An Analysis of Depression and Self-management in Individuals with

Diabetes Mellitus

Azirna Berliana

1

, Lely Safrina

1

and Marty Mawarpury

1*

1

Department of Psychology, Medicine Faculty, Universitas Syiah Kuala

Keywords: Depression, Self-management, Diabetes Mellitus Patients

Abstract: Depression can inhibit DM patients to manage DM. This study aimed to see the relationship between

depression and self-management in individuals with DM. This study used quantitative methods and the

sampling technique was purposive with 150 patients with type 2 DM the subject, consisting of 50 men and

100 women. The Beck Depression Inventory-II (BDI-II) was used to measure depression and the Summary

of Diabetes Self Care Activities (SDSCA) was used to measure self-management of DM patients. Data

analysis used Pearson product-moment correlation with the results of correlation coefficient (r)= -0.390 and

p>0.05. These results indicate that there is a negative relationship between depression and self-management

in individuals with DM. This means that the higher the depression level of DM patients, the lower the level

of self-management or vice versa. The majority of depression levels of DM patients are categorized as low

(28%) and the majority of self-management is in the low category (50.7%).

1 INTRODUCTION

Diabetes mellitus (DM) is a disease found in all

countries and becomes the 4

th

cause of death in the

world (Banna, 2017). DM becomes one of threats

against global health which is caused by the increase

of its sufferer number (World Health Organization in

PERKENI, 2015). International Diabetes Federation

(IDF, 2014) stated that more than 371 million

individuals around the world suffered from DM in

2012. In 2015, there were around 30.3 million

people with DM in the world (Centers for Disease

Control and Prevention, 2017).

The rise of the number of DM sufferers in

Indonesia was also revealed by The Indonesian

Central Bureau of Statistics (BPSI), that Indonesian

people with DM type 2 prevalence in urban area was

for 14.7% and in rural area was for 7.2%, it

estimated that the number of Indonesian suffering

from DM type 2 would increase to be 12 million

sufferers in 2030 (Sudaryanto, Setiyadi, &

Frankilawati, 2014).

DM prevalence in Aceh reached 1.7% in 2007

and increased to be 1.8% of around 5 million of

Aceh people (Bureau of Health Research and

Development, 2008; Bureau of Health Research and

Development, 2013). The number was nationally

high, thus in 2017 Aceh stood on 5

th

position of DM

suffering number nationally after Maluku on 1

st

and

other 3 provinces (Antara, 2013; Bakri, 2017).

The high DM patient prevalence in Aceh is

caused by the high risk factor i.e. unhealthy life

pattern such as diet pattern, obesity, less physical

exercise and activity (Antara, 2013). DM is a

chronic disease occurring when pancreas does not

produce enough insulin (a hormone to control blood

sugar levels) or if body cannot effectively use

produced insulin, the concentration of glucose in

blood will rise (WHO, 2010). According to Tandra

(2008), DM is disease happening when a body

cannot effectively produce insulin or respond to

insulin or both, which needs proper and serious

treatment.

DM consists of type I and type II (WHO, 2010).

In addition, there are also Malnutrition-related DM

caused by disorder or lack of food (malnutrition),

DM during pregnancy and DM among individual

having normal glucose levels however having great

risk suffering the DM (WHO in, Tobing, Mahendra,

Krisnatuti, & Alting, 2008).

DM type I is caused by lack of insulin

production which requires insulin injection as a

treatment in the daily basis and usually happens at

young age, while DM type II is caused by

ineffective insulin role inside the body and being

Safrina, L., Berliana, A. and Mawarpury, M.

An Analysis of Depression and Self-management in Individuals with Diabetes Mellitus.

DOI: 10.5220/0008791602550264

In Proceedings of the 2nd Syiah Kuala International Conference on Medicine and Health Sciences (SKIC-MHS 2018), pages 255-264

ISBN: 978-989-758-438-1

Copyright

c

255

able to be treated by consuming oral medication,

DM type 2 usually occurs at older age beyond 40

(WHO, 2010). According to Suyono (In Sudaryanto,

Setiyadi, & Frankilawati, 2014), DM type II can be

caused by obesity or unhealthy diet pattern like

amount and composition of consumed food,

resulting in damage in tissue or organs.

