics: 32.5%; non-diabetics: 30%) participants, while only 15% of the diabetics and non-diabetics had normal body weight. In terms of education, 82.5% of the diabetics acquired at least basic education, while all non-diabetics had a University level education. Of all diabetics, 87.5% were reported to have employment either as a fulltime homemaker or others, while all non-diabetics such as spouses, neighbours, and friends were recruited to circumvent the difference in socioeconomic and educational differences. A majority of diabetics (87.5%) and non-diabetics (92.5%) perceived their income as adequate, while a minority of both groups smoked cigarettes daily (7.5%).
Means, SD, and internal consistency reliability estimates (Cronbach's α) for quality of life and affective functioning scores are shown in [Table 2]. Additionally, medians and 95% confidence interval (CI) are shown in [Figure 1]. The final participants' scores of each subscale from both tests (NHP and HADS) were normalised by using the following equation:
Max (score) - Participant (score) / Max (score)
|Table 2: Subscale means, standard deviations, and internal consistency reliability estimates for nottingham health profile and hospital anxiety and depression scale (number of items in each subscale is shown in parenthesis)|
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|Figure 1: Subscales' median of the Nottingham Health Profi le (NHP) and Hospital Anxiety and Depression Scale (HADS). EL = Energy level (NHP), P = Pain (NHP), ER = Emotional Reaction (NHP), S = Sleep (NHP), SI = Social Interaction (NHP), PM = Physical Mobility (NHP), A = Anxiety (HADS), D = Depression (HADS). Error bars represent 95% CI.|
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In this way, we obtained comparable scores for both tests ranging from 0 (poor health) to 1 (good health). Also, the cut-off score for the HADS test was transformed to a value of 0.66, using the same equation. Hence, the HADS normalised scores under this cut-off value indicated an abnormal level of distress that is the case for both the anxiety and depression scores obtained by the diabetics group. The HADS and NHP scores obtained on each subscale by diabetics and non-diabetics were compared by using a non-parametric test for two independent samples [ie, the Wilcoxon (Mann-Whitney) test]. The P values obtained by running this statistics [Table 2] showed that the diabetics group scored significantly less (ie, towards poor health condition) than the non-diabetics group for all subscales but two. Indeed, the two groups did not differ for the NHP social isolation (SI) subscale, while for the NHP emotional reaction (ER) subscale the non-diabetics scored less than diabetics.
Finally, we examined the relationship between the indices of quality of life and affective functioning, based on the pretext that there are tandem relationships between quality of life and mood state of an individual. As shown in [Table 3], the level of anxiety was found to correlate significantly only with the energy level, while the level of depression correlated significantly with energy level, pain, sleep, and physical mobility.
|Table 3: Correlations between the different subscales of the nottingham health profile and hospital anxiety and depression scale (N=80)|
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| Discussion|| |
Various studies have suggested that pharmacotherapy and psychotherapy relevant for mitigating affective dysfunction are showing promising results in improving the overall functioning of people with diabetes. , This relationship, albeit indirect, further alluded to the view that affective dysfunctions are important factors to consider in the management of diabetes.  The relationship between emotional variables and diabetes has been attributed to the role of stress hormones via hypothalamic-pituitary-adrenocortical axis (HPA), under functioning of immunised systems and impaired metabolism of polyunsaturated fatty acids. These have been speculated to critically relate to triggered depression.,, On the other hand, adrenaline released in response to hypoglycaemia has been related to increased somatic distress that, in turn, is likely to be perceived as anxiousness or anxiety disorder. In support of this contention, there is abundant empirical evidence showing an increased risk of type-2 diabetes in subjects with emotional distress.  It has been estimated that 20%-60% of people with diabetes are marked with mood disorder. ,, Mood dysfunction tends to be invariably related to quality of life, which, in turn, stems from adherence to treatment. 
