a comparative study of depression, suicidality and quality of

i

A COMPARATIVE STUDY OF DEPRESSION, SUICIDALITY AND QUALITY OF

LIFE AMONG DIABETES MELLITUS AND ESSENTIAL HYPERTENSION

PATIENTS IN ENUGU, NIGERIA

BY

DR IGWE, MONDAY NWITE

(MBBS, MPH NIG.)

A DISSERTAION SUBMITTED TO THE NATIONAL POSTGRADUATE MEDICAL

COLLEGE OF NIGERIA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

FOR THE AWARD OF THE FELLOWSHIP OF THE COLLEGE IN THE FACULTY

OF PSYCHIATRY.

MAY 2011.

ii

DECLARATION

This dissertation is submitted in partial fulfillment for the award of the Fellowship of

the National Postgraduate Medical College of Nigeria. The study reported here is

original and has not been published or presented to any institution for the award of

degree/fellowship.

………………………………

DR M. N. IGWE

MAY 2011.

iii

SUPERVISORS’ CERTIFICATION

We certify that Dr M.N. Igwe of the Department of Psychological Medicine, Ebonyi

State University Teaching Hospital, Abakaliki carried out this study under our

supervision.

Prof. Richard Uwakwe ………………………………………..

Department of Psychiatry

Nnamdi Azikwe University Teaching Hospital

Nnewi, Anambra State

Dr. Gabriel M. Onyeama …………………..…………………..

Department of Psychological Medicine

University of Nigeria Teaching Hospital

Ituku – Ozalla, Enugu State

Dr. Muideen O. Bakare ………………………………………..

Child and Adolescent Psychiatry Unit

Federal Neuropsychiatric Hospital

New Haven, Enugu, Enugu State

iv

H EAD OF DEPARTMENT’S CERTIFICATION

I certify that Dr. M.N. Igwe carried out this study while in the department headed by

me at Ebonyi State University Teaching Hospital, Abakaliki.

………………………………..

DR A. C. AHANOTU

v

DEDICATION

This study is dedicated to the Almighty God who raises the poor out of the dust, lifts

up the beggar from the dunghill to set them among princes and make them inherit

the throne of glory (1 Sam 2:8).

vi

ACKNOWLEDGEMENTS

I am grateful to Almighty God for seeing me through the residency

programme and for making it possible for me to complete this study at this time.

I express my profound gratitude to my supervisor, Professor Richard Uwakwe

who despite his numerous engagements still made out time to guide me through all

the stages of this work. My sincere appreciation also goes to Dr. G. M Onyeama and

Dr. M.O Bakare who were co-supervisors for their accessibility, patience, guidance

and useful comments in the course of this study.

I thank my Head of Department, Dr. A.C Ahanotu for creating an enabling

environment for me to carry out this work. I equally thank Dr. C. Nwigwe, Chairman

Medical Advisory Committee, Ebonyi State University Teaching Hospital, Abakaliki for

his fatherly encouragement while this study lasted.

I also appreciate Dr. K.O Okonkwo and Dr. J.U Achor who played great roles

in my training and were always available whenever I sought their assistance. Dr.

Robsam Ohayi and Dr. N.O.K Obayi were also of immense assistance during the

course of this study. I thank them too.

Finally, I thank my beautiful wife, Nonye and lovely children, Divine, Nneoma,

Ugonna and Chisom for their support, patience, encouragement and prayers during

the period of this study.

vii

ABSTRACT

Background: Diabetes mellitus and essential hypertension are chronic medical

conditions that place a lot of burden on patients. The presence of co-morbid

depression, suicidal behaviour and impaired quality of life may compound the

problems, leading to poor prognosis.

Objective: This study assessed the prevalence of depression, suicidal behaviour,

quality of life and the socio-demographic correlates among subjects with diabetes

mellitus and compared them with subjects with essential hypertension.

Method: A total of 540 subjects, 270 each for diabetes mellitus and essential

hypertension were interviewed. Consecutive and consenting subjects with diabetes

mellitus and essential hypertension that met the inclusion criteria were recruited

from the endocrinology and cardiology clinics in University of Nigeria Teaching

Hospital Enugu. A socio-demographic questionnaire was used to assess the socio-

demographic characteristics. Major depressive episode of Mini-International

Neuropsychiatric Interview (M.I.N.I.) and Beck Depression Inventory were used to

assess depression while the suicidality module of M.I.N.I. was used to assess suicidal

behaviour. The World Health Organization Quality of Life-Bref (WHOQoL-Bref) was

used to assess quality of life.

Results: The prevalence of depression for the subjects with diabetes mellitus was

27.8% and 26.7% for those with essential hypertension. The subjects with diabetes

mellitus had prevalence of 6.3% for suicidal behaviour while those with essential

hypertension had 7.8%. The subjects with diabetes mellitus had been significantly ill

for a longer duration compared to the subjects with essential hypertension. The

viii

subjects with essential hypertension had significantly higher quality of life scores in

physical health, psychological well-being and social relationship domains. Depression

was more likely in subjects with diabetes mellitus if they were not married or had no

formal education while the subjects with essential hypertension were more likely to

have depression if they were not married, had no formal education or not employed.

Suicidal behaviour was more likely in subjects with diabetes mellitus if they had no

formal education while in those with essential hypertension suicidal behaviour was

more likely in females, those not married and those not educated. Males, married,

educated and employed subjects with diabetes mellitus scored higher on the

WHOQoL-Bref while males, married and educated subjects with essential

hypertension had higher scores.

Conclusion: Depression, suicidal behaviour and impaired quality of life may co-

occur with diabetes mellitus and essential hypertension. The negative impact of

these co-occurrences on achieving good glycaemic and blood pressure control calls

for screening for these conditions when indicated. This may enhance early detection

and treatment.

ix

TABLE OF CONTENTS

Title page - - - - - - - - - i

Declaration page - - - - - - - - - ii

Supervisor’s certification - - - - - - - - iii

Head of Department’s certification - - - - - - iv

Dedication - - - - - - - - - v

Acknowledgements - - - - - - - - - vi

Abstract - - - - - - - - - vii

Chapter One

Introduction - - - - - - - - - 1

Chapter Two

Literature Review - - - - - - - - - 4

2.1 Definition of concepts - - - - - - - 5

2.2 Depression and diabetes mellitus - - - - - - 7

2.3 Suicidal behaviour in diabetes mellitus - - - - - 9

2.4 Quality of life in diabetes mellitus - - - - - 10

2.5 Depression and Hypertension - - - - - - 12

2.6 Quality of life and suicidal behavioural in hypertension - - 12

2.7 Nigerian Studies - - - - - - - - 13

Chapter Three

Aims and Objectives - - - - - - - - 16

3.1 Specific Objectives - - - - - - - - 16

3.2 Hypotheses - - - - - - - - 16

x

Chapter Four

Methodology

4.1 study setting - - - - - - - - 18

4.2 Eligibility Criteria - - - - - - - - 19

4.3 Sample size determination - - - - - - 20

4.4 Ethical Issues - - - - - - - - 20

4.5 Instruments - - - - - - - - - 21

4.6 Translation of the study instruments - - - - - 28

4.7 Formal training on the use of instruments - - - - 29

4.8 Pilot study - - - - - - - - - 29

4.9 Procedure - - - - - - - - - 30

4.10 Statistical analysis - - - - - - - - 32

Chapter Five

Results

5.1.1 Socio-demographic variables of the subjects with diabetes mellitus

and Subject with essential hypertension - - - - - 33

5.2 The rates of depression (current episode) among the subject with

diabetes mellitus and essential hypertension - - - - 37

5.3 Suicidal behaviour among the subjects with diabetes mellitus

and essential hypertension - - - - - - - 39

5.4 Quality of life scores among the subjects with diabetes mellitus

and essential hypertension. - - - - - - 43

5.5 Association between depression and socio-demographic variables - 45

xi

5.6 Association between suicidal behaviour (suicidal ideation, plan

and attempt) and socio-demographic variables - - - - 51

5.7 Association between quality of life (QoL) scores and

socio-demographic variables - - - - - - 57

Chapter Six

Discussion - - - - - - - - - - 65

6.1 Socio-demographic characteristics of the subjects - - - 65

6.2 Rates of depression (current episode) - - - - - 65

6.3 Suicidal behaviour (ideation, plan and attempt) - - - 66

6.4 Quality of life - - - - - - - - 67

6.5 Correlates of depression - - - - - - - 68

6.6 Correlates of suicidal behaviour - - - - - - 70

6.7 Correlates of quality of life scores - - - - - 70

6.8 Relevance of the study to the practice of psychiatry - - - 71

6.9 Limitations of the study - - - - - - - 71

6.10 Recommendations - - - - - - - 72

6.11 Conclusion - - - - - - - - 72

References - - - - - - - - 73

Appendix 1: Socio-Demographic Questionnaire- - - - - 80

Appendix 2: Beck Depression Inventory - - - - - 81

Appendix 3: Mini-International Neuropsychiatric Interview - - 90

Appendix 4: The World Organization Quality of Life (WHOQoL)-Bref - 95

Appendix 5: Consent Form - - - - - - 107

xii

CHAPTER ONE

INTRODUCTION

Many chronic medical conditions are complicated by emotional and

psychological disorders and yet the emotional dimensions of such chronic medical

conditions are often overlooked when medical care is considered (Turner & Kelly,

2000). Patients with chronic medical conditions often have to adjust their

aspirations, lifestyle, and employment. Many grieve about their predicament before

adjusting to it. But others have protracted distress and may develop psychiatric

disorders, most commonly depression and anxiety (Turner & Kelly, 2000).

Depressive and anxiety disorders are the commonest psychiatric conditions occurring

in the context of chronic medical illnesses, including diabetes mellitus where

prevalence of affective disorders was reported as 20-25% (Turner & Kelly, 2000).

Emotional and psychological disorders may affect the quality of life of the

patients and may have deleterious concomitants like suicidal ideation and behaviour.

The prevalence of suicidal ideation complicating depressive disorders related to

medical illnesses has been studied empirically. The risk of suicide is greater among

patients with physical illnesses than among the general population with a prevalence

estimate of 22 – 60% (Kishi, et al 2001, Shah, et al 2000).

Depressive symptoms and syndromes are common in the medically ill,

although they are frequently unrecognized and untreated (Rodin & Voshart, 1986).

Diabetes is one of such chronic medical conditions that could be associated with

depressive syndromes. Diabetes mellitus is a group of metabolic diseases

characterized by hyperglycemia resulting from defects in insulin secretion, insulin

action, or both. The chronic hyperglycemia of diabetes is associated

xiii

with long-term damage, dysfunction, and failure of various organs, especially the

eyes, kidneys, nerves, heart, and blood vessels (American Diabetes Association,

2004).

Diabetes mellitus is a chronic and debilitating medical condition that

constitutes a source of stress to sufferers and, as such, affects their quality of life

and usually presents a difficult medical condition to live and cope with (Aldwin &

Revenson, 1987). Adaptation to chronic diseases like diabetes mellitus is a difficult

and complex process. This may necessitate several adjustments in the patient's

lifestyle (Brannon & Feist, 1997). Social relationships may also be severely affected

and commonly emotional responses like withdrawal, loneliness, guilt feelings,

hopelessness and suicidal ideation have been noted. (Mosaku, et al 2008).

Previous research work has shown that a relationship exists between

depression and diabetes mellitus (Anderson, et al 2001). Depression has been

associated with hyperglycemia, diabetes-related complications, perceived functional

limitations of patients with diabetes mellitus, socioeconomic status, marital status,

obesity and smoking habits (de Groot, et al 2001, Everson, et al 2002).

Related to the foregoing, other medical conditions like hypertension can also

co-exist with depressive disorders. Hypertension (high blood pressure) is defined as

a repeatedly elevated blood pressure exceeding 140mmHg systolic and 90 mmHg

diastolic (Devereux, et al 1993). Essential hypertension accounts for 95% of all cases

of hypertension with unknown etiology (Carretero & Oparil, 2000). Hypertension has

been noted to be associated with increased prevalence of depression (Rabkin, et al

1983). Presence of co-morbid depression in patients with hypertension adversely

affects the management and worsens the prognosis in such patients (Simonsick, et

xiv

al 1995). Depression has also been associated with higher risk of stroke in the

elderly with hypertension (Oshira, et al 2001). Hopelessness has also been reported

to be an important factor in cardiovascular disorders, including hypertension

(Everson, et al 2000).

Most of the studies that have assessed depression and quality of life in

chronic medical conditions in Nigeria have been done in the South-western geo-

political part of the country. It seems that studies comparing depression, suicidal

behaviour and quality of life among the patients who have diabetes mellitus and

essential hypertension are scanty in Nigeria. Understanding these interactions in the

setting of consultant clinics in South-eastern Nigeria is relevant to the practice of

psychiatry. Such a comparative data will help expand our knowledge about co-

morbidity of depression and suicidal behaviour in diabetes mellitus and essential

hypertension in addition to assessing the impact of such conditions on the quality of

life of the affected patients.

