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Abstract
Objectives This study aimed to compare the mental health status of patients with diabetes before and after the COVID-19 pandemic and to determine the effect of COVID-19 on their mental health status. This study was the first to investigate the relationship between diabetes and mental health in the Korean population during the COVID-19 pandemic.
Design This retrospective cross-sectional study investigated the prevalence of mental health problems before (2018–2019) and during (2020–2021) the COVID-19 pandemic in individuals with diabetes aged 40 years or older who participated in the Korea National Health and Nutrition Examination Survey. Mental health problems were assessed using self-reported experiences of depression diagnosis, stress perception and suicide ideation. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9). Clinically significant depression requiring treatment was determined using an optimal cut-off score of 10 out of a total of 27 points.
Participants There were 824 men and 763 women in the 2018–2019 survey and 882 men and 887 women in 2020–2021.
Results In the unadjusted analysis, women had a statistically significantly higher prevalence of suicide ideation in 2020–2021 (2.9, 95% CI: 1.5 to 4.2) than in 2018–2019 (1.0, 95% CI: 0.4 to 1.7, but p<0.0067). There was no statistically significant difference in both men and women in 2018–2019 after adjusting for age, education, economic activity, hypoglycaemic drug intake or insulin injection, current alcohol consumption, hypertension and hypercholesterolaemia. A comparison of the results of the PHQ-9 survey conducted in 2018–2019 and 2020–2021 found no statistically significant difference in the prevalence of depressive disorder among both men and women.
Conclusions Long-term, retrospective observations and studies on the effects of COVID-19 on the mental health of patients with diabetes should be conducted in the future.
- mental health
- COVID-19
- diabetes & endocrinology
Data availability statement
No data are available. The datasets generated and/or analysed during the current study are available in the KNHANES repository (https://knhanes.cdc.go.kr/knhanes/sub03/sub03_02_05.do).
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This study’s limitations included its small sample size, short study period and questionnaire method.
To improve clarity and remove all biases related to diagnosis, further studies should only include participants with a fasting glucose level of ≥126 mg/dL and an haemoglobin A1C ≥6.5%.
The study’s strengths included its comparative analysis of the mental health status of patients with diabetes before and during the COVID-19 pandemic using a nationwide sample.
Introduction
Mental health problems, such as depression, mood disorders and anxiety disorders, are common among patients with diabetes.1 2 Additionally, suicide accounts for up to 7% of deaths in people with type 1 diabetes.3 Studies have shown that individuals with diabetes have a higher incidence of major depression than the general population.4 Vascular changes caused by diabetes may contribute to the development of depression, which may exacerbate the diabetes.5 Depression in diabetes can lead to poor self-management, medication adherence and glycaemic control and a potential risk of cardiovascular complications.4 6 7 In addition, previous research has shown that diabetes is an important risk factor for suicide ideation; the prevalence of suicide ideation was higher in patients with diabetes than in patients without diabetes, and it was found to be worse in patients with both diabetes and depression.8 In a previous study based on the Korean population, individuals with diabetes demonstrated a significant increase in suicidal behaviour.9 Among patients with diabetes, 9.1% had experienced suicidal thoughts in the past year, these rates were more than double those of the non-diabetic control group.10
COVID-19, an infection caused by the SARS-CoV-2, was declared a public health emergency of international concern by the WHO in January 2020 and upgraded to pandemic level in March 2020.11 The COVID-19 pandemic has significantly affected our lifestyles. Many countries and regions worldwide have implemented community-level lockdowns, quarantines, work from home policies and social distancing measures since the COVID-19 outbreak. South Korea did not implement a lockdown but maintained obligations and recommendations for protective strategies such as social distancing, hand washing and wearing a mask.12 Compared with 2016–2019, one study found a statistically significant increase in the prevalence of suicide ideation among Koreans in 2020 during the pandemic.13 As patients with diabetes have a high risk of developing severe COVID-19, the psychological burden on these patients is considerable during a pandemic.14–16 Stress and depression in patients with diabetes have also been associated with unhealthy behavioural changes during COVID-19, such as reduced physical activity and sleep time and increased smoking.17 However, the mental health issues of individuals with diabetes during a pandemic, such as COVID-19, are easily overlooked, and sufficient research is lacking. Therefore, to fill this gap in the literature, this study aimed to compare the mental health status of individuals with diabetes in Korea before and during the pandemic, and to determine the effect of the pandemic on their mental health status.