DM type II is the most found type in all countries

and usually happens among 45-year-old individuals,

however it may happen at age over 20 (Putri &

Isfandiari, 2013). Around 90% of DM sufferers

around the world suffering from DM type II (WHO,

2010). If DM patients cannot change their life style

to avoid bad impact of DM like regular exercise,

diet, avoiding cigarette and alcohol, regular check

and drug consumption, the patients can suffer from

stress, frustration, declining of self-control and

depression (Bailey, 1996; Clark, 2005). As Glasgow,

Fisher and Anderson explained (1999), that DM was

the main source of behavioral problem and

psychosocial disorder.

According to Barnard, Skinner and Prevelar

(2006), patient with DM is three times as high as

patient without DM to suffer from depression.

Result of study by Hasanat (2015), showed that there

was the different depression based on the length of

patient in suffering DM, patients suffering DM for

16-20 years suffered depression higher than those

suffering DM for more than 20 years. Depression

prevalence is also higher among patients with DM

who suffer from long-term complication (Raval,

Dhanaraj, Bhansali, Grover, & Tiwari, 2010).

Patient with DM type 2 who has been diagnosed also

experiences the rise of depression symptom risk for

1.7% comparing to DM patient without diagnosis

(Knol, Heerdink, Egberts, Geerlings, Gorter,

Numans et al., 2007).

DM patients suffering from depression will

experiences negative mood, loses passion or

pleasure to do usual activities which will inhibit DM

patient to manage their DM (Clark in Clark, 2005).

DM patients with depression frequently experience

low life quality, low obedience toward medication

and low glycemic control which arouse risk of DM

complication (Gavard, Lustman, Clouse, 1993;

Peyrot & Rubin, 1999; Clark, 2005). DM patients

with depression have been proven to have worse

self-management, disobedience toward medication,

and higher risk factors of cardiovascular diseases

like smoking, obesity and unhealthy life style which

tends to settle like bad diet pattern and lack of

physical activity (Raval et al., 2010).

DM management is necessary to do to assist DM

patient in normalizing glucose levels in blood,

avoiding acute complication and other bad impacts

(Hasanat, 2015; Hill-Briggs, 2003). Self-

management has been confirmed as main mediator

to manage DM effectively as more than 95% of DM

treatments are in form of self-management (Fearon-

Lynch & Stovmer, 2015).

Self-management can assist DM patient to

maintain blood sugar levels to stay at normal level

(Drury in Goodall & Halford, 1991). Self-

management intends to reduce disease impact

toward status and function of physical health and

allow individuals to solve psychological impact of

the disease (Lorig & Holman dalam Nolte &

McKee, 2008). In addition, self-management skill in

DM patients can raise patients’ well-being (Cramm,

Hartgerink, Steyerberg, Bakker, Mackenbach, &

Nieboer, 2013). Self-management helps DM patients

to control medication, keep life role and manage

negative emotion like fear and depression (Lorrig,

Sobel, Ritter, Laurent, & Hobbs, 2001).

Self-management on DM is a sustainable process

to facilitate DM patient related to knowledge, skills,

and ability required for self-treatment against

diabetes (Funnell, Brown, Childs, Haas, Hosey,

Jensen et al, 2012). According to Toobert and

Glasgow (1994), Self-management on DM is an

implementation of healthy life pattern which results

in better control on DM metabolic to help avoid

acute complication and long-term DM.

Result of the research by Hasanat (2015),

showed that self-management was influenced by

psychological factors like self-efficacy and

depression. The researcher added that depression

directly related to self-management and became a

mediator for other psychological factors, as follows

self-efficacy, social support and expressed-emotion.

Surwit and Bauman (2004), stated that DM patients

who were depressed would affect the patients in

implementing self-management. Wagner, Tennen

and Osborn (2010), mentioned that depression could

be linked to self-management on DM, such as the

low obedience toward diet, physical exercise,

medication and the low blood sugar control. Based

on the facts, the present research is important to

conduct because depression is a common

psychological problem among DM patient and can

decrease the vigor of patients to undergo slow

medication (Watkins in Winasis & Maliya, 2009).

Surwit and Bauman (2004), stated that depression on

DM patients would affect their self-management.