This study is designed to determine the interrelationship between depression,

suicidal behaviour and quality of life of patients who have diabetes mellitus, and to

compare these with patients that are diagnosed with essential hypertension.

xv

CHAPTER TWO

LITERATURE REVIEW

Untreated psychiatric illness is associated with increased morbidity, a longer

hospital stay and ultimately, increased costs of care (Gomez, 1987). This often leads

to wasteful, costly and inefficient use of medical services and complications of the

disorders and treatments among these patients (Musisi & Tugumisirize, 2001).

Therefore, early detection and treatment of mental disorders, is essential. This is

especially necessary since symptoms of such mental disorders are frequently not

recognized when co-morbid with chronic medical conditions (Turner & Kelly, 2000).

Diagnosis of depression in the medically ill can be difficult and challenging as

doctors may be well equipped for the biomedical aspects of care but not for the

challenges of understanding the psychological, social, and cultural dimensions of

illness and health, yet diagnosis and treatment are essential (Turner & Kelly, 2000).

The possibility that a significant proportion of the patients attending a medical

outpatient health facility may have unrecognized mental disorders suggests that

psychiatric conditions need to be recognized and managed appropriately (Ndetei, et

al 2009). In Nigeria, there are only about 110 working psychiatrists (World Health

Organization, 2005), 110 resident doctors training in psychiatry (Ayonrinde, et al.

2004) serving a population of approximately 140 million people (National Population

Commission, 2006). This translates to inadequate psychiatric services to the

population.

xvi

2.1 Definition of Concepts

i). Depression

The term depression can variously define an affect, mood state, a disorder,

symptom, syndrome or a specific entity (Gelder, et al 2003). Depressive disorders

are affective (mood) disorders characterized by depressed mood, loss of interest or

pleasure, feelings of worthlessness or inappropriate guilt, recurrent thoughts of

death or suicidal ideation, weight changes, sleep disturbances, fatigue, impaired

concentration and psychomotor disturbance. A positive diagnosis requires five or

more of the nine with evidence of functional impairment and a minimum duration of

two weeks (American Psychiatric Association, 1994).

ii) Suicidality

Suicidal behaviour or suicidality can be conceptualized as a continuum ranging

from suicidal ideation, making plans to suicide attempts and completed suicide

(Gelder, et al 2003). Ideation includes thinking that one is better off dead or wishes

one were dead, wanting to harm oneself or to hurt or injure oneself, think about

suicide and having a suicide plan, while making a suicide attempt involves taking

active steps to prepare to injure oneself with expectations to die and deliberately

injuring oneself without intention of dying (Sheehan, et al 1998).

(iii) Quality of life

The concept of quality of life has received considerable attention as an inclusive

notion of health and as a basis for health interventions (Hendry & McVittie, 2004).

Quality of life has been defined in multiple ways and mean different things

xvii

to different people. The concept has been described as a person’s sense of well-

being that stems from satisfaction or dissatisfaction with the areas of life that are

important to him/her (Ferrans, 1990). It can also be defined as the degree of need

for satisfaction within the areas of the physical, psychological, social, activity,

material and structural areas (Hørnquist, 1990). It has also been defined as a

measure of happiness and satisfaction with life, or goal achievement, or social utility

(Dedhiya & Kong, 1995).

A mathematical approach was brought to quality of life when it was defined

as utility scores that reflect preferences for the health states and allow morbidity and

mortality improvements to be combined into a single weighted measure; quality-

adjusted life years (Revicki & Kaplan, 1993).

A more encompassing view regards quality of life as the individuals’

perceptions of their position in life, in the context of the cultural and value systems

in which they live and in relation to their goals, expectations, standards and

concerns (World Health Organization, 1996). Based on this definition, the World

Health Organization quality of life-100 was developed by the World Health

Organization quality of life Group with fifteen international field centres,

simultaneously, in an attempt to develop a quality of life assessment that would be

applicable cross-culturally (WHO, 1996).

Most researchers are of the opinion that quality of life is complex and

composed of multiple dimensions (Bowling 1995, Ferrans, 1996, Spilker, 1996).

These perspectives of quality of life have been proposed: sociological, economic,

psychological, philosophical and ethical but health has emerged as an important and

distinct perspective (Taylor, et al 2008). World Health Organization quality of

xviii

life-bref (WHOQoL-Bref) which was used in this study has four domains- physical

health, psychological, social relationships and environment.

2.2 Depression and diabetes mellitus

There is a bidirectional association between depression and diabetes. The

presence of diabetes doubles the odds of co morbid depressive disorder (Pompili, et

al 2009). Similarly, the presence of depressive symptoms makes the afflicted

individual more vulnerable to becoming diabetic. In a study of 6,814 men and

women, aged 45 to 84 years, patients diagnosed with diabetes were 54% more

likely to develop depression than patients who were not. Patients with depressive

symptoms were 42% more likely to develop diabetes (Brownlee, 2008). Indeed,

patients who have diabetes mellitus, diagnosed with co morbid depression have an

elevated risk of death from both causes, greater than that of depression or diabetes

alone. (Egede, et al 2005). Furthermore, studies suggest that in patients with

diabetes mellitus who have depression, the severity of depression is correlated with

the severity of diabetes-related complications, independent of the type of diabetes

(Pompili, et al 2009). Depression has also been noted as a modifiable risk factor

whose treatment could improve glycaemic control and health outcomes in patients

with diabetes mellitus (Gendelman, et al 2009).

Katon, et al (2004) in a population-based mail survey study reported that

independent factors that were associated with a significantly higher likelihood of

meeting criteria for major depressive disorder among patients with diabetes mellitus

included younger age, female sex, less education, single status, basal metabolic

index ≥ 30 kg/m2, smoking, higher non- diabetic medical co morbidity, higher

xix

numbers of diabetes complications in men, treatment with insulin, and higher HbA1c

levels in patients ≤ 65 years of age.

In another study, where 506 patients who have diabetes mellitus were

assessed for depressive disorders and depressive symptoms using a structured

interview (Composite International Diagnostic Interview [CIDI]), and a questionnaire

for depressive symptoms (Center for Epidemiological Studies Depression Scale

[CESD], it was reported that the prevalence of depressive symptoms was 22% while

9.9% met a CIDI diagnosis of major depressive disorder (Fisher, et al 2007).

Similarly, the levels of depression were self-rated by using the Hospital

Anxiety and Depression scale in a controlled study of 60,869 individuals with and

without diabetes mellitus. Several factors were correlated with depression in types 1

and 2 diabetes. However, these factors were not different from those of the non-

diabetic population. Co-morbid chronic somatic diseases were associated with

depression in type 2 but not type 1 diabetes mellitus. In type 2 diabetes mellitus,

those without co morbidity had the same odds of depression as the non-diabetic

population with no chronic somatic diseases. No significant associations were found

for hyperglycemia in relation to depression in type 1 and type 2 diabetes mellitus

(Engum, et al 2005).

A research work involving 458 participants with diabetes and 546 without

diabetes and using Beck Depression Inventory-II, reported findings showing that

compared with non-diabetic participants, adults with type 1 diabetes report more

symptoms of depression and more antidepressant medication usage. Mean BDI-II

score, adjusted for age and sex, was significantly higher in participants with type 1

diabetes than in non-diabetic participants and participants reporting diabetes

xx

complications had higher mean BDI-II scores than those without complications

(Gendelman, 2009).

Anderson, et al (2001) in a meta-analysis involving 42 studies, reported that

the odds of depression in the group with diabetes mellitus were twice that of those

without diabetes mellitus. The prevalence of co-morbid depression was significantly

higher in diabetic women (28%) than in diabetic men (18%). Prevalence of

depression in the uncontrolled population was 30% while in the controlled studies it

was 21%. Prevalence of depression in clinical samples was 32% and in community

studies was 20%. Prevalence when assessed by self-report questionnaires was 31%

but by standardized diagnostic interviews it was 11%.

2.3 Suicidal behaviour in diabetes mellitus

Pompili, et al (2009) examined the role of diabetes in suicide ideation and

attempt, independent of mood disorders or the side effects of psychotropic drugs

and found that patients with diabetes, compared to a control group, scored higher

on two subscales of the Beck Hopelessness Scale: Loss of Motivation and Future

Expectations, which are significantly related to suicidality. Patients with diabetes

mellitus also registered higher for suicidality on the Suicide Score Scale and showed

significantly lower self-efficacy than the control group

Adolescents with diabetes mellitus displayed higher than expected rates of

suicidal ideation, but relatively few attempted suicide over the follow-up period.

Among those who did attempt suicide, diabetes-related methods commonly used

were potentially lethal doses of insulin which were easily available to them. Suicidal

xxi

ideation shortly after insulin dependent diabetes mellitus onset was related only to

concurrent severity of depressive symptoms. Also, it has been noted that suicidal

ideation and not complying with medical regimen are strongly associated among

teenagers with diabetes mellitus (Goldston, et al 1994).

Patients with diabetes undergoing polytherapy (the use of multiple

medications or treatments) are at a higher risk for suicide ideation and attempt.

Type of diabetes mellitus is not thought to be a significant risk factor, but rather, the

severity of the symptoms and the inconvenience of the treatment are thought to be

more relevant. Patients with combined treatments tend to score higher on several

measures in the Beck Hopelessness Scale. These deficiencies which may lead to a

poorer quality of life, more depression and nervousness, and more reporting of

hardships due to physical or emotional problems. Patients suffering diabetes mellitus

who are above 50 years of age are at a higher risk for suicide ideation and attempt

(Pompili, et al 2009).

2.4 Quality of life in diabetes mellitus

Patients with a chronic medical illness sometimes report a surprisingly high

level of satisfaction with their quality of life (Cassileth, 1984), but clinicians often

underestimate the quality of life of these patients (Uhlmann, 1991).

Diabetes mellitus has a profound effect on the quality of life and on the

physical and emotional health of the individual, with patients suffering type 1

diabetes mellitus generally reporting a worse quality of life than patients with type 2

diabetes (Pompili, et al 2009).

Some demographic variables are associated with low quality of life in

xxii

people with diabetes mellitus. These variables include female sex, increasing age,

low or no formal education and generally people with diabetes mellitus report worse

quality of life compared to the general population (Rubin, 2000).

Patients who had diabetes mellitus were predominantly dissatisfied with their

life circumstances and patients with type 1 had lower quality of life scores relative to

the control group. However, having additional medical problems, having diminished

sexual desire, being young, unemployed and single were significantly associated with

poor quality of life, but illness duration was not (Awadalla, et al 2006).

A study conducted among patients with type 2 in Portugal, showed that

female subjects had poorer quality-of-life ratings than male subjects. Patients were

more likely to regard diabetes mellitus and the consequent changes resulting

because of the illness as a threat rather than as a challenge. A greater proportion of

the patients who have diabetes used avoidance coping mechanisms, which were

related to worse quality of life. Coping style was significantly correlated with several

dimensions of quality of life of these patients with type 2 diabetes mellitus (Coelho,

et al 2003).

Role limitations, the severity of the diabetes symptoms and the

inconveniences of the treatment lead to a poorer quality of life (Pompili, et al 2009).

Empirical studies suggest that the self-perception of poor health is associated

with a significantly increased risk of suicidal ideation among general medical

patients, even in the absence of common mental and physical disorders (Goodwin &

Olfson, 2002). Perceived good quality of life is associated with reduced suicide risk

and higher self-efficacy. Self-efficacy is a major predictor of strong mental health

and positive feelings of fitness, both of which serve protective functions.

xxiii

2.5 Depression and hypertension

Association between major depression and cardiovascular disease has been

established and hypertension is significantly associated with symptoms of depression

(Scherrer, et al 2003). These authors reported that men who have cardiovascular

disease were significantly more likely to have depressive symptoms.

Assessing prevalence of depression in patients with hypertension has received

some considerable attention. Rabkin, et al (1983) reported that major depression

was three times more common among patients with hypertension even when known

cardiac risk factors were taken into account and mild depressive symptoms were

present in 20% of patients with hypertension (Bonnet, et al 2005).

2.6 Quality of life and suicidal behaviour in hypertension

Individuals’ perception of quality of life may be affected by their illness and

also by their therapy. This is the case with patients who have hypertension (Cote, et

al 2004). Although many patients who have mild to moderate hypertension may

have no symptoms (Lawrence, et al 1996), antihypertensive drug therapies are often

associated with many unpleasant adverse effects that may impact negatively on

many aspects pertaining to the quality of life of the patients (Hill, et al 1985).

Patients with pulmonary arterial hypertension have substantial functional and

emotional limitations that adversely affect their health related quality of life

(Shafazard, et al 2004).

In a cross-sectional survey aimed at determining the relationship between

symptoms and health-related quality of life in patients receiving drug therapy

xxiv

for hypertension, it was reported that symptoms have a greater impact on health-

related quality of life than patient’s characteristics, blood pressure or drug related

factors (Erickson, et al 2004).

Hopelessness was associated with increased incidence of hypertension in 616

Finish men, who had normal blood pressure initially, in a 4-year follow-up

prospective study. Participants who had high levels of hopelessness at baseline were

3 times more likely to become hypertensive than those who were not hopeless, after

adjustments for age, body mass index, baseline resting blood pressure, physical

activity, smoking, alcohol consumption, education, and parental history of

hypertension (Everson, et al 2000).

