Introduction

The World Health Organization defines health as“a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”.¹ This definition illustrates the woven relationship between the physical and mental health and confirms that there is no health without mental health. The number of people affected with mental disorders is increasing and compromising acumulative burden on resources. Noncommunicablediseases (NCD), such as ischemic heart disease and cerebrovascular disease are among the top sixcauses of burden of disease. Mental health disorders (unipolar depressive disorder and alcohol usedisorder) are among the 20 leading causes of burden of disease.²

The understanding of the relationship between chronic physical and mental illnesses has increased dramatically in the last two decades, and studies have reported a close coexistence between both the disorders.³ Individuals with chronic illnesses have higher rates of depression and anxiety compared to the general population.^{3, 4} The coexistence of chronic physical and mental problems increases the burden of physical illness, functional impairment, and medical costs.⁴ In addition, it impairs the ability to selfcare and decreases the adherence to treatment regimens resulting in an increased mortality.^{5, 6}

Depression and anxiety are the most common mental disorders among individuals with chronic diseases,such as cardiac and respiratory illnesses, diabetes,and cancer. It is estimated that one out of five cardiac patients and one out of four diabetic patients suffer from depressive symptoms.⁷ Moreover, 15–25% of cancer patients suffer from depression, especially in the advanced stages of the disease. Depression and anxiety are closely related to unhealthy lifestyles, such as smoking and poor nutritional habits leading to obesity; thus, further increasing the risk of cardiovascular disease (CVD).⁷

NCD is highly prevalent in the Kingdom of Bahrain.The National Noncommunicable Diseases Risk Factors Survey conducted in the Kingdom of Bahrainin 2007 showed that the prevalence of diabetes mellitus, hypertension, and raised cholesterol level was 14.3%, 38.2%, and 40.6%, repectively.⁸ In 2012, mortality due to NCD constituted about 61% of total deaths, wherein, CVD, cancer, and diabetes accounted for 21%, 10%, and 10% of the deaths, respectively.⁹ A study was conducted on the prevalence of depression among diabetic patients attending diabetic clinics in primary care settings in the Kingdom of Bahrain. It revealed that around one-third were potential cases of depression and the majority were under diagnosed and under treated; concluding that psychosocial assessment should be a part of patient assessment criteria._⁹ Another study has shown a prevalence rate of 17.3%, 19.3%, and 5.6% for generalized anxiety disorders, life time depression, and current depression, respectively, inpatients attending primary health care centers in the Kingdom of Bahrain. It also showed that 7.3% of the patients had anxiety or depression in the past and only 41% of them had received treatment.¹⁰

All health care centers in the Kingdom of Bahrain have NCD clinics with full professional teams (doctors, nurses, and health promotion specialists). The main aim of establishing these clinics was to educate patients and help them follow healthy lifestyle in order to control the diseases.¹¹ The present study was conducted to estimate the prevalence and explore the factors associated with depression and anxiety among patients with NCD attending these clinics.

Materials & methods

This cross-sectional study was conducted in the NCD clinics of five health centers in the Kingdom of Bahrain from January to March 2016. Patients attending the NCD clinics during the research period were included in the study; whereas, patients who couldn’t read and write Arabic or English were excluded as the questionnaire was self-filled. The study was approved by the Research Committee in the Ministry of Health. Before commencement of the study, all patients were informed about the procedure and scope of the study and informed consent was obtained.

One health center was randomly selected from each health region and patients attending NCD clinics during the study period were included until the required sample size was achieved. The sample size was calculated using the following formula:

where,

n, desired sample size;

z, standard normal deviate, set at 1.96 corresponding to the 95% confidence level;

d, degree of accuracy desired, set at 0.05;

p, prevalence of depression and anxiety among patients attending NCD clinics; based on literature review it was expected to be around 25%

Therefore,

n = 3.8416 × (0.25×0.75)/(0.052)

n = 289

To account for the design effect with cluster sampling, we multiplied the estimated sample sizeby 1.5, so the minimum required sample size was 434. The required sample size was distributed in the five health centers proportionate to the number ofpatients registered in the NCD clinics in each health region.

