ISSN: 2456-8090 (online)
DOI: 10.26440/IHRJ/0609.12575
DINESH KUMAR1, AJOY TEWARI2, KUMAR PRAFUL CHANDRA3, SANTOSH KUMAR CHAUBEY4, VIVEK AGARWAL5, ARUN KUMAR PANDE6, RAJIV AWASTHI7, NITIN GUPTA8, SAJID ANSARI9, SANDEEP CHAUDHARY10, MUKULESH GUPTA11
Cite this article as: Kumar D, Tewari A, Chandra KP, Chaubey SK, Agarwal V, Pande AK, Awasthi R, Gupta N, Ansari S, Chaudhary S, Gupta M. The Psychological Impact of the Second Wave of COVID-19 on People Living with Type-2 Diabetes Mellitus. Int Healthc Res J. 2022;6(9):OR1-OR7. https://doi.org/10.26440/IHRJ/0609.12575
Author Affiliations:
Contact Corresponding Author at: drmukulesh[at]yahoo[dot]com
ABSTRACT
BACKGROUND: COVID-19 pandemic has led to an increase in various psychological problems for people in India.
AIM: The aim of this research was to assess the psychological impact of COVID-19 on people living with Type 2 Diabetes Mellitus evaluating their stress, anxiety, and depression levels during pandemic.
MATERIALS AND METHOD: The study used validated Hindi version of GASS-21 questionnaire, It was handed out to 1143 eligible and consenting patients across eight secondary care centres in Lucknow.
RESULTS: The study enrolled 1143 participants and out of that, 8% were depressed, 19% were anxious, and 6% were stressed. The significant psychological drivers were family members who tested positive for COVID 19, death of a first degree family member, post covid infections and vaccination status. Patients who were not vaccinated for COVID were significantly more affected psychologically.
CONCLUSION: COVID-19 and associated morbidity and mortality, post covid complications and vaccinations on apprehensions were significantly associated COVID-19 related psychological impacts that were studied.
KEYWORDS: Psychological Impact, Diabetes, COVID-19, DASS-21, Stress, Anxiety, Depression
INTRODUCTION
COVID-19 pandemic being a multi-dimensional stressor, led to an increase in many psychological problems for people. Studies suggest that more than two-fifths of the population experienced mental disorders due to lockdown and the prevailing COVID-19 pandemic, which most commonly include stress, anxiety, and depression.1 Stress is an emotional strain or pressure that might be triggered by any physical or psychological factor an may lead to disturbance in homeostasis. On the other hand, anxiety is the fear of the unknown, which is the body’s natural response to stress. Depression is the constant state of disinterest in daily chores and activities.2
In a pandemic situation, with a lack of substantive cure, emerging variants and sub-variants of the virus, a plethora of fake news via social media, future uncertainties regarding livelihood, and overwhelming media-created fear psychosis, people became more susceptible to anxiety, depression, and stress.3 Any stress caused to the body, mental or physical, has been shown to have significant effects on the individual's metabolism. Hence, it is even more evident in patients with chronic medical conditions and comorbidities. A potential impact of stress is chronic hyperglycaemia in Type 2 diabetes mellitus.4 Globally, Type 2 Diabetes Mellitus has been identified as a significant risk factor for increased morbidity and mortality in the COVID-19 study. Patients with severe COVID-19 and diabetes were significantly more likely to require ventilator support and admission in the ICU and had higher mortality than those with severe COVID-19 without Diabetes.5 Our own study done earlier revealed that lockdown during Covid 19 lead to more stress and change in dietary and sleep pattern.6
This study assessed the mental health of people living with diabetes during the second wave of COVID-19 using the DASS-21 scale. The DASS-21 scale, a 21-item version of the Depression Anxiety Stress Scale, can be easily administered to people with diabetes. Furthermore, its clinical ease of use and ability to produce comparative data on a real-time basis has been commended.7 Its validation in Hindi, the language commonly spoken and understood in North India, was the reason for its choice.8 The study's objective is to gauge the mental impact of the pandemic on people living with diabetes and the probable factors contributing to them.
MATERIALS AND METHOD
Study Design: It was a multicentre, qualitative, cross-sectional study involving people living with diabetes mellitus conducted at eight participating secondary diabetes care centres in the geographic bounds of the city of Lucknow, Uttar Pradesh, India.
Inclusion/Exclusion Criteria:
Inclusion Criteria was
Exclusion Criteria was
To elicit responses from all enrolled patients, study proforma was used and was then digitized by a trained medical assistant.
Research Instruments: DASS-21 questionnaire was the research instrument of choice for this study. The Depression, Anxiety and Stress Scale - 21 Items (DASS-21) is a set of three self-report scales designed to measure the emotional states of depression, anxiety, and stress. Each of the three DASS-21 scales contains seven items, divided into subscales with similar content. DASS-21's psychometric properties were deemed commendable. It is reliable, valid, and easy to use. The Depression Anxiety Stress Scale (DASS) developed by Lovibond and Lovibond is one of the instruments commonly used to assess subjective depression and anxiety in patients.9 Our study used a validated Hindi version of the DASS questionnaire 10. DASS is a quantitative measure of distress based on the three dimensions of depression, anxiety, and stress. It is not a diagnostic indicator. Inherently, emotional syndromes like depression and anxiety vary along a continuum of severity (regardless of the diagnosis). Therefore, selecting a single cut-off score as a measure of clinical severity is necessarily arbitrary (Table 1).
Demographic data, data related to diabetes duration and control, comorbidities associated with diabetes, the financial status of the family, and illness related to COVID-19 were captured in case record form (CRF). The CRF was created specifically for this study and was explained well to the patients during data collection (Figure 1).