2.7 Nigerian studies

Depression is a common disorder that is widely distributed in the population

(Kessler, et al 2003). In a two phase community based cross sectional study carried

out in Oyo state, using 1105 participants with multistage sampling technique, the

prevalence of depression was found to be 5%. Depression was found to be more

prevalent among women than men - 6% and 5% respectively. The adolescent

population had a prevalence of 10% (Amoran, et al 2007).

A study that aimed at assessing the psychological condition of a group of

Nigerians having diabetes mellitus, reported a prevalence rate of 25% for depression

(Akinlade, et al 1996) whereas Coker et al (2000) reported a prevalence of

depression as 4% among attendees of a general hospital department. Both studies

concluded that psychiatric symptomatology was associated with low occupational

status, duration of diabetes and sexual dysfunction.

xxv

A recent study conducted at Ife, among patients with diabetes mellitus, using

patients with asthma and apparently healthy individuals as controls, recorded the

prevalence of depression as 20% compared to that in asthma (12%). Predictors of

depression included age of the patient, poor glycemic control and duration of

diabetes mellitus. Factors that correlated significantly with diabetic general well-

being include depression, anxiety and fasting blood glucose level. Depression and

the presence of co-morbid medical conditions significantly predicted a low quality of

life (Mosaku, et al 2008).

Clinical depression has been documented to be a common problem among

patients who have diabetes mellitus in Nigeria and those with co-morbid depression

tend to have higher health care costs (Agbir, et al 2010). The prevalence rate of

major depressive episode was 19.4% and depression was significantly correlated

with sex, with a female to male ration of 3:1 and was also significantly associated

with unmarried patients and those who had a poor relationship with their partners.

There was no significant association between depression and respondents’ age,

educational qualifications, employment status, place of residence, household

composition and monthly income (Agbir, et al 2010).

Depression is not only highly co-morbid with diabetes mellitus but also affects

treatment goals negatively (James, et al 2010). This study, recently conducted at the

University of Benin Teaching Hospital, Nigeria reported a prevalence of clinical

depression as 30% among those who have diabetes mellitus compared with 9.5% in

the apparently healthy control group. Having a smaller income and more children

were significantly correlated with higher depression symptoms on Beck depression

inventory.

xxvi

Most Nigerians who have diabetes mellitus have been noted to perform fairly

well on World Health Organization quality of life instrument, short version and poor

quality of life was particularly associated with some physical complications of

diabetes mellitus, lower income, lower educational status, low-rated employment

and type 2 diabetes mellitus (Issa & Baiyewu, 2006).

Overall health related quality of life has been documented to be better in the

group of patients who have hypertension with good control of blood pressure.

Increasing blood pressure, physical symptoms, the presence of stroke, and visual

impairment were significant negative predictors of the overall health-related quality

of life among patients with hypertension (Ogunlana, et al 2009).

xxvii

CHAPTER THREE

AIMS AND OBJECTIVES

The general aim of this study was to determine the prevalence of depressive

symptoms, suicidal behaviour and assess quality of life among the subjects with

diabetes mellitus and to compare these with the subjects who have essential

hypertension at the University of Nigeria Teaching Hospital Enugu, Nigeria.

3.1 Specific Objectives

1. To determine and compare the prevalence of depression among the subjects

with diabetes mellitus and those with essential hypertension at the University

of Nigeria Teaching Hospital Enugu.

2. To determine and compare the prevalence of suicidal behaviour among the

subjects with diabetes mellitus and those with essential hypertension.

3. To determine and compare the quality of life of the subjects with diabetes

mellitus and those that have essential hypertension.

4. To relate depression, suicidal behaviour and quality of life scores of the

subjects with diabetes mellitus and essential hypertension to clinical and

socio-demographic variables.

3.2 Hypotheses

The study proposed the following hypotheses:

1 That depression and depressive symptoms would be more prevalent in the

subjects with diabetes mellitus than those with essential hypertension.

2 That suicidal risk would be higher in the subjects with diabetes

xxviii

mellitus than those with essential hypertension.

3 That quality of life in the subjects with diabetes mellitus would be lower

compared to those with essential hypertension.

4 Socio-demographic variables - female sex, lower educational status, low-rated

employment and lower income would be associated with increased prevalence

of depression, suicidal risk and poor quality of life in the subjects with

diabetes mellitus and essential hypertension.

CHAPTER FOUR

xxix

METHODOLOGY

4.1 Study Setting.

This study was carried out at the endocrinology and cardiology clinics of

University of Nigeria Teaching Hospital Enugu. The hospital began as a General

Hospital for Africans at a temporary site in Ogbete area of Enugu metropolis.

At the end of the Nigerian civil war in 1970, the then government of East

Central State converted it to a specialist hospital with effect from July 01, 1970. The

Federal Government by virtue of decree 23 of 1974 took over the Hospital and

consequently approved the construction of a new permanent site at Ituku-Ozalla.

Presently this new site is functional and located 21 kilometers from Enugu city along

the Enugu-Port Harcourt express way. All services hitherto rendered at the old site

have since been moved to the permanent site with effect from 8th January, 2007.

The Hospital site covers an area of 200 acres with the entire parcel of land

measuring about 747 acres.

There are 41 main departments with three outpost comprehensive health

centers at Obukpa (Enugu State), Abagana (Anambra State) and Isuochi (Abia

State). The Hospital has nine institutions for training of nurses, midwives, laboratory

scientists, medical records officers etc. The bed capacity is 702 with average daily

bed occupancy being 500. The hospital offers 24- hour emergency service as well as

outpatient clinics that include diabetic and cardiology units. There is also a wide

range of laboratory and radiological services. University of Nigeria Teaching Hospital

has many consultants in various medical specialties, 377 resident doctors, nurses,

pharmacists and other paramedical staff. There are also non-medical staffs that run

the daily administrative activities of the Hospital.

xxx

The services of the Hospital are highly subsidized by the Federal Government of

Nigeria. Patients from south- east, south-south and north-central geo-political zones

of Nigeria receive care in this tertiary referral centre.

4.2 Eligibility criteria

a. Inclusion criteria

i. Established diagnosis of type 1 or type 2 diabetes mellitus by a

consultant endocrinologist.

ii. Subjects diagnosed to have essential hypertension by a consultant

cardiologist.

iii. Subjects aged 18 - 64 years.

iv. Willingness to give informed consent.

v. Established disease for at least 1 year and stable without need for

hospital admission for 3 months prior to assessment.

b. Exclusion Criteria

i. Subjects aged<18 years or older than 64 years.

ii. Not willing to give informed consent.

iii. Subjects with severe cognitive impairment

iv. Co-morbid diabetes mellitus and hypertension in one subject.

v. Subjects who have hypertension secondary to another identifiable disease

vi. Unconscious patients and those too ill to participate in the study.

vii. History of mental illness, head injury or substance abuse.

4.3 Sample size determination

The sample size for the study was calculated using the formula

xxxi

N = z2pq/d2 (Araoye, 2003).

Where N = sample size

z2 = confidence interval (a constant) which is 1.96

p = prevalence of the problem determined from a previous study done in

Nigeria- 20% (a recent study in patients with diabetes at Obafemi Awolowo

University Teaching Hospital Ile-Ife, Nigeria reported elevated depressive symptoms

based on use of depression-rating scales (Mosaku, et al. 2008).

q = 100-p

d = level of confidence (5%).

Therefore, the sample was calculated as;

N = z2pq d2

= 1.96x1.96x20x80 5x5

= 246

To make allowance for attrition, a 10% increase was made by adding 24. This

gave a minimum sample size of approximately 270 each for the subjects with

diabetes mellitus and essential hypertension respectively. In essence 540

participants took part in the study.

4.4 Ethical Issues

Approval for this study was obtained from Ethics Committee of University of

Nigeria Teaching Hospital, Enugu Nigeria. All participants gave informed consent

before recruitment into the study. The study did not involve any procedure that was

detrimental to the subjects. It was explained to them that non-

xxxii

participation in the study would not in any way attract any form of penalty or affect

the service they received at the hospital. Subjects were free to withdraw from the

study at any time, even after having initially consented. The subjects found to have

clinically significant depression or high suicidal risk, were advised and subsequently

referred for appropriate care.

4.5 Instruments

4.5.1 Socio-demographic Questionnaire

This questionnaire was designed to provide information about the

respondents’ age, gender, marital status, occupation, level of education, ethnic

background, religion, age of onset of diabetes mellitus/essential hypertension,

duration of illness, type of diabetes mellitus and present drug regimen. The socio-

demographic questionnaire is included as appendix 1.

4.5.2 Beck Depression Inventory

The Beck Depression Inventory (Beck et al, 1988) developed by Dr. Aaron T.

Beck in 1961, is a 21-question multiple-choice self-report inventory about how the

subject has been feeling in the past two weeks. It is one of the most widely used

instruments for measuring the severity of depression. Questions on the Beck

Depression Inventory (BDI) assess mood, pessimism, and sense of failure, self-

dissatisfaction, guilt, punishment, self-dislike, self-accusation, suicidal ideas, crying,

irritability, social withdrawal, body image, work difficulties, insomnia, fatigue,

appetite, weight loss, bodily preoccupation, and loss of libido.

xxxiii

Internal consistency studies demonstrated a correlation coefficient of 0.86 for

the test items, and the Spearman-Brown correlation for the reliability of the BDI

yielded a coefficient of 0.93. Content validity is high since the BDI evaluates quite

well a wide variety of symptoms and attitudes associated with depression.

Beck reported a study in which coefficients of 0.65 and 0.67 were obtained in

comparing results of the BDI with psychiatrists’ ratings of patients (Beck, 1988).

When the test is scored, a value of 0 to 3 is assigned for each answer and the scores

are summed to determine the severity of the depression. Higher total scores indicate

more severe depressive symptoms.

The total score is calculated by adding up the scores for all 21 items to give a range

of 0-63. The scores of 0-9 indicates absence of depression, 10-15 mild depression,

16-19 borderline clinical depression, 20-29 moderate depression, and 30-63 severe

depression.

The BDI suffers from the same problems as other self-report inventories

(Bowling, 2005), in that its scores can be easily exaggerated or minimized by the

person completing them. Like all questionnaires, the way the instrument is

administered can have an effect on the final score. If a patient is asked to fill out the

form in front of other people in a clinical environment, for instance, social

expectations might elicit a different response compared to administration via a postal

survey.

Another serious limitation is that in participants with concomitant physical

illness, it has been suggested that the BDI's reliance on physical symptoms such as

fatigue might artificially inflate scores due to symptoms of the illness, rather than of

depression (Moore, 1998).

xxxiv

BDI has been used in various studies in Nigeria by Akinawo, (1993) and

Adewuya, et al (2007). The BDI is presented as appendix 2.

4.5.3 The Mini-International Neuropsychiatric Interview

The Mini-International Neuropsychiatric Interview (M.I.N.I.) is a short

structured diagnostic interview, developed jointly by psychiatrists and clinicians in

the United States and Europe in 1990 for DSM-IV and ICD-10 psychiatric disorders.

With an administration time of approximately 15 minutes, it was designed to meet

the need for a short but accurate structured psychiatric interview for multicenter

clinical trials and epidemiology studies and is expected to be used as a first step in

outcome tracking in non-research clinical settings (Sheehan, 1998).

It is a widely used instrument by health professionals and organizations with

translations into many languages (Otsubo, et al 2005). It can be used by clinicians

after a brief training session while lay interviewers require more extensive training.

Validation and reliability studies have been done comparing the M.I.N.I. to the

Structured Clinical Interview (SCID-P) for DSM-III-R and the Composite International

Diagnostic Interview (CIDI), a structured interview developed by the World Health

Organization for lay interviewers based on ICD-10 criteria. The results of these

studies showed that the M.I.N.I. has acceptably high validity and reliability scores

(Sheehan, et al 1998). The advantage over other diagnostic instruments like SCID-P

and CIDI is its brevity and that it can be administered in a much shorter period of

time.

xxxv

There are many modules for diagnostic categories but only the major

depressive episode and suicidality modules were used in this research.

Mini-International Neuropsychiatric Interview (M.I.N.I.) has been used in Nigeria by

Adewuya, (2006), Adewuya & Mosaku, et al (2006) and Adewuya & Oginni, et al

(2006).

i) Major depressive episode (MDE) of M.I.N.I.

Major Depressive Episode module of MINI which is grouped as A-module has

six sections A1to A6.

Questions A1 to A3 assessed Current Major Depressive Episode.

Question A4 assessed Recurrent Major Depressive Episode, while question A5 to A6

assessed Major depressive episode with melancholia.

In this study questions A1 to A3 were used since the study assessed major

depressive episode (current).

All questions were coded with YES or NO answers.

Question A1 assessed depressed mood in the past 2 weeks.

Question A2 asked about interests and enjoyments of most of the things the

respondents used to experience in the past.

Question A3 was sub-divided into a to g. The questions here assessed other

parameters when the respondent was depressed or uninterested. For instance, sub-

question 3a asked for level of appetite and weight and 3b asked for sleeping

difficulty, waking up in the middle of the night, early morning wakefulness, or

excessive sleeps.

Question 3c assessed reduced speech and movement, being fidgety,

xxxvi

restlessness, or having trouble sitting still, while sub-question 3d assessed frequency

of tiredness or no energy. Sub-question 3e assessed the frequency of feeling of

worthlessness or guilt, while question 3g asked about hurting self, feeling suicidal, or

wishes for death.