All study participants were asked to fill aquestionnaire, which consisted of two parts:first part had questions about the demographic characteristics, type of chronic disease, and personal and family history of mental illness; second part was the screening tool (Hospital Anxiety andDepression Scale/HADS). The questionnaire was made available in two different languages—Arabic and English.

Hospital Anxiety and Depression Scale (HADS)

Hospital Anxiety and Depression Scale (HADS) is a simple and reliable screening tool for identifying depression and anxiety in patients. It is valid for the purpose of screening, while definitive diagnosis can only be reached through clinical evaluation. It is proven that it is valid when used in primary care settings.^₁₂

The scale consists of 7 items each for anxiety and depression. Each item is rated on a four-point scale from 0 (not at all) to 3 (very often). Possible scores for anxiety and depression range from 0 to 21.

Range of scores: 0–7, normal; 8–10, mild anxiety/depression; 11–14, moderate; and 15–21, severe anxiety or depression.¹³

Statistical analysis

Descriptive statistics were calculated for both continuous and categorical variables. The prevalence of depression and anxiety was calculated with 95% confidence interval (CI) using the Wilson method. Chi square test and Fisher’s exact test were used to examine the relation between anxiety/depression and other possible factors. Logistic regression analysis was used to identify factors associated with anxiety/depression; odds ratios (ORs) and corresponding 95% CIs were calculated. Prior toregression analysis, the anxiety and depression scores were dichotomized into normal (0–7) andhigh (8–21) scores.¹⁴ The following variables were analyzed using univariable logistic regression analysis for possible association with anxiety/depression: age, gender, marital status, nationality, occupation, education, income, and personal and family history of mental illness. Variables with a P value < 0.2 were included in the multiple logistic regression analysis. All the analyses were conducted using STATA (version 12) and P values < 0.05 were considered statistically significant.

Results

Among the 515 patients approached for participation in the study, a total of 456 agreed to participate(response rate = 88.5%). The most common chronic condition observed was diabetes followed by hypertension and dyslipidemia (Figure 1). Almost equal number of males and females were observed in the study and most belonged to the age group of 45–60 years. The age ranged between 18 and 85 years. More than 80% of the patients were of Bahraini origin, married, and earned a good income (Table 1).

Prevalence of depression in NCD patients and the associated factors

Amidst the 456 interviewed, 71 (15.6%; 95% CI:12.5–19.2) were diagnosed with mild depression,whereas 53 (11.6%; 95% CI: 9.0–14.9) had moderate to severe depression. Depression was significantly associated with age (P = 0.05), marital status (P = 0.03), education level (P = 0.01), income (P = 0.02), and personal history of mental illness (P = 0.001; Table 2). Among this group of patients, there was no statistically significant difference in the prevalence of depression among different diseases (Table 2).

The results of the univariable and multivariable logistic regression models are described in Table 3. According to the multivariable model, the odds of having high depression (score ≥ 8) was significantly higher in patients aged < 45 years (adjusted OR = 2.01; 95% CI: 1.16–3.47; P = 0.01), with low income (adjusted OR = 1.99; 95% CI: 1.11–3.56;P = 0.02), and those with a personal history of mental illness (adjusted OR = 5.13; 95% CI: 1.92–13.70;P = 0.001). Lower educational level was associated with increased odds of having higher depression score. Compared to patients with university or higher education, patients with secondary level education and those with intermediate or lower level of education had 87% and more than twice the odds, respectively of having higher depression scores.

 Prevalence of anxiety in NCD patients and the associated factors

Of the 456 interviewed, 55 patients (12.1%; 95%CI: 9.4–15.4) had mild anxiety and 34 patients(7.5%; 95% CI: 5.4–9.2) had moderate to severe anxiety scores. Anxiety was significantly associated with gender (P < 0.001), age (P = 0.01), marital status (P = 0.001), income (P < 0.001), and personal history of mental illness (P = 0.001; Table 4). Among this group of patients, there was no statistically significant difference in the prevalence of anxiety among different diseases.