DM patients with depression has been proven to

have bad self-management, therefore it results in

disobedience toward medication, raise risks factors

of cardiovascular diseases like smoking, obesity, and

SKIC-MHS 2018 - The 2nd Syiah Kuala International Conference on Medicine and Health Sciences

256

adherent life style (Raval et al., 2010). DM self-

management assists patients to normalize glucose

levels in blood, avoid acute complication and other

bad impacts (Hasanat, 2015; Hill-Briggs, 2003).

2 METHOD

This research used quantitative approach with

correlational research. Samples characteristics as

follows:

a. Individual with diagnosis of DM type 2

b. 40 to 75-year-old and suffer from depression

c. One had been diagnosed at least for a year, so

one has undergone self-management.

d. Undergoing medication in the latest week

In this research, the researcher had certain

characteristics for research subjects. Total samples

were 150 who were from several regions in Aceh.

Instruments in the research were Beck Depression

Inventory II (BDI-II) to measure depression and the

Summary of Diabetes Self-Care Activities (SDSCA)

to measure self-management.

This research was conducted in 150 subjects with

DM type 2, age 40 to 75-year-old in Aceh. Data was

collected in several areas i.e. Endocrinology

Polyclinic in dr. Zainoel Abidin General Hospital,

Restu Ibu Health Clinic and home visit.

Table 2.1. Demography Data of Subjects

Description Total (N) Percentage

(%)

Age

40-65

66-75

Sex

Male

Female

Marriage Status

Married

Unmarried

Widower

Widow

Educational Level

Never Going to

School

Kindergarten

Primary school

Junior High School

Senior High School

Diploma

Bachelor

Master

Occupation

Civil servant

Private Sector

Laborer

Lecturer

Teacher

Fisherman

Farmer

Merchant

Entrepreneur

Rickshaw Driver

Builder

Pensioner

unemployment

The length of

suffering DM

1-10 years

11-20 years

21-25

y

ears

121

29

50

100

114

1

12

23

1

2

47

22

42

4

26

6

29

17

2

4

1

5

2

1

11

69

112

36

2

80.7

19.3

33.3

66.7

76

0.7

8

15.3

0.7

1.3

31.3

14.7

28

2.7

17.3

4

19.3

11.3

1.3

2.7

0.7

3.3

1.3

0.7

7.3

46

74.7

24

1.3

3 RESULT

3.1. Analysis

Descriptive analysis was conducted to see

description of hypothetical data (if it happens) and

empirical data (based on the reality) from the

An Analysis of Depression and Self-management in Individuals with Diabetes Mellitus

257

depression variable. Research subject category of

depression scale was standard category arranged by

Beck (1996) containing four categories, as follows

high, moderate, low and mild. Based on those

categories, the category of DM patient subject in

depression scale can be seen in table 3.1 below:

Table 3.1. Categories of Depression in DM Patients

Ordinal

Categorization

Category Total Percentage

%

29-63

20-28

14-19

0-13

High

Moderate

Low

Mild

39

37

42

32

26

25

28

21.3

Subject category in self-management used

ordinal category formula as mentioned in table 2.3

Table 3.2. Norm Formula of Self-Management Category

Ordinal

Categorization

Category

(%)

X ≥ (µ + 1.0 σ)

X ≥ (500 + 167)

X ≥ 667

High

(13)

(µ - 1.0 σ) ≤ X < (µ + 1.0 σ)

(500-167) ≤ X < (500 +

167)

333 ≤ X < 667

Moderate

(48)

X < (µ - 1.0 σ)

X < (500 - 167)

X < 333

Low

(50.7)

Result of hypothesis test showed that coefficient

score was (r) = -0.390 and signification score in this

research was p=0.000 (p<0.05) which showed that

there was negative relationship between depression

and self-management in DM type 2 patients. Based

on the hypothesis test result, it can be concluded that

there was significant relationship between

depression and self-management in DM type 2

patients. The negative relationship shows that the

higher depression level is, the lower self-

management level of DM type 2 patients.

Conversely, the lower depression level is, the higher

self-management level of DM type 2 patients is.

Therefore, hypothesis of this research was accepted

because there was the relationship and lower

significance score than p=0.05, between depression

and self-management in DM type 2 patients.