The overall score for major depressive episodes, current was 5 or more yes codes in

questions A1 to A3.

The Major Depressive Episode module of M.I.N.I. is included as appendix 3a.

ii Suicidality module of M.I.N.I.

The Suicidality module of this instrument which is grouped as C Module was

used for this study. There were nine questions in this module labeled C1 to C9.

Questions C1 to C8 assessed events in the past one month while question C9

assessed for suicide attempt in a patient’s lifetime.

C1 asked about suffering any accident and was divided into C1a and C1b. Question

C1a assessed plan or intention to hurt oneself in the accident either passively or

actively while C1b assessed for intention to die as a result of the accident. Scores of

zero were ascribed to C1, C1a and C1b respectively.

C2 assessed for thoughts of being better off dead or wishing for death with a score

of 1 point for yes response.

C3 assessed wanting to harm oneself or to hurt or to injure oneself. This had a score

of 2 points.

C4 asked about thinking of suicide with a score of 6 while C5 assessed for suicide

plan with a score of 8. C6 asked about taking any active steps to prepare to injure

xxxvii

oneself or to prepare for a suicide attempt in which he/she expected or intended to

die and has a score of 9.

C7 assessed deliberately injuring oneself without intending to kill himself/herself with

a score of 4 points. C8 assessed suicide attempt with a score of 10 points.

Each question had a response of either YES or NO with various numerical points

ascribed. For those whose responses were coded yes except C1, summation of the

points specified the level of suicide risk. Scores 1-8 points indicated low suicidal risk,

9-16 moderate and ≥ 17 points as high suicide risk respectively. The Suicidality

module of M.I.N.I. is included as appendix 3b.

4.5.4 World Health Organization Quality of Life-Bref (WHOQoL-Bref)

The World Health Organization quality of life (WHOQoL) project was initiated

in 1991 and aimed at developing an international cross-culturally comparable quality

of life assessment instrument. It assesses the individual's perceptions in the context

of their culture and value systems, and their personal goals, standards and concerns.

WHOQoL instruments were developed collaboratively in a number of centers

worldwide, and have been widely field-tested (WHO, 1996). The WHOQoL-Bref is a

26-item self-administered generic questionnaire, being a shorter version of the

original WHOQoL-100 scale. It is more convenient for use in large research studies

or clinical trials (Murphy, et al 2000).

WHOQOL-Bref instrument emphasizes the subjective responses of patients

rather than objective conditions. It was developed in a wide range of languages for

use in different cultural settings (including Sub-Saharan Africa), and yields

comparable scores across cultures. Together with other measures, the

xxxviii

WHOQoL-Bref enables health professionals to assess changes in quality of life over

the course of treatment and it is anticipated that in future the WHOQoL-Bref will

prove useful in health policy research and will make up an important aspect of the

routine auditing of health and social services (WHO, 1996).

The instrument is made up of four domains or dimensions and sub domains or

facets. The broad domains are physical health, psychological health, social

relationships, and environment.

Three of the four domains of the WHOQoL-Bref (physical, psychological and

environment domains) have been established to demonstrate satisfactory reliability

and validity. However, the social relationships domain exhibited poor validity

(Naumann & Byrne, 2004).

The WHOQoL-Bref produces a quality of life profile. Each of the 26 items has

5 options to which the patient is expected to respond on a 5-point Likert type scale.

It is possible to derive four domain scores. There are also two items that are

examined separately: question 1 asks about an individual’s overall perception of

quality of life and question 2 asks about an individual’s overall perception of their

health. The four domain scores denote an individual’s perception of quality of life in

each particular domain. Domain scores are scaled in a positive direction (i.e. higher

scores denote higher quality of life).

The raw scores for each domain of WHOQoL-Bref were calculated by adding

values of single items according to instructions given at the end of the questionnaire

(WHO, 1996). These raw scores were transformed on the scale ranging from 0 to

100 where 0 was the lowest and 100 was the highest related quality of life scores

respectively. The negatively worded items have reversed scores (Odili,

xxxix

Ugboka, Oparah 2010). The method for calculating raw scores and subsequent

conversion to transformed scores is shown in appendix 4.

Alternatively, the mean score of items within each domain can used to

calculate the domain score. A score of mean ± 1 standard deviation (SD) on each

domain is graded fair, a score of < mean – 1SD is poor and a score of > mean +

1SD is good (Olusina & Ohaeri, 2003).

The World Health Organisation quality of life instrument, short version has

been used in Nigeria by Olusina & Ohaeri (2003), Makanjuola, et al (2005), Issa &

Baiyewu (2006), Fatoye, et al. (2006), Ohaeri, et al (2006). The WHOQoL-Bref is

included as appendix 4.

4.6 Translation of the study instruments

Major depressive episode and suicidality modules of Mini-International

Neuropsychiatric Interview, Beck’s Depression Inventory and the World Health

Organization Quality of Life (WHOQoL-Bref were translated into igbo language which

is the predominantly spoken language in the study area. These instruments were

first translated from English to Igbo language and then back translated from Igbo to

English. The English to Igbo translation was done by an experienced teacher of Igbo

language in Ishiagu Girls’ Secondary School Ebonyi State. She holds a university

degree in Igbo language too and has been involved in other translation works in the

past. The back translation from Igbo to English was done by an Igbo newscaster in

Radio Nigeria FM Abakaliki who speaks both English and Igbo Languages fluently in

addition to possession of a degree in English/Igbo language Education.

xl

Subjects who did not understand English language were interviewed with

Igbo versions of the study instruments.

4.7 Formal training on the use of instruments

The author received a formal training in the use of the instruments for this

study. One of the supervisors (RU) trained the author on the use of Beck Depression

Inventory, Mini-International Neuropsychiatry Interview and World Health

Organization Quality of Life -Bref. The author observed the supervisor administer

these instruments to 10 subjects who met the inclusion criteria for this study.

Thereafter, the author was observed by the supervisor as he administered the

questionnaires. This continued till the supervisor was satisfied that the author was

conversant and properly trained to administer all the instruments required for this

study.

4.8 Pilot Study

A pilot study was conducted at the endocrinology outpatient clinic and

cardiology clinic of University of Nigeria Teaching Hospital Enugu. This pilot test was

done among ten subjects with diabetes mellitus at the endocrinology clinic and

another ten subjects with essential hypertension at the cardiology clinic to determine

the clarity, acceptability, ease of administration of the instruments and identify

logistical problems. The twenty subjects selected met the inclusion criteria for the

study and were consecutive attendees at the endocrinology or cardiology clinic. This

was to ensure that the pilot samples were representative of the original samples for

the study. The subjects who participated in the pilot study were not part of the

xli

main study. The pilot study was done in August, 2010 before the commencement of

the main study under the supervision of one of the supervisors (RU).

4.9 Procedure

Subjects with hypertension were largely seen at the cardiology clinics, which

held three days every week (Monday, Wednesday and Friday). Similarly the subjects

with diabetes mellitus were seen at the endocrinology clinic which held once a week

(every wednesday). The subjects for the study were recruited from the two clinics.

Consecutive attendees who met the inclusion criteria were recruited into the study

until the required sample size was attained. The study was carried out over 6

months period (between August, 2010 and January, 2011).

Subjects diagnosed as having diabetes mellitus or essential hypertension were

initially identified. After confirming that a subject met the inclusion criteria, voluntary

informed consent was obtained. Information about the subject such as age, sex,

religious affiliation, marital status, ethnic group, occupation, age of onset of diabetes

mellitus or essential hypertension, duration of illness and type of diabetes mellitus

were extracted from the subject’s case note and coded into the proforma. Where

applicable, other pieces of information were obtained directly from the patient.

Thereafter, the researcher personally administered all the three instruments to the

participants: Beck Depression Inventory (Appendix 2), Major Depressive Episode and

suicidality modules of Mini-International Neuropsychiatric Interview (Appendix 3) and

The World Health Organization Quality of Life (WHOQoL)-Bref (Appendix 4) one

after the other. Any participant who did not understand English language was

interviewed with Igbo versions of the study instruments by the researcher,

xlii

who is of Igbo extraction with a good command of the written and spoken language.

Problems experienced during the pilot study were noted and necessary

adjustments made which were then applied to the main study. The author observed

that self-administration of the instruments was not feasible because many of the

subjects were not literate and those who were literate had varied levels of

education. The author therefore administered the instruments to the subjects by

reading the questions and options out to them. The subjects chose the options most

applicable to them after ensuring that they understood the questions. Responses by

the participants were recorded and this eliminated the likelihood of not responding

to some questions.

All the instruments were therefore interviewer administered. It has been

shown that these instruments can be validly administered by the interviewer

especially in our environment with different levels of literacy (Issa, Baiyewu 2006,

Odili, Ugboka, Oparah 2010).

This procedure was followed until 270 consecutive attendees who meet the

inclusion criteria at the endocrinology outpatient clinic were recruited for the

subjects with diabetes mellitus. The same number of subjects with essential

hypertension was interviewed at the cardiology clinic. It took an average of 45

minutes to administer all the questionnaires for the study to a subject. Efforts were

made to match closely the subjects who had diabetes mellitus with those who had

essential hypertension in terms of age (± 5years) and sex.

4.10 Statistical analysis

Analysis was done with the Statistical Package for Social Sciences

xliii

(SPSS version 16). Frequency counts and chi-square (x2) test were used for

categorical variables while continuous variables were analyzed using the student t-

test. All statistical values were set at 5% level of significance (p < 0.05).

CHAPTER FIVE

RESULTS

xliv

5.1.1 Socio-demographic variables of the subjects with diabetes mellitus

and subjects with essential hypertension

Table 5.1.1 shows the socio-demographic variables of the subjects separated

(i.e. subjects with diabetes mellitus and subjects with essential hypertension). In

each group, 125 (46.3%) were females and 145 (53.7%) were males (X2 = 0.00, p

= 1.00) The mean age for the subjects with diabetes mellitus was 51.0 ± 10.1 years

and this did not significantly differ from 50.4 ± 9.4 years for the subjects with

essential hypertension (t = 0.73, p = 0.47). Amongst the subjects with diabetes

mellitus, 210 (77.8%) were married while for the subjects with essential

hypertension, 216 (80%) were married (X2 = 0.40, p = 0.53). Twenty four (8.9%) of

the subjects with diabetes mellitus had no formal education while among the group

with essential hypertension, forty seven (17.4%) had no formal education (X2 =

8.58, p = 0.06).

Table 5.1.1 Distribution of the subjects with diabetes mellitus and

essential hypertension according to gender, age, marital status, religion,

xlv

ethnicity and educational attainment.

Variables Diabetes mellitus Essential hypertension Statistics

Sex N (%) N (%)

Female 125 (46.3) 125 (46.3) X2 = 0.00

Male 145 (53.7) 145 (53.7) p = 1.00

Age (years)

20 – 29 12 (4.4) 9 (3.3)

30 – 39 15 (5.6) 27 (10.0)

40 – 49 69 (25.6) 75 (27.8)

50 – 59 102 (37.8) 99 (36.7)

60 – 64 72 (26.7) 60 (22.2) t = 0.73

Mean + SD 51.04 ± 10.07 50.43 ± 9.43 p = 0.47

Marital status

Married 210 (77.8) 216 (80.0) X2 = 0.40

Not married 60 (22.2) 54 (20.0) p = 0.53

Religion

Christianity 258 (95.6) 258 (95.6) X2 = 0.00

ATR* 12 (4.4) 12 (4.4) p = 1.00

Ethnic group

Igbo 264 (97.8) 267 (98.9) X2 = 1.52

Others 6 (2.2) 3 (1.1) p = 0.47

Education attainment

No formal education 24 (8.9) 47 (17.4) X2 = 8.58

Formal education 246 (91.1) 223 (82.6) p = 0.06

ATR* African Traditional Religion

xlvi

5.1.2 Distribution of the subjects with diabetes mellitus and essential

hypertension according to employment status, occupation and

duration of illness.

Table 5.1.2 shows the distribution of the two groups of subjects (diabetes

mellitus and essential hypertension) according to employment status, occupation

and duration of illness. The subjects with hypertension were statistically significantly

more likely to be employed, compared to those with diabetes mellitus (X2 = 9.4, p <

0.001). The subjects with diabetes mellitus had a significantly higher illness duration

(mean 7.0 ± 6.3 years), than those with essential hypertension (mean 5.5 ± 5.5

years), (t = 3.06, p < 0.001).

xlvii

Table 5.1.2 Distribution of the subjects with diabetes mellitus and

essential hypertension according to employment status, occupation and

duration of illness.

