The global prevalence of diabetes is continuously rising. It is estimated that almost 285 million people are currently suffering from diabetes worldwide and the number is expected to rise to 438 million by the year 2030; more than 70% of these people reside in developing countries [1]. Similarly, depression affects all populations worldwide, but more than two-thirds of the affected people live in developing countries [2]. Both diabetes and depression are associated with premature morbidity and mortality, and when these conditions co-exist, the risk of developing co-morbidities, complications, patient suffering and associated cost, escalates [3,4].

Depression is a significant contributor to the global burden of disease and affects people in all communities across the world. Depressive disorders often start at a young age; they reduce people’s functioning and often are recurring. For these reasons, depression is the leading cause of disability worldwide in terms of total years lost due to disability. Depression is a common mental disorder that presents with depressed mood, loss of interest or pleasure, decreased energy, feelings of guilt or low self-worth, disturbed sleep or appetite, and poor concentration. Moreover, depression often comes with symptoms of anxiety. These problems can become chronic or recurrent and lead to substantial impairments in an individual’s ability to take care of his or her everyday responsibilities [5].

Studies conducted in different countries on prevalence of depression among Diabetes mellitus patients shows that 77.6% in UK [6],48.27% in Mexican [7],23% in North India [8], 13.6% in Qatar [9], 8.7% to 21.4% in Leiden University [10], 52.1% in Allied Hospital, Faisalabad [11], 47% in JJM Medical college in Karnataka [12], 50% In Bardarabbas, Southern Iran [13],70.7% in Tehran, Iran [14], 43.4% in Iran [15],11.5% and 40.3% in Malaysia [16,17], 43.5% and 38.35% in Pakistan [18,19] and 39.5% in Nigeria [20].

Moreover, depression is independently associated with increased chronic complication among patients with type 2 diabetes mellitus. Depression has been found to be associated with a negative impact among patients with diabetes mellitus. Despite their known effect on the population, there is no data available in the study area. Therefore, this study was planned to determine the prevalence and associated factors of depression among patients with type 2 diabetes mellitus at Ambo General Hospital, Oromia Regional State, Ethiopia.

Study setting and population

The study was a cross sectional design, conducted from April to May, 2016 in Ambo General Hospital, Oromia regional state, western Ethiopia. All adult patients (age ≥ 18) with type 2 diabetes mellitus who had regular follow were included in the sample. Critically ill patients were excluded from the study. Among 993 DM patients who had regular follow-up at diabetes clinics, 423 type 2 DM patients were recruited for the study. Study participants were included using systematic random sampling technique. No patients refused to participate in the study.

Inclusion criteria

All persons with type 2 diabetes mellitus 18 years and above attending this hospital for follow-up visit.

Exclusion criteria

• Persons suffering from type 1and gestational diabetes mellitus.

• Type 2 diabetes mellitus Patients who are severely ill were excluded.

Data collection

Data were collected by trained psychiatry nurses using pretested interviewer administered questionnaire. The data collection instrument had different components. The first part includes sociodemographic characteristics (age, sex, education, occupation, marital status and others). The instrument was adopted and translated to Afan Oromo language and back to English and highly reliable in the study (Cronbach’s α=0.89). An outcome variable (presence of depression) was collected by Hospital Anxiety & Depression scale (HADS-D). HADS-D is a 7-item questionnaire, commonly used to screen for symptoms of anxiety and depression 7-item sub-scales for depression. It was validated in Ethiopia and its internal consistency was 0.76 for depression subscales and 0.87 for full scale. The scales use a cut off score for depression of greater than or equal to 8 [21].

Data processing and analyses

Data were analyzed using SPSS version 20. Bivariate analysis was done to see the association of each independent variable with the outcome variable. Potential confounders (important) variables were entered into binary logistic regression model to identify the effect of each independent variable with the outcome variables. A p-value of less than 0.05 was considered statistically significant, and adjusted odds ratio with 95% CI was calculated to determine association.