The results of the univariable and multivariable logistic regression models are described in Table 5. According to the multivariable model, the odds of having high anxiety score (≥ 8) was significantly higher in females (adjusted OR = 2.85; 95% CI:1.63–5.00; P < 0.001), patients aged < 45 years (adjusted OR = 2.41; 95% CI: 1.31–4.46; P = 0.005), patients with low income (adjusted OR = 3.62; 95%CI: 1.92–6.80; P < 0.001), and those with a personal history of mental illness (adjusted OR = 4.5; 95%CI: 1.60–12.67; P = 0.004).

Discussion

This is the first study in the Kingdom of Bahrain that examined the prevalence of depression and anxiety among patients attending NCD clinics. A high prevalence of depression (27.2%) and anxiety (19.6%) were observed among the study participants. The prevalence of depression was high in asthmatic patients, followed by diabetic, hypertensive, dyslipidemia, and cardiac patients. The prevalence of anxiety in the decreasing order of occurrence in patients with other comorbidities: cardiac, asthmatic, diabetic, hypertensive, and dyslipidemia patients.

There is a wide variation in the estimated prevalence of depression and anxiety in previous studies conducted in different parts of the world. In Turkey, a study reported 29.4% and 15.5% prevalence of depressive disorder in diabetics and hypertensive patients. In addition, 16.0% and 9.5% of diabetics and hypertensive patients had common anxiety disorder.¹⁵ According to a study conducted in three Southeast Asian countries (Cambodia, Myanmar, and Vietnam), the prevalence of anxiety in patients with diabetes, hypertension, and dyslipidemia was 18.5%, 15.6%, and 14.8%, respectively. Whereas,the prevalence of depression was 49.1%, 45.0%, and 30.9% among diabetics, hypertensive patients, and those with dyslipidemia, respectively.¹⁶ The prevalence of depression in diabetic patients in China was estimated to be 23–39.2%. In India, the prevalence of depression ranged between 16.9% and 84%.¹⁶

Furthermore, studies conducted in the United States of America estimated that 17–27% patients with coronary artery disease and 9–26% patients with type 1 and type 2 diabetes mellitus have depression.^{17, 18} This wide variation in the estimated prevalence of depression and anxiety across studies maybe due to true differences in different communities or different assessment or screening methods. Nevertheless, all of these studies point to a high prevalence of mental disorder in patients with chronic diseases and call for better attention to identify and manage mental disorders in patients with chronic diseases.

The high prevalence of depression and anxiety among patients attending NCD clinics in the Kingdom of Bahrain necessitates the inclusion of screening and evaluation of mental disorders in these clinics. The United States Preventive ServicesTask Force (USPSTF) has recommended screening of depression in adults, especially in those with risk factors of depression, including individuals with chronic illnesses.^{13, 19} In the United Kingdom, the Quality and Outcomes Framework (QOF) of the General Practitioner (GP) contract encourages the screening of depression in patients with coronary heart disease and diabetes.²⁰ In addition, the National Institute for Health and Clinical Excellence (NICE) guidelines recommend being alert for the possibility of depression and anxiety, especially in patients with CVD and diabetes.²¹

In our study, the female gender was significantly associated with a high score of anxiety, however, not with depression screening test. Previous studies have proven that women suffer more from mental disorders in both the chronic disease as well as the general population.^{15, 22, 23} According to our findings, anxiety and depression were also more common in the younger patients (< 45 years of age). This contradicts the findings of the previous studies, wherein, depression was more common in patients > 50 years of age.^{16, 24} In our study, other factors that were significantly associated with high scores of anxiety and depression were low income and a past history of mental illness, which is consistent with previous studies.^{24, 25}

Conclusion

There is a high prevalence of depression and anxiety among patients attending NCD clinics in the Kingdom of Bahrain. Accordingly, screening for mental health diseases should be an integral part of patients’ initial evaluation and regular follow-up. Furthermore, appropriate guidelines should be established for the psychosocial management of patients identified during the screening.

Conflicts of interest

The authors of the study have no conflicts of interest to declare.