Methods
Data source
This study was based on cross-sectional data collected through the Korea National Health and Nutrition Examination Survey (KNHANES) between 2018 and 2021. The KNHANES is a cross-sectional survey conducted annually by the Korea Centers for Disease Control and Prevention (KCDC) of the Korean Ministry of Health and Welfare with a nationally representative sample of the Korean civilian population to evaluate health. The survey combines health and dietary interviews with standardised physical examinations and laboratory tests.18 The KNHANES administers the Patient Health Questionnaire-9 (PHQ-9) every other year. Therefore, the results from 2018 and 2020 were included in this study.
The surveys conducted from 2018 to 2021 included 29 192 participants; 17 887 were aged 40 and above. Patients with diabetes were defined as individuals who had a fasting blood glucose level of ≥126, took antidiabetic drugs or insulin injections, had an haemoglobin A1C ≥6.5% or were diagnosed by a doctor. The number of patients with diabetes was 3356 (771 in 2018, 816 in 2019, 895 in 2020 and 874 in 2021).
Variables
The variables used to characterise the population with diabetes were age, marital status, education level (>12 years of education means that the participant studied at the postsecondary level), residential area, household income (calculated as average monthly household income/number of people in household and expressed as quartiles), economic activity (currently working or unemployed), current use of hypoglycaemic drugs or insulin injections, current alcohol consumption (percentage of alcohol consumption more than twice a week and the average amount of alcohol consumption per time was considered as more than seven drinks for men and more than five drinks for women), current smoking (percentage of people who have smoked more than five packs (100 cigarettes) of cigarettes in their lifetime and who currently smoke cigarettes), physical activity (150 min or more of moderate-intensity physical activity per week or 75 min or more of high-intensity activity or equivalent moderate-intensity and high-intensity physical activity per week), obesity (body mass index ≥25 kg/m2), hypertension (140 mm Hg ≤ systolic blood pressure or 90 mm Hg ≤ diastolic blood pressure or taking antihypertensive medication) and hypercholesterolaemia (fasting total cholesterol ≥240 mg/dL or taking cholesterol lowering medications).
Mental health problems were assessed using self-reported experiences of depression diagnosis, stress perception and suicide ideation. An individual was assessed as having experienced a depression diagnosis if they answered ‘yes’ to the following question: ‘Depression/Diagnosis by a doctor’. The level of perceived stress was measured using the following question: ‘How much stress do you usually feel?’ Four response options were provided: ‘low’, ‘middle-low’, ‘middle-high’ and ‘extreme’. Extreme stress or middle-high stress was considered perceived stress. An individual was assessed as demonstrating suicide ideation if they answered ‘yes’ to the following question: ‘Have you made a plan to commit suicide within the last year?’ Suicide ideation was assessed annually in the same manner.
Depression was evaluated using the PHQ-9. The PHQ-9 is a self-report assessment tool that is beneficial for depression screening and can be used to determine the severity of depressive symptoms.19 It consists of a nine-item depression module that assesses whether individuals have experienced little interest, hopelessness, sleep problems, changes in appetite, fatigue, a sense of guilt or worthlessness, concentration difficulties, moving or speaking very slowly or the opposite and/or suicide ideation over the past 2 weeks. Each item is scored from 0 (not at all) to 3 (almost every day), with a higher score indicating a higher severity of depression. Clinically significant depression requiring treatment was determined using an optimal cut-off score of 10 from a total possible score of 27 points.20 The results of 2018 and 2020 are included in this study.