Ethical considerations

Ethical clearance was obtained from the Research and Ethics Review Committee of the Institute of Public Health (University of Gondar) and Amanuel Mental Specialized Hospital. Permission letter was obtained from Oromia health bureau and submitted to Ambo general hospital. Written informed consent was obtained from each study participant and they were informed about their rights to interrupt the interview at any time. Confidentiality was maintained at all levels of the study. DM patients who were found to have moderate to severe depression were referred to psychiatry clinics for further investigations.

Socio-economic and demographic characteristics

A total of 423 participants were recruited for the study which makes the response rate 100%. The mean (± SD) age of the respondents was 45.21 (± 15.72) years. Among the respondents, 244 (57.7%) were female, 287 (67.8%) were married, 171 (40.4%) were farmers, 132 (31.2%) were attended primary education, and 116 (27%) the median monthly income of the participants was 2151 (Table 1).

Table 1: Distribution of type 2 DM patients at Ambo General Hospital, Oromia Regional State, Ethiopia, 2016.

Clinical and psychosocial characteristics of the respondents

Two hundred eight nine (68.3%) of the respondents reported less than or equal to five years duration of diabetes diagnosis, 98 (23.2%) of the study population had at least one chronic complication of diabetes mellitus and 74 (17.5%) of the respondents had at least one other additional chronic disease and 43 (10.2%) of participants were reported history of current alcohol users (Table 2).

Table 2: Description of clinical, psychosocial and substance use factors among patients with type 2 diabetes mellitus at Ambo General Hospital, Oromia Regional State, Ethiopia, 2016.

Prevalence of depression among Type 2 DM patients

The prevalence of depression among Type 2 DM patients was 47%.

Factors associated with depression among patients with type 2 diabetes mellitus

Binary logistic regression analysis revealed that being female, no formal education, greater than five years duration of diabetes mellitus diagnosis, chronic complication of diabetes mellitus, have history of alcohol use were statistically significant with depression (Table 3).

Table 3: Factors associated with depression among patients with type 2 Diabetes mellitus at Ambo General Hospital, Oromia Regional State, Ethiopia, 2016.

Prevalence and factors associated with depression among patients with type 2 Diabetes mellitus

This study revealed that the prevalence of depression was 47%. The finding was similar with other studies carried out in Mexican (48.27%) [7], in JJM Medical College (47%) [12], in Iran (43.4%) [15], in Pakistan it (43.5%) [18], and in Nigeria (39.5%) [20]. On the other hand, the current study finding was higher than the study done in Malaysia 11.5% [16], in North India [8], in Qatar (13.6%) [9], in Pakistan (38.35%) [19] and in Malaysia (40.3%) [17] and lower than the study was done in Allied Hospital Faisalabad [11], in UK (77.6%) [6], in southern Iran 50% [13] and in Tehran, Iran (70.7%) [14]. The variation might be due to the difference in study design, data collection tool, sample size and the socioeconomically status of participant’s in study.

One of the factors significantly associated with depression was being female and no formal education. The finding is similar with the study conducted in Allied Hospital Faisalabad, Tehran Iran and Pakistan [11,14,19], Being type 2 DM diagnosed greater than five years significantly associated similar with study done in Qatar, in JJM Medical college, in Malaysia and in Pakistan [9,12,16,18]. Hence, history alcohol user’s patients can be at higher risk of depression than have no history of alcohol use similar with study conduct in Qatar and Iran. This could be due to the fact that depression patients are more prone to use substances to relief themselves from the stress or depression symptoms [9,15].

This is similar with a study conducted in in Mexican, in Allied Hospital Faisalabad and in JJM Medical College [7,11,12]. Previous study has proven that presences of other complications (retinopathy, nephropathy, and neuropathy) are highly associated with depression.

The prevalence of depression 47% among Type 2 DM patients was high. Depression had statistically significant association with being female sex, history of alcohol use, no formal education, chronic complication, greater than five duration of type 2 DM diagnosis and other complication. Oromia health bureau should develop guidelines to screen and treat depression among Type 2 DM patients.

Further research on risk factors of depression should be conducted to strengthen and broaden the current findings.

Limitation of the study

This study was cross-sectional study design. It did not allow establishing a temporal relationship between depression and significant associated factors like substance (khat, cigarette and alcohol) use. Additionally, no detailed substance use related factor was not assessed by standard tool.