Levels of Depression in Type 2 Diabetes Mellitus: A Literature Review

Due to the increase in morbidity each year

This open access article is under the CC-BY-SA license.

INTRODUCTION
Insufficient insulin synthesis by the pancreas or ineffective insulin uptake by the body are the causes of diabetes mellitus, a chronic medical condition. One of the four non-communicable diseases (NCDs) with the highest priority that need immediate attention is diabetes, which is a significant public health issue. (WHO, 2016).
According to the Centers for Disease Control and Prevention, type 2 diabetes mellitus affects more than 26 million Americans, or 8.3% of adults and children.Diabetes affects more than 347 million people worldwide, with men more likely to have it (9.8%) than women (9.3%). (AbdElmageed, 2022).
One condition that can be influenced by diabetes mellitus is mental health issues, such as the onset of symptoms of sadness and excessive anxiety that are common in persons with diabetes mellitus (Ascher et al., 2015). This is because diabetes mellitus patients view the condition as a chronic metabolic disease with no guarantee of recovery, difficulties managing medical care, and worries about complications and even disability that may arise. As a result, there is a strong correlation between the prevalence of depression and the risk of suicide. (Kodakandla et al., 2016).
Depression is a psychiatric disorder that affects certain persons with diabetes mellitus and is defined by abnormalities in a person's mood, cognition, and behavior. Those who have depressive illnesses may experience melancholy, loneliness, a reduction in their sense of self, and detachment from their surroundings (Kaplan et al., 1997). A psychiatric condition called depression is characterized by bodily and cognitive symptoms as well as the outward signs of sadness, emptiness, and sensitivity. An individual's function and capacity for performing daily tasks may be impacted by these symptoms. (American Psychiatric Association, 2000).
According to research conducted by Eker (2018), who found a correlation between diabetes mellitus and the incidence of depression, 54 people with diabetes mellitus (31.6%) experienced mild depressive symptoms, and 46 people with diabetes mellitus (26.9%) experienced moderate depressive symptoms, patients with type 2 diabetes mellitus frequently experience two disorders in their mental health, such as symptoms of depression and anxiety.
This study aims to discover factors linked with depression in patients with diabetes mellitus in light of the issue of the prevalence of diabetes mellitus increasing every year, which is proportionate to the increase in the disruption of mental health disorders.

METHODS
The method used in this research is a literature review, where research articles are searched using several keywords and then analyzed through a review of all the search articles. Inclusion criteria are used to filter data obtained from journal databases, including the publication of articles within the last 5 years, the use of Indonesian or English language, and the relevance of the title and abstract to the topic of depression levels in type 2 diabetes mellitus patients. The study used three databases: GoogleScholar, Garuda, and PubMed. After filtering, 8 articles met the inclusion criteria and were analyzed to identify the variables influencing type 2 diabetes patients' degrees of sadness. Future studies in this field may be guided by the findings of this study. The article screening flowchart is shown below. The title, Abstract, and Keyword don't represent the category of depression level in a patient with type 2 diabetes mellitus.