The aim of this study is to compare diabetic patients and non-diabetics healthy controls and observe if they differ in mood disorders and on indices of quality of life. The result is robust, showing that mood disorders are higher in the diabetic population. The presently used measure, HADS, was found to have a high internal reliability. Previous studies have employed many common instruments to gauge the presence of depression including Beck Depression Inventory Hamilton Depression Scale and Geriatric Depression Scale. These instruments are equipped to measure various aspects of depressive illness including cognitive, emotional, motivational and physical symptoms. Conversely, these psychometric instruments for assessing depression have the potential for producing spurious results. This may arise because of lack of clear demarcation between symptoms that stem from mood and physical symptoms. To circumvent such a limitation, it has been suggested that a diagnostic structured interview, such as Composite International Diagnostic Interview (CIDI),  may have a more heuristic value. Pending further studies using gold standard interview, there is a rationale for using HADS. HADS has been specifically designed to elicit 'cognitive distress' for non-psychiatric populations.  The focus on cognitive symptom is likely to reduce the probability of getting spurious results since HADS does not elicit physical and motivational symptoms central to the diagnosis of depression. The findings indicate that physical and motivational symptoms may be an integral part of the sequel of diabetes. More studies on this issue are therefore imperative. From this non-psychiatric population, the present study suggests that mood disorders do exist in an Arab/Islamic population. Additionally, emotional distress could be adequately measured by the commonly used assessment measures - HADS. The related theme of the present study was to examine how diabetes compromises one's well-being across three broad areas of physical, psychological, and social functioning. Compared to normoactive group, in five of six subscales (energy level, pain, emotional reaction, sleep, and physical mobility) significant differences were found between the groups. The two groups obtained similar scores only for the social isolation subscale. From the Omani perspective, it is not surprising that social isolation was not considered to be the source of attrition. Traditional value systems in Oman are those having an affinity to a collective mindset fostering interdependency and, by implication, abhor social isolation. It has been shown that in some communities around the chronic course, refractory illnesses are averted because illness is considered a religious virtue. Accordingly, "sickness is neither condemned nor condoned but an occasion to call the community to restore order" (p. 76).  Such cultural prescription my play a part in moderating the feeling of social isolation in people with diabetes in Oman. It is interesting to note that there were higher indices of emotional reactions apparent in patients with diabetics in Oman, which contradicted the previous notion that expression of emotions is discouraged in communal societies.  Yet, in the patients with diabetes in this study, it was observed that many have the propensity towards losing their temper, to be depressed to the extent that some of them felt that life was not worth living. It is possible that emotional distress was not endorsed in the psychiatric population. This may stem from the stigma associated with something akin to mental disorder.  However, the presence of emotional reactivity is endorsed in the context of physical illness such as diabetes. More studies exploring these issues are therefore indicated.
The third interrelated aim of this study is to explore the relationship between indices of mood and quality of life. This is based on the rationale that there is an intricate relationship between chronic mood illness and quality of life. It has been argued that affective disorders could be a result of either complicated central diabetes or emotional reactions to the disability involved.  Many factors can trigger negative mood and the resultant impaired quality of life, including difficulty of living with the illness, necessary lifestyle changes and among other things aversive symptoms such as neuropathy.  Because of the obvious disability that frequently results from diabetes, both negative mood and impaired quality of life could be considered as an appropriate reaction to the debilitating nature of diabetes. The question remains whether there is a relationship between mood and indices of quality of life. The present data suggest level of anxiety to be correlated significantly only with energy level. Other subscales such as indices of pain, emotional reaction, sleep, social isolation, and physical mobility did not have a direct relationship with level of anxiety. On the other subscale of HADS, the level of depression correlated significantly with energy level, pain, sleep, and physical mobility. The impact of depression on quality of life is consistent with available literature. Depression has been shown to amplify physical illness and, conversely, physical illness tends to trigger depression. 
Some of the obvious limitations of this study should be highlighted. First, the sample size was small and the study was done at a tertiary care centre; therefore, caution is needed in generalising the present findings to patients with diabetes in Oman. There is a suggestion that individuals with emotional disorders like depression and anxiety are likely to be diagnosed with diabetes since, on clinical grounds, patients with emotional disorders are often examined for other physical illnesses. Second, an instrument developed in another population could be obfuscated by certain subtle linguistic and conceptual misunderstandings that might not have been apparent during translation and piloting, as causal attributions tend to differ from culture to culture. As the concept of emotional distress has no universally accepted 'phenotype', studies using taxonomies that are standardised for cross-cultural groups are needed to quantify emotional distress among diabetes. Within the emerging trend in DM in developing countries or globally as a whole, studies with more rigorous methodology are therefore indicated to circumvent some of the weaknesses of the present study. Qualitative research with focus groups to procure in-depth information would be an essential groundwork for such a quest. Finally, another limitation that needs to be mentioned here is that this study used a cross-sectional design, which cannot enable any causal nor even directional inferences concerning the relationship between distress and diabetes. In this case, a prospective study is needed. Despite the aforementioned limitation, the present study suggests that diabetic patients in Oman have poorer quality of life and more accentuated mood disorders than non-diabetics.
| Acknowledgments|| |
The authors thank the participants in this survey. They also thank Ms Meriel Carboni for her generous assistance in the editing and electronic treatment of the data. The authors have no conflicts of interest concerning the work reported in this article.
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[Table 1], [Table 2], [Table 3]