Methodology: The patients were screened from the eight participating secondary diabetes care centres and were shortlisted according to the eligibility criteria. Once they had signed the written consent form, data was collected in the case record form (CRF), followed by providing the DASS-21 questionnaire to patients to collect their responses.
Sampling Sizes and Bias: The sample size was 1143 over a timeframe of (MM) in 8 participating tertiary care centres. As far as geographic representation was concerned, the centres were well distributed all over the study.
Statistical Methods: Statistical analysis was performed using SPSS statistics windows version 18. Categorical data were represented in proportions, and continuous data were defined as mean and standard deviation. Statistical significances were tested using a t-test for means and proportions at 1% and 5% significance levels.
RESULTS
1143 subjects were recruited from at 8 study sites immediately after the second COVID 19 wave. Table 2 highlights the demographic profile of the patients participating in the survey. The mean age of patients was 53.9 years, the total number of female patients was 519, and male patients were 625. The mean BMI came out to be 26.79 kg/m2 and the average duration of the diabetes was 6.23 years. The comorbid conditions that were analysed included hypertension (487), Obesity (211), Hypothyroidism (175), and Psychiatric Illness (88). Table 2 highlights the contribution of each site [Table 2 (a) & (b)].
For this study, Mild, Moderate, Severe, and Extremely Severe classifications of Depression, Anxiety, and Stress in the DASS21 questionnaire were clubbed together as Depressed, Anxious, and Stressed, respectively. Based on the category, of all patients, 8% were Depressed, 19% were Anxious, and 6% were stressed as per the DASS-21 scoring system [Figure 2(a)].
Figure 2 (b) highlights the further break-up of Depression, Anxiety, and Stress as per the DASS21 questionnaire. Significantly few patients reported Severe or Extremely Severe on the three parameters.
Out of the various aspects of stress-inducing COVID-related parameters that were measured in the CRF, the most crucial COVID-19-related drivers of psychological impact were Family members (who tested positive for COVID), first-degree family member’s death because of COVID, and Post COVID infections [Figure 3(a), (b) & (c)].
Vaccination Status is another critical driver of the psychological impact of COVID-19. Patients who were not vaccinated were significantly more affected psychologically. 50% (180 patients) out of 371 patients who were not vaccinated yet, the reasons for not getting vaccinated included doubts about vaccination (n=180), non-availability (n=94), confusion about dosing (n=42), not well versed with the registration process (n=20) and apprehension of harm (n=17)25%. (94 patients) did not get vaccinated because of the non-availability of dosages. Only a few patients, 4% (17 patients), were concerned about potential harm from vaccination.
Alternate link to tables/figures (Copy/paste link in a new browser window): https://drive.google.com/file/d/1oKjvtjDWK-d2xMCRvFR-OKUKl8nqFWPi/view?usp=sharing
DISCUSSION
People with diabetes are at a higher risk of developing depression, almost 24% more than those without diabetes. 11 This has been discussed in studies where depression has been found to be responsible for poor glycaemic index control, increasing the risk of diabetes-related complications and comorbidities.11 While stress directly affects the blood glucose level or indirectly impacts a patient’s ability to maintain a healthy regime, disrupting their adherence to diet and treatment. 13,14 Khuwaja et al.15 reported that anxiety and depression are common among diabetic patients in Pakistan. However, in the indexed study, it has been reported that the prevalence of psychological disorders in type 2 diabetic patients, depression, anxiety, and stress are only 8%, 19%, and 6%, respectively. Studies also show that developed countries had almost double the number of people with similar conditions.16
The conducted index study’s results focus on the factors that cause distress among people with diabetes. The news of post-covid fungal infection did have significant impact on people living with diabetes in causing anxiety. Additionally in people with T2 diabetes stress and depression significantly correlated to their families testing positive or the demise of any first-degree relative. Depression, contradicting the above studies, didn’t show any specific significant correlation.
In the study by Joaquim et al.17, they concluded that losing any family member/friend amplifies psychological distress, especially in patients with existing mental conditions or comorbidities.
Palgi et al.18 demonstrated that hesitancy toward the COVID-19 vaccinations among the population was one of the most significant driving factors for stress, anxiety, and depression among Israelis. Vaccination status also played an essential driver of psychological distress in our study, where higher levels of vaccine hesitancy could double the risk of depression in patients.
The study conducted had certain limiting factors. It included only people with type 2 diabetes mellitus attending secondary diabetes care centres and, possible recall bias for the CRF was administered on the first post-covid visit. Second, since the number of factors triggering psychological distress is innumerable, there could be many factors other than those considered in this exploratory study. Third, the break-up of patients into depressed, anxious, and stressed was entirely done as per the scoring of the DASS questionnaire, which is a screening and not a diagnostic tool.
CONCLUSION
The index study highlights the factors which were associated with increased risk of depression, anxiety and stress in people living with diabetes during second wave of Covid-19. Covid-19 and associated morbidity and mortality, post covid complications, and vaccination apprehensions were significantly associated Covid-19 related psychological impacts studied. The study also highlights the importance of evaluating factors related to psychological stressors in high-risk populations like people with diabetes and preparing patients for stressors like the COVID-19 pandemic in a country like India, where mental health facilities are nascent.
REFERENCES
© Dinesh Kumar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY-NC 4.0, which permits unrestricted use, distribution and reproduction in any medium, provided the use is not commercial and the original author(s) and source are cited.
Submitted on: 20-Oct-2022; Accepted on: 19-Dec-2022