RESULTS AND DISCUSSION
All articles reviewed related to previous studies using data extraction tables include discussion related to factors associated with the level of depression in patients with type 2 diabetes mellitus. The following are the research points obtained from the 8 articles.
Due to an increased symptom burden, diabetic consequences that impair function and lower quality of life, and subsequent vascular alterations in the brain, diabetes mellitus may raise the risk of depression or exacerbate depressive symptoms. (Park et al., 2015).
According to a meta-analysis of 10 studies done by Ali et al. (2006), patients with diabetes mellitus had a considerably greater prevalence rate of depression (17.6%) than those without diabetes mellitus (9.8%). When women with type 2 diabetes mellitus are more likely to exhibit depressive symptoms due to their clinical features. According to Eker's (2018) research, which analyzed the gender characteristics of individuals with type 2 diabetes mellitus, 41.5% of women with the disease reported having mild to severe depression symptoms. This is consistent with the findings of Park and Reynold's (2015) study, which found that women with diabetes have a greater rate of depression (23.8%) than men (12.8%). Women who have diabetes mellitus are twice as likely as men to experience depressive symptoms. This can be explained by the fact that premenopausal, postpartum, and pregnant women frequently suffer major hormonal shifts. (Sartorius, 2018).
Women over 50 who are premenopausal are more susceptible to depression symptoms and at risk of developing them. According to research by Handika et al. (2020), the majority of diabetics with depression are between the ages of 50 and 59. This is because older people typically worry more about their future employment prospects, the possibility of disabilities (such as movement restrictions) brought on by aging, their own declining physical and mental health, and their lack of motivation to adhere to treatment regimens.
Risk factors for knowledge that can be seen through the patient's level of education can influence the patient's thinking in regards to implementing a healthy lifestyle, selfcare, and compliance in diabetes mellitus treatment management so that blood glucose levels are always controlled so that worries about complications from diabetes mellitus can be prevented (Rizky et al., 2019). This is consistent with studies by Bayuningtyas et al. (2018) and Livana et al. (2018), which demonstrate that patients with diabetes mellitus who have completed high school are more likely to have depressive symptoms. This research contrasts with that of Eker (2018), who found that individuals with diabetes mellitus whose last educational level was an elementary school (35% of them) had the highest rates of depressive symptoms.
Because diabetes is a chronic disease that requires sufferers to take antidiabetic medications regularly even for life, it requires extensive medical expenses and treatment. Patients with diabetes mellitus who have a low level of education will directly affect their income. Economic conditions also play a role in controlling blood glucose levels and the level of depression in patients with diabetes. Patients will bear the burden of treatment and care needs if there is no social or financial support available to satisfy them (Putri et al., 2018). The same study, by Mendenhall et al. (2014), demonstrates that low-income groups in India not only have higher levels of depression and social pressure than wealthy groups, but also a lack of knowledge about lower diabetes and limited access to health treatments.
Patients with diabetes mellitus may experience uncontrolled blood glucose levels due to long-term stressors, excessive anxiety, or a sense of worthlessness, which will have an emotional impact and interfere with treatment compliance (Rustad et al., 2011). These are just a few examples of how the presence of minimal, mild, moderate, or severe depressive symptoms can have an impact on a patient's medical conditions (Park., 2015). The metabolism of the cortisol hormone will also be affected by low selfacceptance of the sickness because the level of depression is closely correlated with the amount of cortisol hormone secreted (Bădescu et al., 2016). As a result, it will have an impact on insulin production by increasing gluconeogenesis, which raises blood glucose levels and speeds up the onset of micro and macrovascular complications (Champaneri et al., 2010). Patients will also have a two times higher risk of morbidity than people with diabetes mellitus who do not exhibit depressive symptoms. (Livana et al., 2018)

LIMITATION OF THE STUDY
This literature study only uses three databases; it is likely that more literature will be obtained if the database is more extensive used. We used eight articles for analysis with publications over the last 5 years so there are few studies that have discussed the level of depression in patients with type 2 diabetes mellitus, so further research is needed on this topic.

CONCLUSIONS AND SUGGESTIONS
This review of the literature leads to the conclusion that type 2 diabetes mellitus can affect a person's level of depression, as shown by numerous articles that have been analyzed and various measurement scales, such as the Hamilton Depression Rating Scale, Beck Depression Inventory, and Depression Anxiety Stress Scale, that have been used to gauge a person's level of depression. Age, gender, education level, and income are a few patient factors that are linked to the severity of depression symptoms in people with type 2 diabetes mellitus. The author, therefore, expects that by producing this literature review, doctors will be able to further take into account the psychological impact experienced by type 2 diabetes mellitus patients, allowing for therapy that not only addresses diabetes but also the patient's mental state. so that doctors can determine what causes patients' mental and emotional illnesses. This is anticipated to increase motivation, enhance trust, and improve communication in order to make it easier to fulfill the treatment and care management objectives.

ETHICAL CONSIDERATIONS
Funding Statement.