Diabetes mellitus Essential hypertension Statistics

Employment status N (%) N (%)

Employed 186 (68.9) 217 (80.4) X2 = 9.40

Not employed 84 (31.1) 53 (19.6) p < 0.001

Occupation

Professional/Senior officer/Manager 20 (7.4) 30 (11.1)

Skilled/Service/Associate professionals 48 (17.8) 45 (16.7)

Craft-related/Semi-skilled/clerks 18 (6.7) 18(6.7)

Farmers/ Elementary occupations 184 (68.1) 177 (65.6)

Years of illness

Below 5 years 138 (51.1) 192 (71.1)

5 years and above 132 (48.9) 78 (28.9)

Mean + SD 7.02 ± 6.27 5.47 ± 5.52 t = 3.06

Range 2 – 32 2 – 30 p < 0.001

xlviii

5.2 The rates of depression (current episode) among the subjects with

diabetes mellitus and essential hypertension

Table 5.2 shows the rates of depression (current episode) among the subjects

with diabetes mellitus and essential hypertension. On the Beck Depression

Inventory, the rate of depression among the subjects with diabetes mellitus was

30% and this did not significantly differ from the subjects with essential

hypertension who had 28.5% (X2 = 0.14, p = 0.71). This was also true of the

depression rate using the Mini-International Neuropsychiatric Interview (X2 = 0.08, p

= 0.77).

xlix

Table 5.2 The rates of depression (current episode) among the subjects

with diabetes mellitus and essential hypertension

Diabetes mellitus Essential hypertension

Instrument N (%) N (%)

BDI 81 (30.0) 77 (28.5)

M.I.N.I 75 (27.8) 72 (26.7)

l

5.3.1. Suicidal behaviour among the subjects with diabetes mellitus and

essential hypertension

Table 5.3.1 shows the distribution of the subjects with diabetes mellitus and

essential hypertension according to suicidal behaviour (ideation, plans and attempt).

Subjects with essential hypertension were more likely to exhibit suicidal behaviour

than the subjects with diabetes mellitus but this was not statistically significant (X2 =

0.45, p = 0.50).

li

Table 5.3.1 Suicidal behaviour among the subjects with diabetes mellitus

and essential hypertension


Suicidal behaviour N (%) N (%)

Yes 17 (6.3) 21 (7.8)

No 253 (93.7) 249 (92.2)

lii

5.3.2 Suicidal risk among the subjects with diabetes mellitus and

essential hypertension.

Table 5.3.2 shows the suicidal risk among the subjects with diabetes

mellitus and essential hypertension. Subjects with diabetes mellitus were

more likely to score high on the suicidality module of M.I.N.I. compared to

the subjects with essential hypertension (X2 = 7.5, p = 0.06).

liii

Table 5.3.2 Suicidal risk among the subjects with diabetes mellitus and



Suicidal risk N (%) N (%)

Low - moderate 14 (5.2) 21 (7.8)

High 3 (1.1) 0 (0)

liv

5.4 Quality of life scores among the subjects with diabetes

mellitus and essential hypertension.

Table 5.4 shows the quality of life (QoL) transformed scores among the subjects

with diabetes mellitus and essential hypertension. Subjects with essential

hypertension were more likely to have higher scores in domain 1 (t = -6.13, p <

0.001), domain 2 (t = -2.18, p = 0.03) and domain 3 (t = -4.58, p < 0.001)

compared to the subjects with diabetes mellitus.

lv

Table 5.4. Quality of life transformed scores among the subjects with



Domains Mean ± SD Mean ± SD t p

Domain 1 52.54 ± 12.40 59.41 ± 13.61 -6.13 0.00

Domain 2 61.30 ± 9.03 62.96 ± 8.61 -2.18 0.03

Domain 3 56.12 ± 14.92 62.20 ± 15.91 -4.58 0.00

Domain 4 55.80 ± 9.17 56.28 ± 11.37 -.53 0.59

lvi

5.5 Association between depression and socio-demographic

variables

5.5.1 Association between depression and marital status among the

subjects with diabetes mellitus and essential hypertension.

Table 5.5.1 shows the distribution of depression according to marital status among

the subjects with diabetes mellitus and essential hypertension. Two hundred and ten

subjects with diabetes mellitus were married and 48 (22.9%) of them had

depression. The non-married subjects were more likely to have depression than

those who were married (X2 = 11.41, p < 0.001).

Similarly, Fifty four subjects with essential hypertension were not married

(single, widowed, divorced or separated) and 24 (44.4%) of them had depression.

Significantly more non-married subjects were likely to have depression compared to

those who were married among the subjects with essential hypertension (X2 =

10.91, p < 0.001).

lvii

Table 5.5.1 Distribution of depression according to marital status among the


Marital status N Yes Percent (%)

DM

Married 210 48 22.9

Not married 60 27 45

HPTN

Married 216 48 22.2

Not married 54 24 44.4

*DM Diabetes mellitus

* HPTN Essential hypertension

lviii

5.5.2 Association between depression and educational status among

the subjects with diabetes mellitus and essential hypertension.

Table 5.5.2 shows the distribution of depression according to educational status

among the subjects with diabetes mellitus and essential hypertension. Twenty four

patients with diabetes mellitus had no formal education and 13 (54.2%) of them had

depression. The subjects with no formal education were more likely to have

depression compared to those with formal education (X2 = 14.51, p < 0.001).

Depression was higher among the subjects with essential hypertension

without formal education compared to those with formal education (X2 = 17.32, p <

0.001).

lix

Table 5.5.2 Distribution of depression according to educational status among


Educational status N Yes Percent (%)

DM

No formal education 24 13 54.2

Formal education 246 69 28

HPTN

No formal education 47 24 51.1

Formal education 223 48 21.5

lx

5.5.3 Association between depression and employment status among


Table 5.5.3 shows the distribution of depression according to employment

status among the subjects with diabetes mellitus and essential hypertension. One

hundred and eighty six of the subjects with diabetes mellitus were employed and 45

(24.2%) had depression. Eighty four patients were not employed, 30 (35.7%) of

whom had depression.

Two hundred and seventeen of the subjects with essential hypertension were

employed and 51 (23.5%) of them had depression. Depression was more likely in

patients with no jobs (X2 = 5.67, p = 0.02).

lxi

Table 5.5.3 Distribution of depression according to employment status

among the subjects with diabetes mellitus and essential hypetension.

Employment status N Yes Percent (%)

DM

Employed 186 45 24.2

Unemployed 84 30 35.7

HPTN

Employed 217 51 23.5

Not employed 53 21 39.6

lxii

5.6 Association between suicidal behaviour (suicidal ideation, plan and

attempt) and socio-demographic variables.

5.6.1 Association between suicidal behaviour and gender among the


Table 5.6.1 shows the distribution of suicidal behaviour according to gender

among the subjects with diabetes mellitus and essential hypertension. Eight females

(6.4%) had suicidal behaviour and this did not significantly differ from the 9 (6.2%)

males with diabetes mellitus who had suicidal behaviour (X2 = 0.00, p = 0.95).

Female subjects with essential hypertension were more likely to have suicidal

behaviour (X2 = 5.79, p = 0.02).

lxiii

Table 5.6.1 Association between suicidal behaviour and gender among the


Gender N Yes Percent (%)

DM

Female 125 8 6.4

Male 145 9 6.2

HPTN

Female 125 15 12

Male 145 6 4.1

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5.6.2 Association between suicidal behaviour and marital status among


Table 5.6.2 shows the distribution of suicidal behaviour according to marital

status among the subjects with diabetes mellitus and essential hypertension. Five

(8.3%) of the subjects with diabetes mellitus who were single (never married,

widowed, divorced or separated), exhibited suicidal ideation, plans or attempts

compared to 12 (5.7%) married subjects who had suicidal behaviour.

However, subjects with essential hypertension who were single (never

married, widowed, separated or divorced) were more likely to have suicidal ideation,

plans or attempt (X2 = 19.63, p < 0.001).

lxv

Table 5.6.2 Distribution of suicidal behaviour according to marital status

among the subjects with diabetes mellitus.

Marital status N Yes Percent (%)

DM

Married 210 12 5.7

Not married 60 5 8.3

HPTN

Married 216 9 4.2

Not Married 54 12 22.2

lxvi

5.6.3 Association between suicidal behaviour and educational

status among the subjects with diabetes mellitus and


Table 5.6.3 shows the distribution of suicidal behaviour according to educational

status among the subjects with diabetes mellitus and essential hypertension.

Subjects with diabetes mellitus having no formal education were more likely to

exhibit suicidal ideation, plans and attempts. Twenty four subjects with diabetes

mellitus had no formal education and 5 (20.8%) of them had suicidal behaviour

compared to 12 (4.9%) who had formal education and also had suicidal behaviour

(X2 = 9.44, p < 0.001).

Subjects with essential hypertension who had no formal education were more

likely to exhibit suicidal behaviour compared to the subjects who had formal

education. Nine (19.1%) of the subjects who had no formal education had suicidal

behaviour while 12 (5.4%) of the subjects who had formal education (primary,

secondary or tertiary) had suicidal behaviour (X2 = 10.26, p < 0.001).

lxvii

Table 5.6.3 Distribution of suicidal behaviour according to educational

status among the subjects with diabetes mellitus and essential

hypertension.

Educational status N Yes Percent (%)

No education 24 5 20.8


HPTN

No education 47 9 19.1


lxviii

5.7 Association between quality of life (QoL) scores and socio-

demographic variables.

5.7.1 Association between QoL scores and gender among the subjects

with diabetes mellitus and essential hypertension.

Table 5.7.1 shows the distribution of QoL scores with gender among the

subjects with diabetes mellitus and essential hypertension. Male subjects with

diabetes mellitus scored significantly higher in domain 1 (t = -3.72, p < 0.001) and

domain 2 (t = 2.57, p = 0.01).

Male subjects with essential hypertension scored higher than the female

subjects in all the four domains. Males had statistically significant higher scores than

females in domain 2 (t = 2.09, p = 0.04) and domain 3 (t = -2.54, p = 0.01).

lxix

Table 5.7.1 Distribution of QoL scores and gender among the subjects with


Gender Domain 1 Domain 2 Domain 3 Domain 4

DM

Female 53.62 ± 9.09 60.00 ± 9.55 57.17 ± 14.52 52.78 ± 11.70

Male 57.68 ± 8.85 62.81 ± 8.17 55.22 ± 15.26 52.34 ± 13.01

HPTN

Female 55.09 ± 12.07 61.94 ± 9.44 59.58 ± 17.13 59.08 ± 11.77

Male 57.30 ± 10.67 64.13 ± 7.42 64.46 ± 14.46 59.70 ± 13.52

lxx

5.7.2 Association between QoL scores and marital status among the

subjects with diabetes mellitus and essential hypertension

Table 5.7.2 shows the distribution of QoL scores and marital status among

the subjects with diabetes mellitus and essential hypertension. Married subjects with

diabetes mellitus had higher QoL scores in domain 1, domain 3 and domain 4 but

this difference was statistically significant in only domain 3 (t = 2.69, p = 0.01).

Subjects with essential hypertension who were married were more likely to

have higher QoL scores. The scores differed significantly in domain 1 (t = 2.19, p =

0.03) and domain 3 (t = 2.07, p = 0.04).

lxxi

Table 5.7.2 Distribution of QoL scores and marital status among and the


Marital status Domain 1 Domain 2 Domain 3 Domain 4

DM

Married 56.09 ± 9.43 61.41 ± 7.87 57.41 ± 14.41 52.89 ± 12.73

Unmarried 54.80 ± 8.20 61.60 ± 12.33 51.60 ± 15.90 51.35 ± 11.17

HPTN

Married 57.01 ± 11.50 63.25 ± 8.73 63.13 ± 16.25 58.75 ± 13.29

Unmarried 53.24 ± 10.48 61.95 ± 8.23 58.15 ± 13.83 61.74 ± 14.69

lxxii

5.7.3 Association between QoL scores and educational status among the


Table 5.7.3 shows the distribution of QoL scores and educational status

among the subjects with diabetes mellitus and essential hypertension. The subjects

with diabetes mellitus who had formal education had higher QoL scores in all the

four domains but the scores differed significantly in only domain 4 (t = 3.01, p <

0.001).

The subjects with essential hypertension who had formal education had

higher QoL scores in the four domains but the scores differed significantly in domain

1 (t = 3.03, p < 0.001) domain 3 (t = 2.91, p < 0.001) and domain 4 (t = 4.28, p <

0.001).

lxxiii

Table 5.7.3 Distribution of QoL scores and educational status among the


Education Domain 1 Domain 2 Domain 3 Domain 4

DM

Educated 55.84 ± 8.92 61.52 ± 8.90 56.72 ± 15.40 53.35 ± 11.96

Not Educated 55.16 ± 10.64 59.86 ± 9.92 52.51 ± 11.18 46.86 ± 13.39

HPTN

Education 57.24 ± 11.23 63.14 ± 8.85 63.49 ± 15.79 61.01 ± 13.06

Not Education 51.83 ± 11.06 62.12 ± 7.44 56.23 ± 15.23 52.01 ± 13.82

lxxiv

5.7.4 Association between QoL scores and employment status among the


Table 5.7.4 shows the distribution of QoL scores and employment status

among the subjects with diabetes mellitus and essential hypertension. Subjects with

diabetes mellitus who were employed had higher QoL scores in domain 1, domain 2,

domain 3 and differed significantly in domain 1 (t = 3.07, p < 0.001). The subjects

who were not employment scored higher in domain 4 but the difference was not

statistically significant (t= -1.27, p = 0.21).