3.2. Discussion

Negative result of correlation test in this research is

in accordance with Gonzalez, Peyrot, McCari,

Collins, Serpa, Mimiaga and Safren (2008) as well

as Raval et tal., (2010), that individual with

depression symptoms has low DM self-management,

like low obedience in term of diet, medication, and

lack of physical exercise and blood glucose check

up, moreover the individual also has higher risk

factor of cardiovascular diseases, enhance smoking

habit, obesity and unhealthy life. According to

Toobert and Glasgow (1994), self-management is

application of healthy life pattern which will result

in better control of DM metabolic to help avoid

acute and long term complication of DM.

Individuals with depression will be hopeless and

helpless to control their behavior including

implementation of health life pattern (Rehm, 1990).

Depression emerges when pressure and stress come

caused by displeasing circumstances then results in

negative perception on oneself, life and future (Beck

dkk., 1999). Negative perception can influence self-

regulation process which is foundation of self-

management against chronic diseases (Bandura,

1991; Berg, 2014).

Interesting matter of this research is the

discovery that depression measurement showed the

majority of subjects suffered from low level

depression for 42 subjects (28%) and self-

management measurement showed that the majority

of subjects had low self-management level for 76

subjects (50.6%). Based on R-squared score or

coefficient of determination, coefficient score was

0.152, the score showed that depression had effect

on self-management for 15.2%, while the rest was

(84.8%) affected by other factors. The total of

coefficient of determination was range from 0-1, the

lower coefficient of determination score is, the lower

the effect of independent variable on dependent

variable is. Conversely, if coefficient of

determination score gets closer to 1, the effect of

independent variable on dependent variable will be

higher.

SKIC-MHS 2018 - The 2nd Syiah Kuala International Conference on Medicine and Health Sciences

258

Majority of low depression level could be caused

by the existence of free health care which functions

as protecting factor against depression for DM

patients (Dunlop, Song, Lyons, Manheim, & Chang,

in Devarajooh & Chinna, 2017). According to

demographic data of this research, there were 23

subjects (15.3%) suffered from low level depression

who were working subject. Low self-management of

DM patients is related to patients’ low understanding

about health, bad disease monitoring, and increasing

complication (Schillinger, Grumbach, Piette, Wang,

Osmond, Daher et al., 2002). It is in accordance with

this research, subject explained that they did not

only undergo treatment for DM, but also undergo

treatment for DM complication like heart disease

treatment, treatment for unhealed wound on the

body, kidney treatment, and thyroid treatment.

Schulman-Green et al. (2012), stated that

complication or so-called comorbidity can influence

the effectiveness of DM self-management.

Comorbidity is the presence of one or more chronic

conditions in DM patients who also suffer from

heart disease, retinopathy, nephropathy, and wound

in DM patient’s leg (Rashid, Anandhasayanam,

Kannan & Noon, 2015). According to Hasanat

(2015), accumulation of glucose in blood is main

cause of DM comorbidity (complication).

Based on demographic data of subjects in this

research, it can be seen that the subjects had low

self-management whose latest education mostly at

senior high school for 22 subjects (14.6%), age

under 60 years for 49 subjects (32.6%) and female

for 53 subjects (35.3%). Research by Maneze,

Everett, Astorga, Yogendran, and Salamonson

(2016), found that low self-management could be

caused by low educational level, lack of knowledge

on self-management for diabetes, experiencing

depression, and age under 60, because old patients

had high awareness of death and health became

main focus, moreover, older patients had more time

to self-manage because they had less priority than

younger patients.

Research by Chlebowy, Hood and LaJoie (2013),

found that there was different self-management for

DM between male and female, in which female had

some obstacles to do self-management for DM, the

obstacles were difficult to receive diagnosis, did not

work so that lack of fund, embarrassment, negative

thinking toward the disease and afraid of the bad

impact of consumed drug. Failed self-regulation is

also related to low self-management, like bad

obedience toward treatment and low metabolic

control (Berg et al., 2014; Hughes, Berg, & Wiebe,

2012). Furthermore, research by Hasanat (2015),

found that self-efficacy had positive relationship

with self-management among DM type 2 patients, it

meant that self-efficacy could reveal self-

management level of DM patients.