Statistical analysis
For the characteristics of persons with diabetes, values are presented as weighted mean (SE) or weighted percentage (SE) unless indicated otherwise. P values were calculated using Student’s t-test or the Rao-Scott χ2 test. For the weighted prevalence of mental health problems among persons with diabetes, the p value was calculated using the Rao-Scott χ2 test (when not adjusted), and by logistic regression (when adjusted for age, education, economic activity, adjusted age, education, economic activity, taking hypoglycaemic drugs or insulin injections, current alcohol consumption, hypertension and hypercholesterolaemia).
PHQ-9 scores and prevalence of depressive disorders between 2018 and 2020 were compared using Student’s t-test, or the Rao-Scott χ2 test as appropriate when it was not adjusted. When adjusted, p values were determined by logistic regression and analysis of covariance. Internal consistency was determined using Cronbach’s alpha.
The sampling plan used in the KNHANES to represent non-institutionalised Korean nationals residing in Korea followed stratified, multilevel clustering.15 All statistical analyses were performed using the SAS PROC SURVEY procedure (SAS V.9.4; SAS Institute, Cary, North Carolina, USA) to apply stratification, primary sampling units and population weights. Statistical significance was set at p<0.05.
Ethical considerations
The KNHANES is reviewed and approved annually by the Research Ethics Review Board of the KCDC. This study was conducted in accordance with ethical standards, as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
All surveys were conducted after informed consent was obtained from the participants.
Patient and public involvement
None.
Results
Of the 3356 participants, there were 824 men and 763 women in the 2018–2019 survey and 882 men and 887 women in the 2020–2021 survey. The average age of women in the 2018–2019 survey was 65.7, and in 2020–2021 it was 65.5. The average age of the men was 59.9 in the 2018–2019 survey, and in 2020–2021 it was 60.2. Statistically significant differences were observed between the 2018–2019 and 2020–2021 surveys in women’s education, taking hypoglycaemic drugs or insulin injections, and hypertension, and in men’s economic activity, current alcohol consumption and hypercholesterolaemia (p<0.1; table 1).
Characteristics of patients with diabetes
Table 2 presents a comparison of differences between men and women with diabetes regarding prevalence of depression diagnosis, perceived stress and suicide ideation in the 2018–2019 and 2020–2021 surveys. In unadjusted outcomes, women had a statistically significantly higher prevalence of suicide ideation in 2020–2021 (2.9, 95% CI: 1.5 to 4.2) than in 2018–2019 (1.0, 95% CI: 0.4 to 1.7; p<0.0067), but men had no statistically significant increase in either category. When adjusted for age, education and economic activity, no statistically significant difference was found between 2018–2019 and 2020–2021 for both men and women. After adjusting for age, education, economic activity, taking hypoglycaemic drugs or insulin injections, current alcohol consumption, hypertension and hypercholesterolaemia, which showed differences in population characteristics (p<0.1; table 1), no statistically significant differences were found between the 2018–2019 and 2020–2021 surveys (table 2).
Weighted prevalence of mental health problems among persons with diabetes
A comparison of the results of the PHQ-9 surveys conducted in 2018 and 2020 showed no statistically significant difference between surveys for both men and women in the mean or LS-mean of PHQ-9 scores and the prevalence of depressive disorders with a score of 10 or higher (table 3). Cronbach’s alpha was 0.801.
Depression detected by the PHQ-9 in the KNHANES 2018 and KNHANES 2020 samples in Korea
Discussion
This study found that suicide ideation was significantly higher in women in the post-COVID-19 pandemic survey without adjusting for stress levels, experience of depression diagnosis and suicide ideation, which are indicators of health in people with diabetes. However, no statistically significant difference was observed after adjusting for these socioeconomic factors. Considering that access to medical institutions became difficult during the pandemic, the difference in depression status before and during the pandemic was examined using the PHQ-9 Questionnaire; no statistically significant increase was found.