The QoL scores by the subjects with essential hypertension who were

employed did not significantly differ in any of the four domains compared to the

scores by those who had no jobs.

lxxv

Table 5.7.4 Distribution of QoL scores and employment status among the


Employment Domain 1 Domain 2 Domain 3 Domain 4

DM

Employed 56.94 ± 8.30 61.66 ± 8.10 56.66 ± 13.99 51.90 ± 10.67

Not employed 53.29 ± 10.48 60.50 ± 10.83 54.93 ± 16.82 53.96 ± 15.55

HPTN

Employed 56.24 ± 11.43 63.33 ± 8.55 62.83 ± 16.07 59.10 ± 13.26

Not employed 56.44 ± 11.22 61.46 ± 8.80 59.69 ± 15.13 60.65 ± 15.02

lxxvi

CHAPTER SIX

DISCUSSION

6.1 Socio-demographic characteristics of the subjects.

The mean age of the subjects with diabetes mellitus was 51.04 ± 10.07 years

and was similar to 54.65 ± 9.5 years reported in a study that comparatively assessed

depression, anxiety and quality of life among patients with diabetes mellitus (Mosaku

et al, 2008).

It is not surprising that majority of the subjects were of Igbo ethnic

extraction, being the dominant ethnic group in the study site. In the diabetes mellitus

group, 88.9% were married, 95.6% were Christians, and 68.9% were employed. This

was in agreement with results from previous work (James et al, 2010).

A significant proportion of the subjects with diabetes mellitus were not

employed (31.1%) compared to the subjects with essential hypertension (19.6%).

One reason may perhaps be that diabetes mellitus is a chronic and debilitating

medical condition that constitutes a source of stress to the subjects and also affects

their quality of life (Aldwin & Revenson, 1987).

The years of illness ranged from 2 to 32 years for the subjects with diabetes

mellitus and 2 to 30 years for the subjects with essential hypertension. The mean

duration of illness for the subjects with diabetes was 7.0 ± 6.3 years while for the

lxxvii

subjects with essential hypertension, it was 5.5 ± 5.5 years ( t = 3.06, p < 0.001).

6.2 Rates of depression (current episode)

On the Beck Depression Inventory (BDI), the rate of depression among the

subjects with diabetes mellitus was 30% and did not significantly differ from the

subjects with essential hypertension who had a rate of 28.5% (p = 0.71). This was

also true of the depression rate using Mini-International Neuropsychiatric Interview

(M.I.N.I.) where the subjects with diabetes mellitus had 27.8% and the subjects

with essential hypertension had 26.7% (p = 0.77).

The finding was in agreement with an earlier hospital based study conducted at a

teaching hospital in Benin, Nigeria among patients with diabetes mellitus. The study

employed similar methodology with the present study and reported a 30%

prevalence of clinical depression among the subjects with diabetes mellitus using the

depression module of the Schedule for the Clinical Assessment in Neuropsychiatry

(James et al, 2010).

Furthermore, the prevalence of depressive symptoms using a cut-off score of

10 and above on the BDI was 30% among the subjects with diabetes and this was

close to the 25% reported in another study in Western Nigeria that employed the

use of a rating scale among a cohort of Nigerians with diabetes mellitus (Akinlade et

al, 1996), but much higher than the 20% reported in a different study which also

used a rating scale among the subjects with diabetes mellitus (Mosaku et al, 2008).

The finding of prevalence of 26.7% of depression among the subjects with

essential hypertension was similar to a previously reported 20% in a study that

assessed depressive symptoms and association with unhealthy lifestyles in

lxxviii

subjects with hypertension (Bonnet et, al 2005).

6.3 Suicidal behaviour (ideation, plan and attempt)

The findings from this study showed that proportionally, subjects with

essential hypertension were more likely to exhibit suicidal ideation, plan and attempt

(7.8%), compared to the subjects with diabetes mellitus (6.3%). However, suicidal

risk was higher in patients with diabetes mellitus. Three (1.1%) patients with

diabetes mellitus scored high on the suicidality module of M.I.N.I.

These findings were in agreement with a previous Italian study of quality of

life and suicidal risk in subjects with diabetes mellitus (Pompili et, al 2009). The

authors reported that subjects with diabetes mellitus showed greater hopelessness

and suicidal ideation (7.4%) than internal medicine outpatients (6.5%).

The present finding is however in contrast to that reported in a US study (Druss &

Pincus, 2000). The authors examined the association between the presence of a

general medical illness and suicidality in a representative sample of US young adults

and reported that 25.2% of those with a general medical illness had suicidal ideation

and 8.9% had made suicide attempts at a point in their lives. The reason for the

high figures may be because the US study assessed lifetime prevalence of suicidal

behaviour while the present study assessed only suicidal behaviour over the last one

month prior to the interview.

Moreover, majority of the subjects were predominantly Christians (95.6% for

subjects with diabetes mellitus and 95.6% for subjects with essential hypertension).

Suicide is intolerable among Christians and considered a sin of disobedience against

God (The Holy Bible, 2004).

lxxix

6.4 Quality of life

Subjects with diabetes mellitus had statistically lower quality of life scores in

three of the four domains (physical health, psychological and social relationships)

compared with patients who had essential hypertension. This lower mean scores

may perhaps be attributed to the burden that diabetes mellitus places on the

subjects as a result of its demanding nature in management and potential

debilitating complications. Similar scoring pattern was reported in a study that

assessed the impact of diabetes mellitus on the health-related quality of life of

Nigerians. The study compared 112 subjects with diabetes mellitus and 81 healthy

controls (Odili et, al 2010).

Domain 4 (environmental domain) assesses physical safety, financial well-

being, condition of physical environment and living place. There was no significant

difference in the mean scores by subjects with diabetes mellitus and those with

essential hypertension. It could be reasoned that the environment affected the

quality of life of those with diabetes mellitus and essential hypertension equally.

Inclusion criteria for the subjects in this study had been those who were medically

stable for at least 3 months prior to the study. Previous study had reported a similar

finding that when subjects with diabetes mellitus are compared with apparently

healthy control group, the health-related quality of life of the subjects with diabetes

mellitus was lower in all the domains except the environmental domain (Odili et al,

2010).

6.5 Correlates of depression.

lxxx

This study found a significant association between not being married and

having no formal education and having diagnosis of depression among patients with

diabetes mellitus. Depression was more likely in patients with essential hypertension

if the subjects were not married, not educated and not employed. Marriage offers

caregiving and social supports to subjects with diabetes mellitus or essential

hypertension. It has been shown that the family is a major source of support for

psychological adjustments of patients to disease (Bloom &Spiegel, 1984). Such may

not be available to subjects who were single, divorced or widowed.

Having no formal education was associated with depression in this study. Lack

of education is a strong impediment to understanding the dynamics of chronic

medical conditions and complexities involved in good glycaemic control for the

subjects with diabetes mellitus. This finding was in agreement with a previous study

that reported less number of years of formal education as significantly associated

with depression among subjects with diabetes (Mier et al, 2008).

By extrapolation, subjects with less education or no formal education may

earn less as they are likely to get poorly paid jobs. Subjects with low earning power

face the burden of maintaining life style changes that could sustain cost of

medication adherence and dietary restrictions necessary for good glycaemic control

in diabetes mellitus. The relationship between earning power and depression in

diabetes mellitus has been reported in a similar cross-sectional study of 200 subjects

with diabetes mellitus at the University of Benin Teaching Hospital, Nigeria. The

authors used the depression module of Schedule for the Clinical Assessment in

Neuropsychiatry (SCAN) to diagnose depression and Beck Depression Inventory to

assess depression and its severity. (James et al, 2010).

lxxxi

Although female subjects and those not employed with diabetes mellitus were

more likely to have depression, this study found no statistically significant

associations. This agreed with another study which reported no significant

associations between female gender and depression among subjects with diabetes

(James et al, 2010). However, this contrasts with a report of another study that

found significant associations between female and depression among the subjects

with diabetes mellitus. (Mier et, al 2008).

6.6 Correlates of suicidal behaviour.

Suicidal behaviour (ideation, plans and attempts) was likely in subjects with

diabetes mellitus if they had no formal education while in patients with essential

hypertension suicidal behaviour was likely in females, those not married and those

not educated. Diabetes mellitus may have profound effects on physical health,

emotional health and quality of life (Pompili et al, 2009). Having no formal education

may predispose to low self-esteem and lead to feelings of hopelessness as the

patient battles with understanding the dynamics of the disease. Presence of the

disease in a subject with no education is therefore a double burden.

6.7 Correlates of quality of life scores.

Lower quality of life scores were likely in females, those not married,

those not educated and unemployed subjects among those with diabetes

mellitus while lower scores were likely in females, those not married and

those non-educated subjects in those with essential hypertension. Lower

income, lower education and low- rated employment had been reported

lxxxii

to adversely affect the quality of life of subjects with diabetes mellitus in a

cross-sectional study of 251 patients with diabetes mellitus attending the

University of Ilorin Teaching Hospital, Nigeria. (Issa & Baiyewu, 2006). Like

the present study, the authors administered a socio-demographic

questionnaire and World Health Organization quality of life instrument, short

version to the subjects. The findings of the present study concur with this

6.8 Relevance of the study to the practice of psychiatry

Diabetes mellitus and essential hypertension are two chronic medical

conditions that place a lot of burden on patients, health care resources utilization,

work productivity and quality of life. The presence of co-morbid depressive

symptoms, suicidal behaviour and impaired quality of life may compound the

problems, leading to a poorer prognosis in both diabetes mellitus and hypertension.

The identification of the presence of depressive symptoms, suicidal behaviour

and changes in functioning may enhance health workers’ effectiveness in helping

patients maintain adherent behaviour with drug and non-drug interventions in

diabetes mellitus and essential hypertension. This will ultimately become beneficial

to patients with diabetes mellitus and essential hypertension who may have co-

morbid depressive symptoms, suicidal behaviour or impaired quality of life.

6.9 Limitations of the study

1. This study was a cross-sectional based non-population representative

study. Its results cannot be generalized to the entire population.

lxxxiii

2. No causal links or directions can be inferred in a cross-sectional survey of

this nature.

Despite these caveats, the findings from this study should serve as a

baseline data for comparison in future studies especially in South-eastern

Nigeria.

6.10 Recommendations

In view of the findings from this study, the following recommendations will be useful

to caregivers, policy makers and patients.

1. Future studies should address the deficiencies of the present investigation.

More specifically, studies that will establish the cause of depression,

suicidal behaviour and impaired quality of life in subjects with diabetes

mellitus and essential hypertension should be the area of focus.

2. It is possible that collaboration between psychiatrists and internists who

manage diabetes mellitus and essential hypertension may be helpful. This

could be explored.

3. Intervention programmes to raise the quality of life and reduce depression

in diabetes mellitus and essential hypertension may be necessary.

6.11 Conclusion

The findings of this study have shown that depression, suicidal behaviour and

impaired quality of life may co-occur with diabetes mellitus and essential

hypertension. The negative impact of these co-occurrences on achieving good

glycaemic and blood pressure control calls for screening for these conditions when

indicated. This may enhance early detection and treatment.

lxxxiv

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APPENDIX 1

Socio-Demographic Questionnaire

This is to obtain some information about you Please kindly answer the

questions as much as you can They are for research purposes and measures have

been put in place to ensure confidentiality of the data. Thanks for your time.

1. Age in years__________________

2. Gender: (a) Male [ ] (b) Female [ ]

3. Religious Affiliation: (a) Christianity [ ] (b) Islam [ ]

(c) African Traditional Religion [ ] (d) Others (Specify) [ ]

4. Marital Status: (a) Married [ ] (b) Single [ ]

(c) Separated [ ] (d) Divorced [ ] (e) Widowed [ ]

5. Ethnic Group: (a) Igbo [ ] (b) Yoruba [ ]

(c) Hausa [ ] (d) Others (Specify) [ ]

6. Level of education: (a) No formal education [ ]

(b) Primary [ ] (c) Secondary [ ] (d) Tertiary [ ]

7. Occupation

8. Employment status:

(a) Student [ ] (b) Not employed [ ] (c) Employed [ ]

9. Age of onset of diabetes/hypertension.

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10. Duration of illness……………….

11. Type of diabetes: (a) Type1[ ] (b) Type 2 [ ]

12. Present drug regimen.

xciii

APPENDIX 2

Beck Depression Inventory

Name: ____________________ Marital status: ________ Age: _____________ Sex:

__________ Occupation: _______________________

Education:_____________________________

Instructions: This questionnaire consists of 21 groups of statements. Please read

reach each group of statements carefully, and then pick out the one statement in

each group that best describes the way you have been feeling during the past two

weeks, including today. Circle the number beside the statement you have picked. If

several statements in the group seem to apply equally well, circle the highest

number for that group. Be sure that you do not choose more than one statement for

any group, including Item 16 (Changes in Sleeping Pattern) or Item 18 (Changes in

Appetite).