According to this research result, based on age, it

showed that 11 subjects (7.3%) aged 66-75 years old

suffered from high level depression. The result is in

accordance with an explanation by Black, Markides

and Ray (2003), that older patients have higher risk

to suffer from either moderate or high depression

and the development of depression is five times

faster at the age. The same thing is mentioned by

Berge, Riise, Tell, Iversen, ostbye, Lund and

Knudsen (2015), that individual aged 70s with DM

disease history slightly increase depression

prevalence, meanwhile individuals aged 40s with

DM disease history had depression level twice as

high as individual without DM. There are several

risk factors which were known can enhance the

possibility of an older individual to develop

depression, the factors are chronic diseases,

medication, bearing a lot of loss, declining physical

and cognitive function, or both, depression history,

losing friends and important others and losing job

(US Department of Health and Human Services, in

Cahoon 2012). Based on sex, majority subjects

suffering from depression were female for 100

subjects (66.7%), 31 of whom were at high

depression category (20.6%). Anderson, Freedland,

Clouse and Lustman (2001), stated that depression

commonly happened to female DM patients rather

than male. A research conducted in Brazil by

Dessotte, Silva, Furuya, Ciol, Hoffman and Dantas

(2015), found that depression among female could

be caused by biological aspect like hormone

transformation during reproduction or menopause

period, as well as social aspects like role in society

and family, greater workload than male, doing

carrier along with household duty (taking care kids,

husband and sick family members), having lower

educational level and lower salary than male.

Further analysis found that there were 23 female

subjects who had high depression had low self-

management. According to Mathew, Gucciardi, De

Melo and Barata (2012), comparing to males,

females consider DM as negative disease which can

affect their lives, like decreasing of husband-

children-caring ability as well as inhibiting usual

activities, so that the depression among females can

decline obedience toward medication (self-

management). Research by Unden, Elofsson,

Andreasson, Hillered, Eriksson and Brismer (in

Chlebowy, Hood, & LaJoie, 2013), found that

females had worse mental health than males and

An Analysis of Depression and Self-management in Individuals with Diabetes Mellitus

259

males were less worry on DM and had better self-

management and females.

Based on marriage status, it found that subjects

without partner, like never married, widowers and

widows, had the highest depression level which

were at high category for 15 subjects (10%). In

accordance with research by Wade, Hart, Wade,

Bajaj and Price (2013), that if compared to

individuals with partner, individuals with chronic

disease already left by their partners would suffer

from frustration, fear, anger, anxiety and depression.

Moreover, depression can be triggered by worrying

situation occurring in individuals’ lives, particularly

the events which involve loss, the loss of family

member or friend (Borrill, 2000). A main social

factor which cause depression is marriage status and

several studies showed that married individuals had

better mental health than unmarried individuals,

widowers and widows (Bulloch, Williamsa,

Lavorato, & Pattena, 2017).

According to analysis result, it was found that

there were 69 subjects (46%) were jobless. Social

and economic status mostly influence individual’s

mental health, those who have high income, high

education and occupation are likely to be happy and

less depressed or less experience other mental

problems (Clark, Frijters, & Shields, 2008; Diener &

Biswas-Diener, 2002; Frey & Stutzer, 2002; Lorant

et al., 2003; dalam Jokela & Jarvinen, 2011).

Furthermore, social and economic status become

factors that can influence the effectiveness of self-

management among DM patients. Social and

economic status are related to cost which should be

expensed by patients to treat long-term disease

(Schulman-Green et al., 2012). It is in accordance

with this present research that majority subjects do

not had permanent job, they were housewife and

private sector workers. It made subject difficult to

get fund for their treatment and for DM self-

management. Although Aceh and several other

provinces have health care facility to help cut

medication cost, patients must pay dues monthly and

there are certain medications which must be paid

with their own cost (Healthcare and Social Security

Agency, 2017).

4 CONCLUSIONS

This study aimed to know the relationship between

depression and self-management in DM patients.

The result showed that there was the relationship

between depression and self-management in

individuals with DM. Further analysis showed that

majority of DM patients had low depression and

self-management level. Moreover, from each

variable is known that there are several factors

which can influence depression and self-

management, as follows age, sex, marriage status,

economic status and comorbidity.

Family becomes the nearest media for DM

patients to help and support them in order that they

are able to avoid depression and improve their self-

management. Therefore, family has to support and

provides motivation for DM patients in order to be

able to self-adjust with negative impact emerging

because of the disease.

Future researcher who will study about

depression and self-management is expected to

extend or conduct further analysis about the

relationship between depression and self-

management. Furthermore, the future research is

expected to extend research samples in both

variables, research is not only conducted in DM

patients, but also patients with other chronic diseases

in order to enrich research result with similar

variables.

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