A previous US study showed that the prevalence of depressive symptoms in patients aged 65 years or older with diabetes was more than 1.6 times higher during COVID-19 than before the pandemic.21 A study of patients with diabetes aged 18 years and older in the Netherlands found that perceived stress increased during the pandemic.22 During the COVID-19 pandemic in Brazil, about half of the patients with diabetes aged 18 years and older complained of psychological distress, such as anxiety and depression, and in another study, 9.3% of patients with diabetes thought about ending their lives during the pandemic.23 24 These findings suggest the importance of careful monitoring of mental health challenges in people with diabetes during a pandemic. As the previous studies in other countries used patients belonging to specific institutions, the present study aimed to determine the mental health status of individuals with diabetes through a nationwide sample in Korea. A previous study examining mental health during the pandemic in South Korea found that women and young people were more susceptible to suicide ideation during the pandemic. This is consistent with our finding that suicide ideation was high in women.25 26
The results of the study after adjusting for socioeconomic factors can be explained as follows. First, it could be due to methodological differences in the sampling and recruitment strategies. As this study collected population data face-to-face in accordance with national policy, social desirability biases may have led some participants to under-report depression compared with online data collection.14 Second, this study used data from the PHQ-9, a depression-related scale administered every other year (in 2018 and 2020). Thus, the pandemic period may have been insufficiently reflected. Third, Korea did not impose a lockdown and implemented government policies based on social distancing recommendations, such as wearing masks, hand washing, restrictions on large gatherings and reduced business hours. Fourth, during the pandemic period, companies increased telecommuting, schools delayed school attendance and large gatherings were restricted; however, because the majority of the population aged 40 or older in this study were older adults, they were not greatly affected by these policies.
This study has limitations. First, this study defined a ‘patient with diabetes’ based on the definition used by Korea Centers for Disease Control and Prevention and used it to calculate the prevalence of diabetes in Korea. To improve clarity and remove all biases related to diagnosis, further studies should only include participants with a fasting glucose level of ≥126 mg/dL and an HbA1c ≥6.5%. Second, it is difficult to assess the effect of the COVID-19 pandemic over the long term because of the small sample size and short duration of the study. In the future, long-term retrospective research should be conducted using continuously released COVID-19-related data. Third, the objectivity of the research methods should be increased by conducting an online survey rather than face-to-face interviews, diversifying the evaluation of mental health, and reconsidering the use of the self-reported survey method and the uneven distribution in education levels and residency in the sample. Additionally, further studies could also use a validated measure of perceived social support, such as the Multidimensional Scale of Perceived Social Support. To gain a global understanding of the mental health status of people with diabetes before and during the pandemic, additional research combined with other similarly measured datasets in other countries may be needed. Nevertheless, this study has clinical significance because it comparatively analysed the mental health of individuals with diabetes before and during the pandemic using a nationwide sample.
Conclusion
When the health indicators of patients with diabetes, such as stress level, depression diagnosis experience, suicide ideation and depression index, were investigated for the period before the COVID-19 pandemic (2018–2019) compared with during (2020–2021) the COVID-19 pandemic, suicide ideation increased among women. However, no statistically significant difference between men and women before and during the COVID-19 pandemic was found after adjusting the results between the two samples. Long-term, retrospective observations and studies on the mental health of patients with diabetes should be conducted in the future.
Data availability statement
No data are available. The datasets generated and/or analysed during the current study are available in the KNHANES repository (https://knhanes.cdc.go.kr/knhanes/sub03/sub03_02_05.do).
Ethics statements
Patient consent for publication
Ethics approval
The study was conducted in accordance with the Declaration of Helsinki, and the KNHANES is reviewed and approved by the Research Ethics Review Board of the Korea Centers for Disease Control and Prevention (KCDC) annually exempted this study.
Acknowledgments
The author is grateful to Ji Sung Lee for assistance in analysing the data used in this study.
References
Footnotes
Contributors HJ conceived the study and wrote the paper. HJ is responsible for the overall content as guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.