1. Sadness

0. I do not feel sad

1. I feel sad much of the time

2. I am sad all the time

3. I am so sad or unhappy that I can’t stand it

2. Pessimism

0. I am not discouraged about my future

1. I feel more discouraged about my future than I used to be

2. I do not expect things to work out for me

3. I feel my future is hopeless and will only get worse

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3. Past Failure

0. I do not feel like a failure

1. I have failed more than I should have

2. as I look back, I see a lot of failures

3. I feel I am a total failure as a person

4. Loss of Pleasure

0. I get as much pleasure as I ever did from the things I enjoy

1. I don’t enjoy things as much as I used to

2. I get very little pleasure from the things I used to enjoy

3. I can’t get any pleasure from the things I used to enjoy

5. Guilty Feelings

0. I don’t feel particularly guilty

1. I feel guilty over many things I have done or should have done

2. I feel quite guilty most of the time

3. I feel guilty all of the time

6. Punishment Feelings

0. I don’t feel I am being punished

1. I feel I may be punished

2. I expect to be punished

3. I feel I am being punished

7. Self-Dislike

0. I feel the same about myself as ever

1. I have lost confidence in myself

2. I am disappointed in myself

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3. I dislike myself

8. Self-Criticalness

0. I don’t criticize or blame myself more than usual

1. I am more critical of myself than I used to be

2. I criticize myself for all of my faults

3. I blame myself for everything bad that happens

9. Suicidal Thoughts or Wishes

0. I don’t have any thoughts of killing myself

1. I have thoughts of killing myself, but I would not carry them out

2. I would like to kill myself

3. I would kill myself if I had the chance

10. Crying

0. I don’t cry anymore than I used to

1. I cry more than I used to

2. I cry over every little thing

3. I feel like crying, but I cant

11. Agitation

0. I am no more restless or wound up than usual

1. I feel more restless or wound up than usual

2. I am so restless or agitated that it’s hard to stay still

3. I am so restless or agitated that I have to keep moving or doing

something

12. Loss of Interest

0. I have not lost interest in other people or activities

xcvi

1. I am less interested in other people or things than before

2. I have lost most of my interest in other people or things

3. it’s hard to get interested in anything

13. Indecisiveness

0. I make decisions about as well as ever

1. I find it more difficult to make decisions than usual

2. I have much greater difficulty in making decisions than I used to

3. I have trouble making any decisions

14. Worthlessness

0. I do not feel I am worthless

1. I don’t consider myself as worthwhile and useful as I used to

2. I feel more worthless as compared to other people

3. I feel utterly worthless

15. Loss of Energy

0. I have as much energy as ever

1. I have less energy than I used to have

2. I don’t have enough energy to do very much

3. I don’t have enough energy to do anything

16. Changes in Sleeping Pattern

0. I have not experienced any change in my sleeping pattern

1a. I sleep somewhat more than usual

1b. I sleep somewhat less than usual

2a. I sleep a lot more than usual

2b. I sleep a lot more than usual

xcvii

3a. I sleep most of the day

3b. I wake up 1-2 hours early and can’t get back to sleep

17. Irritability

0. I am no more irritable than usual

1. I am more irritable than usual

2. I am much more irritable than usual

3. I am irritable all the time

18. Changes in Appetite

0. I have not experienced any change in my appetite

1a. My appetite is somewhat less than usual

1b. My appetite is somewhat greater than usual

2a. My appetite is much less than before

2b. My appetite is much greater than usual

3a. I have no appetite at all

3b. I crave food all the time

19. Concentration Difficulty

0. I can concentrate as well as ever

1. I can’t concentrate as well as usual

2. it’s hard to keep my mind on anything for very long

3. I find I can’t concentrate on anything

20. Tiredness or Fatigue

0. I am no more tired or fatigued than usual

1. I get more tired or fatigued more easily than usual

xcviii

2. I am too tired or fatigued to do a lot of the things I used to do

3. I am too tired or fatigued to do most of the things I used to do

21. Loss of Interest in Sex

0. I have not noticed any recent change in my interest in sex

1. I am less interested in sex than I used to be

2. I am much less interested in sex now

3. I have lost interest in sex completely

Becks Depression Inventory -----Igbo version

N’me ihe ndi a e deputara, horo nke kacha wee metuta gi n’ime izu uka abuo

gara aga.

1. 0 Anaghi m enwe obi mwute.

1. Anam enwe obi mwute kwa mgbe kwa mgbe.

2. Anam enwe obi mwute oge obula.

3. Anam enwe obi mwute nke na mgaghi ebuli ya.

2. 0. Enwerem olileanya maka odinihu.

1. Obi esighi m ike maka odinihu otum si enwebu.

2. Echeghim na ihe ga agaram nke oma.

3. O di m ka olileanya adighi tinyere na ihe ga aka njo no odinihu.

3. 0. Echeghi m na anaghim eme nke oma.

1. Adagom karia kam kwesiri ida.

2. O buru na m leghachi anya na azu na ndum, ihe m na ahu nani bu

emeghi nke oma.

3. Dika mmadu, ana m ahu onwe m dika onye n’ emeghi nke oma

xcix

ma ncha na ndu.

4. 0. Ana m enwe afo ojuju n’ ihe dika m si enwe na mbu.

1. Ihe anaghi atokwa m uto dika o si atom na mbu.

2. Anam enweta obere afo ojuju n’ ihe ndi natabum uto

3. Anaghim enwetazi afo ojuju obula n’ihe ndi natobum uto.

5. 0. Obi m anaghi ama m ikpe.

1. Obi m na-ama m ikpe banyere ihe ufodu mmere ma obu mkwesiri ime.

2. Obi m na- ama m ikpe otutu oge.

3. Obi m na-ama m ikpe oge obula.

6. 0. Anaghim eche na a na-ata m ahuhu.

1. O di m ka e nwere ike ita m ahuhu.

2. Ana m atu anya na a ga-ata m ahuhu.

3. O di m ka a na-ata m ahuhu.

7. 0. E nwerem ntukwasi obi n’ onwem

1. E nweghim ntukwasi obi n’ onwem.

2. Onwe m adighizi m mma.

3. A kporom onwem asi.

8. 0. Adighim akwa onwem emu ma obu ita onwem uta karia kam si emebu.

1. Anam akwazi onwem emu karia kam si emebu.

2. Anam akwa onwem emu mgbe obula maka ihe ndi m n’emetachaghi.

3. Ana m ata onwe m uta maka ihe ojoo obula mere.

9. 0. A naghi m eche uche obula maka igbu onwe m.

1. Uche igbu onwem dim n’obi mana enweghi m ike ime nke a.

2 Oga amasim igbu onwe m.

c

3. M nwee ohere nga egbu onwe m.

10. 0. Anaghi m ebe akwa karia ka m si ebe na mbu.

1. Ana m ebezi akwa ugbua karia ka m si ebe na mbu.

2. Ana m ebe akwa nihe ntakiri obula.

3. Ona amasim ibe akwa ma enweghim ike.

11. 0. O dighi m ka m na enwe mgbakasi ahu karia ka m si enwe bu.

1. Ana m enwetu ngbakasi ahu karia ka m si enwebu.

2. Ana m enwe mgbakasi ahu nke nam aghaghi I nonwu otu ebe.

3. Ana m enwe mgbakasi ahu ruo nam ga nagaghari.

12. 0. Enwere m mmasi n’ebe ndi ozo no.

1. Mmasi m na-enwe n’ebe ndi mmadu no gbadatara nwaobere.

2. Mmasi m na-enwezi n’ebe ndi mmadu no pere nnukwu mpe

3. Enweghizim mmasi obula gbasara ihe obula.

13. 0. Ana m enwe mkpebi nke oma dika m si enwebu na mbu.

1. Ona esirim ike inwe mkpebi karia ka m si enwe na mbu.

2. Ana m enwezi nnukwu nsogbu inwe mkpebi karia ka m si enwe na mbu

3. Anaghi m enwezi mkpebi obula ma ncha.

14. 0. Anaghi ahu onwe m dika onye nabaghi uru.

1. Odim ka mabazi uru ruo otu mdi na mbu.

2. Odim ka uru mbara gbadara nnuku ma atunyere ndi ozi.

3. Odim ka enwezi uru m bara ma oli.

15. 0. E nwere m ike igaghari dika m si emebu na mbu

1. Ike m gbada karia ka odi na mbu.

2. Enwezim ike ime ihe nke ukwu.

ci

3. Ike adighim iru oru obula ma ncha.

16. 0. E nwere m ike irahu ura nke oma dika m si arahu na mbu.

1. Anaghi m arahu ura nke oma dika m si arahu na mbu.

2. Anaghi m arahu ura ebe odikarisiri nta karia ka m si arahu na mbu

3. Ana meteta ura n’oge otutu awa karia ka m si eteta na mbu ma

agaghim arahu ozo.

17. 0. Anaghim ewe iwe karia ka m si ewebu.

1. Anam ewezi iwe ugbua karia ka m si ewebu.

2. Iwe na ewekarizi m ugbu karia ka m si ewebu.

3. Iwe na ewezi m oge obula.

18. 0. O nweghi mgbanwe na ka m si eri bu nri.

1. Ka m si eri ihe adighizi ka o si adibu na mbu.

2. Ka m si eri ihe joro nnukwu njo ugbua.

3. Aguu anaghizi agu m ma ncha.

19. 0. Anam esogide ihe dika otu m si emebu.

1. Anaghim esogide ihe dika otu m si emebu. .

2. O narazim ahu isogide ihe ogologo oge.

3. Enwezim ike isogide ihe obula.

20. 0. Ike adighi agwum karia otu odi na mbu.

1. Ike n’agwuzim karia otu odi na mbu.

2. Ike n’agwuzim ugbua ime ihe m na emebu na mbu.

3. Ike n’agwuzim ugbua ime otutu ihe m na emebu na mbu.

21. 0. Onwebeghi mgbanwe m choputara nso nso a maka mmasi m n’ebe mmeko

nwoke na nwanyi no.

cii

1. Mmasi m na-enwe n’ebe mmeko nwoke na nwanyi no adighizikwa ka o

si adi na mbu.

2. Mmasi m nenwe n’ebe mmeko nwoke na nwanyi o pere nnukwu mpe.

3. Enweghizi m mmasi obula n’ebe mmeko nwoke na nwanyi no.

APPENDIX 3a

Mini-International Neuropsychiatric Interview (M.I.N.I.)

Major Depressive Episode

A1 Have you been consistently depressed or down, most of the day, nearly every

day, for the past two weeks? NO YES

A2 In the past two weeks, have you been much less interested in most things or

much less able to enjoy the things you used to enjoy most of the time?

NO YES

A3 Over the past two weeks, when you felt depressed or

uninterested:

a Was your appetite decreased or increased nearly every day? Did your weight

decrease or increase without trying intentionally (i.e. by +_5% of body weight

or +-3.5kg for a 70kg person in a month)?

NO YES

b Did you have trouble sleeping nearly every night (difficulty falling asleep,

waking up in the middle of the night, early morning or sleeping

excessively)? NO YES

c Did you talk or move more slowly than normal or were you fidgety, restless

ciii

or having trouble sitting still almost every day? NO YES

d Did you feel tired or without energy almost every day? NO YES

e Did you feel worthless or guilty almost every day? NO YES

f Did you have difficulty concentrating or making decisions almost every day?

NO YES

g Did you repeatedly consider hurting yourself, feel suicidal or wish that you

were dead? NO YES

A4 a During your lifetime, did you have other episodes of two weeks or more

when you felt depressed or uninterested in most things, and had most of the

problems we just talked about? NO YES

b In between 2 episodes of depression, did you ever have an interval of at

least 2 months, without any depression and any loss of interest?

NO YES

M.I.N.I Major Depressive Episode-----Igbo version

A1 N’ ime izuuka abuo gara aga I na-enwe obi idamba otutu oge?

Ee Mba

A2 N’ ime izuuka abuo gara aga o na emetuta gi nke na I naghi enwe mmasi

n’otutu ihe I na-nwebu mmasi na ha maobu na ihe na-atobu gi uto abughizi

ihe I na-enwe mmasi na ha? Ee Mba

A3 N’ime izuka abuo gara aga mgbe I nwere obi idamba:

a). Ka I si eri nri o gbagoro ka ogbadara ?. I chere na aru gi ogbagoro maobu

gbadaa n’esiteghi n’igbambo nke gi n’ ihe dika pasenti ise?

Ee Mba

civ

b). I ne-enwe nsogbu irahu ura maobu ibili n’etiti, abali maobu n’ isi ututu

maobu irabiga ura oke ? Ee Mba

c). Ka I si ekwu okwu maobu na agaghari na mbu o gbanwere nke na I na-emezi

ihe ndi a nwayo nwayo karia ka odi na mbu,I na enwe nsugbo I kwu maobu

ino otu ebe? Ee Mba

d). Ike o na-agwukarizi gi ubochi obula? Ee Mba

e). I na uhuzi onwe gi dika onye n’enweghi isi maobu onye na abaghi uru?

Ee Mba

f). I na enwe nsogbu itinye uche gi n’ihe maobu inwe mkpebi nke gi ubochi

obula? Ee Mba

g). O na-adi gi otutu ugboro ka I meruo onwe gi ahu, gbou onwe gi maobu

buru onye nwuru anwu? Ee Mba

A4 (a). Nime ndu gi nile onwela mgbe I nwere onodu mmuo idamba maobu hapu

inwe mmasi n’otutu ihe ihe dika izu uka abuo maobu karia ma nwee nsogbu

ndia arutugasiriaka? Ee Mba

(b). N’etiti oge abua I nwere mmuo idamba onwere mgbe I nwere ihe ruru

onwabuo I n’enweghi mmuo idamba na enweghi mmasi n’ihe na-aga?

Ee Mba.

cv

APPENDIX 3b

Mini-International Neuropsychiatric Interview- Suicidality Module

In the past month did you:

C1. Suffer any accident? NO YES

C1a. Plan or intend to hurt yourself in that accident either passively or actively?

NO YES

C1b Did you intend to die as a result of this accident? NO YES

C2 Think that you would be better off dead or wish you were dead?

NO YES

C3 Want to harm yourself or to hurt or to injure yourself? NO YES

C4 Think about suicide? NO YES

C5 Have a suicide plan? NO YES

C6 Take any active steps to prepare to injure yourself or to prepare for a

suicide attempt in which you expected or intended to die? NO YES

C7 Deliberately injure yourself without intending to kill yourself? NO YES

C8 Attempt suicide? NO YES

In your lifetime:

C9 Did you ever make a suicide attempt? NO YES

M.I.N.I. Suicidality Module-----Igbo version

N’onwa gara aga:

C1. I nwere ihe mberede o bula? Mba Ee

cvi

C1a. I ji aka gi cho I meru onwe gi ahu n’ihe mberede ahu? Mba Ee

C1b. Ebum nobi gi o bu ka I nwuo n’ihi ihe mberede ahu? Mba Ee

C2. I chere na o kara ika gi mma ma o buru na I nwuru n’ihe mberede ahu?

Mba Ee

C3. I choro imeru onwe gi ahu? Mba Ee

C4. I chere echiche Igbu onwe gi? Mba Ee

C5. I metula nkwado maka igbu Onwe gi? Mba Ee

C6. O nwetula mgbe I kwadoro I ga I meru Mba Ee

C7. I matula uma meruo onwe gi ahu n’ebughi n’obi igbu onwe gi?

Mba Ee

C8. I gatula igbu onwe gi? Mba Ee

Na ndu gi n’ile

C9. E nwela mgbe I choro igbu onwe gi? Mba Ee

cvii

APPENDIX 4

The World Health Organization Quality of Life (WHOQoL)-Bref

The following questions ask how you feel about your quality of life, health, or

other areas of your life. I will read out each question to you, along with the response

options. Please choose the answer that appears most appropriate. If you are unsure

about which response to give to a question, the first response you think of is often

the best one.

Please keep in mind your standards, hopes, pleasures and concerns. We ask

that you think about your life in the last four weeks.

S/N Very poor Poor Neither poor

nor good

Good Very

poor

1 How would you rate your

quality of life?

1 2 3 4 5

S/N Very

dissatisfied

dissatisfied Neither

satisfied

nor

dissatisfied

Satisfied Very

satisfied

2 How satisfied are

you with your

health?

1 2 3 4 5

cviii

The following questions ask about how much you have experienced certain things in

the last four weeks.

S/N Not at all A little A moderate amount

Very much

An extreme amount

3 To what extent do you feel

that physical pain prevents

you from doing what you

need to do?

1 2 3 4 5

4. How much do you need any

medical treatment to

function in your daily life?

1 2 3 4 5

5. How much do you enjoy

life?

1 2 3 4 5

6 To what extent do you feel

your life to be meaningful?

1 2 3 4 5

S/N Not at all A little A moderate amount

Very much

Extremely

7 How well are you able to

concentrate?

1 2 3 4 5

8 How safe do you feel in

your daily life?

1 2 3 4 5

cix

9 How healthy is your

physical environment?

1 2 3 4 5

S/N Not at all A little moderate Mostly Completely

10 Do you have enough

energy for every day life?

1 2 3 4 5

11 Are you able to accept your

bodily appearance?

1 2 3 4 5

12 Have you enough money to

meet your needs?

1 2 3 4 5

13 How available to you is

information that you need

in your day-to-day life?

1 2 3 4 5

14 To what extent do you

have the opportunity for

leisure activities?

1 2 3 4 5

S/N Very poor Poor Neither

poor

nor good

Good Very poor

15 How well are you able to

get around?

1 2 3 4 5

cxi

S/N Very dissatisfied

dissatisfied Neither satisfied nor dissatisfied

Satisfied Very satisfied

16 How satisfied are

you with your sleep?

1 2 3 4 5

17. How satisfied are

you with your ability

to perform your

daily living activities?

1 2 3 4 5


you with your

capacity for work?

1 2 3 4 5


you with yourself?

1 2 3 4 5


you with your

personal

relationships?

1 2 3 4 5


you with your sex

life?

1 2 3 4 5

cxii


you with the support

you get from

your friends?

1 2 3 4 5

23

How satisfied are

you with the

conditions of your

living place?

1 2 3 4 5


you with your

access to health

services?

1 2 3 4 5

25. How satisfied are

you with your

transport?

1 2 3 4 5

The following question refers to how often you have felt or experienced certain

things in the last four weeks.

S/N Never Seldom Quite often Very

often

Always

cxiii

26 How often do you have

negative feelings such as

blue mood, despair,

anxiety, depression?

5 4 3 2 1

cxiv

Do you have any comments about the assessment?

Calculating transformed domain scores

Raw domain scores are calculated by straight forward summative scaling of

constituent items. Three negatively-worded items need to be reverse-scored (Q3, Q4

and Q26), as shown in the formulae (WHO, 1996).

The raw domain scores are calculated as follows:

Physical health = (6-Q3) + (6-Q4) + Q10 + Q15 + Q16 + Q17 + Q18

Psychological health = Q5 + Q6 + Q7 + Q11 + Q19 + (6-Q26)

Social relationships = Q20 + Q21 + Q22

Environment = Q8 + Q9 + Q12 + Q13 + Q14 + Q23 + Q24 + Q25

cxv

Method for converting raw scores to transformed scores

DOMAIN 1

Raw Score

Trasnformed score

4-20

0-100

7 4 0

8 5 6

9 5 6

10 6 13

11 6 13

12 7 19

13 7 19

14 8 25

15 9 31

16 9 31

17 10 38

18 10 38

19 11 44

20 11 44

21 12 50

22 13 56

23 13 56

24 14 63

25 14 63

26 15 69

27 15 69

28 16 75

29 17 81

30 17 81

31 18 88

32 18 88

33 19 94

34 19 94

35 20 100

DOMAIN 2

Raw

score

Transformed

4-20 0-100

6 4 0

7 5 6

8 5 6

9 6 13

10 7 19

11 7 19

12 8 25

13 9 31

14 9 31

15 10 38

16 11 44

17 11 44

18 12 50

19 13 56

20 13 56

21 14 63

22 15 69

23 15 69

24 16 75

25 17 81

26 17 81

27 18 88

28 19 94

29 19 94

30 20 100

DOMAIN 3

Raw

score

Transformed

4-20 0-100

3 4 0

4 5 6

5 7 19

6 8 25

7 9 31

8 11 44

9 12 50

10 13 56

11 15 69

12 16 75

13 17 81

14 19 94

15 20 100

DOMAIN 3

Raw

score

Transformed

4-20 0-

100

8 4 0

9 5 6

10 5 6

11 6 13

12 6 13

13 7 19

14 7 19

15 8 25

16 8 25

17 9 31

18 9 31

19 10 38

20 10 38

21 11 44

22 11 44

23 12 50

24 12 50

25 13 56

26 13 56

27 14 63

28 14 63

29 15 69

30 15 69

31 16 75

32 16 75

33 17 81

34 17 81

35 18 88

36 18 88

37 19 94

38 19 94

39 20 100

40 20 100

cxvi

Igbo Version of WHOQoL-Bref

Ajuju ndi a bu maka i mata etu i si ahuta ndu gi, ahu gi nakwa ihe ndi ozo gbasara

ndu gi. M ga aguputara gi ajuju o bula tinyekwuoro aziza ya. Biko horo aziza nke

dabara adaba. Ya buru na o gbagwo-juru gi anya bu osisa nke i ga enye, nke mbu

ahu batara gi n’obi na-abukari nke dabara adaba.

Biko buru n’obi maka udi mmadu i bu, olile-anya gi na ihe na-enye gi obi uto. Anyi

na-aju ka i chee maka etu i si bie ndu n’izu uka ano gara aga.

O joro njo O

rigughi

afo

O dighi mma, o

dighikwanu nfo

Odi

mma

O di ezigbo

mma

1 Kedu etu i si huta

ndu gi?

1 2 3 4 5

O rijugi

afo ma otu

O jugi

afo

O bughi na o

juru afo o bughi

kwanu na o jughi

afo

O

juru

afo

O juru ezigbo

afo

2. Kedu etu ndu gi si

judebe gi afo?

1 2 3 4 5

cxvii

Ajuju ndi a na-eso na-aju maka etu i si huta ihe ufodu n’izu uka ano gara aga

O nweghi

ma otu

obere Etu dim

ma

O buru

ibu

O buru

nnukwu ibu

3. Kedu etu i si chee echiche

na nsogbu i nwere n’ahu

gin nwere ike igbochi gi

ime i choro ime?

5

4

3

2

1

4. Kedu etu i si choo ka e

mee gi ogwu ka i na-eme

ihe i kwesiri ime na ndu gi?

5

4

3

2

1

5. Kedu etu i sin a-enwe

anuri na ndu gi?

1 2 3 4 5

6. Kedu etu i si hutadebe ndu

gi di ka ihe bara uru?

1 2 3 4 5

7. Kedu ka uche gi niile si adi

n’ike I na-eme?

1 2 3 4 5

8. Kedu etu obi si esi gi ike

na i nwere nchedo na ndu

gi?

1 2 3 4 5

9. Kedu etu gburu gburu ebe

i bi si didebe mma?

1 2 3 4 5

cxviii

Ajuju ndi a na-eso na-aju maka etu i si huta ma o bu menwuo ihe ufodu n’izu uka

ano gara aga

O nweghi

ma otu

obere Etu dim

ma

O

buru

ibu

O buru

nnukwu ibu

10. I na-enwe ume zuru oke

ubochi niile nke ndu gi?

1

2

3

4

5

11. I nabatara etu ahu gi di?

12 I nwere ego ga-ezuru gi ime

ih

1

2

3

4

5

13 Kedu etu ozi obula i choro i

nu si eru gi nti

1

2

3

4

5

14 Kedu etu i si enwedebe

ohere ime ihe o bula na-

enye gi onwu?

1

2

3

4

5

O juru

njo

O

rigughi

afo

O dighi

mma, o

dighikwanu

njo

O dim

ma

O di

ezigbo

mma

15. Kedu etu i na-esi agagharitu 1 2 3 4 5

16. Kedu etu i si e nwedebe afo

ojuju n’ihi ura gi?

1 2 3 4 5

cxix

17. Kedu etu i si enwedebe afo

ojuju n’ihe di iche iche i na-

emegasi na ndu gi?

1 2 3 4 5

18. Kedu etu i si enwe afo ojuju

n’ etu I sin a-aru oru?

1 2 3 4 5

19. Kedu etu onwe gi si judebe

gi afo?

1 2 3 4 5


na mmekorita gin a ndi ozo?

1 2 3 4 5


n’ihe gbasara mmekorita

nwoke na nwaanyi?

1 2 3 4 5

22. Kedu etu i si enwe afo

ojuju na nkwado i na-

enweta n’aka ndi enyi gi?

1 2 3 4 5

23. Kedu ka i si enwe afo ojuju

n’ihe gbasara onodu ebe i

bi?

1 2 3 4 5


n’etu i si huta ahu gi?

1 2 3 4 5


n’ime njem gi?

1 2 3 4 5

cxx

Ajuju a na-eso na-aju maka ugboro ole I hutagoro ihe ufodu n’izu uka ano gara aga

Onwebeghi Mgbe

ufodu

Otutu

mgb

Kwa

mgbe

kwa

mgbe

Oge niile

26. Ugboro ole ka i hutagoro

onwe gi n’onodu ufodu di ka

iwe, e nweghi olile-anya, obi

ezughi oke, ngharipu?

5 4 3 2 1

I nwere ihe nkwuputa o bu na maka ajuju a?

cxxi

APPENDIX 5

Consent Form

Introduction

You have been selected to participate in a study aimed at assessing depressive

symptoms, suicidal behavior and quality of life among patients with diabetes mellitus

and essential hypertension in a teaching hospital in Enugu, Nigeria.

Voluntary nature of participation: Participation in this study is completely

voluntary. Though selected for this exercise, you are free to accept or reject. If you

decide to participate, you are free to withdraw from the study any time you deem fit.

You are not required to do any investigations or undergo any invasive procedures.

Objection or participation in this study will not in any way influence the services you

receive in this hospital.

Study procedure: You will be asked questions about your age, religion, marital

status, level of education as well as presence of depressed mood in the past two

weeks, plans to harm or kill yourself and how you feel about your quality of life,

health or other areas of your life. Please give the most appropriate responses to the

questions.

Risks: There are no expected risks as no invasive procedures are involved.

Confidentiality: All information provided will be treated with confidentiality. Any

data emanating from this research will not in any way reveal information about

individual participant.

Feedback: The researcher will be available at any time to answer questions you

may have concerning this project. You can reach him on 08033116952 or through

the Department of Psychological Medicine, UNTH Enugu.

cxxii

Response: I have read though and understood the above information. I fully

understand the nature, risks, benefits of the study and hereby consent willingly and

fully to take part in it.

-------------------------------------------- ---------------------------------------------

Name/signature of Respondent Name/signature of Researcher

Date Date

---------------------------------------------

Name/signature of witness

Date

a comparative study of depression, suicidality and quality of

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